INDEX

Basic Questions: HMO Opthamologist | Diagnosis / Recommendation | Dry Eyes, Why At Night? | Pain | Anatomy: The Tear Glands and Tear Film | Physical Problems: Computers and Dry Eyes | Computer Use Tips | Dry Air | Humidifier | Warm Washcloth | Allergic Reactions: Caffine | Decongestants | Nutrition: Flaxseed oil | vitamin E | Fish Oils | Tuna Fish | DHA | Hormone Problems: Hormone Replacement Therapy | Androgens | Increasing Androgens w/out Drugs | Tests | Neurological Problems: Neural Arc | Drops and drugs: Restasis | Pollution: Pollution and Dry Eyes | Dioxin | Time Line | References

Basic Questions

The HMO Opthamologist

I asked my HMO ophthalmologist, "Has anyone come to you with dry eyes who later got rid of the problem?"

Answer: "No."

She said I'd be surprised at how this problem is increasing. We talked a bit and she said that as a scientist I know more about it than she does. I obviously don't know enough, because I haven't solved my own problem yet. Opthamologists are aware of university research but the clinical setting is different. She has heard about hormone connections, for example, but is unable to order any hormone tests because she would not know how to interpert the results.

Diagnosis / Recommendation

Test Results from 2/24/2004 : Eye exam shows my tear film breaks up rapidly which indicates my oil glands aren't producing enough or the right kinds of oils for my tear film. My eyes aren't dry enough to warrant tests for any other disease. Tear strips showed a reading of 11 on the left eye, 3 on the right after 5 minutes. (I'm certain of those numbers, but when I called 3/26/04, she said my lower number was a 5, not a 3. I counted to 60 five times so I know it was 5 minutes and I recall clearly that she said 3 in my right eye, becuase that was what I thought was my best eye and I was surprised that it was lower than the other. ) Anyway, the Fluorescein dye showed the doc that my tear film does break up quickly. Rapid tear break-up time (the time for dry spots to occur on the cornea) indicates dry eye syndrome.

Opthamologist's Recommendation: Use over the counter anti-biotic ointment ( erythromycin - slight eye irritant, ointment goes on lids, not in eyes - 48 ) for blepharitis several times per day and soak eyes and massage eyelids several times per day with warm washcloth. The idea is to give the tear film a chance to build back up. Tears naturally contain enzymes that neutralize the microorganisms that colonize the eye.

Dry Eyes, Why At Night?

Before I went to the HMO ophthalmologist, I asked my optometrist why my eyes are dry only at night. He didn't know.

Here is the answer: Tears are produced when we blink. People normally blink the eyelids of their eyes about every six seconds to replenish the tear film. 14 We don't blink at night, so eyes dry out more then.

Since no one blinks at night, but not everyone has this problem, there must be some difference between the eyes of those with and those without dry eye syndrome. I haven't always had this problem but now I do. What changed?

Pain

This condition can be a drag. One person writes, "Due to the fact that there are an enormous amount of nerve endings in the cornea, a dry eye condition can be enormously painful. Even reports of suicide driven by this pain have been recorded."

There are plenty of happy blind people out there, but I'm not aiming to be one of them. The goal of this search is to find a cure for this problem, not just relief for the symptoms.

 

Anatomy

The Tear Glands and Tear Film

Tears are a complex mixture of water, lipids, salts, mucins, immunoglobulins, anti microbial proteins, and growth factors. - 38 Several glands work together to produce tears. In my case, since my tear film breaks up quickly according to the test done by my ophthalmologist, my tear glands aren't doing their job.

 

The three layer tear film is made up (surface down to eyeball) of:

1) a lipid or oil layer

2) a lacrimal or aqueous (water) layer

3) a mucoid, mucin or mucous layer.

The first layer (lipid or oil film layer) is produced by the “Meibomian” and “Zeis” glands which are both sebaceous glands. This outer layer slows evaporation and prevents contamination of the tear layer.

The middle aqueous or lacrimal tear film layer is the thickest. Its contents are water soluble. This layer is formed by lacrimal glands, primarily by the “Krause” and “Wolfring” glands and secondarily by the “lacrimal” gland, all of which are located in the eyelids.

The innermost mucin layer is semi-solid and functions much like two sided sticky tape or velcro bonding the cornea and the aqueous layer. The meibomian glands located in your eye lid produce the mucin layer.

 

Healthy Sebaceous Glands

Sebaceous glands are found in the skin of mammals. They secrete an oily substance called sebum. In hairless areas, the sebum surfaces through ducts.

The Lacrimal Gland

The lacrimal gland, located at the upper outer region of the bony orbit, above the eyeball, is the tear-producing gland. If this gland malfunctions, the body does not produce enough tears, or produces tears without the proper layers. 15

 

 

 

 

 

 

Physical Problems

Computers and Dry Eyes

Studies show those who spend time looking at computers blink less frequently. As you might guess from the huge amount of content on this web site, I have spent many more than eight hours per day for several years looking at a computer monitor. In the last year or two I've been using an LCD monitor. The onset of my dry eye problem has been very slow but it is now at the point where I notice it every night and it is getting worse. Did not blinking normally over a long period of time mess up my brain's signals to my tear producing glands?

According to a National Institute of Occupational Health and Safety study, "nearly 90% of employees who work with computers for more than three hours a day suffer from some form of eye trouble. ... blinking is the key. When computer users sit in front of a screen for an extended period of time, they blink less causing eye moisture to evaporate. The result is often a condition called dry eyes which manifests itself in numerous ways including itching, burning, double vision, color fringes and heavy, blurry, gritty or fatigued sensations. " - 34

Computer Use Tips

- Avoid glare. Never keep a bright light directly behind the screen, and never place a terminal in front of a large window.

- Do not work in the dark. The contrast between computer-generated light and lack of background light strains eyes.

- Break at least once an hour for about 10 minutes and blink frequently.

Dry Air

Dr, air-conditioned air brings out the worse in dry eyes. You can get a gadget at Radio Shack to measure humidity in your room.

Humidifier

Moisture in the air makes dry eyes less painful. One person writes: "I have found that having a humidifier in the bedroom helps keep me from waking up in the middle of the night with painful eyes . The humidifiers that put out extremely fine mists seem to work best. I have a Bionaire Clear-Mist 3S"

Warm Washcloth

Steam your eyes for several minutes several times per day to loosen up the glands.

 

Allergic Reactions

 

Caffeine

One person wrote, "If you wake up in the morning with dry eyes and mouth you are likely ingesting too much caffeine. I fixed my dry problems by cuttin' the caffeine." Sources of caffeine include coffee, tea, soft drinks, cocoa and chocolate, drugs like NoDoz, Weight-control drugs like Dexatrim, Dietac and Prolamine. - 35

Decongestants

My doctor had me on sudafed for several weeks. I think this made my eyes worse. One person writes, "flonase, after six months my nose was completely clear and has been ever since (though I only used flonase for those six months). The problem is, I also developed this sleepy dry eyes condition."

Drug Reactions

Dry eyes may at times be the result of adverse reactions to drugs such as diuretics, oral contraceptive pill, drugs with antimuscarinic effects (e.g. antihistamines, tricyclic antidepressants, atropine derivatives), or beta-blockers. - 38

I was on antihistamines (oral Sudafed 3 times a day) for several weeks due to an ear infection. My ophthalmologist was certain there was no connection between my ear infection and my dry eyes.

 

Nutrition

Fish Oils

Fish Oils. The blepharitis and meibomitis components of dry eye syndrome involve inflammation. Numerous double-masked, controlled, peer-reviewed studies have shown fish oils reduce inflammation. and work to treat rheumatoid arthritis. Fish oils amplify the effects of flaxseed oil and contain the profoundly anti-inflammatory ecosanoid called ecosapentanoic acid (EPA) as well as docosahexaenoic acid (DHA).

Flaxseed Oil

Flaxseed oil. Americans are typically starved for omega-3 essential fatty acids. Meibomian gland secretions of patients with dry eye become thinner and clearer with omega-3 treatment. An improved oil layer further contributes to improved comfort throughout the day. The abundance of the omega-3 fatty acid called alpha-linolenic acid (ALA) in flaxseed oil is converted to the profoundly anti-inflammatory ecosanoid called ecosapentanoic acid (EPA).

Vitamin E

Vitamin E. 1. Acting as an antioxidant and maintains the integrity of oils. 2. long-term supplementation with omega-3 fatty acids, whether from flaxseed oil or fish oil, depletes serum levels of vitamin E.

Tuna Fish

Tuna Fish. A huge Women's Health Study of 32,470 female health professionals showed that five or six four-ounce servings of tuna every week lowered the risk of dry eye syndrome by a whopping 66%.

DHA - Docosahexaenoic Acid

DHA (Docosahexaenoic Acid). An Omega-3 fatty acid, DHA is a major building  block of brain and retinal tissue that plays a role in blood clotting, blood vessel  dilation, and the inflammation response.

Amino Acids

A full complement of essential amino acids are crucial to the proper function of the mucin and lipid layers of the tear film.

 

 

Hormone Problems

Hormone Replacement Therapy

I'm fairly young and male, but the following tells me one important thing: hormones can be connected to dry eye syndrome.

"Those red, burning eyes may not be the result of too many hours in front of the computer. If you're a woman past menopause who takes hormone replacement therapy, the treatment could be causing those parched peepers, reports a new study.

The study, appearing in the Nov. 7 (2001) issue of the Journal of the American Medical Association , looked at more than 25,000 postmenopausal women and found that hormone replacement therapy (HRT) could cause as much as a 69 percent increase in risk for developing dry eye syndrome. - 13

Androgens

Androgens are male sex hormones. According to one harvard web site, Dr. David A. Sullivan at The Schepens has found that androgens (which? what concentrations?) regulate the function of the tear-producing glands - the lacrimal and meibomian glands. Increasing these hormones could restore proper functioning to these glands. "We believe that administering androgen topically may serve as a safe and effective therapy for the treatment of dry eye syndromes," Dr. Sullivan said.

"At The Schepens, which has the largest dry eye research program anywhere in the world, biomedical scientists are piecing together the puzzle of dry eye syndrome. They are attacking the problem at the molecular level, tearing apart the tear film, examining layers of cells, learning what makes tears and what goes wrong."

Allergan Inc. initiated Multi-Center Phase II clinical trials in Sept 2001. On May 16, 2003 Allergan acquired all assets of Bardeen Sciences Company, LLC, including "compounds under development and research projects" such as Androgen Tears. 19 , 20 Androgen Tears is expected to reach the market in 2005 in Europe. 21

The androgen hypothesis is supported by clinical research. "Our findings show that the meibomian gland is an androgen target organ and that androgen deficiency may promote meibomian gland dysfunction and evaporative dry eye."

A USC team found that when androgens are low, more immune cells migrate into the gland. It appears that simply the presence of immune cells can lead to these cells attacking the gland, and eventually to more serious autoimmune disease.

"androgen receptor protein exists in the human lacrimal gland, meibomian gland, cornea, bulbar and forniceal conjunctivae, lens epithelial cells, and retinal pigment epithelial cells" - 36

"Evaporative loss is due predominantly to meibomian gland dysfunction... It has been postulated that in MGD a deficiency in androgens results in loss of the oil layer, exacerbating the evaporative tear loss." - 37

Androgens are produced in the ovaries, testes ( Leydig cells in young men produce ), adrenal glands ( walnut sized glands that sit on top of the kidneys ) and fat cells. Androgens include testosterone and dihydrotestosterone (DHT), as well as other hormones that can be converted into testosterone or DHT, including androstenedione, dehydroepiandrosterone (DHEA) and DHEA sulfate." 25, 26

Here are some side effects of taking androgens.

Increasing Androgens without Drugs

NO ATKINS: Research suggests that eating a high protein, low carb diet can cramp your testosterone levels. High amounts of dietary protein in your blood can eventually lower the amount of testosterone produced in your testes. Your protein intake should be about 16% of your daily calories. If you're the average 170 pound man eating 2,900 calories per day, you should be eating as part of that 140 grams of protein ... about two (chicken) breasts and a 6 ounce can of tuna.

WORKOUT: squats, bench presses and back rows increase levels more than curls, and tricep push-downs.

REST: If you don't adequately rest between training sessions circulating testosterone levels can plunge by as much as 40% as discovered by studies at the University of North Carolina.

MORNING SEX: Scientist in Germany found that simply having an erection causes circulating testosterone levels to rise dramatically and significantly. - 28

WEIGHT LIFTING SUPPLEMENTS: I don't know about long term safety, but this might be worth a try for dry eyes, just for curiosity.

"ZMA Fuel will raise your natural body-producing anabolic testosterone levels by 30%. If you're looking to maximize your gains, try stacking ZMA with high quality Tribulus Terrstris . Tribulus Terrestris increases testosterone levels naturally by increasing levels of another hormone, LH. When LH levels increase, testosterone increases to compensate. What a great combo! Such a stack, along with 7-isopropoxyisoflavone found in Proxylon will enhance the strength/muscle-building potential of your body even further by putting your body in an enhanced anabolic state. The combination of these three products in a stack will safely raise your testosterone levels a total of 90%! If you really want to spike your stack, add the most potent (and least side-effect producing) andro there is... 4-Androstenediol .

4-Androstenediol converts to testosterone at three times the level of regular androstenedione...AND, it doesn't convert to estrogen or DHT. By the time you are finished with the complete 4 product stack, your testosterone levels will have attained the rank of professional bodybuilder... steroid free! A regular person has an average testosterone level of 500 ng/dl. After the stack it will be somewhere around 1350 ng/dl!"

Tests

You can actually buy test kits where you send in saliva sample and they check your androgen levels. The test is $40. I wonder if my HMO ophthalmologist will approve this so I don't have to pay for it? Logic: my tear film tests as braking up quickly. That means there is a problem with the tear glands. Tear glands are attacked by immune cells when androgens are low.

 

Neurological Problems

 

The Neural Arc

The Neural Arc is comprised of the interaction between the corneal sensory nerves, the brain, and the three main tear producing glands in the eye. The corneal sensory nerves send signals to the brain, these signals are then processed, and in turn, sent to the various glands that participate in the production of tears. If the Neural Arc is dysfunctional or damaged, there is a resulting decrease in these signals.

The three glands ( lacrimal, Meibomian and sebaceous) are the manufacturing network for healthy tear production. Each receives signals from the brain independently of the others and the dysfunction of any one can result in dry eye symptoms.

 

Drops and Drugs

Arthritis Drug Helps Dry Eyes

Note the hormone connection to dry eyes. "For years doctors have known that arthritis and dry eyes usually go hand in hand, and if an arthritis drug (Vioxx) has helped me with my eyes then I am going to let people know. I do not even have arthritis. " This drug is a hormone-like compound that increases metabolic rate and causes weight loss. "... KB-141, works on the same principle as the hormone normally produced by the thyroid." Here is a page with some normal thyroid test ranges. If you have dry eyes, why not have a thyroid test?

 

Restasis

Your ophthalmologist can now prescribe this drug: "Restasis (cyclosporine) from Allergan is the first therapeutic product aimed at the underlying inflammatory process that is present in dry eye. By preventing T-cell activation, both on the ocular surface and in the lacrimal gland, Restasis maintains homeostasis in these tissues, explains David Power, Director, Global Eye Care Pharmaceutical Marketing." Mine says she wouldn't prescribe this until after I had punctal plugs because it increases tear production and there is no reason to increase tear production if the tears are just going to run away. (Wha!?) She also said there are preservatives and other things so you want to use this only when other options are exhausted.

Benzalkonium Chloride

"Benzalkonium chloride has been shown to be toxic to the corneal endothelium; therefore, the more frequently drops containing benzalkonium chloride are used, the greater the risk of ocular toxicity and irritation." - 38

 

Vitamin A Drops

"Vitamin A ointment seemed logical, but did not work when tested in a lab. It now appears that this was the result of interaction between Vitamin A and male sex hormones like testosterone, also known as androgens. ... Androgens also appear to control function of the meibomian glands on the edges of the eyelids which produce oil that keeps tears from evaporating. Ubels notes that retinoids usually work against androgens. Examples of this action include such things as drugs like Retin-A and Accutane, which contain forms of Vitamin A and are used to treat acne, which is stimulated by androgens. In fact, people who take Accutane often suffer from dry-eyes because the vitamin A in the medicine works not only against the androgens causing oily skin, but also the androgens which help tear glands lubricate the eye." - 39

Interesting. Will too much oral vitamin A will suppress androgens? Need to find out of Retin-A and Accutane are topical or oral and if oral, what do they do?

One site says, "Ointments containing vitamin A can help dry eye if it is caused by unusual conditions such as Stevens-Johnson syndrome or pemphigoid." - 44

 

 

Pollution

Pollution and Dry Eyes

Certain environmental toxins can interfere with the endocrine (hormone- producing) and reproductive systems to a degree that merits public concern. Environmental pollutants that can mimic the hormone estrogen include DDT, DDE, kepone, heptachlor, PCBs, dioxin, and break-down products of detergents. Many of these compounds can be carried for long distances through air pollution (from municipal solid waste incinerators, cars) and then deposited into soil and water, and eventually into the food chain. 

Dioxin

Dioxin, one of the most toxic chemicals in the environment, is capable of blocking estrogen action, lowering levels of androgens (male hormones), and affecting the amount of thyroid hormones produced.
http://www.nutramed.com/environment/airpollutionintro.htm
http://www.monitor.net/rachel/r508.html

Airborne dioxin eventually makes its way into the food chain, concentrating especially in fish, a favorite food of the Japanese. There is a blood test for dioxin. As proposed for the United States, people should consume no more than 0.01 trillionths of a gram per kilogram (of body weight?)
http://www.lexingtonma.org/swat/Sep0398N.htm

Dioxins are produced when chlorinated products ( weed killers, paper bleached with elemental chlorine and polyvinyl chloride (PVC) plastic) are made and again when these products are burned.

 

Bisphenol A (BPA)

The chemical bisphenol A or BPA is a xenoestrogen (hormone disrupter). BPA is one of the most commonly used plastic materials. It is found in all kinds of common products, mostly in polycarbonate plastics. Nearly all plastic baby bottles in the U.S., many common food containers, water storage bottles, aluminum can linings, and even some kinds of dental sealants. It is ubiquitous, one of the top 50 chemicals in production.

According to the Los Angeles Times, two billion pounds of Bisphenol A are used yearly and at least one study has linked it to severe birth defects.

"Bisphenol A can also act as an antiandrogen, blocking the action of dihydrotestosterone in a yeast screen containing a human androgen receptor (Sohoni and Sumpter, 1998). In this screen bisphenol a was approximately as potent as flutamide, a well known anti-androgenic chemical." - lineone

BPA does not bind to normal androgen receptor known as AR-T877A, but BPA induces androgen receptor activation according to one study.

ACTION: Get new glasses.

WHY: If the lenses and frames of your glasses are made of polycarbonate plastic and they are yellowing a bit this could be a problem. Old polycarbonate leaches much more rapidly than new polycarbonate. Mine are "High Index Plastic" and I've had them for two and a half years. They are yellowing. Today, 3/25/04, I replaced the nose pads which were also yellowing and I ordered some new glasses.

ACTION: Don't eat food heated (e.g., microwaved) in polycarbonate containers.

WHY: The hotter polycarbonate gets, the faster bisphenol A leaches out of it. Other than the "eggmit" bagels at Noah's I've been avoiding microwaved food for a long time. Microwave in glass or ceramic.

ACTION: Stop drinking from plastic water bottles.

WHY: bottled water may be packaged in polycarbonate plastic. (A #7 recycling code on the bottom of some containers like large water bottles in water dispensers, indicate that they are made of polycarbonate.) Use glass, ceramic and metal containers. This is pretty hard to do. I've been drinking at least two bottles of plastic water per day for the last year or more.

ACTION: Move.

WHY: For the past few years I've lived by a freeway and a plastic recycling plant.

"The effect we saw is pretty dramatic," Hunt tells WebMD. "We were stunned by how low a dose it took. I am becoming pretty convinced there are significant effects [of BPA] at pretty low exposures. I can't say how scared you should be because our studies don't say anything about humans. But that's why we study animals. We assume the processes are pretty well the same in humans." - 40

According to one study, 2 ng/g or 20 ng/g of body weight is an environmentally relevant concentration of BPA. - 41

ACTION: Check with dentist about sealants used.

WHY: "Some plastic dental sealants leach bisphenol A, others do not. According to some estimates , the use of bisphenol A in sealants is declining and no sealants currently recommended by the American Dental Association leach BPA. Ask your dentist about the details of the sealants he/she is using." - 42

More ideas

One article mentions these things: all-trans retinoic acid, pilocarpine, bromhexine chloride and eloisin. Anti-inflammatory medications, such as steroids, antimetabolites and cyclosporine A, as well as tetracyclines and hormones, are used to treat more severe forms of dry eye. Surgical techniques used to preserve tears include punctal cautery, punctal plugs and tarsorraphy.

Interesting, but not sure what to make of it:

1. Abnormal protein profiles in tears with dry eye syndrome. Found decrease in both lactoferrin and EGF proteins. - Am J Ophthalmol. 2003 Aug;136(2):291-9.

RESULTS: After one night of the fish oil, some protein powder, flaxseed oil and the warm washcloth before bed, I woke up without dry eyes. It was raining outside and that made the air more humid. Will have to see how things go over time. Problem continues however on other nights.

 

My Dry Eye Journal

 

4/2/04 Tried the same formula as below, except I did use my cell phone. Woke with dry eyes again. Slept longer, probably 1 AM to 8 AM (7 hrs). If DHEA does help, perhaps it only lasts 5 hours? Or it could be something else. Something in the air? Tried getting away to the country and one night of clean air didn't help any.

3/30/04 Did something right! No dry eye in the morning! Drank a shake before bed at about 2 AM and got up at 7 AM (5 hrs). It had 1 banana, a scoop of protien powder, about 5 mg of DHEA, 2 grams of cod liver oil, 2 grams of vitamin C, and two eye formula vitamins (ingredients to follow). Also I've stayed away from bottled water for the past 3 or 4 days. Also stopped using my cell phone (temporarily lost it.) And, I've been running and lifting weights for an hour every other day. Feelin' pretty damn good, other than having a bit of a headache. Will see how I do tomorrow.

3/26/04 Humidity 43%. Only a little red and sore right now. Woke up this morning with eyelids stuck to eyeballs. Protein and multi vitamin shake in the morning. This is day of rest for exercise.

3/25/04 Ordered new glasses with high-index plastic. Had yellowing plastic nosepads on current glasses replaced. Asked lens maker about chemicals in high-index plastic.

3/24/04. Not bad in the morning, terrible at night. Tried DHEA 10 mg in the morning. Then Ran 20 minutes, lift weights for 35 minutes. Protein and multi vitamin shake in the morning. Eyes seemed better. Had some headaches during the day. Very dry and stinging at night, one of the worst time yet. DHEA might be dangerous long term from what I've read.

References

1. http://www.google.com/search?q=three+layer+tear+film
2. http://www.google.com/search?q=sebaceous+glands
3. http://www.google.com/search?q=lacrimal+glands
4. http://www.google.com/search?q=meibomian+glands
5. http://www.google.com/search?q=mucin+layer
6. http://www.google.com/search?q=Neural+Arc+dry+eyes
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41. http://ehp.niehs.nih.gov/docs/2003/5440/abstract.html
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43. Wetherill, YB, CE Petre, KR Monk, A Puga, and KE Knudsen. 2002. The Xenoestrogen Bisphenol A Induces Inappropriate Androgen Receptor Activation and Mitogenesis in Prostatic Adenocarcinoma Cells . Molecular Cancer Therapeutics 1: 515–524 .
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45. http://eces.org/articles/000116.php
46. http://www.checnet.org/healthehouse/chemicals/chemicals-detail.asp?Main_ID=275
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49. http://website.lineone.net/~mwarhurst/bisphenol.html