Instruction on cleaning your eyes: A Tiered, Step Ladder Approach to treating eye discomfort

Any discomfort related to your eyes can be very frustrating and at times scary. I am here to help you feel better.

Below is my Tiered, Step ladder Approach. The most important step is step 1. That is the building block which prevents symptoms from worsening. Be sure to continue at least the warm washing of the face every day and night no matter what.

Hopefully with practice, you will learn what your eyes and eyelid skin area likes and does not and we will get your eyes back to feeling normal again.

Step by step instructions are located below at ***

Integrated Dry Eye, Rosacea, Blepharitis Treatments
START at STEP 1 & 2 which should be continued each day especially if symptoms return. Sometimes steps are skipped to try to help improve your symptoms faster. If you do not improve with the early steps, you may have scar tissue in the glands (fibrotic changes can cause obstructive Meibomian Gland Dysfunction [MGD] despite constant warm compresses and lid massage) and may need to have one of the options in step 8 to feel relief.
Multi Tier, Step Ladder Approach to DRY EYE TREATMENTS:         
    19. Lacrimal Gland Stimulation (in testing phase)
                                                      18. Not FDA approved yet: Mucin Secretagogue (rebamipide);   Lacritin;1% DHEA
17. Lid Tarsorrhaphy &/or Conjunctivalchalasis surgery
        16. Cord Blood Serum   
      15.  Anti-inflammatory pills (low dose steroid if severe dryness)       14. PROSE or JUPITOR Scleral lenses:
  13. 3% Testosterone Cream (off label use; not FDA approved)     
          12. Amniotic Membrane Transplant: available at VO
        11. Prokera Contact Lens: available at VO
     10. Autologous serum: available in our office (VO)
  9. Moisture Chamber Glasses: Panoptx, Tranquileyes: online

8. Innovations in Dry Eye: Out of pocket investment in eyelid & eye health. Works well in many patients. 
Intense Pulsed Light (IPL): 4-6 treatments needed 
LipiFlow: FDA approved; usually lasts 10mo
Intraductal Probing (+/- Intraductal steroid)

                        7. Punctal Plugs (Temporary or Permanent); Probe & Irrigation of Ducts may be needed
                     6. Steroid drop: short term low dose; risks of chronic use: high eye pressure/glaucoma, cataract
                 5. Cyclosporine Restasis drops: works well; may take weeks to feel benefit
              4. Doxycycline 20mg pill: Avoid Sun; low risk of diarrhea; don’t use if pregnant
         3. Artificial tears: Non-preserved: cost more (i.e., Refresh; Oasis tears alternating
with Retaine 4-8x/day depending on severity works well) (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. Anti-allergy drops needed if significant itchiness (i.e., Lastacaft, Pataday) see

    2. DIET/Life: Omega 3’s in Wild Salmon, Fish Oils, Cod Liver Oil: medical grade works best (i.e., PRN 2x/day) [Blink plenty of times a day especially while working on the computer. Dry eye 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). 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.  Consider drinking 2 glasses of coconut water a day; Recommended though no randomized studies have proven benefit to date: anti inflammatory diet (i.e., consider Organic, Paleo Gluten free diet; see Inflammation Nation; Use Cinnamon, curcumin/turmeric (anti-angiogenic) as spices on foods. Severe dry eyes: take 160 mg/day GLA from black currant seed oil.]

1. Lid Hygiene (crucial for treatment): (1)Warm Compresses 10min 2x/d, (2) Baby Shampoo (diluted 50%) Scrubs (or Ocusoft Foam):1-2x/day; (3)+/- Erythromycin or Tobradex ointment before bed on lashes; or AzaSite:; If no improvement, suspect DEMODEX: 1x per week: lid scrub with 50% Tea Tree Oil (TTO) & daily lid scrub with Tea Tree Oil shampoo (1 part in 50 TTO shampoo in warm water). Cliradex also works very well. Burning, itching, redness can occur with TTO: can be allergy or death of demodex mite; decrease frequency; stop any of above if intolerable & let us know.

Step Ladder Approach to Treating: Tearing, Burning, Itching, Foreign Body Sensation [Blepharitis, Meibomian Gland Dysfunction (MGD), Dry Eye Syndrome, Conjunctivitis]
You should not feel eye discomfort when you blink or move your eyes. Constant foreign body sensation, burning, irritation, tearing is NOT normal. If you have such symptoms, we know how to help. There is hope! Patience and a multi tiered approach is the best way to help your eyes feel better, fast.
During your visit, we will check under the microscope (Slit Lamp) for:  Viral Conjunctivitis (usually very itchy; history of a cold or around someone with “Pink Eye”? We check for a pre-auricular lymph node; Antibiotics do not help viruses); Bacterial Conjunctivitis (profuse yellow or green discharge; treated with antibiotics); Allergic Conjunctivitis (follicles seen; can be due to pollen, contact lenses (CL) use, pets, using new detergents, fingernail polish, makeup); Giant Papillary Conjunctivitis (GPC) (papillae seen in a CL wearer); Blepharitis (crusting on lids); Meibomian Gland Dysfunction (clogged/scarred glands); Dry Eye Syndrome (dry tear film &/or conjunctival &/or corneal changes); Ocular Rosacea. Tell us if you have these conditions and/or arthritis & dry mouth symptoms: Sjogren’s syndrome tests may help: antinuclear antibodies (ANA), SS-A and SS-B antibodies (Sjögren’s syndrome A and B antibodies; anti Ro, anti La), RF (rheumatoid factor), TFTs (thyroid function tests & thyroid antibodies), CBC (complete blood count to look for anemia), ESR (sedimentation rate), CRP (C-reactive protein).

STEPS for TREATMENT: We start with as natural remedies as possible.
1. Lid Hygiene

1)Warm Compresses: 

a. place a hot towel on your eyelid/lash margin [this is where your meibomian glands are located] (you can use hot water, hot tea bags, rice in a tied off sock in the microwave): make it as hot as you can stand it without burning or damaging skin. 

b. put it on eye for as close to 10 minutes in the morning, 10 minutes at night: if you do not have time, even a couple of minutes 2-3 time a day will help keep your glands open. You can start with less, but the longer, the better and sometimes no improvement is seen till it’s been 10 minutes. Studies have been done to show a high temperature over at least 7 minutes makes the eyelid gland (the meibomian gland or pour) open up and express its lipid material.

c. After you have completed the hot compress, use diluted Baby Shampoo Scrubs (50% water/50% shampoo) or Ocusoft Foam or other eye cleaner to wipe at the base of the eyelash (Q tips are best or tip of hot wet towel: just be careful to not poke your eye and scratch your cornea which is very rare). Do these scrubs initially 2x/day if severe symptoms, 1x/day if mind; 2-3x/week if symptoms start returning after things have improved. Avoid drying out skin around eyelid.

d. If prescribed, use Erythromycin or Tobradex ointment at night. This ointment blurs vision as it is thick, so that is why we prescribe it at night. On a clean finger, put about 1/4 inch on your eyelids. It is ok if it goes into your eye, but try to gently massage it into the base of the eyelashes as best you can being careful not to poke into your eyeball. You can place a towel on your pillow. Go to sleep. In the morning, wash it off with hot water as above. If you tend to wake up at night or are a risk of falling if vision is blurred, you can apply the ointment to only one eye on alternating nights. 

e. If you have been told you might have Demodex inside the eyelash follicle (do not despair, see my posting on Demodex to see how it is part of our skin’s normal flora in most everyone).
Use the following, though, to get those critters out of your eyelash follicles! We do not want them there. There are many ways to get rid of them:

(1) Cliradex is fastest, easiest (I have no stock in the company or any of the companies listed in this blog). 
(2) Lid scrub with 50% Tea Tree Oil (TTO) & daily lid scrub with Tea Tree Oil shampoo (1 part in 50 TTO shampoo in warm water). 
(3) There may be other treatments out there but these are the best known. If you know of others that have a proven record, please let me know.
Burning, itching, redness can occur with TTO: can be allergy or death of demodex mite; decrease frequency; stop any of above if intolerable & let us know.

Remember Step 1 (Lid Hygiene) is key. Continue periodically even if your eyes feel better. The heat opens the meibomian glands to help its Lipid come out to help your tears stick on your eye longer. If you get tired of step 1, look at step 8 IPL, LF, IDP;

2. Diet & Environmental Modifications: Omega 3’s [Fish Oils, Cod Liver Oil (be aware of mercury level & be sure not rancid)]. Medical grade oils are best like PRN. Increase intake of Walnuts, wild Salmon, Tuna, Mackerel, Sardines, Eggs from omega 3 fed chickens, ground flaxseed; flaxseed, soybean or palm oil. Avoid sun exposure. Stop smoking. Eat green leafy veggies. Check with your Primary MD to eliminate offending systemic medications if possible.
3. We may measure your tear osmolarity to objectively quantify the inflammation in the tear film.
4.Artificial Tears: Non-preserved (NPAT) are best but more expensive. If symptoms include itchiness, we recommend putting in refrigerator to keep cool and help with itchiness. If significant allergic component present, we’ll prescribe an anti-allergy drop.
4. Doxycycline 20mg helps MGD; also helps in rosacea, ocular rosacea: avoid sun even with sunblock.
5, 6. If symptoms severe, and #1 is being done, Restasis may be added early on. It can take 6 wks to work effectively so a low dose steroid drop (Lotemax) is added for 2 weeks to help as Restasis works decreasing inflammatory factors (knowing long term steroid use can increase risk eye pressure, glaucoma, cataract).
7. When ocular inflammation is controlled with above steps, we might use Punctal Plugs (temporary or permanent) to keep tears in eye longer. This is a short in house procedure with usually minimal discomfort.
8. Intense Pulsed Light (IPL), LipiFlow (LF), Intraductal Probing (IDP) (+/-intraductal steroid): help relieve discomfort, especially if warm compresses too time consuming. Not covered by insurance. Initial studies show good results in opening Meibomian Glands and relieving dry eyes.
9. Moisture Chamber Glasses: these can be purchased online: helps in moderate to severe dry eye.
10. Autologous Serum helps patients if other treatments have failed.
11-15. Prokera Contact Lens; Amniotic Membrane Transplant, 3% Testosterone Cream, PROSE or JUPITOR Scleral lenses,  Anti-inflammatory pills: needed in patients with severe dry eye
17, 18. Lid Tarsorrhaphy; needed in patients with severe dry eye
New therapies that are not FDA approved yet but show promise: 3% testosterone cream; Cord Blood Serum; waiting further approval: Mucin Secretagogue(rebamipide); Lacritin;1% DHEA;    

19. Still in experimental phase: Lacrimal Gland Stimulator

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