As part of the benefits of joining the HealthTap Medical Group, doctors gain access to exclusive educational opportunities. On Sunday, April 18, 2021, at the monthly HealthTap Medical Group Webinar, Dr. Sandra Lora Cremers, of Johns Hopkins Medicine and the Visionary Eye Doctors, presented on the causes of dry eye disease and meibomian gland dysfunction. Dr. Cremers is a widely respected and experienced researcher and clinician in dry eye disease, having spent a decade at Harvard Medical School and the Massachusetts Eye and Ear infirmary. She is a fellow with the American College of Surgeons, specializing in cataract and pterygium surgery. HealthTap is delighted to share the learnings from her presentation below:

[Dr. Geoff Rutledge]: I am delighted to introduce today - we are delighted to see Dr. Cremers, Sandra Cremers, who is presenting, is going to tell us about dry eye disease. Dr. Cremers is an ophthalmologist who has specific expertise. And we're delighted that she's going to share it with us. I'll advance the slides for you. Just tell me each time.

[Dr. Sandra Lora Cremers]:

Thank you, Dr. Rutledge, and thank you, Angela, for inviting me. This is an honor to speak to everybody on this very important issue. All of us that are listening and that will listen to the future will come into this issue very probably within a few years, if not yourself, or a loved one.

And so we are very, very happy to note that we had a paper that just got accepted for publication in a top ophthalmology journal that has to do with the children we're seeing with really significant dry eye disease. And when we always among my colleagues, we joke when, when my colleagues from Boston, when I was at Harvard, we used to talk about how dry eye disease was an old lady disease. And the patients we saw with dry eye issues, such as foreign body sensation, redness, tearing, burning dryness, itching, even were usually, you know, unless it was an allergy season, it was a young person. Most of the time, a significant dry eye patient was an old woman. And now we're seeing it in children as young as six years old. And we are one of the first to kind of show how we can show this and I'll show you how we figured this out, with some interesting twists to this issue. So we have submitted this publication, after COVID, but all the research was done pre-COVID and now since COVID started and all these children are on Zoom and all of us are on screen times more, we're seeing more and more people, especially teachers, physicians that are on screens coming with, I feel my eye at the end of the day, I can't put my contact lenses in, and it's burning, my eyes are so tired and a record number of styes and chalazions are coming in in record numbers. So I wanted to tell everybody about this, please look out for this paper, because it's going to make, I think, quite an impact.

And so we can go to the next slide and kind of go through this here, but I want to just present a classic patient. We see, and some of you are in this category or, you know, somebody like a child or a parent even, or a colleague or a spouse that has this. So the typical examples of 40 year old programmer, especially a woman, comes in with redness and burning for months before they see us, because they've been trying to ignore, trying to do over the counter drops and their screen time electronic screen time or cumulative screen time is often more than four hours. If you think about yourself, how many hours am I on a screen? How many hours are you on a screen? Well, most people are on 10-12. And so a lot of these patients like this patient for instance, was feeling seven out of 10 pain and was unable to put her contact lenses in. And that was a big issue, because of course she needs her contact lenses.

We can go to the next screen. And so basically the question is, what do we do? So we do a full eye exam, on the bottom right is a little bit of a Schirmer's test, just the past medical history here. This particular patient had Accutane. And then, basically had LASIK before, which we know these two factors of Accutane and LASIK can dry out the eye.

And then we did a full exam and we noticed that her Schirmer scores were a little on the low side. That's a little strip test in the bottom right. And then we can go to the next screen.

Everything else looked fine. She had a little bit of Demodex mites. A lot of, a lot of us have this without knowing these tiny little kind of, I don't know if you guys can see my cursor, but at the base of the eyelash of these tiny little mites, most of us have on our body, especially for a Caucasian, for some reason, these mites love Caucasian patients, especially if you have rosacea, some of us here listening have rosacea. And so these tiny little mites we think bore into the meibomian gland, which I'll show you what that looks like. And they cause the gland to scar. And we'd like to clean that off. So it used to be, we always used to think, well, in the morning you might have some crusties and that's normal. Actually, it's not normal. You shouldn't really have crusties. And so you should not feel your eyes ever, even when you wake up and if you do, there's a combination of bacteria, these mites, dead cells, you’ve got to clean it off cause they will, they will actually cause damage to the glands. So this patient did have ocular rosacea and we can go to the next slide here.

And we can tell that on the microscope. And the way we can tell is basically on these kinds of videos here, you can see the little red blood vessels under the slit lamp microscope crossing into the meibomian gland. And so she had already inflammation in her eye, the redness, and it was starting to have the inflammation creep on the cornea. Let's go to the next slide.

And so we do tear osmolarity, which is a measure of inflammation. Otherwise, everything else was normal from her medical exam. She didn't have diabetes, no history of autoimmune disease in the past, no joint aches, no dry mouth. We can go to the next slide.

So we did what’s called a meibography. There's many kinds of meibography, but on the bottom right, you can see these kind of what it says, normal glands on the bottom left. It has these white little lines that are parallel like white piano keys. And everyone that's listening should have these white looking piano keys until you're about 90 years old. I've had many 90 year old patients that look perfect. A friend of mine, who's 90-something came in, we imaged her and she had perfect glands. And she just got her first flip phone. So there's certain things that affect these as you go towards the right there's severe gland loss, where these white keys are, these white lines start to shrink. And that's a lack of meibum, which is an oil, which is crucial for us not to feel our eye ever. And when you don't blink, if you don't blink for five minutes, let's say, you know, you don't try this and you don't blink. Everyone will have horrible pain. You'll be forced to blink. You'll have blurry vision, it'll burn. And it might even be painful for a few minutes, seconds, two minutes afterwards because the oil is so crucial in lubricating, the most sensitive part of the body, which is the cornea, which has the most number of nerve fiber endings per square millimeter in the entire body. So this oil is priceless and when the oil dries up, it's very difficult to bring it back. So that's the number one complaint. After any eye surgery, whether it's a stye removal, cataract surgery, pterygium surgery, corneal transplant, the number one complaint is foreign body sensation, burning, dryness, pain. And it's almost always due to the glands being dried up either from aging, previous issues with not blinking screen time, genetics, contact lens use and auto immune disease. We can go to the next slide.

So this patient's glands look like this. So this is kind of a schematic of how we grade it and scale of zero to really four. Now it's zero to three. So it's basically a kind of a four point scale. You can go to the next one there.

And then, so if you can see, it's very hard to see, but there'll be these tiny, you see them on the upper, right? And the upper left here, these tiny little white kind of, this is the eyelid everted. So the eyelid's been everted and you see these tiny little white dots that's what's remaining of her glands, which means her glands are almost completely gone on the bottom is the infrared and on the upper, right. You can see she has a little bit more oil on her left, lower lid. And just to remind you on the bottom left, this is the normal way she should look. She's 40 years old and she's lost the majority of her oil glands. And so when we see somebody on the bottom, right, which has lost one gland, we treat it as an urgent issue because it is very difficult to bring back that gland. We have an IRB investigational research protocol, trying to bring back those glands. And it is very difficult. So we want to save the glands. So we've seen children, and that's what this paper is about. That looks like this 40 year old computer programmer with scar tissue on the cornea. And I've now had to tell patients that their, or the parents of a child, your child probably could not become a computer programmer until we fix the blinking issue. So the idea is people are staring at the screen. They don't blink, especially kids. And they teach themselves to forget to blink. Even if they have symptoms, they'll train their brain, focus on the video game, focus on whatever they're doing on the screen and don't blink. And when you blink, you're milking out that oil gland. And that's the only thing at home besides warm compresses, which we tell people, and we'll go through and just a few minutes, but warm compresses, 15 minutes, twice a day is the minimum plus frequent blinking. Meaning every two seconds you should be blinking or close your eyes. And I tell people, close your eyes. If, if you know what I look like, close your eyes, you know, try to express yourself with your voice, your hands, whatever, but close your eyes. So that's the number one thing we're concerned about is the blinking rate in these children. The second thing is the blue light. Most of us that are here, don't have a blue light filter on your screen, but we think that that is probably something we should all really consider, especially for on a screen, more than four hours a day, the data is not there yet to prove this. That's why most optometrists, most ophthalmologists, most doctors don't discuss this because it has not been proven. But my theory is, and this is now obviously being passed around is that if you have rosacea or you're Caucasian, or you have blood vessels closer to the surface of your eyelid and skin, the blue light is being absorbed by those blood vessels, leading to the cycle of inflammation, inflammation leads to scar tissue. And for the first time in history, we can show patients the scar tissue. This is a brand new machine that just came out about five years ago in the world. We were lucky to be one of the first in our area to have it. That's how we got this paper published, but you can finally show patients that there is scar tissue. And if you ignore your eyes, it's a disaster. So you never want to ignore your eyes. We can go to the next slide.

This patient's upper lids, the right upper lid on the left upper slide here, you can see the white, tiny lines under the everted upper lid is what's remaining of her oil and on the upper right slide. This is her left upper lid that’s been everted, and you can see where the glands were located. So her glands are really significantly dried up. We can go to the next slide.

We always ask the question. What's the next most important question to ask? Well, of course we will ask things about allergies because we know allergies is a component, but really the next most important question to ask is, do you have any joint aches, dry mouth back pain? You have to be very specific.

And what we found- and we can go to the next slide- is that in the children we were seeing the majority of patients had no systemic symptoms at all. And this is true for most of our patients. There's no complaints of arthritis or any type of issue, but there's an underlying potential auto-immune disease going on in these patients that for some reason dry up their glands, even faster than just the screen time. So we can go into the next slide.

The most common cause of dry eye symptoms is this, meibomian gland dysfunction that little, those little white lines are called. Meibomian glands are filled with meibum oil. And that lack of oil is the number one cause for any dry eye symptoms. So we can go into the next slide.

It's become a $5 billion industry. I'm sure many of us know people that have issues with their eyes. There are three parts of the tear film. The oil is the most important that comes from the eyelids. The watery part comes from the lacrimal gland under your orbit here. And the third as you know, oil and water don't mix. So the third is called mucin, which mixes the water and oil really perfectly for most patients. And that comes from the goblet cell on the surface of the white part of your eye. The number one issue as I mentioned is the oil, but we also look for the watery part being affected. And then the goblet cells is harder to kind of assess. We know that dry eye pain is equivalent to chronic angina in terms of quality of life scores. We treat it very seriously. I tell people, if you feel your eyes, it's like feeling your heart. If you feel your heart, you're going to the emergency room. So do not ignore it. Do not think it's normal. Just get it checked out right away with a meibography. You can go to the next slide.

And of course this issue increases with aging. So the thing that we were surprised with this patient is that that was so, so dry for a 40 year old. Her glands were so dried up. So we now know that auto-immune diseases not only attack the watery part called the lacrimal gland or the aqueous component, but it also attacks the oily component. So we always have to look out for autoimmune disease like lupus, rheumatoid arthritis, any type of the sclerosing sclerodermas, even thyroid of course, rosacea, any type of autoimmune disease can cause this, we can go to the next slide.

So we asked her other questions about any type of weight loss or any type of issues with depression, anxiety, and so forth. So we do know that we want to pick up some of these autoimmune diseases, such as Sjogren's syndrome, which is one of the most common things we've been now diagnosing with this technology because they have a rate of about 10% can develop malignant lymphoma, like a low grade MALT. And so we want to be the ones to kind of help those patients get checked out for that because that's something that sometimes your local eye doctor is the first one to diagnose this. So in my entire career and I was at Harvard for 10 years, I have never diagnosed as many patients with Sjogren's that I have in the last four years since this technology came out because we are, It's probably one of the first symptoms is a dry eye component with a lot of these autoimmune diseases. So we've really been shocked by that. And especially in young people, which is kind of surprising. So our patient tested for Sjogren's was positive. We referred her to rheumatology, and it was that's how this kind of paper started. And even though my paper did not show a statistically significant difference between the controls and cases with autoimmune disease and the children, we found about 56, I think it was, or 60% of these children had a positive auto-immune disease marker. The ones that had very dry glands, the glands had dried up. So we're hoping that some will be able to expand the cohorts to see if this is really something that needs to be looked at long-term. Oh, you can go to the next slide.

So I do recommend to everybody who's on a screen more than four hours a day to get in meibography at least once a year. And so all of you remember some of the symptoms of the Sjogren's dry eye, dry mouth arthritis, that the classic one, they can also get all kinds of things in terms of muscle discomfort, vaginal dryness, dryness of their skin, peripheral neuropathy, stomach upset, all kinds of stomach issues and so forth. But of course you know, we're looking at the eyes and, and thinking about the, the underlying issues that can kind of spiral in terms of dry eyes, in terms of anxiety, depression, and so forth.

[Dr. Geoff Rutledge]: I would comment, if I may, Dr. Cremers, that, we recently had a presentation by one of our esteemed neurologists who was talking about small fiber neuropathy. And one of the things he commented on was the discovery of how many people with the unexpected small fiber neuropathy actually had Sjogren's also. So we're getting a lesson on Sjogren's here. I have a question, but I'm going to wait to let you finish your presentation to get to the questions, by the way, for the other docs in the group. If you have questions, please type them into the Q and A session. And we'll ask Dr. Cremers, when she's ready to respond.

[Dr. Sandra Lora Cremers]: Thank you. I did read a little bit of that presentation and it is true that that is a big issue, but it is much less uncomfortable to get a meibography than a biopsy of a nerve. So, so in doubt, always see your ophthalmologist. But this is not--

[Dr. Geoff Rutledge]: Speaker 1: Hang on, in all fairness, Dr. Machanic was describing a punch biopsy of the skin.

[Dr. Sandra Lora Cremers]: Oh, okay. Okay.

[Dr. Geoff Rutledge]: Easier than having a dissection and a nerve biopsy, yes.

[Dr. Sandra Lora Cremers]: So you can go into the next slide. So basically we do want to treat these patients early, as I mentioned, and these are many of the risk factors. Many of us of course have the aging and genetics screen time issue. Some of us have a contact lens, rosacea previous refractive surgery. Accutane has been a big problem for our patients in terms of the way the Accutane can dry up the meibomian glands. And of course, things like previous eye surgery, diabetes auto-immune disease, poor diet, allergies, environmental issues are also risk factors.

[Dr. Geoff Rutledge]: Can I ask on this point about Accutane? I think that's something many primary care doctors would see in practice, which is people have a history of having had it at some period. Are you saying saying that a single course of Accutane at one point in adolescent development will lead to- and is there a clear timeframe around--

[Dr. Sandra Lora Cremers]: That's a great question. We are of course, skewed to see the worst of the worst in the world, in the country. And I do get consults from all over the world now on patients that have had Accutane, even one course, and we don't know how to explain why it is. Some people do great. Like my best friend was at one Accutane for months, and she has no problems with her eyes. But then again, you know, she's not that old. And so we don't know why some people have a really negative reaction in terms of their glands and dry eye symptoms. And some people have no issues. But my theory is that it's a couple of issues with maybe turning on an epigenetic, like a gene or there's something other gene, not Accutane, but it turns it on or the combination of Accutane plus screen time, plus maybe a poor diet or whatever it may be. There's a couple of issues. So Accutane for sure, in our practice, I would say we clearly believe Accutane is drying up the meibomian glands in a particular way in certain patients, whether it's been proven in a randomized control prospective study in terms of meibography and dry eye disease, I have not seen that study, but if you go to any blog on dry eye, you're going to see thousands of patients that say that Accutane made their dry eye worse, or caused them to have dry eye.

[Dr. Geoff Rutledge]: But it's something that happens right away. It's not something you get 10 years later?

[Dr. Sandra Lora Cremers]: It can happen a few years down the line. For instance, we have a bunch of patients that had Accutane when they were teenagers, and then they have LASIK in their twenties or thirties. And then all of a sudden, you know, and, if they had Accutane early on, but then they're in a very, heavy computer environment where they have to be on the screen for 10 hours. It tips them over the tipping point. So I think all dermatologists should mention that risk to Accutane patients and most do not. And that's a problem, but we do see a lot of patients that have Accutane related dry eye disease.

The problem with dry eyes, you probably all know is there's no definitive diagnosis. There's no, you know, pregnancy tests. That's easy to say that that's clearly, you know, the issue. So it's a combination of symptoms and what we see under the microscope at the slit lamp exam, that meibography has been very helpful, as well as MMP nine and tear osmolarity. Those things help- Schirmer's- but they also have false positives too, in terms of the Schirmer's, the tear osmolarity and MMP nine. So it can be sometimes tricky to say, it's truly dry eye, or is it the meibomian gland or the aqueous, or what's the real cause. And so we always tell doctors when we're talking, if you have any patient that does have redness, any type of foreign body sensation or even excessive tearing, which is like a free flex tearing, the eye senses dryness, and it sends a signal to the brain and locally to produce more tears, because the tear film is evaporating too quickly, because there's not enough oil. So that's actually a sign of dry eye, that excessive tearing, which is counterintuitive. Itching, vision being blurry. If it's not going away in a few weeks or months, by all means, send them for meibography. You will be doing your patient a big favor, especially if they're young because you need these glands until you're a hundred years old. And there is nothing worse than seeing a patient that is in chronic pain from something that was preventable, you know, obviously years down the line. So we recommend that referral as soon as you can. You can go to the next slide.

And so we basically always ask what's the next treatment? So this patient had Lipiflow, which I'll go through in just a few minutes of what it is. So the number one treatment we recommend, and I talked to people in my office about the two paths to getting you better. The most important are: save those glands, save yourselves, avoid further scar tissue. And the second most important is to get rid of the symptoms. So within that path of saving your glands, there's really only three ways to save your glands. The first way is warm compresses, 15 minutes, twice a day. Like I mentioned, blinking exercises, all that typing with your eyes closed. I tell patients all the time, print things out, don't read it on the computer. Don't worry about the trees, worry about your meibomian glands. You know, that's the first way and the only way at home to kind of blink and keep the oil pumping is with that heat and blinking or a little bit of just gentle massaging without hurting the eyeball, getting that oil to pump out. The second way is called thermal pulsation. And I have a picture of that in just a few minutes, which is a little apparatus that takes about 12 minutes. One is called LipiFlow when it's called iLux. And it's just a little apparatus that goes along all four eyelids, and it just provides heat and compression like milking a cow, same idea. The more you milk the oil, the more oil will be produced. It's FDA approved. It's just not covered by insurance. The third way, which we've been now doing thousands of patients around the world, is not FDA approved, It's uncomfortable. And it is experimental really, it's called intense pulse light and meibomian gland probing. So intense pulse light is where we shine a very bright light. This is the IPL that's been used for years for wrinkle removal, tattoo removal, skin, blemish, cosmetic stuff, with rosacea. But it turns out that is one of the best ways to liquefy the oil, kill mites and decrease inflammation. And then the doctor or surgeon will express the oil to get the oil to come out. So like another milking machine, meibomian gland probing is where we take a microscopic probe under the microscope. And you go into every single gland to break open the inner scar tissue. Both of those procedures are uncomfortable, not covered by insurance and not FDA approved, but we have thousands of patients from all over the world coming in for those, we try to catch patients really early on, so they will not need option three.

It's not pleasant for anybody, but we have had to do it because there's nothing else that's helping. We can go into the next slide.

So for this patient, we recommended continue the warm compresses and if Lipiflow didn't help, which it doesn't help, if you don't have enough oil to milk, LipiFlow is not going to help. You need to go on to that third option. So that's what she did. We can go on to the next slide.

So this is kind of on the bottom left is the intense pulse light where we shine this very bright light. In the middle is the probe, a very microscopic probe that goes into each gland, a breakup in the scar tissue and on the bottom, right, is the expression of the oils. You can kind of see this oil is very thick. It's kind of toothpaste-y. It should come out like olive oil, literally like pouring out olive oil. And when it doesn't, it means that when you blink the oil is not coming out either and you need to put either some heat or compression to kind of get it to liquefy, so it'll come out like olive oil. So that's kind of those two procedures. And there was a paper that was not sponsored by any of the companies, not by the IPL machine, not by LipiFlow, not by the meibomian gland crew- and I have no stock in any of these companies. They had a cohort of just patients that had intense pulse light for dry eye, another group that had just probing for dry eye and one that had both. And the group that did best on their symptom score and what their meibography did over time was the one that had the combination. So it looks like by opening up the scar tissue and then milking it, you have a better chance of getting relief and saving those glands. You can go on to the next slide.

And so LipiFlow, on the bottom right, and the bottom left, is FDA approved, and also on the bottom right. This is a patient having a LipiFlow. It's basically a machine, really minimal pain. There's a YouTube video of me having it done. I do mine usually twice a year because I don't want to need option three, but basically it kind of just milks the oil, not painful. It's just not covered by insurance yet. You can go to the next slide.

And so this patient basically continued to increase their warm compresses to three times a day for five minutes. The studies say 15 minutes, twice a day is the gold standard, but we try to do whatever we can. We recommend looking away every 20 minutes from the screen blinking, looking 20 feet away for 20 seconds. If you can do even more, better type with your eyes closed. If you know what somebody looks like, close your eyes, like I mentioned, I tell people whenever I wash my hands, I wash my eyes. Don't worry about, you know, anything with makeup. You want to save those glands. And the patients that have Demodex crusting there're many products over the counter. Now, it used to be only diluted tea tree oil was available, which is very effective, but can burn like the dickens. So you have to be very careful with it. I have videos on YouTube to explain how to use it, but there's now over the counter products like hypochlorous acid, something called Avanova. So there's sprays that kind of just kill these mites on contact. And most of us, if any of you have ever had a style, you've had Demodex or if you feel crusting in the morning, you probably have Demodex. It’s part of our flora. It's just, we want to keep it away from the glands because they will destroy those glands. And so this patient did have meibomian gland probing and had a significant decrease in the pain, to a two, from seven out of 10 to two out of 10. And the idea is that there's a buildup of pressure that leads to the pain. And so by opening up each gland in some patients, it can really help with the pain score. So we've been kind of surprised by this because it's not something I learned in residency, but it does seem to really work. We can go onto the next slide.

So the key thing is to basically make people aware, especially your children, grandchildren, spouse, people you love that the screen and just dry eye disease is real. It is a global pandemic. It really is. Especially now with COVID. This was, I would have said the same thing pre-COVID and now it's even more of an issue to recognize that eye discomfort can be equivalent to chronic angina. As I mentioned, you want to really be aware of that, minimize screen time, as much as you can, make sure you're blinking, taking breaks, you know, blink as much as you can. We are now of course, recommending things like blue light filters for screens, even though we don't have the data. It's going to take about maybe 5-10 years to see if that's really true, but why would you wait to do it? Because it's such a low risk. And then of course we always recommend ruling out any auto-immune disease.

[Dr. Geoff Rutledge]: Just to underscore that point a little bit, Sandra, if I may ask, when you're talking to a number of doctors who are working- their life work involves doing video consultations, using the computer screen to meet patients and deliver care. Did you have any specific recommendations or suggestions for doctors who are giving video visits?

[Dr. Sandra Lora Cremers]: Absolutely. I still say the same thing. And I tell patients if you know what I look like, and I'm not telling you to look at me, close your eyes, you're not going to, I'm not going to be offended. You know, we can kind of close our eyes. I turned down the light of my screen as low as possible, and a blue light filter on my screens is also very helpful. Take long pauses, make sure you're blinking every two seconds, if you can. Those kinds of things help to try to minimize looking away a little bit, you know, trying to avoid that kind of constant blue light on the eyes and then trying to blink to get that oil to pump out. So I tell people things like, you know, dictate to Siri, call your friends, don't text them, avoid social media at all costs, unless you have to and really try to emphasize different things. You can use, like your hearing or your dictation to Siri or, or whatever you're using to kind of help you use your voice and your hearing as opposed to just your eyes. So you use your other senses.

[Dr. Geoff Rutledge]: Okay, cool.

[Dr. Sandra Lora Cremers]: So basically we of course mentioned that the warm compresses, the lid hygiene, the cleaning of the, basically blinking exercises with a little bit of massaging, and you can try and get that oil to come out. We talked about LipiFlow, which is FDA approved and the other two ways to save the glands, which is intense pulse light and meibomian gland probing, which are not FDA approved. You can go onto the next slide.

We're trying to minimize debilitating pain. And we're seeing a lot of people, even physicians, that are really starting to almost become suicidal because of the pain, it's going to be really anxiety provoking to have this kind of constant pain. So as I mentioned, the two paths to get you better, the most important is to save the glands. That's the three options, the warm compresses, thermal pulsation Lipiflow. And then the, meibomian gland probing, or the IPL, that's to save the glands to help with the symptoms, which do not always have, have not been proven to save the glands or things like artificial tears over the counter, eating Omega-3, which is still controversial, but we still recommend it. The three FDA approved drops for dry eye are Xiidra, Restasis, and Cequa. There's no generic yet. Punctal plugs, which is a little cover over the drain, which is one of the oldest treatments of dry eyes. It just keeps the tears in the eye longer. It's not really therapeutic. Other than that, we now know biologics are one of the best ways to help with the symptoms such as your own serum, your own platelets, cord, blood serum. We know these things help. It's been published in the literature for years. And so that is something that can be used even on children because it's their own cells and very, very safe. They have natural antibiotic, natural anti-inflammatory growth factors, interleukins that heal the surface of the eye. And so when patients that cannot afford the Xiidra, Restasisor, or Cequa, because sometimes those insurances won't cover them and they can be as expensive as $900 a month serum and platelet rich plasma, or a fraction of that because it's the patient's own cells. So that's been very therapeutic and very helpful, things like testosterone cream, amniotic membrane has also been used for this, scleral contact lenses. And then of course helping with the other environmental factors, such as the humidifier, allergy controlling the allergies. So trying to use only disposable contact lenses, only use your contact lenses for contact lens worthy events, take them off as soon as you can. Try to take breaks on the weekend. Those things help you last longer in your contact lenses, if that's important for you, and if you can avoid refractive surgery even better.

So the issue is that now this used to be, as I mentioned, an 80 year old disease, and now we're seeing the need for these biologics and these other drops at age eight and as young as six now in my practice and no drops in the FDA realm that are approved for dry eye by the FDA are allowed in children younger than 16. So what do you do for those, you know, six and eight year olds that you see? You know, it's becoming an issue for us. So, those are the risk factors we discussed. You can go to the next slide.

So take home message is if you have constant redness and it's not getting better, it's an urgent condition. Get a meibography. I highly recommend anyone that's on screens, more than four hours a day for your own sanity to get a meibography at least once a year, I get mine twice a year. I put it on my blog. And I also, you know, decreasing with screen time. It's really crucial because you do not want to ignore this. You take breaks minimal screen time, type with your eyes closed. Like I mentioned, taking breaks every 20 minutes, at least. I do it even more. Consider blue light filtered glasses, warm compresses. I have a plug-in next to my bed, have a little kind of, mine's called the Wizard, but there's now one called a Roma. They’re just kind of like this heat, that just goes right along your meibomian glands. So I put it on before I go to bed. And then before I get out of bed for 15 minutes, it lasts, mine goes up to 40 minutes, but it just provides enough heat. And then I just push a little bit of pressure or I lift it and then blink to try to get that well to pump out. So I keep my oil glands pumping and that's really a minimum at home that we need to do. And I recommend LipiFlow once a year and anyone that has any gland scarring because you do not want to come see me for option three. It's very uncomfortable, next slide.

And so check out, you know, ironically I tell people, check out my YouTube channel or my blog, but you can listen to me on my YouTube channel. You don't have to watch me. One of the, the first videos there, it talks about this paper that we just got accepted for publication about these kids that really look like this 40 year old woman, that's a computer programmer. And, that really was kind of a surprise for us to find that, but you know, we're all researching this because this is the number one complaint ophthalmologists see in the world is dry eye issues. And so we always take this very seriously before any eye surgery, we get a meibography because we want to tell a patient, their prognosis of having this discomfort, or if we're doing pterygium surgery, which is a growth on the eye, if we remove it, the risk is it can come back and we have another paper we're about to kind of submit for publication is that we now know that those patients that have a recurrence of the growth tend to have less oil. So there's a predisposition. So by having the patient know what their meibography looks like before any eye surgery, you can give them a prognosis of how the quality of their vision is going to be because the tear film is in charge of quality of vision and quantity of vision. So I can take out a cataract in 10 minutes, but the patient might not be happy with the result because their eyes dry. And so this is really important for us to kind of keep in mind, especially for all of us that are on screens now more and more.

[Dr. Geoff Rutledge]: Sandra, that was a wonderful presentation. There are actually several questions that doctors have asked. I wonder if you, if it's okay. I know we're at the top of the hour, but I'd be delighted if you're able to stay on for a little bit, just to answer these additional questions. Dr. Grim asked two questions. One of them is mentioning tea oil. I assume that was directly applied in the eye, but he was asking, is this something taken by mouth?

[Dr. Sandra Lora Cremers]: No, it's a very good question. So diluted tea tree oil is for the outside of the eyelashes. It does not go in the eye. It doesn't go in the mouth. It's a natural, basically anti-mite killer. So I have a video on YouTube on how I use it. I just take a couple of, like a drop of water, a drop of tea tree oil or two drops of water for a drop of tea tree oil. So, a bottle of tea tree oil will last you a year and it's very effective, but it burns really badly. So you have to be very close to a sink. Apparently the more mites you have, the more burning you have. So there's now products with these little wipes that don't burn as much called Optase. There's one called Clear-o-dex, there is tea tree oil inside the wipe. So it's not so strong. It doesn't burn as much, but the idea is that you scrub your eyelashes, like you're brushing your teeth, to get these mites off the eyelashes. And that will help kind of prevent that chronic crusting that we really should not have even in the morning. So those kinds, I use pure tea tree oil, I dilute it myself. I take the bottle, I tip it over. I take the top off the bottle and whatever's in that top, which is almost nothing. I take a little wet towel or even my finger that's wet or like a Q-tip and I just cleaned it inside. And then I just rub it onto my eyelashes. If I'm in a rush, leave it on for a couple seconds. And then if I need to, I wash it off. And so it seems to be pretty safe unless you have an allergy to tea tree oil to kind of kill the mites on contact, the ones that don't burn, or the sprays that you can get on Amazon or over the counter, like Avanova or hypochlorous acid. There's a bunch of them to kind of kill these mites on contact. Just don't get it into the eye.

[Dr. Geoff Rutledge]: Dr. Grim also asks, and this is, of course, very relevant for doctors doing virtual consultations, which is, how do you get a good eye exam? When a patient comes with a red eye and a virtual visit, you have a high resolution video connection with your patient. And do you have any tips or suggestions or recommendations for what doctors should be doing? And if, is it useful to ask the patient to take a photo using their camera? which we in our application, by the way, the patients can say, I want to take a picture in the middle of the consult. If they're doing it on their mobile device, they can push the camera button, take a picture when they take the picture, it's automatically loaded.

[Dr. Sandra Lora Cremers]: Absolutely. Yes, absolutely. It's better than obviously anything that we can do online is a high resolution picture, right? Really close. I've been known to tell people to flip their eyelid and teach them because I'm worried there's a foreign, a metal foreign body. You can sometimes see with a camera on a virtual visit. Obviously the best is a microscopic exam in the office, but virtually there's some things you can tell. For instance, you can sometimes see a white dot on the cornea, which can mean an ulcer in a contact lens patient or diabetic. That's an eye emergency. You can sometimes see a little foreign body, you're trying to look, of course, for episcleritis see what the, what the redness is due to. Is it allergy, dryness, foreign body, infection, inflammation, autoimmune disease? So those kinds of things you're looking for. But it's harder of course, than with a slit lamp. So any high resolution photo, if you can have them use the iPhone to get really close, trying to still stay in focus does help.

[Dr. Geoff Rutledge]: And I would, I would add to that, in order to get a high resolution picture, you can also ask sometimes is helpful when you're doing a video consult is to ask if there's someone there with them and they'll listen to work on their, their loved one, their partner, and the other person who's available. It's really hard to hold the camera one, two inches in front of your eye and take a picture. But with someone else's help, that might be useful. So thank you for that.

[Dr. Sandra Lora Cremers]: There's a product that, um, it's hard. Patients don't have this, but there's a product that kind of goes right on the actual camera that even takes really, really very, very high focused, pictures that we've used in the office for public or for blogs and things like that. But obviously patients don't have that, but in the future, we'll have it, I'm sure.

[Dr. Geoff Rutledge]: The whole series of in-home measurement devices that would be helpful. But in fact, most people calling from anywhere with the particular problem won't have the device needed. It's a different issue for managing chronic conditions over time. You know, patients go home on glucometers and asthmatics have peak flow meters and everybody has a thermometer and the scale and so on, there are a couple more questions here. Dr. Pasniciuc asked, I think you answered this before, but we'll just confirm. It sounds like heavy screen use is a stress test for eyes. There's probably vision accommodation issues, as well as dry eyes being elicited by screen overuse. Would it be easier to reduce screen use when possible probably never, to treat what seems to be an endemic disease? You said, yes, didn't you?

[Dr. Sandra Lora Cremers]: Yeah, absolutely. And we do know that screen use is being associated with headaches, you know, neck pain, of course, ADHD sleep issues with the blue light, maybe even affecting REM sleep, which then adds to the cycle of inflammation. So it's kind of this computer vision syndrome of anxiety and depression, poor sleep, your ability, you know, people are seeing this headaches, migraines and all this kind of stuff that is kind of related to that stimulation and needing to kind of be on the screen. And we know that dry eye of course can lead to headaches and all kinds of other symptoms, even with things you might not even understand. But yeah, that's definitely related. We think the screen time that the lack of blinking the blue light being the number one and two potential issues that are, that are leading to this cycle of concern with the eyes and even the whole upper body.

[Dr. Geoff Rutledge]: Great. And Dr. Ungerleider, I'll mention, is a pediatrician asks, do you recommend warm compresses, blinking ,washing eyes for anyone who's on computers a lot, which is all of us, right? Even if meibography not done and dry eyes not diagnosed and no pain as prophylactically?

[Dr. Sandra Lora Cremers]: I remember when, you know, growing up little Rascals, the mother would give the kids the, you know, the Cod liver oil, and was so hated. And now I remember, now I know why, because it's, we used to have our kids wash our face every morning. Like my mother always told me, wash my face, and now we're all so busy. We forget to tell our kids to wash their face. So yes, absolutely twice a day, you have to wash your face. And I run around with my kids, hot water. Like I give them their hot compress every day. It's like giving their multivitamin. I make them wash their eyes every day in front of me because they have to learn to do this. So it's a must for everybody.

[Dr. Geoff Rutledge]: But if you're in the shower, letting the warm water run on your eyelids and wash your lids, kind of?

[Dr. Sandra Lora Cremers]: Yes, absolutely. So most people are not there for 15 minutes. That's the problem. And that's what the studies say. Anything is better than nothing, but the studies say 15 minutes, twice a day is the minimum. So, if we do five, five, five, five, does that count? We think so. You know, but there's not been a study on that, but Lipiflow, the thermal pulsation, I mentioned that's the apparatus that does milk. The oil was compared to 15 minutes, twice a day in the FDA trial. So that's why it's kind of the gold standard at home. But yes, I recommend it to every trial that's on any screen. I even tell people do not give your child a cellphone, never give your child a cellphone, maybe a flip phone, but ideally no video games really just think about this Trojan horse, because we are seeing such young people applying for disability because of chronic dry eye, which could have potentially been avoided if they had not, you know, gotten into this addiction of the screens. So really think avoid cell phones, avoid screens. I tell people this all the time.

[Dr. Geoff Rutledge]: Your insights are greatly valued, Dr. Cremers. Thank you so much for your time today. Thank you also to everyone who stayed beyond the hour on a Sunday. Thanks again, Sandra, we really appreciate it. And with that, we'll say thanks again and we'll see you next time.