Dry Eye - Dr. Zigler discusses signs, symptoms, treatment — erythromycin ophthalmic ointment dosage
The Dry Eye Show | How to Apply Eye Ointment and What Causes Watery Eyes? 1
Hola Dr. Travis Zigler here and Dr. Jenna Zigler and welcome to The Dry Eye Show!
We’re going to get things started out by talking about epiphora which is a very common question we get asked. We're having our contest for the 6-month supply of the Heyedrate Lid and Lash Cleanser and today is the last day to enter that contest. So, make sure you enter it today.
We're going to talk about what causes watery eyes or epiphora. So, we get this question all the time. You guys say that your eyes are watering like crazy, or maybe it's just one eye that waters like crazy. It's incredibly embarrassing for people because it looks like you're crying, but epiphora (the medical term for teary eyes) actually can occur because the eyes are dry. It sounds really strange, but the tears of your eyes are made up of three different layers and when these three layers aren't functioning properly, the tears aren't doing their job and the tears just fall out of your eyes instead of sticking to the front of your eye.
There are other ways that tearing can occur and we're going to talk a little bit about that too, but we wanted to go into this for you guys. So, basically there are a couple different causes. First of all, your tears are composed of three different layers. You have your oily lipid layer, you have your watery aqueous layer, and then you have a mucin layer. The outer layer of your tear film is the oily one that kind of seals in the tears and prevents any evaporation. The middle layer is your aqueous layer. That's your watery layer that keeps your eyes nice and moist, know as your lacrimal gland. So, the aqueous is from your lacrimal gland. Then, the innermost layer is your mucin layer which functions to keep the rest of the tears kind of stuck to your eyeball. When you have meibomian gland dysfunction, blepharitis, and dry eye, these layers are disrupted and this can really lead to watering eyes because those tears are no longer sticking to your eye.
There are a couple of different other things that can cause watering. One of them is that sometimes, especially in older individuals, the eyelids are not positioned right up against the eye like they should be. They might be falling away a little bit or they might just be a little lacks and that can cause watering. They get all that water in there, and all those tears in there, and then those lids just don't keep it in. Then, it could also be a drainage problem. We have little holes in our eyelids that help our tears drain and sometimes those holes can be plugged up for various different reasons which is called nasolacrimal duct obstruction. That’s a big, long-term but it just means that those holes are plugged up and those tears aren't able to escape. That's why sometimes we actually purposely plug those holes, which is a punctal plug. Nasolacrimal duct is the puncta that goes into the nasolacrimal duct which drains into your nose. So, when you start to cry over a long period of time, if those holes are open, you'll start to notice you get a sniffy nose. Then, you might even notice some kind of post nasal drip in the back of your throat and that's because your eyes connect to your nose, your nose next to your mouth.
How do you treat watery eyes?
It's essentially the same treatment if it's determined that it's that lipid layer, that oily layer on the outside that's causing it. You just want to treat it like you want to do with meibomian gland dysfunction. Cleaning up your eyelids with a hypochlorous acid cleaner and eating fats like avocados, flax seeds, ground flax seeds, fish oil supplements and things like that. Then, just treating it in general with warm compresses, lipiflow, and then blephEx. Those all are going to help with meibomian gland dysfunction which is in turn going to help with your watery eyes.
How to apply eye ointment?
Pretty much I'm going to walk you through how to apply an eye ointment, and more specifically erythromycin, which we have right here. Then, we're going to show you how to administer eye drops, as well. I'm going to be talking you through it and then Jenna is going to be demonstrating. So, you're going to be blurry the rest of the show. It's going to be fun!
What is erythromycin ointment and what is it used for with your eyes?
Erythromycin ointment is very similar to a Neosporin, it's just an antibiotic ointment. An ointment is a little thicker and it's going to retain contact with the eye a little longer and that's the goal of an ointment. We want to keep it on the eye a little longer.
Two reasons erythromycin ointment is usually prescribed is if you have something like a cut on the eye, you're going to put erythromycin ointment in the eye, and then if you have blepharitis sometimes we put it on the eyelids. Blepharitis, as we know, is an increase in the bacterial load on your eyelids causing inflammation so we want to get that bacteria down which then in turn decreases your inflammation.
Jenna is going to show you how to do it in the eye and then she's going to show you on that same eye how to put it on the eyelid. Basically what we're going to do is we're going to look up and I like to hold the ointment tube in my dominant hand. Some people like to look in a mirror too because you can kind of see what you're doing a little better. So, what you're going to do is take the finger of your other hand, your index finger, and you're just going to pull down on your lower eyelid and you can see there's a little pocket in there now. Now, we're just going to squeeze a little strip, about a quarter inch ribbon, and we're going to close our eyes. We're going to blink and what that's going to do is it's going to spread that ointment across your eye. It’s nice and blurry right now but that's okay because that's what ointment does it spreads across your eye when you're putting it on your eyelashes or your eyelids.
This is for something like blepharitis. First, wash your hands, and clean your fingers. I'm just going to put a little strip, about a quarter inch strip and close my eyes because that can get your top and your bottom lid at the same time. So with your eyes closed put it across your eyelids right at the lash line then kind of rub it in a little bit and blink a couple times. This one's not going to blur your eyes as much. I like to make sure it's on those eyelashes and then move over to the other side. Now, if you happen to be using eye drops it si very similar and we get a lot of questions about that as well.
Ointment is a little tougher to administer than just a general eye drop but I can show you here. It’s the same process. Basically you're going to look up, hold it in your dominant hand, then pull down on your lower lid, then put a drop in that little cul-de-sac there and blink a couple times and you're good to go. If you want to keep an eye drop in your eye a little longer to maintain longer contact time what you can do for that is literally close your eyes and hold your puncta right there. That's going to keep it in your eyes longer. So, if you're taking like a steroid or a Restasis or something like that or even an artificial tear and you want to keep it on your eye longer you can plug that puncta.
The reason that after you take drops you get that kind of metallic taste is because your eyes again drain to your nose which then drains to your mouth and your bitter taste receptors of your tongue are in the back of your mouth. Therefore, when the drop goes into your mouth you're going to taste it and it's going to taste very bitter or metallic. This is something that we also tell people that you can plug those puncta up if you are concerned about systemic absorption for any reason.
If I had a pregnant woman come in and she had a corneal abrasion and I absolutely had to put her on something that wasn't known to be safe then I would have her plug those puncta up. We know that it's not systematically absorbing as much. So, the reason I don't prescribe erythromycin as much anymore is because we have come out with our Heyedrate Lid and Lash Cleanser . A hypochlorous acid cleanser is actually an antiseptic which means it kills bacteria and you're going after the same thing erythromycin does. The difference between the two is erythromycin is an antibiotic and like all antibiotics they develop resistance. So, eventually you're creating superbugs because, let's say, you have a hundred bacteria on your eyelid and you kill ninety eight of them and there's two of them that survived that antibiotic so then those two reproduce and create another hundred and then the next time you take it five of them survived. So, what we do is we were creating this super bug that is resistant to antibiotics which can in 100 years, 50 years maybe, or 10 years create a lot of problems for us in the future. So. we try to not prescribe antibiotics as much. Heyedrate Lid and Lash Cleanser is a hypochlorous acid which is an antiseptic. This means it does not develop resistance and it kills pretty much everything like that. Truthfully if your doctor wants to put you on an ointment at night or something like that for your dry eyes, there are ones available over-the-counter just in your drugstore. We don't talk about drops and ointments very often but there are things that do not have that antibiotic in them that work just as effectively and coat your eye at night so that you're not peeling the skin off the front of your eye when you open your eyes in the morning.
The great thing about ointments like Systane nighttime ointment and Refresh PM are those ointments are not preserved. So, that's one thing that's nice about them. They will of course cause blurry vision because they are an ointment and they are thicker so you will notice a little bit of blurry vision with that. Ointments are great and I recommend Systane PM most, and then Systane nighttime ointment probably second most, and then Refresh PM as well. So, many of those work really well for dry eye. Put them on the eyelid or in the eye themselves for night time and then you can also put them in the day as well, but they're just going to cause a lot of blurry vision. We usually recommend non preserved gels and I think Refresh makes a non-preserved now which is a very very thick drop and it works really well. Those are all good to use because they're non preserved.
How long will it take a steroid drop to help with blepharitis or MGD?
A steroid drop is an anti-inflammatory. Blepharitis and meibomian gland dysfunction, by definition, is pretty much caused by inflammation. A steroid drop is going to mask the problem and it's not going to fix it but it will reduce the inflammation and it will reduce the redness. Usually when I prescribe it to my patients they notice relief right away. You'll notice relief within a day or so, I wouldn't say right away but like 24 hours you'll start to feel better and you have to take the full dose of it.
The key thing with the steroid is a lot of people take it until they feel better and then they stop. A steroid has to be weaned off. Let's say you're taking it four times a day to get rid of the inflammation, you can't just stop it immediately. You have to go down to three times a day for about a week, then twice a day for a week, then once a day for a week. You have to wean yourself off of it because if you just stop it then the inflammation is going to build right back up. Think of a mitoq pack where you take seven the first day, then six, five, four, three, two, then finally one. It's because you hit it hard and then you wean yourself off of it slowly. Make sure you're taking the steroid as prescribed by your physician and make sure you're not just stopping it. When you start to feel better you have to wean yourself off of it slowly.
Can you talk about the difference between blue blockers and anti-fatigue lenses?
That's a great question! Blue blockers tend to have just a coating that is kind of a bluish coating. Our blue blockers have 30% blue block. We actually just got them back in stock on Amazon, just search for Eye Love blue blockers. We block about 30% of blue light. What blue blockers do is they just block blue light that increases or decreases your melatonin production which then will kind of hurt your sleep at night.
Anti-fatigue lenses tend to have a little bit of plus power. Typically they'll have a plus 0.5. So, think of readers, readers come in a +1.00, +2.00, +3.00. Anti-fatigue lenses tend to have a +0.50 and you don't tend to notice those as much because it is so light, but those just help relax your eyes a little bit more when you're looking at a computer screen all day. Mostly for people that are about 40-41 and below. That's kind of the difference between the two and if you can combine the two that's even better. So, I have a pair that's like a +.50 and they do have blue blockers as well. I don't wear them too often because I don't like them, so I wear these more. Some people like having that extra little bump of plus power and some people put them on and if you don't need it normally then you'll hate it. So, it's just kind of a personal preference there.
Do dry eye sufferers suffer from eye fatigue especially related to computer use?
I kind of think it's the other way around actually. So, computer use and just staring at a computer all day or doing lots of reading, is incredibly hard on your eyes and it can cause dry eyes. Because when you're looking at a computer all day, or you're reading all day, or you're going back and forth between the two and you're rarely looking up, you tend to blink less. It's a proven fact that you blink less when you read and work on the computer and that really dries your eyes out. Whereas anti-fatigue lenses can really help with the glare and it can help with all of that strain that you're getting on your eyes just from blinking less and it will potentially help you blink more, too. But you kind of have to do that on your own. You need to tell yourself to look far away every once in a while and blink a little more often.
I have eyelid swelling and not feeling better. If swelling isn't reduced in two days then is it working?
Not necessarily! Everybody's different and everybody has inflammation differently. You have to think of it sort of like cancer. So, don't think of your eyelid like cancer but think of how breast cancer affects millions and millions of people every year. Some people get rid of it in a month and some people never get rid of it. So, everything affects everybody differently and you can't just say that this isn't working after two days of trying it. A steroid ointment and any ointment that you're using for a swollen eyelid, if it's prescribed for a swollen eyelid, is less likely to work quickly. If it were prescribed for something on your eyeball it will absorb a little bit more quickly onto your eye then it will into your eyelid. So, it could be that it's just taking a little bit longer. Give it a couple of days. If it's stagnant that's fine for now but if it's getting worse and not better then that's something that you need to have seen again because it's possible that the steroid isn't effective or it's something else that's going on.
It's a steroid drop so a steroid drop isn't going to penetrate your eyelid as much as a systemic steroid. It's just hard for us to answer that question because eyelid swelling can be caused from infections or it can be caused by inflammation allergies. This is probably the biggest thing right now because it's allergy season. It depends how painful it is and there's so many factors. A steroid drop isn't going to help with eyelid swelling that much and you need to figure out what's causing the eyelid swelling, which could be water accumulation. If you're maybe not eating healthy, if you're not sleeping well, if you're not drinking enough water, this could all be contributing to it. Water can cause bags under your eyes too. I don't know if you've tried icing your lids or anything like that. Try to put a cold pack (not ice) directly on your lids and that can kind of tell you sometimes if it's allergies related because it can lessen some swelling there if it is. There are a lot of things that it can be and without seeing you it's really hard to know.
They said it's from eye drying at night but I don't see too often eyelid swelling from dry eyes. It's not as common, but again we're not seeing you in person so it's very hard for us to determine what is causing your swelling. I know if you're starting to switch your diet, which is going to be huge, you're going to start to see a plethora of good symptoms. I say "diet" not in the diet sense, but changing your diet to "healthier eating" is going to create a better lifestyle. You're going to start feeling better and you're going to notice a lot of good side effects.
How long does it takes for diet changes to make a difference with dry eye?
We tell people that especially with green smoothies, which we are big proponents of for breakfast smoothies, can take 21 days for your body to really get used to it. To get used to having that smoothie you might feel awful for the first couple weeks and that's okay because your body has to kind of reset a little bit. So, at least 21 days for your body to feel good about it. For it to actually help your dry eyes can take a little longer. Clean eating takes awhile unfortunately it takes 3 to 6 months sometimes for you to notice the difference in your dry eyes. Then, some people notice it right away and they're like “oh my gosh I feel so much better right away”, but for other people it does take 6 months to notice the difference. I just encourage you to really stick with it because it can make a huge difference.
I find it funny that people will go on Restasis and Xiidra and these drops take anywhere from two weeks to one month for Xiidra, and then six months for Restasis. If you want to see change in your dry eye, change your diet, change how much you're drinking water and exercise. You will see results in the first week if you follow what we talk about in the Rethinking Dry Eye Treatment book. If you start hydrating like we talk about, and if you start eating like we talk about, you will literally see results within the first week. You will feel better not only with your eyes but systemically. This is an inflammatory condition meaning your body is in inflammation and when your body's in inflammation it's going to cause dry eye, it's going to cause heart disease, it's going to cause high blood pressure, diabetes and everything in-between. But, if you change your diet then you're going to feel a ton better. Stop looking at doctors to give you Restasis and Xiidra and then figure out what you're eating that is wrong and just go all in to educating yourself on a healthy diet. That's what our book Rethinking Dry Eye Treatment does is it helps a lot.
Is there a specific mask or method of keeping eyes closed at night? My eyes seem to not close well and my eyes are very sore in the morning.
This is a great question! We don't recommend any mask in particular. You can try ours Dry Eye Warm Compress Mask.
What I recommend is taking like medical tape and just taking a strip and putting it over. Actually, in the community you can search there and I know people have tried like saran wrap and taped that over their eyes. If you search in the search bar, just type saran wrap, or saran, and it should bring up a bunch of different threads that people have talked about how they tape their eyelids shut at night and it does work really well for a lot of people to help keep the moisture in especially for those of you that do maybe sleep with your eyes open a little bit at night. That's completely normal for people to do that, but it does dry your eye out. So, search for that in the group and there are some people that even have taped their eyelids to kind of show you how they do it.
Are there any allergy eye drops that don't contain BAK?
There are really not any allergy eye drops. We have Alaway, or Zaditor, or Pataday, they're all going to contain preservatives. Unfortunately, there are certain steroid drops, newer ones more like gels I believe, and Durezol that do not contain preservatives but those are more heavy-hitting. A lot of the time if it's just a simple allergy you're just going to want a simple allergy drop. I just use a Walmart's brand of Alaway, and it's the same thing. BAK is a preservative that's used and it has toxicities for some people. You don't have to worry about it as much and it's not going to cause you any problems if you're not using the drop more than four times a day. I don't recommend cutting out a drop unless you're allergic to it, or if you have had problems with it, or if you're using it more than four times a day.
Why do you get your eyes dilated and why does it cause annoying distortions in your vision?
Eye dilation is done because we need to be able to see the very back of your eye. When you go to the eye doctor and you're not dilated, for us it's like looking into your eye through a keyhole so you can see kind of what's right in front of you but you can't see everything out to the side. Whereas if I dilate your eye it's like I'm stepping through a door into your eye and I can see all of the areas of the back of your eye. I can see the farthest areas of the back of your eye and that's really important for things like retinal detachments and retinal tears that tend to happen way out there in the periphery. Without you being dilated there's really no way to see a lot of that stuff that goes on.
And, why does it cause annoying and distortion of your vision? Because, the dilation drops relaxes your iris, or the colored part of your eye, and the colored part of your eye is responsible for how much light gets in your eye. So, it gets bigger and smaller. So when we relax that muscle it gets really really big, but a side effect of that drop is it relaxes the muscle that causes your eye to focus. So, you lose the ability to focus for a couple hours because we relax that muscle, as well, and that's what causes that annoying distortion where you can't read. It can be different for everyone. It affects some people a lot more than it does and for others.
How do you know if allergies are affecting eyes?
They itch! Itchy eyes are the number one symptom of allergies and that's normally the first thing we think about if you say your eyes itch. In your case, you did say your eyes itch so it's very possible that allergies could be the problem.
There's a lot going on right now with summertime and swollen eyelids are another symptom or another sign of allergies.
Thanks for joining us we've answered a lot of questions today and thanks everybody for joining us LIVE. If you have any other questions don't be afraid to put them in the Dry Eye Syndrome Support Community and we might be able to answer them next week.
Thanks everybody for joining!
Dr. Jenna Zigler and Dr. Travis Zigler
- Dr. Travis Zigler
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