Getting a good diagnostic is critical to the treatment of your dry eyes. Having the wrong diagnostic can result in the wrong treatment plan while your disease progresses, and sometimes causing permanent irreversible damage. Most optometrists do not have the necessary equipment to make a proper diagnostic, for example, most optometrists do not own a meibography machine (i.e., Keratograph 5M or LipiView) to image your meibomiam glands.
Ask your doctor for these things:
The meibography will allow your doctor to see your meibomiam glands. Your doctor will be able to see any internal inflammation or atrophy of the tissue. Meibomian Glands Yielding Liquid Secretion (MGYLS) is a standard metric where your doctor pushes your meibomiam glands and counts the number of glands that yield liquid meibum secretions.
Tear Breakup Time (TBUT) is also a good quantitative diagnostic tool, however I find it has high variance and does not evaluate the actual health of the glands.
Consult your doctor for the appropriate treatment plan.
Amniotic Membrane Transplant (AMT; Prokera) is a lot less scary than it sounds. AMT takes donor placenta tissue and places it into a contact lens, which is inserted into your eye. The procedure takes less than 3 minutes and is relatively low risk. Your eye then absorbs the amniotic tissue in approx 3 days and up to 2 weeks, depending on the patient. AMT historically was more typically used for severe eye injuries or severe dry eye patients, however it is now a treatment option for moderate dry eye patients, or patients who experience neuropathic pain with otherwise an healthy ocular surface. For reasons not exactly known, it is hypothesized that the donor tissue contains growth factors and stem cells which can help heal and grow your ocular surface and nerves.
Antibiotics (Azithromycin, Doxycycline) can be taken in both topical and oral form. They may or may not be taken for their antibiotic properties, but rather more often taken for their anti-inflammatory properties. For reasons not exactly known, the antibiotics can reduce inflammation and change the lipid behaviours of the meibomian glands to emit more liquid secretions. Azyter is a perservative free format of topical ophthalmic Azithromycin; it is available in EU and Hong Kong, and coming to Canada in 2019. AzaSite is topical ophthalmic Azithromycin available in the USA but contains preservatives.
I've personally had a lot of success with topical Azithromycin, compared to steriods and other eye drops, I've had the most immediate symptomatic relief from topical Azithromycin and I can feel my oils flowing much better immediately. Unfortunately, topical Azithromycin is not easily available in Canada despite approved by Health Canada. You can get it made in Canada by a compounding pharmacy for around $30 per month.
Autologous Serum are tears made from your own blood. Your blood is drawn, then spun to remove red blood cells, and the remaining serum is diluted with saline to create natural tears. For reasons not exactly known, it is hypothesized that the autologous serum tears contain nutrients, growth and anti-inflammatory factors that can heal and improve your ocular surface.
Blinking Exercises are vital treatment to any MGD patient. Your meibomian glands express oil when your eye lids physically squeeze each other during blinking. Unfortunately, many MGD patients are partial blinkers, when our eyes blink, they don't actually touch and squeeze each other. When you read or use the computer, your blink rate also goes down compounding the lack of full blinks. When your eye lids don't complete full blinks, your meibomian glands are not used and can get clogged and dysfunctioned. With blinking exercises, you want to squeeze your eye lids together and make sure they touch. It is difficult but critical to incorporate blinking exercises into your daily life. Please see this excellent video by Dr Laura Periman.
I personally try to do blinking exercises 10 times every 10 mins.
Cyclosporine (Ikervis 0.1%, Restasis 0.05%, Teva 0.05%) is an anti-inflammatory and immunosuppressant drug. Cyclosporine is hypothesized to reduce T-cell production. Cyclosporine can reduce inflammation in your meibomian glands and improve oil quality output. Teva-Cyclosporine is a generic version of the drug available in Canada at less than half the price of Restasis.
I am personally on both Restasis and Xiidra twice a day.
Diquafosol is a drug that promotes tear production. It is currently approved for use in Japan and Korea but not available in Canada nor USA.
Intense Pulsed Light (IPL) flashes light on your skin around your eye. IPL was originally used for skin conditions (e.g., rosacea and acne). For reasons not exactly known, IPL somehow reduces inflammation of the meibomian glands and improves oil quality output. Some of the latest research suggests that after IPL reduces inflammation, your meibomian glands may heal with tissue growth.
I am personally on IPL monthly.
LipiFlow is a thermal pulsation treatment for MGD. LipiFlow heats up your eyelids to 42.5C and mechanically expresses your meibomian glands to clear any blockages inside the gland.
I personally tried LipiFlow 4 times, and while I think LipiFlow helped, LipiFlow definitely did not cure me. Many doctors make over 50% margin on this treatment, you can get LipiFlow for around $1000 CAD per treatment, call around and ask for pricing of this treatment.
Lifitegrast (Xiidra) is an anti-inflammatory and immunosuppressant drug. Lifitegrast is a T-cell inhibitor, which binds and deactivates T-cells and consequently suppresses your immune system. Lifitegrast may help in reducing inflammation in your meibomian glands and improve oil quality output.
I am personally on both Restasis and Xiidra twice a day.
Omega 3 supplements are supposed to improve the oil quality of your meibomian glands. You want to take around 4000mg of DHA+EPA in triglyceride form, if the packaging does not say, then it is in ethyl ester form which you want to avoid. However, I have yet to find a reputable research study to show that Omega 3 supplements statistically improves the disease or symptoms. Do not buy Omega 3 supplements from your doctor, you can get this much cheaper online.
I personally take Nordic Naturals Ultimate Omega 3 or just eat a lot of salmon.
Platelet-Rich Plasma (PRP), like autologous serum, is made from your own blood. Think of it like a concentrated serum. It is theorized this concentrated serum contains lots of growth and anti-inflammatory factors that can help heal your eyes. PRP can be very effective in healing your cornea even when autologous serum is not effective.
Additionally, latest research suggest that injecting your meibomian glands with PRP can induce tissue growth.
Punctal Plugs close off your tear ducts. This will maintain a larger volume of tears in your tear well and may result in some symptomatic relief. Punctal plugs will not improve the underlying disease, but may help manage the symptoms of the disease.
Probing is an invasive procedure and insert metal probes into meibomian gland duct openings. Probing is often used on patient with scar tissue covering the meibomian gland duct openings, or even to remove internal obstruction inside the meibomian gland. Some of the latest research suggests that if there are obstructions in your glands, and probing removes them, your meibomian glands may heal with tissue growth.
Scleral Lens are large contact lens that vault over the entire cornea. Sclerals can keep your eye moist and acts as a shield for your eyes. Sclerals will not improve the underlying meibomian gland disease, but may help improve the health of the ocular surface and manage the symptoms of the disease.
BostonSight PROSE lens are a specific brand of custom scleral lens with the latest technologies. BostonSight PROSE lens were supposed to come to the Kensington Eye Institute in 2017, however the government has NOT released funding. Contact your MP.
Steriods (Lotemax, Prednisone) are anti-inflammatory and immunosuppressant drugs. Steriods typically can not be taken long term, as they can cause glaucoma. They often give immediate symptomatic relief as they can reduce and control inflammation of the ocular surface right away.
Warm Compresses are vital treatment to any MGD patient, you microwave a heat mask/pack and apply to the eye lids at 45C. Your meibomian glands may be clogged with thick oil that can not be easily expressed naturally through blinking. Warm compresses simply liquefies the thick oil and remove clogs. I personally feel great after warm compresses as I can feel/see the oil expressed.