Dry Eye And Eyelashes – Making The Connection

To understand the connection between dry eye and eyelashes, it is necessary to investigate past the ocular surface.

Inflammation – A Common Connection

Inflammation can be the root cause of many health problems, ranging from arthritis to heart disease. When it comes to the eyes, inflammation can result in an instability of the tear film, this, in turn, can lead to dry eye. Ocular surface inflammation can be the culprit in a host of associated concerns, however,trichiasis, acquired distachiasis, local madarosis, and poliosis, are some of the noteworthyeyelash related problems. Each of the above conditions has a connection to dry eye.

Trichiasis

Trichiasis, a common condition within this health area, often present itself with the sensation of a foreign body. The cilia raising itself from its normal anatomical position and being misdirected causes this eyelash abnormality. Tissue changes, often age-related, along with ocular surface disease, result in inflammation, margin changes within the eye, and ultimately lead to the condition known as trichiasis.

An abnormal position of the eyelashes can also contribute to ocular irritation. In addition, corneal thinning, scarring, decreased vision, corneal pannus, and in rare cases, corneal perforation can also be caused by male-positioned eyelashes.

When trichiasis is at a mild level, the lid and gland health can be successfully treated with artificial tears, omega supplements and MiBoFloThermoFlo. However, when the level of trichiasis is classified as severe, anti-inflammatory therapy, Epilation, or at times surgery, is required to restore the eye health.

Acquired Distachiasis

This condition, caused by the meibomian glands, presents itself in the form of flimsy or stunted eyelashes. The differentiation between the meibomian glands and lash follicles and a normal pilosebaciousunit causes such a condition to present itself. Chronic inflammation can often be a significant factor. 3,4

Dry eye has a direct connection to tear film evaporation. It is the sebaceousglands, which are crucial in preventing this evaporation. Both the quantity and size of meibomian glands can be negatively affected by chronic irritation, inflammation and extended use of contact lenses.

Ocular cicatricial pemphigoid, chemical injury, trauma, eyelid margin and Stevens-Johnson syndrome, are all potential causes.

Epilation is often the easiest method to treat such abnormal eyelashes, coupled with addressing the underlying reason for the condition. In rare cases, surgery is necessary to successfully treat the condition.

Local Madarosis

Coming from the Greek expression, ‘madro’, carrying the meaning of falling off, madarosis is known within the clinical world as an absence of eyelashes within a certain area. Atopic keratoconjunctivitis, chronic blepharitis, and surgery are some of the causes of local madarosis. Destructive tissue conditions can also play a role, such include systemic lupus, icthyosis, neoplasms, trauma, alopecia, drug abuse, radiation, chemotherapy, toxicity, and medications.

Determining whether the loss of hair is localized to the eyelids, is a crucial factor when hair or lash loss is being evaluated. This leads to a higher degree of accuracy in the diagnosis of underlying pathology.

Ocular Poliosis

Premature whitening of the eyelashes, within a localized area, identifies this cilia abnormality. Chronic anterior blepharitis, sympathetic ophthalmitis and idiopathic uveitis are the causes of ocular poliosis.

Using Lipid-Based Eye Drops To Treat Dry Eye

Treating dry eye has emerged as a significant area for the practice of optometry. Many optometrists are experiencing growth in this area of their practices. There will be an increase in patients complaining about uncomfortable, irritated and dry eyes as the Baby Boom generation continues to age and using digital devices, which is associated with the reduced blink rate, keeps increasing.

An estimated 40 million individuals in the U.S. suffer currently from dry eye. How prevalent dry eye is reported to be varies based on the specific parameters used for gathering data. It ranges from 33 percent in Japan and Taiwan to 25 percent in Canada and 14 percent of U.S. patients over the age of 48.

There are several different aspects that relate to the dry eye that are not well understood still, and it can be challenging to manage the problem. Nearly all, or a majority of dry eye symptomatic forms have some form of the evaporative component, which probably contributes to the loss of aqueous tears via a defective lipid layer. In turn, this may lead to further damage, ocular surface inflammation and increased osmolarity.

Meibum is secreted by the meibomian glands inside the eyelids. This is a liquid complex forming a protective lipid layer of the tear film. This lipid layer helps to prevent drying and aqueous tear evaporation. Meibomian gland dysfunction (MGD) results in a lipid deficiency and is the most common cause of symptoms that dry eye disease is associated with.

Why The Lipid Layer Is So Important

The lipid layer function has been extensively studied recently. Although some think that it is just a protective layer that helps to prevent the evaporation of aqueous tears, recent studies have shown that the lipid layer is actually more complex than that.

It keeps the tear film intact, which allows it to spread over the ocular surface rather than collapsing. That also helps to prevent the tears from flowing over the eye and inside the punctua. If this layer isn’t there, the tear film is unable to properly spread and even worse will be prone to evaporation.

Traditionally treating meibomian gland dysfunction has been through using artificial tears, lid scrubs, and warm compresses. Adding some kind of liquid to tears usually provides some initial relief from discomfort caused by dry eye. However, patients frequently complain that this relief is very short lived. There are numerous eye drops that contain lipids that are available in the marketplace that have been underutilized in the past.

An artificial tear containing lipids can be used to help with reforming the tear film’s protective layer and provide patients more relief from aqueous tear evaporation and the overall tear film collapsing. One study showed lipid-based tears to be as acceptable, effective and safe as aqueous-based artificial tears.

As a better understanding of the tear layers is acquired, it does appear to make sense to add liquid eye drops to the tears to help recreate the spreading and the protective function of tears that is provided by the lipid layer. That might be more helpful than just using artificial tears to increase the aqueous layer.

Imaging The Eye’s Lipid Layer

We have recently measured the thickness of the lipid layer and using interference techniques to observe the lipid layer. We use a stroboscopic microscope that Ewen King-Smith developed and are able to measure the lipid layer thickness and also view videos and use a color scale to visualize the thickness.

We have taken images of a 62-year-old man’s lipid layer. The patient had a moderate level of MGD along with visual fluctuations. In the past, he had undergone comprehensive treatment, including LipiFlow (TearScience treatment) and lid margin debridement. He currently uses a lipid-based eye drop and Restasis (Allergan, cyclosporine) one time per day or less. Our instrumentation was used to show what effects the eye drops had on the man’s lipid layer. The first image showed his lipid layer prior to using any drops.

Lipid-based artificial tears were used that were made by four different manufacturers. The lipid thickness was measured 15 minutes after the drops had been put into the eyes. The lipid layer was still significantly thicker compared to before using the eye drops. Photography and mathematical analysis, both showed result, lipid layer enhancement results.

As the lipid layer starts to thicken, the amount of color that can be seen in the interferometry photographs continues to increase. When the color scale is referenced on the right hand side of every photo, you are able to tell that the tears that have more colors also have thicker lipid layers.

The gray color indicates a lipid layer than is as much as 80 nm. This can be seen most clearly in the image that was taken prior to when the lipid-based eye drop was put in. Brown has a thickness of about 130 nm, and blue starts becoming apparent whenever the lipid layer thickness reaches approximately 230 nm.

It is evident that striking improvements have been made to the lipid layer. In the photographs, positive changes in the tear film’s lipid layer are easy to see whenever lipid-containing drops are utilized. There are numerous OTC lipid-containing eye drops that are available. So why are we not recommending the lipid-base tears?

There are of course many other aspects that need to be considered when we treat our MGD patients as well as those who have other kinds of dry eye. Our patients might benefit from increasing their hydration through drinking the additional non-dehydrating liquid, eating a diet high in omega-3 fatty acids, blinking more consistently and fully (which can be taught), and avoiding low humidity.

If the above measures do not produce the results that are desired, anti-inflammatory eye drops can be prescribed, such as antibiotic-steroid combinations or steroids in order to treat cyclosporine or blepharitis-related information as well as oral antibiotics like low-dose doxycycline along with using hot compresses on a continuous basis. A comprehensive treatment is a need and must be adhered to.

A Thorough Examination

A patient’s life quality can be significantly improved by early identification and efficient management of eyelash conditions. The reduction of inflammation, the improvement in the quality of tear film and, in turn, a considerable decrease in dry eye occurrences, are largely dependent on successful patient treatment.

References

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King-Smith, PE, Reuter KS, Begley CG, Braun RJ. Tear Film and Lipid Layer Structure in Relation to Four Phases of the Blink Cycle. Poster presented at The Association for Research in Vision and Ophthalmology; 2014 May 4-8; Orlando, FL.

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