Dry Eye Disease

How do you know if you have dry eye disease?

Here are some of the most common symptoms of Dry Eye disease as reported by patients at our Seattle clinic:
~A gritty feeling in the eyes upon awakening or after lots of computer time
~A sensation of having something in your eye, often with dryness, irritation, or discomfort
~Excessive tearing. Oddly enough, a tendency to over-produce tears while reading or in windy conditions is a common symptom of dry eye disease.
~Inability to wear contact lenses due to discomfort or dryness
~Vision that is intermittently blurry or vision that changes significantly after blinks
~Red eyes that sting late in the day. This symptom is often associated with computer use.

Dry Eyes can feel like the sands of the Sahara desert

When your eyes are dry and irritated, sometimes putting in a drop of artificial tears is just not enough.

Dry Eye Disease (DED) is a common condition. It’s also a chronic condition. This combination means that lots of people have this problem, and many of them don’t know it. These people know their eyes feel uncomfortable late in the day (or all day).  Yet most of these people don’t know they have dry eye – nor do they know how to treat it properly.

The eye doctors at Cannon EyeCare are experienced optometrists who have lots of tools at their disposal for managing dry eye disease. You can learn more about our dry eye treatment protocol later in this article. It’s worth noting that related terms like ocular surface disease, superficial keratitis, and meibomian gland disease are also sometimes used as if they are synonymous with ‘Dry Eye Disease,’ but these terms are all describing different slices of the same monster. Dry Eye Disease is a good overall term that is worth discussing.

As a general rule in medicine, chronic conditions are likely to get worse if left untreated. Dry Eye is no exception to this rule. In most cases, the dry eye patient worsens over time if we are not actively working to keep it controlled. Our goal at Cannon EyeCare is to get dry eye disease under control by helping the eyes heal themselves. Our eye doctors will strive to reverse the downward spiral of dry eye disease – so it’s no longer causing our patients to suffer. Then we slowly back off the treatments one at a time. Long-term we want your treatments to be affordable and easy.

The optometrists at Cannon EyeCare want to get patients off of the slow, insidious decline into chronic dry eye disease as soon as possible. We want to give your body a fighting chance to heal itself. We aim to curb the inflammation and/or irritation that might be exacerbating your dry eye symptoms so that we can restore homeostasis. Long-term, expensive medical (drug) therapy is our last resort. Chronic pharmaceutical drug therapy is only utilized in our practice when our initial attempts to restore function to the eye have not sufficiently controlled the symptoms of dry eye.

Some people may wonder, are there really dry eyes in Seattle, Washington? We are known for our rainy climate, after all. Clearly, that must mean we have less dry eye than arid places like New Mexico and Arizona, right? It turns out there are many important causative factors that determine dry eye risk, and they don’t all revolve around the weather. Things like climate, temperature, and relative humidity do play a role, yet tens of thousands of patients in Washington have dry eye. Most of these cases are undiagnosed.  This problem is more prevalent in arid climates though.

Dry Eye causes and treatment:

There are a number of different causative factors for dry eye disease. Our goal in managing dry eye is to restore function to the tissues that are affected. We want to get to the root of the problem, restoring function as we treat it. We do not just throw artificial tears on a hot, irritated eye like some dry eye treatment centers in Seattle. Our approach is multi-faceted because ocular surface diseases such as dry eye syndrome are complex, with many variables at play.

Some of the major causes of dry eye are dehydration, incomplete blinks/ sleeping with lids slightly open, and clogged oil glands in the lids (aka Meibomian Glands). Other factors can play a role for sure, but the major causes we see in clinic are:

1. Not having enough tears (often from dehydration)
2. Having poor quality tears (typically from clogged meibomian glands), and
3. Exposure, wherein the ocular surfaces are desiccating as a result of incomplete blinks, infrequent blinks (very common in computer users), and/or sleeping with the eyes open.

There have been tens of millions of dollars spent on research and development of dry eye devices in recent years. One of the big players in this arena is LipiFlow. This company has devised a tool that scans the health of your tears and the meibomian glands in your lids. They call their imaging device LipiScan. This imaging info can then inform doctors about which patients are a good candidate for treatment with LipiFlow, which is a rather expensive in-office lid treatment. The device costs tens of thousands of dollars, and each patient treated uses up hundreds of dollars of single-use equipment. As a result, the treatment cost for Lipiflow is typically $1100 or more per treatment. Many Seattle-metro clinics are charging $1500 to have both eyes treated once with Lipiflow.

Cannon EyeCare in Seattle does not have Lipiflow, nor do we intend to purchase one. We address the same issues (lid health and meibomian gland function) using a warm compress and lid massage protocol, as outlined below. Our goal is to restore function with as little cost and fuss as possible. On a related note, we have brought new technology called NuLids into our practice. NuLids is a great way to kickstart the healing and is best done in conjunction with the warm compress/ lid massage treatment you’ll read about next. One in-office treatment with NuLids is quite a bit more affordable at $50.

As of summer 2023, we are offering thermal expression of the oil glands in our Pike Place office.

Doctor Cannon’s Two-Step Method to Unclog the Oil Glands in your Lids: Warm Compress & Lid Massage

Background info: Many people don’t realize there are oil glands in their eyelids, but it turns out there are a bunch of them. We have about 50 per eye, and these glands come to the edge of the lids in a radial pattern, much like spokes in a wheel. The glands should be freely flowing with an olive oil-like substance.

FYI, in medical lingo, these are called meibomian glands, and the problem we are treating is called meibomian gland dysfunction (MGD).

If your doctor has prescribed this treatment, then some or all of your glands are clogged with stagnant, solid oil, kind of like butter or Crisco. As a result, there is not enough healthy oil in your tears. This lack of oil in the tears makes them evaporate rapidly.  These poor-quality tears contribute to symptoms like dry eye, irritation, itching, and/or intermittently blurry vision that improves after you blink. Sometimes clogged glands in the lid can even become infected, causing a stye, also known as a hordeolum. The hot compress and lid massage treatment described below is also utlized to treat styes.

Many patients ask why their glands are clogged, which is a good question. It turns out that the eyelids are not quite 98.6 degrees F like your body’s core. This cooler temperature allows the oil to solidify. Combine this factor with the fact that most patients don’t blink thoroughly enough to pump oil out of the glands, and you get clogging in a lot of eyelids.

Now let’s discuss the treatment. Mark J. Cannon, OD of Cannon EyeCare in Seattle created this simple treatment to help his patients feel and see better by optimizing their ocular health.

Step 1: Hot Compress This technique will heat the lids to melt the oil in the glands. Grab a clean, dry washcloth and fold it once so that you have a rectangle in your hands. Then soak it with hot tap water, like hot shower water – in fact, a lot of patients do the treatment in the shower. Do not use a kettle or microwave to heat the cloth due to the risk of thermal burns. The water needs to be hot but not scalding!

Hold the compress on both eyes for a minute or two until it starts to cool off, then heat it up again and repeat. Heat it again and repeat the compress several times until you get at least five minutes of heat on the eyes. If you have time to do ten minutes, that is even better.

As a side note, some patients prefer to use a therapeutic eye mask like the Bruder Moist Heat Eye Compress. The mask stays hot enough to relax on the couch with the mask in place for up to ten minutes. Due to the fact that a damp washcloth with hot water will transfer heat more quickly, we generally ask patients to re-heat the Bruder Mask briefly after five minutes to get a full ten minutes of heat treatment.

Step 2: Lid Massage You won’t get much benefit from the warm compress alone, as the oil would end up staying put, cooling off and re-solidifying. Step two is crucially important, as it gets the (now liquefied) oil to flow. In this step, you are going to be expressing the old, stagnant oil out of the glands. Your meibomian glands open up right on the edge of the lid, near where the lash follicles are.

To get the oil flowing, you will use the tip of your index finger kind of like a rolling pin. Use a rotational movement of the wrist, with your index finger extended. Start out on the right upper lid (temporal side) with the pad of your right index finger resting about ½” (1 cm) or more above the edge of the lid, then roll down towards the pupil all the way to the edge of the lid. Again, Dr. Cannon likes the rolling pin analogy to help you conceptualize the movement. It’s also useful to think of flattening a toothpaste tube to get the contents out.

It is important to use a substantial amount of force but not enough to hurt. If you feel pain or your vision distorts, then you are pressing too hard. Do about three lid-rolls on each lid, one each on the temporal, central, and nasal sides). Always roll towards the pupil. This means when you are working on the lower lids, you should roll up to the edge of the lid.

Most patients need the treatment twice a day for about two weeks, and some are asked to continue it once a day to maintain healthy gland function. Most report a significant improvement in ocular comfort and sometimes even improved vision, but this only happens if they do their homework. If the treatment is only done for a day or two and then discontinued, the patient is rather unlikely to notice any benefit.

Other key factors for treating dry eye include maintaining adequate hydration (2+ quarts of water/day) and using appropriate artificial tears as directed by your doctor. Some patients even need prescription drops, but your optometrist or ophthalmologist will be able to determine what is best for your eyes. Getting the lids to function optimally is a key first step.

©2017 Dr. Mark J. Cannon, OD, of Cannon EyeCare in Seattle, Washington

Version 3.2021 MJC

Finally, here is some info on NuLids from NuSight Medical:

Image of the NuLids device by NuSight Medical

Image credit: NuSight Medical, used with permission

The NuLids device is an innovative, doctor-directed at-home therapy for dry eye and blepharitis.  This handheld tool can be used in office or at home to treat dry eyes, meibomian gland dysfunction (MGD), blepharitis, or Demodex mite eyelids infestation.  It’s so easy, you can (and should) do it with your eyes closed.

NuLids is kind of analogous to an electric toothbrush, but made for cleaning your eyelids.  The rotating single-use soft tip design gently cleans the lashes and exfoliates the lids while also stimulating the meibomian (oil) glands in the lids to release healthy oils into your tears. The device stimulates these glands to function better and can rejuvenate the glands, bringing them back to a healthier, more functional, and youthful state.

If dry eyes without mites or bacterial overgrowth is your main diagnosis, you’ll use a non-preserved artificial tear on the tip each time. NuSight has started shipping their NuLids device with 10ml of NuLids Revitalize Eyelid Gel, which also works quite well.

This quick, painless, and safe treatment takes 1 minute a day, and feels like a spa treatment for your eyes.  It also reduces the bacterial load on your lids by removing biofilm and crusting. This, in turn, reduces the inflammation that creates much of the irritation related to blepharitis and dry eye. If bacterial overgrowth is determined to be a part of your diagnosis, you will likely be directed to use a special antimicrobial solution or gel on the tip with each treatment.

Demodex mite infestation of the lashes can cause Demodex-related blepharitis and symptoms such as burning, itch, and permanent loss of eyelashes. If our optometrist determines that your lids have mites, you’ll use the device on the eyelids with a tea-tree solution (or gel) specially-formulated for this condition.

We offer in-office treatments to deep-clean the lids for $50 at a dry eye evaluation and management visit. The NuLids treatment and device purchase is not yet covered by insurance and is an out-of-pocket expense.  This is a great way to “Try Before You Buy” to make sure you like the product.  We have been using and recommending NuLids since 2020, and started stocking and selling them in 2023.

There is no pressure to purchase this product. That being said, Cannon EyeCare strongly encourages you to try it. If one of our doctors gave you this handout, they have determined that you will benefit from NuLids.  The cost is just $300, and this includes a training (and deep cleaning) by our optometrists.

The treatment is typically just once a day, and it takes only 30 seconds per eye to complete. Treatments can be done from home, and the device is compact and easy to travel with.

Most patients notice some improvement in their symptoms after the first treatment, others may need 3-6 weeks of daily treatments to get real improvement.  Some patients may be able to reduce treatment frequency to twice a week once a favorable result has been reached.

We look forward to seeing your progress at a brief follow-up 4-6 weeks after starting treatment with NuLids. We anticipate you having healthier lids and feeling significantly better.
Sincerely, Drs. Mark & Miranda Cannon

Should you have questions about why you need this product, please email us at PP@DrCannon.com

*Please note: NuLids pricing is accurate as of this writing June 2023

If you have questions about how to use your NuLids device properly, please contact Debbie Laux at NuSight Medical, dlaux@nusightmedical.com or cell: 203-644-3384