Ocular Surface Disease
Infection! Oil! Inflammation! Dryness! These are easily the most common eye problems that make eyes dry, red, and irritated.
Significance and effects
Numerous patients come to see me for dry, irritated, burning, crusting, sticky, red, swollen eyes and eyelids (what we call ocular surface disease). Why? Understanding ocular surface disease is half of the battle and is the reason for this very long explanation. This is what I want my patients to understand about these frustrating problems.
Across cultures, humans typically have developed varying habits of hygiene. We shower or bathe, we wash and comb our hair, we brush our teeth, etc. We do this as a way of maintaining our bodies, keeping ourselves healthy, and being pleasing to others around us. Generally speaking the main weapons we use in the fight for hygiene are simple: water and soap. The idea is that soap loosens dirt and bacteria and the water washes them away. Simple.
However, when it comes to the eyes, soap stings (because of the alkaline pH) and many people don’t even light getting water in their eyes! Satisfying the hygiene goal thus becomes more complex and leads to problems with infection, oil, inflammation, and dryness.
The eye care community wants to improve the basic ocular health of millions of people suffering with dry, irritated, burning, crusting, sticky, red, swollen eyes and eyelids, and have stepped up efforts to teach patients to be as mindful of cleaning their lids and lashes as they are of bathing and brushing their teeth.
The three main factors in ocular surface disease are infection, oil, and inflammation. Dryness is a somewhat separate but related factor that also often needs to be addressed.
Imagine going to your dentists office. One thing you can count on at the end of your visit is that your dentist will emphsize the importance of daily brushing and flossing. If we skip brushing and flossing, we end up with cavities (dental infections). Basic. Likewise, we all know that our breath starts kickin’ like Bruce Lee when we don’t brush. That’s because of the build up of bacteria. Our mouths have a mucous membrane lining. Where we have mucous membranes, we also have bacteria. We all have bacteria in our mouths yet we don’t rinse our mouths out with antibiotics every day to decrease bacteria; we just brush. Similarly, the ocular surface is a mucous membrane and has a similar tendency to accumulate bacteria because of the moisture present.
In addition to bacteria, the follicles of the eyelashes commonly are a home for a skin mite called Demodex.
One hundred percent of us have bacteria on our lids and lid margins and it has be found that most of us also have Demodex! These organisms can lead to oil gland problems and inflammation (redness). However, we each have a slightly different reaction to these microbes. How do we routinely keep these critters at bay?….lid scrubs.
Now imagine going to your dermatologists office for acne. We all know that bacteria, oil, and inflammation are part of acne yet we don’t think of acne as an infection of the face. We also don’t expect acne to completely resolve in a day or a week (even though we all want it to). It takes significant effort and daily attention over long periods of time to improve the quality of the oils and the functioning of the oil glands to decrease acne. The same is true for the oil glands of the eyelid margins. These glands are called meibomian glands. The oils they secrete should be the consistency of olive oil. These oils serve to coat the surface of the eye, prevent the rapid break up of the tear film, and reduce the evaporation of tears. When influenced by bacteria and inflammation, the meibomian gland oils become thick like butter and can be squeezed from the lids like toothpaste.
The thickness of the oils can clog the gland leading to the formation of a chalazion (stye). We called this meibomitis or meibomian gland dysfunction. This process is cumulative and as it occurs, more and more glands become involved making the lids thicker and redder. This process can even cause permanent scarring and destruction of the meibomian glands. As you can see, although chalazia involve bacteria, they are not actual infections. Instead, they are much more like really big pimples and as such can lead to severe “acne” of the eyelid margins. Meibomian gland dysfunction encourages bacterial growth and inflammation. The interaction between bacteria and eyelid oils can actually lead to the chemical formation of soap bubbles in the tear film which stings irritates just like regular soap does.
The strategies for handling meibomitis involve thinning the oils with heat, expressing them from the lids, and reducing inflammation.
Inflammation (redness and swelling)
People that have experience with asthma or eczema have an intimate understanding of the recurring nature of inflammation. In these conditions, the immune system which normally acts as a defense mechanism for protecting us from infections and cancers gets “confused” and becomes overactive causing damage to our body’s normal tissues. Overactive inflammation of the eyelids and conjunctiva (the white of the eye) causes the collateral damage of redness, swelling, and itching. It can even cause the growth of blood vessels into the cornea leading to scarring and blurred vision. This inflammation in ocular surface disease comes and goes depending on the severity of the problems with infection, oil accumulation, and dryness.
Therefore, it’s important to remember that red eyes or red lids do not necessarily mean that an infection is present, but rather that inflammation (from many possibly causes) is present. The pathway of inflammation can be interrupted with many strategies, the most common of which is steroids.
Most ocular surface dryness is due to one or all of the factors above. It is for this reason that I feel that most patient’s symptoms of ocular dryness is not actually due to truely dry eyes (meaning not enough tears) but rather dry eye sensation (the feeling of not having enough tears). In most cases, treating infectious problems, oil gland problems, and inflammatory problems leads to substantial improvement in the dryness symptoms. It is not uncommon for some people to either not blink completely during the day or sleep with their eyes partially open. These are considered evaporative dry eye problems because they cause the tears (which are adequate in quantity) to either not spread across the eye properly or evaporate from the eye too quickly. True aqueous tear deficiency (not having enough liquid tears) is much more rare.
Common ocular surface disease states
Various combinations of the ocular surface disease factors described above make up the common states of ocular surface disease outlined below. The main causitive factors of each condition is written in parentheses. Notice the high degree of overlapping symptoms between these conditions. This causes them to be easily confused for one another and leads to a high degree of overlap in the treatments. Keep in mind that many of these conditions are chronic and are therefore managed with treatment rather than cured.
bacterial blepharitis and conjunctivitis (infection): bacterial infection of the eyelid margins and the white of the eyes; commonly caused by Staphlyococcus, Streptococcus, Haemophylus; symptoms include: redness, swelling, itching, tearing, burning, crusting.
Viral conjunctivitis (infection): often referred to as “pink eye” and caused by Adenovirus that can cause corneal spot scars (keratitis); symptoms include: severe redness, swelling, itching, tearing, burning, blurred vision.
Staphylococcal hypersensitivity (infection and inflammation): hyperactive immune response to the exotoxins of Staphylococcal bacteria on the lid margins and lashes leading to scarring of the cornea; symptoms include: recurring redness, swelling, pain, blurred vision.
Demodex blepharitis (infection and inflammation): infection of eyelash follicles by the Demodex mite; symptoms include: redness, dryness, crusting, itching.
Meibomitis (oil and inflammation): inflammation of the meibomian glands with thickening of the eyelid oils: symptoms include: redness, dryness, blurred vision, fluctuating vision, recurring chalazia (styes), pain, swelling.
Ocular rosacea (infection and oil and inflammation): inflammatory response to Demodex, bacteria and oils affecting the lids, the white of the eyes, cheeks, nose and forehead with dilated vessels, sometimes also with thickening of the skin of the nose (rhinophyma); symptoms include: redness, flushing, dryness, burning, pain, blurred vision, fluctuating vision.
Allergic conjunctivits (inflammation): immune response leading to inflammation of the eyelids and the white of the eyes; commonly caused by environmental allergens and medications; symptoms include: itching, redness, tearing, dryness.
Dry eye syndrome (infection and oil and inflammation and true dryness): either the sensation of dryness or actual dryness of the ocular surface; symptoms include: dryness, burning, pain, blurred vision, fluctuating vision.
The basic regimen of treatment for all of these conditions is the cleaning of the eyelid margins at least once per day, and in active disease, twice per day. There are many effective strageties for cleaning the eyelid margins including various cleansing formulations and baby shampoo. I discourage the use of baby shampoo and instead shout that the best long term daily cleaning regimen is with Cetaphil Gentle Skin Cleanser For All Skin Types which I describe here: Cetaphil Lid Scrubs
In addition to this basic cleansing regimen, the treatments of ocular surface disease are tailored based on the major underlying factors that are causing the problems.
Customized treatments for the various states of ocular surface disease are categorized below according to the factors they address. This is an extensive (but not exhaustive) list of the most common treatments available.
Treatments for infection
Antiseptics: Avenova, Povidone iodine
Antibiotics: Bacitracin, Besivance, Zymar, Zymaxid, Vigamox, Moxiza, vancomycin,
erythromycin, Azasite, many others
Demodex: Claridex, Avenova, Soolantra
Treatments for oil related problems
Warm compresses: rice in a sock, TranquilEyes, other heated eyelid masks
dietary Omega 3
Treatments for inflammation (redness and swelling)
steroids: Lotemax, Pred Forte, Durezol, Prednisilone acetate, Blephamide
non-steroidal medicatons: Prolensa, Ilevro
Azasite (an antibiotic with anti-inflammatory properties)
intense pulsed light therapy
amniotic membrane: ProKera and others
antihistamines: Pazeo, Bepreve, Lasticaf
avoidance of allergens
avoidance of certain foods: alcohol, cheese, caffeine, spices
avoidance of extreme temperatures
Treatments for dryness
artificial tear drops
artificial tear ointments
Buminate or serum tears
thoughtful complete blinking
avoiding air currents (wind and fans)
patching at night
moisture goggles at night
scleral contact lenses
I am happy to work with you in managing, and hopefully reducing if not eliminating, your symptoms of ocular surface disease.