Dry eye syndrome affects approximately 20 percent of the
population, points out Dr. Desai, a fellowship-trained ophthalmologist and a
cornea, cataract, and refractive specialist with The Eye Institute of West
Florida. Dr. Desai is a top graduate of the Pennsylvania State University
College of Medicine and completed an advanced fellowship in cornea, cataract
and refractive surgery at the world-renowned Wilmer Eye Institute at Johns
Hopkins University. He is recognized throughout the country and internationally
as one of only 100 surgeons able to perform advanced corneal transplants and
other complex cataract, corneal, and refractive procedures. Additionally, he
holds pending patents on new surgical products and advanced cornea surgical
procedures of his own design.
“Nationwide studies have shown that only forty-five
percent of those people with dry eye syndrome, or less than half of those
suffering from dry eye, are even aware of their condition,” observes Dr. Desai.
“Of those who seek help, many are undertreated.”
To learn more about its symptoms, causes, and treatments,
we turn to Dr. Desai and Robert J. Weinstock, MD, known as “Dr. Rob” by his
patients, who is board certified by the American Board of Ophthalmology and
fellowship trained in cataract and refractive surgery. He was the first eye
surgeon to successfully remove a cataract through a 1.2 millimeter incision and
has been invited to lecture and teach other surgeons from around the world on
this safer, less invasive technique for removing cataracts.
FAQs
Q. Dr. Desai, what causes
dry eye syndrome?
A.
As I point out in my patient’s guide to dry eye, there are many predisposing
factors that can lead to various forms of dry eye syndrome. The common link
among the causes is that they all result in inflammation within tear-producing
glands of the eye and on the ocular surface. This inflammatory response is
disruptive to the delicate balance within normal, healthy tears and results in
a decline in the quantity and quality of tears produced.
Q. Dr. Weinstock, what is
the importance of the quantity and quality of tears produced?
A.
When light enters the eye, the very first thing it hits is the cornea, or
window into the eye. Normally, the cornea is coated with tears. However, if
healthy tears are not coating the cornea, it dries out and no longer has a
nice, smooth surface for you to look through, so no matter how good your eyes
are, your lens implant is, or your LASIK surgery was, your vision can’t be good
if the cornea does not have a healthy, smooth layer of tears over it.
Q. What do you mean by a
healthy
layer of tears?
A.
Tears are made up of three components: a water layer, an oil layer, and a mucus
layer. Those three layers have to be in the right concentrations in order for
the tear film to cover the eye properly.
Q. What is the most common
cause of dry eye syndrome?
A.
Tears are produced by glands up under the eyebrow towards the outer portion of
the eye. As part of the natural aging process, these tear glands begin to
produce fewer tears. Therefore, it is very common for older people, as the
hormones of their bodies change, to experience dry eye syndrome.
Q.
Dr. Desai, what does it mean when physicians say that dry eye is often
undertreated?
A. For far too long, the paradigm for treating dry eye has
been to hand patients samples of artificial tears and send them on their way.
This really does an injustice to them because dry eye is a fairly complex
disease and needs to be treated as such. Relying solely on artificial tears
ignores the underlying reason for dry eye, which is ocular surface
inflammation. Unless and until that inflammation, which really drives dry eye
disease, is treated, patients will continue to suffer long-term.
Q. Dr. Weinstock,
what is the correlation between surgeries such as cataract and LASIK, and dry
eye syndrome?
A. The tear production is a very complicated process
because there are other factors that control how fast the tear gland produces
tears. For example, the corneal nerves send messages constantly to the tear
glands to make tears and, if the corneal nerves are not working properly, or
are damaged for example, by a viral illness or by other conditions, the message
will not be properly received.
Even eye surgery temporarily damages those nerves. There
is no way to avoid cutting a few nerves in the cornea, and while those nerves
will regenerate, during that healing time the feedback between the tear gland
and the nerves of the cornea is disrupted. The tear gland does not produce
enough tears.
Q. Is that where
your micro-incisional surgery comes into play?
A. I use the smallest incisions of any surgeon in the
country. The smaller the wound, the fewer nerves are cut, which means the less
dry eye patients have after surgery. So it is definitely advantageous for
patients.
Q. Dr. Desai, we
are including a list of dry eye symptoms with this article, but we would also
like to know if dry eye can be a symptom itself of other diseases.
A. Interestingly, I have diagnosed hundreds of other
medical conditions for patients who initially presented with dry eye. Any
number of autoimmune conditions and inflammatory conditions that affect the
rest of the body, such as rheumatoid arthritis or Sjogren’s syndrome, can cause
dry eye. A good dry eye specialist should be able to examine the patient’s dry
eye and lead the investigation to further diagnosis.
Dramatic Illustration
There is a significant correlation between ocular surface
diseases such as dry eye and certain eye surgeries.
At the age of 19, Tom Higginbotham suffered an eye injury
while serving with the 82
nd
Airborne Division overseas.
“As a result, I had a scar across the lower section of the
cornea in my right eye,” confides the 69-year-old veteran. He says the vision
in his right eye was approximately 20/70 until April of 2009: “Then my vision
began to deteriorate. It digressed to 20/400 [at which point a patient can
barely see the largest letter on a typical eye chart]. First, I went to my own
primary care physician who referred me to a cataract specialist. After
examining my eye and consulting with two other surgeons, she said they all
agreed that I needed a cornea transplant. The reason was because the scar was
blocking their view of the cataract so they couldn’t see where to make the
incision to remove it.”
Tom says that, at that point, he knew it was going to be
expensive; consequently, he wanted to get a medical opinion from the Veteran’s
Administration.
“The eye surgeon who examined me said she concurred with
the civilian doctor I had consulted with and that I needed a corneal
transplant. Because she did not have the facilities available to her, she
referred me to an outside doctor.”
That physician happened to be Dr. Desai.
“When I shared with Dr. Desai what the other four surgeons
had recommended, he said,
I can help you
,”
recounts Tom. “He suggested removing portions of the scar first to see if that
would reveal the cataract for removal without the necessity of a corneal transplant.”
“Tom’s scar was very dense and opaque,” describes Dr.
Desai, “precluding any view of the cataract, thereby making cataract surgery
close to impossible for his referring physicians.
“When I suggested that we try to take care of the scar
first, he agreed. I performed a procedure, which is very similar to the one we
use to treat other ocular surface diseases, including dry eye, where we smooth
out the surface of the eye. In this case, we removed a significant portion of
the scar and used a medication to dissolve what was left, making it more
translucent.”
Following that, Dr. Desai used an amniotic membrane graft,
which was derived from human amniotic sacs, and suturelessly applied it to the
eye to promote healing.
“Within a week or so, my vision improved from 20/400 to
approximately 20/70,” marvels Tom.
Only the beginning
Although the small amount of Tom’s scar which remained on
the surface still caused a mild haze, Dr. Desai says he could now remove the
cataract safely: “Following the painless, no-stitch, no-patch, micro-incisional
cataract surgery, which took no longer than six minutes to perform, Tom had a
new clear lens that, despite the presence of the remaining scar, improved his
vision all the way to 20/30.”
“At that point, I went back to the VA to have their eye
doctor examine me again,” shares Tom. “She was absolutely astounded by the
improvement; she hadn’t thought it would be anywhere near that.
“Then when I told her that Dr. Desai said he could improve
my vision even more by reshaping the cornea, she approved that as well.”
“Tom’s remaining scar was inducing astigmatism,” explains
Dr. Desai, “which impairs vision to the degree that the eye is shaped like a
football rather than a basketball.”
The reshaping of Tom’s cornea went perfectly. He saw an
immediate result.
“Tom now has 20/20 vision in his right eye,” observes Dr.
Desai.
“Although his case was more dramatic than most, it does
illustrate the significant correlation between ocular surface diseases,
including dry eye, and procedures, including refractive surgery, LASIK, and
cataract surgery. Ocular surface disease, which is very common but is too often
ignored or undertreated, is a very integral part of accomplishing the best
surgical results, both pre- and post-operatively.”
“I really appreciate what Dr. Desai and the staff of The
Eye Institute of West Florida did for me,” concludes Tom. “Whenever I had a
question, they would sit down and explain everything in detail. I had a really
comfortable feeling with them. They are just magnificent people, very
professional and very courteous.”