Multi-Tiered, Step Ladder Approach
to DRY EYE, Reflex Tearing, Eye Redness, Itching, Rosacea, Blepharitis,
Eyelid Swelling:
to DRY EYE, Reflex Tearing, Eye Redness, Itching, Rosacea, Blepharitis,
Eyelid Swelling:
Sandra Lora Cremers, MD, FACS
START STEPS 1, 2 & 3 daily,
especially if symptoms return. Every skin type/eye is different, so be patient with your
eye as we help find the best treatment for you. If no improvement with the early
steps, scar tissue (fibrotic changes cause obstructive Meibomian Gland Dysfunction [MGD]) is likely
present: may need step 8 for relief.
My goal: to arm you with the tools you need when
you need them & to teach you when to move to the next tier
Below is my attempt to Paste all the Details of the Step Ladder Approach to Blogger: I hope this helps.
Sandra Lora
Cremers, MD, FACS’s Multi-Tiered, Step Ladder Approach
to DRY EYE, Reflex Tearing, Eye Redness, Itching, Rosacea, Blepharitis,
Eyelid Swelling: START STEPS 1, 2 & 3 daily,
especially if symptoms return. Every skin type/eye is different, so be patient with your
eye as we help find the best treatment for you. If no improvement with the early
steps, scar tissue (fibrotic changes cause obstructive Meibomian Gland Dysfunction [MGD]) is likely
present: may need step 8 for relief.
My goal: to arm you with the tools you need when
you need them & to teach you when to move to the next tier.
Cremers, MD, FACS’s Multi-Tiered, Step Ladder Approach
to DRY EYE, Reflex Tearing, Eye Redness, Itching, Rosacea, Blepharitis,
Eyelid Swelling: START STEPS 1, 2 & 3 daily,
especially if symptoms return. Every skin type/eye is different, so be patient with your
eye as we help find the best treatment for you. If no improvement with the early
steps, scar tissue (fibrotic changes cause obstructive Meibomian Gland Dysfunction [MGD]) is likely
present: may need step 8 for relief.
My goal: to arm you with the tools you need when
you need them & to teach you when to move to the next tier.
20. Lacrimal Gland Stimulation (Stanford, Bascom Palmer, Oculeve)
19. Not FDA
approved yet: Mucin Secretagogue (rebamipide); Lacritin; 1% DHEA
approved yet: Mucin Secretagogue (rebamipide); Lacritin; 1% DHEA
18. Lid
Tarsorrhaphy: surgery required to
help lids cover eye better
Tarsorrhaphy: surgery required to
help lids cover eye better
17. Cord Blood Serum: still experimental: see blog
below.
below.
16. Anti-inflammatory pills (low dose steroid for severe
dryness)
dryness)
14. 3% Testosterone Cream (off
label; not FDA approved); 203-268-4964
label; not FDA approved); 203-268-4964
13. Amniotic Membrane
Transplant: available at our office
Transplant: available at our office
12. Prokera Contact Lens: available
at our office
at our office
11. Platelet Rich Plasma: blood
is used to create PRP rich in growth factors
10. Autologous serum: available
in our office: clear tears drawn from your serum
in our office: clear tears drawn from your serum
9. Conjunctivochalasis: folds in conjunctiva that destabilize
the tear film. If present, fornix
reconstruction may be needed for relief: Laser &/or Surgery
the tear film. If present, fornix
reconstruction may be needed for relief: Laser &/or Surgery
8. Innovations in Dry Eye: Works well in most patients. Treats MG directly. Out
of pocket investment in eyelid
& eye health. No guarantees but few options remain.
of pocket investment in eyelid
& eye health. No guarantees but few options remain.
·
LipiFlow: FDA approved; usually
lasts about 10-16months; reboots MG
LipiFlow: FDA approved; usually
lasts about 10-16months; reboots MG
·
Intense Pulsed Light (IPL): 4-6 treatments needed
Intense Pulsed Light (IPL): 4-6 treatments needed
·
Meibomian Gland Probing (+/-Intraductal steroid):multiple treatments often needed
Meibomian Gland Probing (+/-Intraductal steroid):multiple treatments often needed
7. Punctal Plugs (Temporary or Permanent); Probe & Irrigation of Ducts
may be needed
6a. Steroid drops (Lotemax, Alrex, FML, Pred Forte, Durezol): chronic use
has risks: high pressure/glaucoma, cataract; if using steroid long term, get
eye pressure checked every 4-8wks
may be needed
6a. Steroid drops (Lotemax, Alrex, FML, Pred Forte, Durezol): chronic use
has risks: high pressure/glaucoma, cataract; if using steroid long term, get
eye pressure checked every 4-8wks
6. Cyclosporine Restasis drops: FDA approved; works
well; takes 3 months to feel benefit
well; takes 3 months to feel benefit
5. Doxycycline 20-50mg
pill 1-2x/d (anti-inflammatory to prevent MG
scarring or enterically coated Doxy: AVOID Sun; low risk of diarrhea; don’t
use if pregnant; can take with food
pill 1-2x/d (anti-inflammatory to prevent MG
scarring or enterically coated Doxy: AVOID Sun; low risk of diarrhea; don’t
use if pregnant; can take with food
4. Xiidra: FDA approved;1 drop 2x/d;works in
2-3wks; call (844)-694-4747 for free samples or Text
“SAVE” to 37500
2-3wks; call (844)-694-4747 for free samples or Text
“SAVE” to 37500
3. Artificial
tears: Best: Non-preserved=best: cost more (i.e., Refresh; Oasis tears alternating
with Retaine 4-8x/day depending on
severity) (put in refrigerator if eyes itch); Thicker drops (Soothe, Refresh
Dry Eye Therapy) great for severe dryness, though may blur vision; Preserved
tears: use no more than 4x per day to avoid reaction to preservative; Liposomal
Sprays: Tears Again Advanced Dryness also recommended. If significant itching, anti-itch drops
needed (i.e., Lastacaft, Pataday or steroid drops); LACRISERTs (inserted by the patient) require a prescription; eyedoc2020.blogspot.com
tears: Best: Non-preserved=best: cost more (i.e., Refresh; Oasis tears alternating
with Retaine 4-8x/day depending on
severity) (put in refrigerator if eyes itch); Thicker drops (Soothe, Refresh
Dry Eye Therapy) great for severe dryness, though may blur vision; Preserved
tears: use no more than 4x per day to avoid reaction to preservative; Liposomal
Sprays: Tears Again Advanced Dryness also recommended. If significant itching, anti-itch drops
needed (i.e., Lastacaft, Pataday or steroid drops); LACRISERTs (inserted by the patient) require a prescription; eyedoc2020.blogspot.com
2. DIET/Life: Omega 3’s in Wild Salmon, Fish/cod liver Oils,
foods (2000-4000 mg): medical
grade works best (i.e., PRN 2x/day) Blink often during day. Dry eye symptoms worsen
if blink less. AVOID ceiling fan and direct
AC while sleeping at night, or wear a sleep mask. Recommend Moisture Chamber Glasses: Panoptx, Tranquileyes; Personal Humidifier. Wear wrap-around sunglasses
while in the wind/sun). Drink minimum: 8 glasses (64oz) of filtered/spring
water/day. Avoid intake of reverse osmosis or distilled water due to high
acidity/low mineral content; [Recommended
though no randomized studies have proven benefit yet: anti-inflammatory diet (consider Organic, Mediterranean/Paleo
Gluten free diet); read: Grain Brain, Good Calories Bad Calories; Use curcumin/turmeric (anti-angiogenic) as
food spices. Severe dry eyes: take
160 mg/day GLA rom black currant seed oil; drink 2 glasses of coconut water
daily.TELL MD if have dry mouth &/or arthritis/joint
aches: may need Sjogren’s Test.
foods (2000-4000 mg): medical
grade works best (i.e., PRN 2x/day) Blink often during day. Dry eye symptoms worsen
if blink less. AVOID ceiling fan and direct
AC while sleeping at night, or wear a sleep mask. Recommend Moisture Chamber Glasses: Panoptx, Tranquileyes; Personal Humidifier. Wear wrap-around sunglasses
while in the wind/sun). Drink minimum: 8 glasses (64oz) of filtered/spring
water/day. Avoid intake of reverse osmosis or distilled water due to high
acidity/low mineral content; [Recommended
though no randomized studies have proven benefit yet: anti-inflammatory diet (consider Organic, Mediterranean/Paleo
Gluten free diet); read: Grain Brain, Good Calories Bad Calories; Use curcumin/turmeric (anti-angiogenic) as
food spices. Severe dry eyes: take
160 mg/day GLA rom black currant seed oil; drink 2 glasses of coconut water
daily.TELL MD if have dry mouth &/or arthritis/joint
aches: may need Sjogren’s Test.
1. Lid
Hygiene, Lid Massage, Blinking Exercises (2-3x/day
to prevent symptoms from worsening or returning): see blog
Hygiene, Lid Massage, Blinking Exercises (2-3x/day
to prevent symptoms from worsening or returning): see blog
(1) Wash face with hot/warm water (as hot as eyes can stand it without
burning skin); 2-3x/d to keep bacteria & Demodex away
burning skin); 2-3x/d to keep bacteria & Demodex away
(2) Apply Warm
Compresses 3-15min 2x/d: heat is the only way
to open up MG Orifice naturally.
Compresses 3-15min 2x/d: heat is the only way
to open up MG Orifice naturally.
(3) Tea Tree Oil (TTO): dilute TTO with water to 50% or use CLIRADEX or
Ocusoft HypoChlor (over the counter) or Avenova
daily, if
TTO burns. Use daily x 2 wks then every other day x
2wks or till symptoms resolve: Close eyes & wipe base of eyelashes; allow
to air dry 1 minute, wash off before opening eyes; if severe burning, dilute in
water, though goal is to use 50% TTO. Burning, itching, redness with TTO can
last few days: usually due to death of Demodex mite; decrease or stop if have
allergy or worse symptoms. TTO
shampoo in warm water:1 part in 50 for eyebrows, lashes 1x/wk recommended if no
improvement with just TTO.
Ocusoft HypoChlor (over the counter) or Avenova
daily, if
TTO burns. Use daily x 2 wks then every other day x
2wks or till symptoms resolve: Close eyes & wipe base of eyelashes; allow
to air dry 1 minute, wash off before opening eyes; if severe burning, dilute in
water, though goal is to use 50% TTO. Burning, itching, redness with TTO can
last few days: usually due to death of Demodex mite; decrease or stop if have
allergy or worse symptoms. TTO
shampoo in warm water:1 part in 50 for eyebrows, lashes 1x/wk recommended if no
improvement with just TTO.
(4) Maintenance: Use Diluted (50%) baby shampoo or Ocusoft Foam daily if not
using TTO or Avenova; may cause skin dryness
using TTO or Avenova; may cause skin dryness
(5) If no
improvement or immediate improvement needed: use ¼ inch Erythromycin,
Bacitracin, Neo-Poly-Dexa or Tobradex ointment before bed on eyelashes (ok
if it gets into eye; use ointment inside eyelid if you have an early
stye/chalazion),
improvement or immediate improvement needed: use ¼ inch Erythromycin,
Bacitracin, Neo-Poly-Dexa or Tobradex ointment before bed on eyelashes (ok
if it gets into eye; use ointment inside eyelid if you have an early
stye/chalazion),
(6) Or AzaSite 2x/d: works in some patients: studies are drug
sponsored: waiting for unbiased publications
sponsored: waiting for unbiased publications
Step Ladder Approach to Chronic Eye Itching:
Allergy Treatments
Sandra Lora Cremers, MD, FACS: Chronic Eye Itching:
Allergy Treatments
Allergy Treatments
START with STEPS
1, 2 & 3 each day especially if symptoms return. My goal is to
arm you with the tools you need when you need them and to teach you
when to move to the next tier.
1, 2 & 3 each day especially if symptoms return. My goal is to
arm you with the tools you need when you need them and to teach you
when to move to the next tier.
Multi-Tiered,
Step Ladder Approach to Allergy TREATMENTS: All the Tools available
Step Ladder Approach to Allergy TREATMENTS: All the Tools available
13. Anti-inflammatory pills: low dose steroid or high dose if severe
12. Autologous serum: available in our office
11.
Moisture Chamber Glasses: Panoptx,
Tranquileyes
Moisture Chamber Glasses: Panoptx,
Tranquileyes
10. Conjunctivochalasis: folding of conjunctiva (clear
covering of white part of eye) due to chronic inflammation (other risks:
contact lens use, older age, autoimmune thyroid disease) if present, reconstruction of fornix may be needed for relief;
covering of white part of eye) due to chronic inflammation (other risks:
contact lens use, older age, autoimmune thyroid disease) if present, reconstruction of fornix may be needed for relief;
9. Punctal Plugs (Temporary
or Permanent); Probe & Irrigation of
or Permanent); Probe & Irrigation of
Ducts
may be needed; used if itching due to dry eyes
may be needed; used if itching due to dry eyes
8. Systemic anti-allergy pills: in conjunction with your PCP: may
need if also have systemic allergic symptoms.
7. If itching is due to Rosacea, we will prescribe: Doxycycline 20mg pill/d:
Avoid Sun; low
risk of diarrhea; don’t use if pregnant; If
itching is due to
risk of diarrhea; don’t use if pregnant; If
itching is due to
baseline significant dryness, we’ll prescribe: Cyclosporine Restasis
drops: works well; may take weeks to feel benefit
6. Steroid drops: If
severe allergy, we recommend a short term low dose
severe allergy, we recommend a short term low dose
steroid (i.e., Lotemax drops or gel; FML ointment). Use
steroids sparingly as chronic
steroids sparingly as chronic
use
causes risks: high eye pressure/glaucoma, cataract
causes risks: high eye pressure/glaucoma, cataract
5. Allergy Screening test: Takes about 5 minutes to assess
60 common
60 common
allergens: If positive, you will know which allergens to
avoid & can
avoid & can
consider desensitization &/or discuss
with an allergist
with an allergist
4. Rx: If significant itching present, we will prescribe an
anti-itch drop —
anti-itch drop —
Lastacaft
and Pataday are 1x per day; Bepreve is 2x/day; use for 2 weeks
and Pataday are 1x per day; Bepreve is 2x/day; use for 2 weeks
before
allergy season to stabilize cells that cause allergy
allergy season to stabilize cells that cause allergy
3. COLD Artificial tears: put in refrigerator: BEST TO USE Non-preserved but they can costmore (i.e.,
Refresh; Oasis tears alternating with Retaine 4-8x/day depending on severity
works well). Thicker drops (Soothe, Refresh Dry Eye Therapy) great for severe
dryness & itching, though may blur vision; Preserved tears: use no more than 4x per day to avoid allergic reaction
to preservative; eyedoc2020.blogspot.com www.youtube.com à type in search Visionary Eye
Doctors for patient education videos
Refresh; Oasis tears alternating with Retaine 4-8x/day depending on severity
works well). Thicker drops (Soothe, Refresh Dry Eye Therapy) great for severe
dryness & itching, though may blur vision; Preserved tears: use no more than 4x per day to avoid allergic reaction
to preservative; eyedoc2020.blogspot.com www.youtube.com à type in search Visionary Eye
Doctors for patient education videos
2.
DIET/Life: Goal is to minimize inflammation inside your body: Omega 3’s in Wild
Salmon, Fish Oils, Cod Liver Oil: medical
grade works best (i.e., PRN 2x/day)
DIET/Life: Goal is to minimize inflammation inside your body: Omega 3’s in Wild
Salmon, Fish Oils, Cod Liver Oil: medical
grade works best (i.e., PRN 2x/day)
Blink often while working on
the computer. Dry eye & allergy symptoms worsen if you blink less. Avoid
ceiling fan, direct AC while sleeping at night; or wear a sleep mask. Wear
wrap-around sunglasses while in the
wind and sun). Personal Humidifier may
help also. Drink at least 8
glasses (64oz) of filtered or spring water. Avoid intake of reverse osmosis or
distilled water due to high acidity & low mineral content; [Recommended, though no randomized studies have
proven benefit to date, anti-inflammatory
diet (i.e., consider Organic, Paleo Gluten free diet); read books: Grain
Brain, Good Calories Bad Calories, Inflammation Nation. Keep doors &
windows to outside shut: in spring/summer: use AC when possible (pollen levels
increased in open windows/attic fans); Do not hang laundry outside to dry:
change clothes, shampoo & shower after being outside when pollen counts are
night; Stay indoors during windy weather. Do not mow lawn; Do not rub eyes: if
you must rub eyes, wash them first to remove pollen; Keep pets out of bedroom
& off bed; Remove all down & feather products from bed, pillows,
comforters; Use allergy-free pillow case.
the computer. Dry eye & allergy symptoms worsen if you blink less. Avoid
ceiling fan, direct AC while sleeping at night; or wear a sleep mask. Wear
wrap-around sunglasses while in the
wind and sun). Personal Humidifier may
help also. Drink at least 8
glasses (64oz) of filtered or spring water. Avoid intake of reverse osmosis or
distilled water due to high acidity & low mineral content; [Recommended, though no randomized studies have
proven benefit to date, anti-inflammatory
diet (i.e., consider Organic, Paleo Gluten free diet); read books: Grain
Brain, Good Calories Bad Calories, Inflammation Nation. Keep doors &
windows to outside shut: in spring/summer: use AC when possible (pollen levels
increased in open windows/attic fans); Do not hang laundry outside to dry:
change clothes, shampoo & shower after being outside when pollen counts are
night; Stay indoors during windy weather. Do not mow lawn; Do not rub eyes: if
you must rub eyes, wash them first to remove pollen; Keep pets out of bedroom
& off bed; Remove all down & feather products from bed, pillows,
comforters; Use allergy-free pillow case.
1.
Lid Hygiene: helps remove allergens that get caught in the lashes & base of
lashes (a daily must in order to improve
and prevent symptoms from returning):
Lid Hygiene: helps remove allergens that get caught in the lashes & base of
lashes (a daily must in order to improve
and prevent symptoms from returning):
(1) Wash face with, hot/warm
water (as hot as eyes can stand it without burning skin);
water (as hot as eyes can stand it without burning skin);
(2) Apply Warm Compresses 3-5min 2x/d;
(3)
Use Tea Tree Oil (TTO), Cliradex or Avenova daily
[may also use TTO shampoo (TTO shampoo in warm water: 1 part in 50) 1x/wk &
50% TTO Daily]: You can cut a piece of Cliradex into pieces with clean scissors
and place in Ziploc bag (so it does not dry out); Close eyes & wipe base of
eyelashes; allow to air dry 1 minute, wash off before opening eyes; if severe
burning, dilute in water. Burning, itching, redness with TTO can last few days:
can be allergy or death of demodex mite; decrease or stop if any of above Sx
intolerable & let us know.
Use Tea Tree Oil (TTO), Cliradex or Avenova daily
[may also use TTO shampoo (TTO shampoo in warm water: 1 part in 50) 1x/wk &
50% TTO Daily]: You can cut a piece of Cliradex into pieces with clean scissors
and place in Ziploc bag (so it does not dry out); Close eyes & wipe base of
eyelashes; allow to air dry 1 minute, wash off before opening eyes; if severe
burning, dilute in water. Burning, itching, redness with TTO can last few days:
can be allergy or death of demodex mite; decrease or stop if any of above Sx
intolerable & let us know.
(4)
Diluted (50%) baby shampoo or Ocusoft
Foam: daily if not using TTO or Avenova.
Diluted (50%) baby shampoo or Ocusoft
Foam: daily if not using TTO or Avenova.
(5)
If no improvement or if immediate improvement needed: will
prescribe steroid drops (Lotemax, FML) or ointment (Lotemax, FML, Erythromycin,
Bacitracin, Tobradex) at bedtime to apply on lid base.
If no improvement or if immediate improvement needed: will
prescribe steroid drops (Lotemax, FML) or ointment (Lotemax, FML, Erythromycin,
Bacitracin, Tobradex) at bedtime to apply on lid base.
.