Chapter 10 - Dry Eye Treatment According to DEWS II
There are a LOT of dry eye treatment options out there. What we are going to do for the rest of this book is go over the accepted treatment options according to severity level and the Dry Eye Workshop (2017) definition. I try not to mention specific products here, but I do mention some. For a complete updated list of our product recommendations, head to www.RethinkingDryEye.com and look under the Dry Eye Treatment tab.
Trace to mild dry eye syndrome
Modifying the local environment (getting rid of fans, moving your computer screen, etc)
Dietary modifications (eg, increasing omega-3 fatty acids and increasing leafy green vegetable consumption)
Eliminating offending systemic and topical medications, like antihistamines, hormone replacement, and others
Eliminating medications, drops, and food with preservatives
Regarding ocular lubricants, they recommend lipid-containing eye drops if there is meibomian gland disease present
The treatment and modifications listed above should be done by ALL dry eye syndrome sufferers and are what the basis of this entire book is about. This is also the basis to treatment for all disease. These are crucial for anyone that has dry eye and other diseases to implement. Don’t think that because you have severe dry eyes, that you can avoid these modifications, because these very well could make the greatest difference in your relief.
Remember that a disease is your body's way of telling you that something YOU are doing is wrong.
Mild to moderate dry eye syndrome
Changing to a non-preserved topical lubrication
Using tea tree oil products if demodex is present
Tear conservation, such as punctal occlusion
Moisture chamber spectacles or goggles
Overnight treatments such as ointments
With meibomian gland dysfunction, in-office treatments such as LipiFlow® or intense pulsed light (IPL) therapy
Topical antibiotics or antibiotic/steroid combinations
Limited-duration topical steroids
Topical anti-inflammatory medications such as cyclosporine (Restasis®)
Topical LFA-1 antagonists such as lifitegrast (Xiidra®)
Oral macrolide or tetracycline antibiotics (such as doxycycline)
Moderate to severe dry eye syndrome
Therapeutic soft contact lenses
Rigid [gas-permeable] scleral lenses (eg, BostonSight® PROSE or others)
Severe dry eye syndrome
Topical steroids of longer duration (though, of course, this comes with an increased risk for potential side effects)
Amniotic membrane grafts
Surgical punctal occlusion with cautery
Permanent lateral or even central tarsorrhaphy
Salivary gland transplantation
Natural Dry Eye Remedies
We have already discussed most of these quite a bit, but they are worth summarizing again. As we discuss other conditions like blepharitis, meibomian gland dysfunction, demodex, and rosacea, you are going to see similarities between treating all these. Treatment is again aimed at reducing inflammation by finding the cause and not just covering the symptoms.
Let’s summarize and briefly touch on natural ways to heal your dry eye.
1. Clean your eyelids right before bed and right upon waking with a hypochlorous based eyelid cleanser (more on this later). Bacteria live normally on your eyelids, but if they become overpopulated this leads to biofilm formation (a collection of bacteria), which leads to inflammation. Dry eyes are caused from inflammation. So keep your eyelids clean and reduce symptoms of dry eyes, blepharitis, meibomian gland dysfunction, demodex, and more.
2. You are what you eat. If you eat unhealthy food that causes inflammation (processed foods, sugar, fast food, anything fried), then your body is going to be inflamed and in pain, and you may notice joint pain, dry eyes, or you will have diseases like high blood pressure, high cholesterol, and diabetes. Instead, embrace a plant-based, alkaline diet that is rich in leafy green vegetables like spinach and kale.
3. Flood your cells with oxygen by taking in omega-3 fatty acids and healthy fats. Add avocados, coconut oil, ground flaxseed, and chia seeds into your diet. Take an omega-3 supplement that is formulated for dry eye. Also, exercisehelps bring more oxygen to the rest of your body resulting in less inflammation and a healthier you.
4. Hydrate yourself. You should drink 32 ounces right when you wake up and 16 ounces before you eat any meal. Also, keep a water bottle with you and drink throughout the day. Each time you think, drink, meaning if you think about water, drink some. Did you know that 80% of the population is dehydrated? Dehydration can lead to a plethora of disease symptoms. Another bonus is that hydrating first thing in the morning boosts your metabolism by 30%, which is just as good as a workout!
5. Make sure you're not deficient in vitamins and minerals. Up your intake of magnesium, and ensure that you're taking in enough of Vitamins A, C, B6, D, and E.
6. Sleep more, stress less. Get outside and ground yourself daily (walk in the grass without your shoes on!) Keep a daily gratitude journal. Try to get 7-8 hours of restful sleep per night.
7. Cut off TV, smartphone, and computer use two to three hours before you go to bed. Remove all electronic devices from your bedroom. The blue light that back lights most screens can also be disruptive to your sleep, and fatigue aggravates dry eye symptoms.
8. Eye blinking exercises аrе hіghlу bеnеfісіаl in rеlіеvіng drу еуеѕ and can іnсrеаѕе tear production. Thіѕ tесhnіԛuе is called Sԛuееzе Blinking, which іѕ соnѕіdеrеd an effective therapy for dry еуеѕ. Kеер уоur eyes shut tіghtlу fоr 3 ѕесоndѕ аnd thеn ореn thеm once аgаіn tо ѕtаrt blinking ѕеvеrаl times. Rереаt thіѕ рrосеѕѕ 5 or 6 tіmеѕ untіl tеаr рrоduсtіоn іnсrеаѕеѕ, and try to do this multiple times throughout your day.
9. Eliminate toxins. Toxins are everywhere. Learn how to eliminate them throughout your life, house, and food and reap the benefits. Read the toxins section for more ideas
Prescription Dry Eye Medications and Their Uses
What is Restasis?
If you've been searching high and low for an effective treatment for your dry eye disease, you've likely stumbled upon Restasis (cyclosporine ophthalmic emulsion 0.05%). Maybe you've even given it a try! Restasis is a prescription medication FDA approved to help treat dry eyes by making more of your own tears. It helps strengthen your body's natural ability to produce the tears it should, which is often an issue when dealing with inflammation from chronic dry eye.
Restasis comes in both single dose vials and a multidose bottle, and both act in the same way to produce the same results. It is recommended to make Restasis part of your daily routine and use it twice per day, morning and evening, for best results. From our experience in practice, it can often take patients six months or more to notice a change in their symptoms.
We've found Restasis to be especially great for those planning to have ocular surgery (such as LASIK or cataract surgery). It also works well post-surgery, when many of these patients find that their eyes get even drier.
Restasis Side Effects
What can you expect when using Restasis for the first time? To begin with, anyone with any degree of redness and inflammation on their eyes (i.e. ALL dry eye patients) will experience a temporary burning or stinging sensation. This is normal for any drop that you will put in with inflammation and should not be a cause for concern.
The drop may even seem to cause a bit more redness and dryness, but this is due to that inflammation. If either of these persists, make sure to discuss it with your eye doctor, but it should not be a reason to discontinue the medication unless there is an allergy. Some patients note that keeping the eye drops in the refrigerator helps with the burning, and we have found this to be quite true.
Another very common but harmless side effect you'll likely notice is a bad taste in the back of the mouth. Because the eyes, nose, sinuses, and mouth are all connected, when you put eye drops in you'll often be able to taste them in the throat. If this is bothersome for you, we recommend drinking a large glass of water or a smoothie directly after using the drops. This will help decrease that taste and you'll also get a little extra hydration in, which is always helpful for those with dry eyes!
Restasis Costs and Coupon Information
So, let's talk pricing. The biggest complaint we hear about Restasis in our practice is that it's too expensive for most people to afford and it is often not covered by insurance. Well, you're in luck! Restasis does have coupons available through your eye doctor and online. We always recommend that our patients get 3-month supplies, since this medication can take up to six months to notice benefits. At this time, many insurances will often help cover some of the cost, and you may only need to pay your usual copay.
Restasis Generic and Alternatives
If you don't want to worry yourself with affording Restasis, there are SO many other things you can do to begin finding relief for your dry eyes. First of all, diet and hydration are key and are the first things you should be changing in your life. Make sure you're drinking at least half your body weight in ounces of water per day, and get rid of the processed foods, sugary beverages, dairy, and other inflammatory meals. I find repeating this point over and over again is essential to really emphasize that it is that important.
What Is Xiidra®?
Xiidra® (lifitegrast ophthalmic solution 5%) became FDA approved in mid-July 2016 and has been widely successful since its release. However, this is still considered a new medication that’s still finding its way into the pharmaceutical marketplace. Some things have yet to be determined, but sharing what is known is important for the millions of people who could benefit from this medication.
During FDA trials, Xiidra was found to start working in test subjects as early as two weeks after the beginning of the application and most felt a positive difference in their dry eyes within 12 weeks. The efficacy and safety of this medication was studied in four well-controlled trials over a period of 12 weeks, and over 2100 patients were studied. Improved symptom relief was noted in two of the four studies at two, six, and 12 weeks.
Also at 12 weeks, Xiidra was shown to improve the signs of dry eyes, measured by inferior corneal staining. This is a huge jump forward from Restasis (cyclosporine ophthalmic emulsion 0.05%), which typically takes about six months before a real difference is felt by users or seen by your eye doctor. We’ll go into a bit more about Restasis vs. Xiidra later.
How Does Xiidra Work?
Xiidra is FDA approved to treat the signs and symptoms of dry eye disease, or keratoconjunctivitis sicca, as we discussed above. We know this can get a little confusing, but it basically works by inhibiting the binding of inflammatory cells.
This mechanism decreases inflammation mediated by T lymphocytes (a type of white blood cell that plays a critical role in your body’s immunity), therefore improving dry eye signs and symptoms. More specifically, Xiidra blocks the interaction of ICAM-1 and LFA-1, which are key players of the inflammation behind dry eye. Although we know all of this, the exact mechanism of action is still unknown.
Xiidra comes in a preservative-free solution in eye drop form and is dispensed in small, single-use vials as a 30-day supply. It is prescribed as one drop in each eye, twice per day, morning and evening.
Xiidra Side Effects
Keep in mind, the FDA trials tested only a few thousand subjects, so further side effects could be found as the drops hit the market and are used more comprehensively for dry eye patients. But the side effects determined by the trial are noted to be the following:
Between 5-25% of those using the drops felt burning in their eyes when they first put them in
Blurry vision immediately after insertion
A strange or bad taste in the mouth (dysgeusia) immediately after application
Between 1-5% reported a headache, redness of the eyes, watering eyes, discharge from the eyes, and runny nose, to name a few relatively insignificant others
It is important to note that, if your eyes are inflamed (as most are with dry eye disease), anything you put into your eyes has the potential to sting or burn. Xiidra is no different, and it is very common for the medication to burn for a few seconds to minutes after instillation. This side effect, although very common, is harmless and will subside as your eyes heal.
Xiidra Cost and Coupon Information
According to GoodRx, Xiidra, as of this writing in 2019, is going to cost you over $500 without insurance or coupons. Of course, even if you do have an insurance plan, everyone’s insurance is different. We know that many will cover some of the cost of Xiidra, which is a huge help for the millions of Americans that need it. It’s estimated that about 30% of Medicare plans will cover this medication, so you’ll be left with a small copay. Even better, if you’re eligible, you can use a coupon through Xiidra’s website.
Xiidra Generic and Alternatives
Xiidra is so new that there is no generic for this medication. However, there are loads of alternative ways to treat your dry eyes, as we’ve already discussed in this book.
Xiidra vs Restasis
Now onto this important distinction and one of the main questions we are asked when discussing either of these medications.
Which is better?
Well, one main difference between Restasis, a decade-old medication used to treat dry eye, and Xiidra, is that Xiidra is approved to treat not just dry eye signs but its symptoms as well. That distinction is because of the nature of the product.
Xiidra stops a chemical chain reaction in the cells. When the drop hits the eye, the drop binds with proteins in the cells that stop the signals that would otherwise create many of the problems and symptoms of dry eye including itching, burning, pain, and redness. This effect can be noticed quite quickly!
Restasis, on the other hand, is a slower process. Although the exact mechanism of action is also unknown, we do know that it contains a topical immunomodulator with anti-inflammatory effects. Over time, this medication helps the eyes produce more of their own high quality tears which, in turn, helps the patient feel relief.
The important thing to note with both of these medications is that they are not artificial tears. They’re not designed to give you immediate relief because they’re healing your eyes from the inside out, not simply putting a bandaid on the problem. Healing takes time.
What is Cequa?
Recently, Cequa (cyclosporine ophthalmic solution 0.09%) became only the third dry eye medication to be approved by the FDA in the past 19 years. This is exciting for those of us suffering from dry eyes, as well as for those who treat it.
FDA approved to treat dry eye disease by enhancing tear production, it works as an immunomodulator in a similar fashion to its earlier competitor. Like Restasis that we know all too well, Cequa uses cyclosporine but in a much higher concentration. This higher concentration is also part of a formula that includes nanomicelles. Micelles are gelatinous congregates of hydrophilic and hydrophobic molecules that can help with absorption of a substance. Sun Pharma (the manufacturer of Cequa) says these will help increase the ability of Cequa to penetrate the ocular tissues and overcome any solubility changes.
For the patient, this means a more effective medication, because penetration into the cells of the cornea and conjunctiva will be enhanced. Hopefully, this also means the medication will work more quickly, since it is well known that Restasis can sometimes take six months for the patient to notice changes in their dry eye symptoms.
Cequa was evaluated in two randomized studies with over 1000 patients suffering from dry eye disease. Compared to control at day 84, use of Cequa for 12 weeks showed a statistically significant increase in tear production (measured by Schirmer Score). Corneal and conjunctival staining was evaluated earlier, and positive changes were noted as early as four weeks.
Now available from Sun Ophthalmics in the US, Cequa is dosed just like Restasis and Xiidra twice per day, 12 hours apart, morning and evening. The new medication comes in single-use vials that should be discarded immediately after each use.
Cequa Side Effects
As with any medication, Cequa has a few common side effects. 22% of those studied experienced a burning or pain sensation upon instillation. 6% of those people noticed redness of the eyes, but both of these should subside within a few moments of using the medication. Typically, burning and redness are very common side effects for any eye drop, especially when inflammation is present. With dry eyes, inflammation is going to make burning and redness much more likely side effects no matter what is instilled into the eyes.
Other reactions noted were blepharitis, eye irritation, headache, and urinary tract infection, which is interesting. There are no adequate studies to show that Cequa is safe for pregnant and nursing mothers, so this should be either avoided or discussed with your doctor, weighing the benefits of the medication versus the risk to the unborn child or infant.
Autologous Serum Drops
Autologous serum drops have been specifically shown to be beneficial for those with dry eyes due to Sjogren's Syndrome. But these aren't just normal artificial tears, and they're not designed to lubricate the eyes. They're designed to repair tissue, meaning that they can provide relief for those with Recurrent Corneal Erosions (RCE), exposure keratitis, aqueous deficient dry eye, and other conditions that negatively affect the ocular surface.
The pH, osmolarity, and many growth factors are roughly the same as your tears, meaning that they do a wonderful job at healing the surface of the eyes.
While artificial tears may be alright for occasional use to supplement the tears in someone with mild dry eye, autologous serum is a much better route to take in those with a more severe condition. Autologous serum is an eye drop made by separating the cellular and liquid components of a patient’s blood. This serum is a much more effective tear substitute because it contains the exact biological nutrients that are included in the patient’s own tears. There have been few studies performed on this subject, but we’ve had great success using autologous serum in our clinics.
The process is simple. Your eye doctor will write a prescription for 20% autologous serum eye drops for use every few hours during the day. Blood can be drawn anywhere that is convenient, and the blood and prescription are taken to a compounding pharmacy to be made into the eye drops. The drops will come in individual vials that must be discarded after use, and they last in the refrigerator unopened for a few months. Usually, there are minimal adverse effects because the eye drops are being made directly from the patient’s own blood. This is definitely an interesting treatment, but the success has been worth mentioning.
Avenova Hypochlorous Acid Eyelid Cleanser
Avеnоvа is a prescription hypochlorous acid (HOCl) eyelid cleanser that is intended for uѕе undеr the supervision of hеаlthсаrе professionals fоr сlеаnѕіng and removal of foreign mаtеrіаl, іnсludіng: microorganisms аnd dеbrіѕ frоm wоundѕ, сlеаnіng mіnоr сutѕ, minor burns, ѕuреrfісіаl аbrаѕіоnѕ, аnd mіnоr іrrіtаtіоnѕ of the ѕkіn, as well аѕ mоіѕtеnіng аbѕоrbеnt wound dressings.
Avenova is a hypochlorous acid eyelid cleanser that оffеrѕ раtіеntѕ relief from their red, sore, асhу еуеѕ. In ѕоlutіоn, Avеnоvа has аntіmісrоbіаl асtіvіtу and lаbоrаtоrу rеѕultѕ demonstrate аntі-іnflаmmаtоrу activity as well.
We used this in our clinic as an eyelid cleanser, because cleaner eyelids lead to less dry eye, blepharitis, meibomian glands dysfunction (MGD), demodex infestation, and contact lens intolerance, so an eyelid hygiene regimen such as this is very important.
Other Hypochlorous Acid Eyelid Cleansers
A few over-the-counter hypochlorous acid eyelid cleansing рrоduсtѕ have recently come out on the market with promising results. This includes Heyedrate Lid and Lash Cleanser, which works well to soothe eyelids suffering from blepharitis and MGD because it helps to keep the eyelids clean.
What is Hypochlorous Acid?
Hypochlorous acid is an organic, completely natural substance released from the body's neutrophil cells. HOCl functions in the body as an antimicrobial agent, and it also neutralizes bacteria, toxins, and inflammatory mediators in the body. It works to prevent biofilm formation as well as deactivate problematic enzymes.
As you can see, this important substance is a vital one for keeping the body healthy! Because of its antimicrobial activity, HOCl is the perfect replacement for many antibiotics and antiseptics used in medicine today.
Much of the research on hypochlorous acid promotes its use as a wound care agent because it is a bactericidal compound, meaning it kills bacteria in and on the body. It also demonstrates very low toxicity, which makes it a great candidate for use throughout the body. Aside from wound care, research is being done which uses HOCl as an antiseptic prior to surgery, meaning we could potentially avoid the messy iodine that is now used.
In dentistry, HOCl has been shown to be great for cleaning biofilm-contaminated implant surfaces, has the potential to be used during dental surgery, and is an effective oral rinse. In eye care, this natural compound eliminates microorganisms on the skin and mucous membranes making it a very effective eyelid and eyelash cleaner.
How To Use Hypochlorous Acid Eyelid Cleansers
Sіmрlу ѕрrау twісе оntо a соttоn round or make-up pad, аnd rub the eyelids two оr three tіmеѕ, twісе реr day. If you find this too daunting, you can simply spray the solution onto your closed eyelids, rub it in with your clean fingertips, and let it dry. Simple as that!
Most раtіеntѕ ѕtаrt to оbtаіn relief in as little as a few days, but many have found best results in two weeks.
Brush, Floss, Clean Your Eyelids
Wе аll knоw that good dеntаl care іnсludеѕ daily bruѕhіng with periodic еxаmѕ. Wе nоw rесоgnіzе thаt thе рrеvеntіоn and trеаtmеnt of blерhаrіtіѕ and drу eye is a lоng tеrm рrосеѕѕ ѕіmіlаr tо dеntаl care. Avеnоvа and Heyedrate Lid and Lash Cleanser are іdеаl products for dаіlу uѕе in thоѕе раtіеntѕ with сhrоnіс lid dіѕеаѕе аѕ раrt оf daily eyelіd hygiene thеrару.
Avеnоvа and Heyedrate Lid and Lash Cleanser are a major breakthrough in the рrеvеntіоn of blерhаrіtіѕ and drу еуе. Lack of bacterial rеѕіѕtаnсе tо thіѕ product іѕ unique and a compelling reason for both eye doctors and patients to use it.
Scleral lenses are also being utilized for the treatment of severe dry eye disease. In general, we usually think of contact lenses as being bothersome to dry eye, and scleral lenses in particular are usually utilized for those with corneal shape irregularities like keratoconus and extensive scarring. However, scleral lenses can be a wonderful option for dry eye treatment. These large, rigid lenses are so beneficial for dry eye because they can vault over the entire cornea and literally bathe the eye in tears all day.
When scleral lensesare fit for dry eye, they will be fit so that they completely vault over the cornea. Lenses are inserted by placing the lens onto a small plunger that holds the lens upright. It is then filled with non-preserved saline solution or non-preserved artificial tears before the lens is placed onto the eye. Using non-preserved solution ensures that no extra preservatives or irritants are introduced to the front of the eye.
During wear, vision should be optimal. If vision ever clouds over during the day, the lenses may need to be removed so that new artificial tears can be added into the lens.
While a great option for dry eye, scleral lenses do require special care to ensure the health of the eyes. Usually, a hydrogen peroxide cleaning solution will be prescribed so that when the lenses are removed at night, they can be optimally cleaned. While it may seem cumbersome to wear large, rigid lenses in order to improve dryness, it makes sense! These lenses allow the eyes to bathe in tears all day, and they can be a game changer for many people who have found no relief from their dry eyes otherwise.
What is an Amniotic Membrane?
An amniotic membrane is actually the innermost layer of the placenta, an organ which a woman's body makes naturally when carrying a child. No fetal tissue is harvested or disturbed while these membranes are collected and made, and most membranes come from women who had a planned cesarean section.
This avascular membrane requires no tissue typing because it carries no Human Leukocyte Antigen (HLA), which is responsible for tissue typing in humans. This makes it easy to use in medicine, because there's no worry about graft failure or problems with a patient rejecting the membrane.
These membranes can be used in a few ways. First, they can act as grafts post surgery. And second, they can be used as bandages for a variety of different eye conditions. When used in this way, the actual tissue does not integrate with the host tissue but rather acts as a temporary cover while the eye heals.
Why are amniotic membranes so amazing? Amniotic membranes contain many anti-inflammatory and antimicrobial properties that make them super useful in eye care. They contain cytokines and growth factors that can be used to regenerate corneal and conjunctival cells in conditions like Stevens-Johnson syndrome, ocular cicatricial pemphigoid, persistent epithelial defects from recurrent corneal erosions (RCE) and epithelial basement membrane dystrophy (EBMD), neurotrophic ulcers, and even severe dry eye.
Amniotic Membrane Types, Costs, and Side Effects
Amniotic membranes must be either cryopreserved or dehydrated before use because using a fresh membrane can carry disease transmission risks. Cryopreservation involves slow freezing at –80°C using DMEM/glycerol to allow for slow-rate freezing without ice formation. This allows the tissue to maintain the natural quantity and quality of key biological components needed for healing, including hyaluronic acid. The tissue must be stored in a –80°C freezer and brought to room temperature as needed for use on a patient.
Freeze dried, dehydrated membranes are another option, and these are preserved using a vacuum with low temperature heat to retain devitalized cellular components. There are conflicting thoughts on whether or not these maintain all of their helpful, healing components throughout this process, but they are still healing for many conditions. These are conveniently able to be kept at room temperature, but they must be rehydrated for use on a patient.
To cover the cost a bit, amniotic membranes (depending on the type) will cost your eye doctor anywhere from $300-1000 each. This means that the cost will be higher for you. However, insurance will often cover this service or at least relieve some of the financial burden. Your doctor will likely attempt to get prior approval from your insurance company, but they will still have you sign a financial statement, insurance preauthorization form, and informed consent.
As far as side effects go, they are minimal because most people tolerate them very well. The biggest side effect is going to be blurred vision, because the membrane is opaque (you can expect 20/200 vision, usually). The only membrane which will not interfere as much with vision is the ProKera Clear, which has a 6mm opening for optimal vision. Some people will also report irritation with the ProKera brand of membranes because they do contain a large ring holding the membrane in place.
ProKera by BioTissue
ProKera makes the only cryopreserved amniotic membranes available for ocular use, and they are made using the proprietary CryoTek process to maintain the extracellular matrix of the membrane and allow it to support the regenerative process. They are FDA approved for reducing inflammation and promoting scarless healing of the eye. Contraindications include those who have a glaucoma filtering bleb and those with allergies to Ciprofloxacin or Amphotericin B (which the membrane is stored in).
The ProKera comes in ProKera Slim, which is thinner, more comfortable, and works well for a wide variety of conditions, the ProKera Plus for those with more severe issues, and the ProKera Clear, which has a 6mm opening for optimal vision during the treatment. The ProKera Clear may make the most sense for those with limbal stem cell deficiency or for those with dry eyes.
AmbioDisk by IOP
Each AmbioDisk is cleaned, dehydrated, and sterilized before use on a patient. Most of the time, freeze dried or dehydrated amniotic membrane allografts are used along with a bandage contact lens to ensure that the membrane stays in place. This is great news for those who have issues with the comfort of membranes such as the ProKera. There is no large ring on the AmbioDisk, and it's as thin as tissue paper, so you'll notice it much less.
VisiDisc and OculoMatrix by Skye Biologics
These two are preserved by a controlled moisture HydraTek process, which preserves a viable extracellular matrix with biologic components needed to support tissue function, reduce scar formation, and modulate inflammation. Each membrane can be applied in either direction, forward or backward, with no orientation issues, making for super easy application for your clinician. No bandage contact lens is needed either, which is helpful and even more comfortable for the patient. These are available in a thin, amnion-only or a thicker chorion-based variety for improved handling and optimal treatment coverage.
If you suffer from dry eyes and your eyes do not produce enough tears, punctal plugs might be a valid treatment option. These tiny plugs are inserted into the tear ducts to stop the tears from flowing out of your eyes. Instead, they force the tears into the eyes, which increases the tear film and bathes the cornea in tears. Most plugs are about the size of a grain of rice. Usually, these become an option if eye drops and gels do not help keep the eyes wet enough.
Types of Plugs
At this point, there are two types of plugs — though that could always change in the future. The first type are semi-permanent plugs that are made of silicone and are meant to last a long time. The other type are dissolvable plugs made of materials easily absorbed by the body, such as collagen. Temporary plugs can last anywhere from a few days to a couple of months and may be used primarily to determine if the plugs work for that patient before upgrading to the semi-permanent varieties.
Plugs come in many shapes and designs to fit the individual patient, and materials used in making them are collagen, silicone, hydrogel, polydioxanone, and hydrophobic acrylic polymer. Some of them even have a slick coating on the surface to make insertion easier for the doctor.
What’s the Process?
First, your eye doctor will take a look at your puncta (or tear ducts) and may measure the openings. A proper fit is vital to balance both comfort and keeping the plugs firmly in place. However, there are also some versions of the plugs that conform to fit almost all eyes without needing to measure. Your eye doctor should know the fit choice for you, but don’t be afraid to ask questions or know the other options as well and why your specialist thinks one is better than another.
In many cases, there won’t be a need for any anesthetic, but your doctor may suggest it to make you more comfortable. Let your professional know if you have particularly low tolerance for pain, or if you prefer not to have any drugs. These plugs may be inserted into the tear duct openings of your lower lids, your upper lids, or both.
Most patients say they feel some initial discomfort, but the eyes easily adjust to the change and after that, you shouldn’t feel them at all. They can be removed if there’s a problem, but that also needs to be done by an eye specialist. Side effects are rare, but rubbing the eyes can dislodge the plugs and then you may have irritation in the eyes from the material being where it shouldn’t be. Also, eye infections can occur, but this is not common.
Chapter 11 - What is Blepharitis?
Eyelids are more complex than they appear with the naked eye. Your eyelids contain millions of bacteria living on the surface that help keep your eyelids in a normal state. There are also many glands that secrete oils and tears on to your eyes, keeping them comfortable. If any of this becomes disrupted, dry eyes and eyelids can lead to irritation, inflammation, redness, and more uncomfortable situations. This inflammation of the eyelids is known as blepharitis.
What is Blepharitis?
Blepharitis is, by definition, an inflammation of the eyelids. There are two different types of blepharitis: anterior (front) and posterior (back) blepharitis which is location dependant. Anterior blepharitis is sometimes called Staph Blepharitis as it is an overgrowth of the normal Staphylococcus Aureus that lives on our eyelids. Posterior blepharitis is also called meibomian gland dysfunction (MGD), which we will discuss in the next section.
Anterior Blepharitis Symptoms and Signs
Anterior blepharitis, like stated above, tends to be more bacterial-related. We have normal bacteria that live on our eyelids that can become overpopulated.
When this occurs, it is going to cause the following signs and symptoms of blepharitis:
Red, inflamed eyelids
Lids stuck shut upon awakening
Dandruff on the eyelashes
Blepharitis Treatment With Eyelid Hygiene
If you have these signs and symptoms, treatment is simply keeping your eyelids cleaner with a hypochlorous acid eyelid cleanser. This spray is a natural antiseptic and mimics your body’s natural ability to heal. It is free of any harsh chemicals, alcohol, parabens, sulfates, or other preservatives.
Some examples of hypochlorous acid eyelid cleansers are Heyedrate Lid and Lash Cleanser (our brand and OTC), Avenova (prescription only), and Acuicyn (prescription only). Eyelid hygiene should be performed twice daily, both morning and evening.
What Eyelid Hygiene NOT to Use?
In the 90’s and early 00’s, it was common practice for eye care practitioners to prescribe baby shampoo as eyelid hygiene. With further research into this, it has been shown to actually make your eyelids WORSE! Baby shampoo contains a mild detergent which may cause irritation to the eyes. It was not designed for eyelid use. With the availability of better products on the market, you owe it to yourself to upgrade and treat your eyelids right!
Baby shampoo contains multiple synthetic ingredients and detergents that throw off the pH balance of your eyelids, and many of the ingredients can actually lead to eye allergies (including Cocamidopropyl Betaine, PEG-80 Sorbitan Laurate, Phenoxyethanol, and fragrance). It's difficult to even pronounce most of the ingredients.
Chapter 12 - What is Meibomian Gland Dysfunction?
What Are Meibomian Glands?
Meibomian glands are located on the posterior or back surface of your eyelid. Their primary responsibility is to secrete an oil called meibum into the eye which prevents your tears from evaporating. This leads to more comfortable and less dry eyes. If meibomian glands are disrupted in any way, it can lead to meibomian gland dysfunction (MGD), which results in symptoms of dry eyes, grittiness, irritation, inflammation, redness, and that feeling like you have sand in your eye.
Meibomian glands have little oil producing factories, called acini, that produce oil. Acini release the oil into the meibomian gland and, with the help of the eyelid muscle (the orbicularis oculi), oil is milked down the gland and out the opening, called the terminal duct. This occurs every time you blink. The oil is then released onto the eye’s surface to help prevent evaporation of your tears.
What is Meibomian Gland Dysfunction?
Meibomian gland dysfunction (MGD), or posterior blepharitis, occurs when any part of the process discussed above is dysfunctional. The muscle can lose its function, the oil factories can stop working, and the opening can become clogged. This disease is a progressive, obstructive disease that advances from the production of normal, healthy oils of the tear film into thicker secretions that cause stagnation and blurry vision. If left untreated, the glands can become completely obstructed and eventually atrophy. Unfortunately, this disease currently has no cure, but there are ways to effectively treat it and reverse some of the issues.
MGD Symptoms and Signs
Meibomian gland dysfunction (MGD) is going to cause the following signs and symptoms of blepharitis:
Red, inflamed eyes and eyelids
MGD Treatment: At Home
Step 1: Warm Compresses
Warm compresses are best performed with a mask that is specifically formulated for dry eye. You can also make a warm compress by taking dry rice or whole flaxseed and putting it into a clean sock.
Instructions for our Home Spa Therapy (aka Warm Compresses)
Microwave your warm compress for 20 seconds.
Shake the mask to ensure even heating.
Test on the inside of your wrist for temperature as to not burn the eyelids.
Place over closed eyes and secure onto head.
RELAX…. For 15-20 minutes! You may need to reheat the mask as necessary to maintain a higher heat.
We recommend applying warm compresses at least every night, but you cannot overdose, so feel free to do it as often as you want for symptom relief. More recent studies have shown that warm compresses are not as effective as other treatment options for meibomian gland dysfunction, but we still consider it a staple in the routine of our dry eye patients. Other treatment options are more expensive, but not as convenient. We will discuss these briefly below and in more detail later.
Step 2: Meibomian Gland Expression After Warm Compresses
Meibomian gland expression is the process of expressing the meibomian glands after heating. Heating up your meibomian glands helps turn the oil into more of a liquid (think of placing a stick of butter on the stove... it melts). After doing this you can milk the glands by rolling a q-tip starting away from your eyelid margin and rolling towards it (or you can use your finger).
Step 3: Use a Hypochlorous Acid Cleanser
After you perform your warm compresses and meibomian gland expression, it is essential to clean your eyelids with a great eyelid scrub to eliminate all the exfoliated oil and debris from the surface. We recommend a hypochlorous acid eyelid cleanser in our clinic, like our Heyedrate Lid and Lash Cleanser.
Simply spray the solution onto your closed eyelids. Rubbing the solution in and then letting it dry is enough, although some people prefer to spray onto a cotton ball or round before application. Either is fine and very effective at keeping the skin clean! A hypochlorous acid cleanser should be used twice per day for maintenance of clean eyelids.
Step 4: Increase Intake of Omega-3 Fatty Acids
Omega-3 fatty acids are so important for those with MGD. Because the meibomian gland oils of those with MGD are of poor quality, it is imperative to ensure you're ingesting a good ratio of Omega-3 to Omega-6 either through food or supplementation. A healthy Omega-6 to Omega-3 ratio is 4:1 but, sadly, our Western diet almost guarantees that yours may be closer to 20:1 or even 50:1. To make sure your ratio is healthy, eliminate all processed and fried foods and sugars and replace them with healthy omegas like wild caught salmon, mackerel, walnuts, chia seeds, flaxseed, and avocados.
For those who wish to supplement, find a triglyceride-based omega-3 supplement that is fished sustainably. We made Heyedrate Omega-3 for Eye Health due to the lack of quality control in the omega market. We wanted to create something that we felt comfortable taking ourselves and recommending for our patients.
MGD Treatment: In Office
What is LipiFlow?
The LipiFlow Thermal Pulsation System is a medical device proven to improve the function of the meibomian glands in those who suffer from meibomian gland dysfunction (MGD). The device consists of a computer console and single-use activators that are used directly on the eyelids.
When you're at your eye doctor's office, they may offer you this procedure if you have dry eyes and MGD. During the actual procedure, an anesthetic drop will be instilled in your eyes. The single-use activators are then placed on your eyelids, one side between your eyelids and your eyeball and the other side on the top of your lids (this ensures heating from both sides of the eyelid).
The activators have a corneal protector that vaults over the front of the eye, so it is completely protected from heat and pressure. The device is turned on and delivers heat and pulsation to the eyelids for approximately 12 minutes.
This system is great because not only is it heated (to 42.5 degrees Celsius, to be exact), but it also pulses in a peristaltic motion that works oil from the beginning of the glands to the terminal ends. Obstructed oil in the meibomian glands is able to be liquified and released onto the eyes, therefore working to prevent dry eyes.
LipiFlow is, unfortunately, not covered by insurance and can be quite pricey. The cost of the computer system for your doctor's office is around $100,000 and offices normally charge between $1000-1500 for each procedure.
The reason for the expense is because the single-use activators used on your eyelids are incredibly expensive for your eye doctor to purchase. However, many offices will offer payment plans that make this procedure a bit more accessible to those who need it.
Is the procedure worth it? We believe it absolutely is, especially for those with diagnosed MGD with meibomian gland atrophy. Small studies are beginning to show that LipiFlow may be able to reverse meibomian gland atrophy in those who have the procedure performed regularly.
Some patients will be able to go up to two years without needing another LipiFlow treatment (because their symptoms have improved), but many will need to be retreated every six to 12 months for lasting benefits.
Does LipiFlow Work?
The safety and long-term effectiveness of LipiFlow has been proven in quite a few peer reviewed studies. They have shown that, after one treatment, over 85% of people saw sustained relief of their symptoms and improved meibomian gland secretions for up to 12 months, when compared to the usual warm compresses and eyelid hygiene used twice per day.
LipiFlow Side Effects
Of course, we do need to discuss a few side effects of the LipiFlowprocedure. Because the single-use activators are heating up and pulsing that stagnant oil out of your eyelids and onto your eyes, there is bound to be some inflammation afterward.
Your eyes may become red and inflamed following the procedure, which is quite common. It is also common to experience burning, stinging, tearing, itching, and discharge. You may be given a steroid or combination steroid-antibiotic eye drop to use following the procedure, which will help with all of the above.
It is possible that the eyelids can become irritated and swollen due to the activators, yet this is less common, and you may experience blurred vision, which will go away on its own shortly after.
TearCare System by Sight Sciences
This system is a new device that will be available in many dry eye practices soon. The wearable eyelid technology provides adjustable heat treatment to the upper and lower eyelids without the need for closed eyes. This is important because it is able to use the full functionality of the blink to release meibum onto the eye. You can even scroll Facebook while you're having the treatment done! The thin films used in this procedure attach to the eyelids and are adjustable to reach every meibomian gland. The treatment has, so far, been shown to be much more effective in relieving the symptoms of MGD vs. warm compresses alone.
Similar to other procedures discussed here, MiBo Thermoflo uses heat to help loosen the oils of the meibomian glands so that normal, healthy oil can continue to be released onto the eyes. It uses a proprietary thermoelectric heat pump to deliver consistent heat to the glands, and this is done in the comfort of your doctor's office. MiBo Thermoflo has a spa-like feel that delivers consistent heat for ten minutes, which will lead to a melting of hardened oil leading to less symptoms and signs of meibomian gland dysfunction. This is usually more affordable than Lipiflow.
A technician will perform the procedure on your upper and lower eyelids, and this device does not make the use of anything actually attached to the eyelids, so it might be better for those who get squeamish with devices close to the eyes.
iLux Dry Eye Treatment Device by Tear Film Innovations
This neat device uses an LED light-based heat source to heat your meibomian glands in your doctor's office. After warming the glands, the technician will apply gentle pressure with the device onto your glands, helping to express them. Throughout the procedure, the technician is able to view your glands and oil secretions through a small magnifying lens on the device. The process is usually performed on two areas of the lower lids (nasal and temporal) and two areas of the upper.
Intense Pulsed Light (IPL) Therapy
Originally used as a treatment for Rosacea, patients that were having IPL, or Intense Pulsed Light Therapy, on their skin condition noticed improvement in their dry eye symptoms. IPL is also used for laser hair removal. IPL gives brief, powerful bursts of light that cause changes in the blood vessels near the surface of the skin, which raise the skin's temperature, and this eliminates problematic flora (bacteria) on the skin and eyes.
For meibomian gland dysfunction, the increase in temperature acts like the world’s best warm compress and helps eliminate stagnant oil from the glands. It will also decrease inflammation from the treatment area due to changes in the blood vessels.
Chapter 13 - What is Demodex?
Demodex are tiny mites found in or near hair follicles. They are most commonly found on the face and around the eyelashes. They are usually about 0.3 mm long, have eight legs, and their body is covered in scales for anchoring into a hair follicle. They eat skin cells and oils which accumulate in hair follicles. Demodex is mostly nocturnal and can be transferred via contact. Itchy yet?!
Infestation is very common, especially in the elderly, and usually does not cause symptoms, but skin disease can develop from demodex. They are considered parasitic, however most of the time no adverse symptoms are observed.
Demodex Symptoms and Signs
If your immune system is compromised or if the mite population grows uncontrollably, then symptoms can develop.
Red, inflamed eyelids
Dandruff on eyelashes
Demodex treatment is centered around using a tea tree based product on your hair, face, and eyelashes every day to prevent and eliminate demodex. Do not use straight tea tree essential oil, as it is very powerful and toxic. Use a product that contains tea tree oil and has been specially formulated.
Tea tree essential oil has known antibacterial properties that work well to kill off microorganisms on the skin around the eyelids. Tea tree oil is a known killer of demodex and it's imperative to keep your facial and eyelid skin clean while treating demodex, because more bacteria will only exacerbate the issue.
We have made a tea tree oil soap bar to use for your hair, face, and eyelash area. We recommend using it once or twice per day. To use, simply lather the soap between wet hands and apply in circular motions to your wet face, taking care to close the eyes tightly and rinse them well afterward. You can even use this soap in the shower as a shampoo for scalp demodex and dandruff. There are a few other commercially prepared tea tree eyelid cleansers, such as Cliradex and We Love Eyes, that are also beneficial.
Chapter 14 - What is Ocular Rosacea?
Ocular Rosacea Overview
Everyone has probably heard the term ‘rosacea' at least once or twice in his or her lifetime. Rosacea, in this case, is one that deals with the face; however, most people don't know the term can also apply to a condition which targets the eyes. Burning, itching, and redness could sometimes be symptoms of ocular rosacea.
This condition is a type of inflammation which typically corresponds with chronic skin rosacea. In certain instances itchy, red eyes are the initial sign that an individual has ocular rosacea. Whilst there isn’t a cure available for rosacea, great eye care and eyelid hygiene practices could help manage it and reduce the symptoms.
What Causes Ocular Rosacea?
Ocular rosacea is typically caused by environmental and genetic factors. The majority of the causes below could also exacerbate ocular rosacea.
A glaring redness around the eye is the initial symptom associated with ocular rosacea. People with ocular rosacea might notice a dilation of blood vessels in their eyes and on the surface of their eyelids, causing them to become extremely visible. This condition could also make the eyes itchy and dry.
Burning and stinging of the eyes are common. Whilst discomfort, dry eyes, and cosmetic defects are some of the ocular rosacea’s most widespread symptoms, the condition sometimes affects vision due to dry eyes. Sufferers might have blurred vision or increased sensitivity to light. Ocular rosaceais also capable of causing the eyelids to swell, and it can lead to meibomian gland dysfunction due to insufficient oil glands.
Ocular Rosacea Treatment
Ocular rosacea can be managed by keeping to a strict eye care routine. This routine should be kept up even when the condition seems to clear up. This aids in the prevention of flare-ups.
The tips below can also be used to help manage the condition:
Wash face and eyelid area with an all natural, tea tree oil based soap.
Ensure eyelids are cleaned twice in a day: a cotton round/ball should be sprayed with a hypochlorous acid eyelid cleanser, such as Heyedrate Lid and Lash Cleanser, and then moved across the eyelid to eradicate oil and debris from the area. Also, spray this hypochlorous acid eyelid cleanser on areas of rosacea on the skin to help alleviate symptoms.
A warm compress should be applied: blocked glands can be loosened by applying a warm compress eye mask that has been microwaved for 20 seconds. Allow it to sit on closed eyes for 10 to 20 minutes, reheating as needed.
Makeup should be avoided: the moment a flare-up happens, makeup should be avoided, as well as any facial products which consist of skin irritants like fragrances.
Stick to glasses instead of contact lenses: the moment the eyes get irritated, contact lenses should be avoided. Once the episode subsides you can return to wearing contact lenses.
Sun exposure should be limited: sunglasses, sunscreen and a hat should be used to limit exposure to sunlight. UV rays are a common rosacea trigger.
Consume omega-3 fatty acids: various studies have shown that flaxseed oil and fish oil consumption could help lower rosacea flare-ups.
Ocular rosacea diet
Be sure to stay hydrated!
Consume fatty acids such as omega-3 and healthy omega-6 fatty acids, which have unique anti-inflammatory properties.
Avoid spicy, hot foods: for numerous people, consuming spicy, hot food is capable of triggering ocular rosacea.
Alcohol consumption should be limited, especially as it can be a potential ocular rosacea trigger. It is best to limit consumption to a couple drinks each week (or less).
Chapter 15 - One Key to Successful Dry Eye Management
Clean eyelids are key to dry eye management. As we discussed above, the outermost layer of your tears, the lipid layer, helps prevent the tears from evaporating and keeps them stable on the eye. Keeping your eyelids free of debris, bacteria, excess makeup, and clogged glands will help prevent blepharitis, MGD, demodex, ocular rosacea, and more, which will lead to reduced dry eye symptoms. Cleaner eyelids means fewer dry eye symptoms. Therefore an eyelid hygiene regimen that is performed twice daily is recommended (think brushing your teeth to prevent cavities and keep teeth healthy).
Let’s go over both Dr. Jenna’s and my routine that we do morning and night. You can also check out the accompanying video, by going to www.RethinkingDryEye.com under the Dry Eye Routine tab.
Start an eyelid cleansing routine morning and night. Head to www.RethinkingDryEye.comunder the Dry Eye Routine tab, watch our demonstration video, and download the checklist.
Shower - Wash entire body and hair with tea tree soap, like Heyedrate Tea Tree Oil Soap
Apply a warm compress, like Heyedrate Warm Compress, to the eyes for ten minutes
FOAM FACE WASH
Wash face with tea tree oil soap, like Heyedrate Foaming Tea Tree Face Wash, and pat dry
LID & LASH CLEANSER
Two to four sprays of a hypochlorous acid eyelid cleanser, like Heyedrate Lid & Lash Cleanser, directly to closed eyelids
Wrapping Up - YOU CAN DO THIS
I hope you enjoyed reading this book as much as I enjoyed writing it. We have seen drastic changes in our patients and customers around the world that have adopted these changes to their lifestyle. We often don’t realize the fuel (food) that we are putting in our body is what is really the problem, because we are educated otherwise by the government, big business, and factory farms who have all the money.
Additionally, no doctor is responsible for your health… YOU ARE. We are trained in Western medicine, which is mostly about symptom relief by use of medications, not disease prevention. We believe in a different approach to medicine and it involves healing your body from the inside out with natural solutions, hydration, exercise, diet, detox, and more.
Thousands of people have been successful doing this, we did it, and know you can do it too!
You need to make a move RIGHT NOW in the right direction while this book is fresh. START TODAY!
Prove to yourself that you can do this!
You are capable of doing anything you set your mind to!
Your health is in jeopardy if you don’t make these changes.
Your life is in jeopardy if you don’t make these changes.
Your future depends on the actions you take today.
Choose to take the right actions!
STOP waiting for someone else to change your life!
STOP waiting for it to magically improve on its own!
STOP making excuses!
STOP thinking you can’t do it!
STOP abusing your body!
STOP feeling hopeless and start to take the actions in this book ONE STEP AT A TIME!
STOP saying you can’t do it!
STOP putting it off until tomorrow, next week, or next year!
Be honest about what you need to do to change your life.
Get up right now and take that step to change your life forever.
Start Rethinking Dry Eye Treatment!
All the steps and action items can seem very overwhelming when you are first getting started. Which is why I put the chapters in the order that they are in. All the information is important and can help in your journey to healing your dry eye and other disease. Start with the smallest and easiest win and move on from there. Make these habits that stick and aren’t just the latest fad in your life.
Visit www.RethinkingDryEye.com for the accompanying action items and checklists for each chapter. On the website we also have links to the products we recommend for each step. Some of these products we sell, our company includes Eye Love and Heyedrate, but most of the products we recommend are not our products.
Do it with someone to help with accountability. Join the conversation and find an accountability partner on our Facebook Group, the Dry Eye Syndrome Support Community. In each section at www.RethinkingDryEye.com there will be a Facebook icon to click and join the conversation in regards to that section. Come join the conversation!
Stick to it! YOU CAN DO THIS!! I know I have said it over and over again, but you can. It takes a belief that you can do it and you will do it. Write your newly developed habits on your mirror and look at it daily to remind yourself how far you have come. The list will start small and grow from there. When you experience a setback, look at the list to see how much you have accomplished. Examples would be “Drink 80 ounces of water per day” or “Lose 50 pounds in 12 months” or “Green smoothies for breakfast.” It doesn’t matter how “small” the win is, it is still a win and moving your life toward less inflammation and better health.
This will hopefully inspire you to take action and educate yourself even more!
Nothing fulfills us more than seeing patients succeed with a plan that we have set out for them. Please share your successes with any of our programs or products! Please don’t be afraid to reach out to myself, Dr. Travis Zigler, or my wife, Dr. Jenna Zigler, in theDry Eye Syndrome Support Community on Facebook to learn more.
Make sure to include pictures.
Also if you know anyone that can benefit from our products or program, a referral is one of the biggest compliments you can give us! :)
Side Note on ALL Natural Treatments
EVERYONE SHOULD BE DOING THE FIRST LINE OF TREATMENT (Natural)… EVERYONE!!! Persevere with this first line of action items. It may take up to 6-8 weeks for the symptoms of dry eye to be managed. Some of these will have to be continued for life, but you will notice other ailments disappearing as you begin to implement these habits.
The Kind Mama by Alicia Silverstone - We had the opportunity to meet Alicia in December 2016 and while we were already vegetarian, she completely shifted and rattled our beliefs even more. Her mission with her company, My Kind Organics, is incredible.
Campbell and Campbell, China Study, 7, 89, 93, 184, 205, 230
Gann et al., “Effects of a Low-Fat/High-Fiber Diet.”
Chavarro, Willett, and Skerrett, Fertility Diet, 44.
“Position of the American Dietetic Association: Vegetarian Diets,” Journal of the American Dietetic Association 109, no. 7 (July 2009); 1266-82
R. L. Blaylock, “A Possible Central Mechanism in Autism Spectrum Disorders, Part 3,” Alternative Therapies In Health and Medicine 15, no. 2 (March-April 2009): 56-60, http://www.ncbi.nlm.nih.gov/pubmed/19284184 .
Karl Weber, ed., Food, Inc. (New York: Public Affairs, 2009), 23. Robert W. Sears, MD, FAAP, and Amy Marlow, MPH, RD, CDN, HappyBaby: The Organic Guide to Baby’s First 24 Months (New York: William Morrow Paperbacks, 2009), 24.
National Toxicology Program, CERHR Expert Panel Report for Bisphenol A, US Department of Health and Human Services, November 26, 2007. Breast Cancer Fund, Disrupted Development: The Dangers of Prenatal BPA Exposure, September 2013
Disrupting Chemicals: From Basic Research To Clinical Practice (New York: Humana Press, 2007)
Authority Nutrition, 5 Toxic Chemicals Hiding in Your Deodorant.
MEDICAL DISCLAIMER: THIS BOOK DOES NOT PROVIDE MEDICAL ADVICE
Eye Love LLC ("we" or "our"), a South Carolina Limited Liability Company, maintains this book for purposes of information, education, and communication. Nothing in this book should be construed as a promotion or solicitation for any products, or for the use of any product in a particular way that is not authorized by the laws and regulations of the country where the user is located.
The information, including but not limited to, text, graphics, images and other material contained in this book are for informational purposes only. The purpose of this book is to promote broad consumer understanding and knowledge of various health topics. It is not intended to be a substitute for professional medical advice, diagnosis or treatment.
Although practicing physicians, Doctors Travis and Jenna Zigler are not responsible for any actions taken by you, the consumer, after reading the information in this book. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read in this book.
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