Dry Eyes and Lupus: Eye Doctor Tips and Tricks

posted in Sjogren's and lupuss on October 27, 2024 by

Donald Thomas, MD

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Dry eyes are very common in lupus patients, especially those with Sjogren’s disease. Around 25 to 30% of systemic lupus erythematosus patients also have Sjogren’s. Untreated, it can cause vision problems and eye discomfort. However, there are many things patients can do to help.

This blog post lists tips and tricks that are guaranteed to help dry eyes and lupus. If you have dry eyes, do more than just read these and think these are good ideas. Instead, print them out. Read all of them. Highlight each tip you are not doing or did not know you should do. Then, gradually incorporate all of them into your life.

Common symptoms of dry eyes and lupus

• Dry, gritty eyes
• Foreign object sensation in the eye
• Redness of the white (sclera) of the eyes
• Blurred vision
• Photophobia (intolerance of light)
• Ropey, thick secretions in the eyes, especially when first awakening
• Difficulty opening the eyes after sleeping due to dryness
• Red, tender eyelids (blepharitis)

Tips for caring for dry eyes and lupus

GENERAL MEASURES TO HELP DRYNESS

• Stay hydrated but avoid drinking excess fluids, which results in going to the bathroom frequently at night, contributing to fatigue. It also washes away the mucous salivary lining that keeps your mouth feeling moist.
• Avoid dehydrating fluids, like alcohol and caffeine.
• Avoid smoking (dries out the mouth, eyes, and nose).
• Use a humidifier (at 55%–60% humidity) in each room where you spend significant time.
• A humidifier near the bed is a must (we spend the most time there). Our eyes dry out more when asleep. Turn on at least an hour before bed.
• Clean and dry out humidifiers daily to prevent mold and fungus.

• A centralized humidifier in the furnace is even better.• Consider a central air UV light plus filter or an air scrubber to decrease infections.

• Also use a desk top humidifier at home and work

• Avoid direct airflow to the eye including wind and fans blowing directly towards you at night (such as ceiling fans).

• If you use a CPAP mask when sleeping, try to ensure a good seal that prevents airflow towards your eyes. Using a specially designed sleep mask that fits with a CPAP mask may be helpful. This can be found over-the-counter and online.

• Consider the use of sleep masks overnight, or the use of ‘moisture goggles’ (available over the counter and online) for night or even daytime wear.

• Avoid topical medications and lotions that can be irritating (including facial creams with retinol).

SUPPLEMENTS TO HELP DRY EYES

Fish oil, flaxseed oil, or omega-3 fatty acid supplements may help. (Natural sources such as fish, flaxseed, walnuts, and olive oil are even better.) Many eye experts recommend high-quality brands, such as Nordic Naturals Ultimate Omega and PRN’s “De 3 Dry Eye Omega Benefits.”

ARTIFICIAL TEARS AND GELS

• Use artificial tears a minimum of once daily (even if the eyes do not feel dry). Use regularly; do not wait for your eyes to dry out.
• Use preservative-free brands if you use them more than 4 times a day.
• For severe dry eyes, start using preservative-free artificial tears every 1–2 hours regularly. After 1 week, slowly back off on how often you use it. As soon as your eyes feel any dryness at all, go back to the previous, more frequent application to figure out how often you need them.
• Try different brands and formulations to find the one most suited to you. Some are more viscous and may stay in the eye longer but may also blur vision. Some are for people with coexistent Meibomian gland dysfunction.
• Freshkote and Hylo are preservative-free tears in bottles instead of individual vials.
• If you don’t like eye drops, consider aerosolized spray (such as Nature’s Tears EyeMist).
• An alternative is the prescription Lacrisert, inserted in the lower eyelids to moisten the eyes all day.
• Use a lubricating eye ointment or gel before bed. At first, apply it just to your eyelids and lashes and blink several times to see if it helps. If not, apply one-eighth to one-fourth inch (about a rice grain size amount) under your lower eyelids.

• This is expected to make vision blurry after blinking but usually clears by morning. If you wake with vision still blurry or eyes too goopy/messy, decrease the amount you apply. Any artificial tear ointment is acceptable, ingredients should be white petroleum and mineral oil – common brand names include:
  • Refresh PM, Lacrilube, Systane Nighttime Ointment, Genteal Ointment, etc.

  • Use artificial tears more often when flying (air is drier in the plane) or when reading or doing computer work (you blink less often).

• Vitamin A eye ointments may be preferred in certain cases as they provide good lubrication overnight, soothing, and support for Goblet cells to promote mucin production and epithelial cell healing. Vitamin A eye ointment products can be found online (Optase Hylonight, Hycosan, etc.).
• To put in eyedrops or ointment:
  • Tilt your head back and pull your lower eyelid down with one finger.
  • Apply the drop inside the lower eyelid but avoid touching the dropper tip to your eyelashes or other surfaces.
• Common examples of high-quality thin artificial tears include:
  • Systane Ultra, Systane Complete, Refresh Tears, Blink, Soothe, TheraTears, etc.
  Common thicker lubricants include:
  • Refresh Celluvisc, Refresh Liquigel, TheraTears Liquigel, Genteal Gel, etc. Hylo brand contains hyaluronate, is preservative-free, and comes in a convenient bottle rather than single-use vials.
  In patients with oil gland dysfunction, lipid based artificial tears are recommended. These include:
  • Soothe XP (comes in preservative-free vials)
  • Retaine MGD (preservative free drops in single use vials)
  • Systane Complete
  • Refresh Optive Advanced
  • Refresh Optive Mega-3
  • Hylo-Forte (preservative free in a multi-use dispenser)

DRY EYE PROTECTION

• Decrease air and wind drying by wearing moisture chamber glasses, moisturizing goggles, or wrap-around sunglasses (Eye Eco, Ziena, and Wiley X brands).
• If light bothers your eyes, wear sunglasses or have the lenses in your eyeglasses tinted with FL-41 (a rose-colored filter).
• Avoid fans, drafts, and air vents; air movement dries out eyes.

BLINK MORE OFTEN TO HELP DRY EYES AND LUPUS

• When reading, watching TV/movies, using a smartphone, or doing computer work, perform “blinking exercises” every 20 minutes. Close your eyes, squeeze hard, hold for a few seconds, open, and repeat a few times.

• Have your computer screen about an arm’s length away and lower so that your eyes gaze down slightly.
• Follow the 20:20:20 rule: every 20 minutes, stand and look at something at least 20 feet away for at least 20 seconds.

TIPS TO HELP BLEPHARITIS (EYE LID INFLAMMATION) AND MEOBOMIAN GLAND DYSFUNCTION

• Use warm compresses to the eyes is to open the meibomian glands, warm the thickened oil in the glands, and increase oil flow out of the glands onto the surface of the eye that improve surface lubrication and limit tear evaporation. Warm compresses can also soften crust, scales, or discharge if present.
o Warm compresses can be moist or dry. Your doctor will instruct you based on your condition. However, moist heat conducts warmth to the meibomian glands better and may be more effective.
o Aim for heat that is comfortable, not too hot, applied for around 5-10 minutes up to 1-2x/day. Overuse of compresses, too hot or too long, may cause irritation.
o You may use a clean damp washcloth that is run under hot water or heated in the microwave. As the cloth cools, refresh it with warm running water. Once a warm but comfortable temperature of running water is established, avoid increasing the temperature as your skin acclimates, as the thin/delicate skin of the eyelids can scald easily.
o You may choose to use an over-the-counter warming eye mask such as the Bruder Medibead Eye Compress or the Thermalon Dry Eye Moist Heat Compress. These reusable compresses are heated in the microwave. Be careful not to get them too hot or to scald your skin. There are also electric heated eye masks may be more convenient for some patients.
o Consistency is important; applying warm compresses every day will promote oil gland health in the long term.
• Clean sore, irritated eyelids daily with baby shampoo. Use warm, moist cloths on the eyes, and gently massage the eyelids.
• Use products that clean the eyelid edges, such as Cliradex pads, tea tree and coconut oil eye wipes, and Avenova.
• Apply a warm, moist washcloth to the eyes before sleeping and upon awakening for 5 minutes.
• Carry a wet washcloth in a zip-lock bag when you travel; apply to your eyes when needed.
• Keep makeup and lotions away from eyelids.

• Eyelid scrubs/hygiene can improve blepharitis, an inflammatory dermatitis of the eyelid margins that often results as a reaction against Staphylococcal bacteria, which is part of a normal bacterial flora that colonizes skin and eyelids. Blepharitis may also be caused by tiny mites called Demodex. Using eyelid scrubs regularly, removing the debris, excess bacteria, and the buildup of Demodex mites may improve dry eye symptoms. Lid scrubbing following warm compress application also results in a massage to the oil glands that increases oil flow. It is especially helpful to do this after an eyelid massage (see the above).
o Baby shampoo can be used on clean fingertips, a clean washcloth, or cotton pad to cleanse the base of eyelashes, with eyelids closed.
o You may elect to use commercial eyelids cleansers/foams or lid wipes (Alcon, Ocusoft, etc.) to clean eyelid margins.
o For Demodex blepharitis specifically, consider using tea tree oil-based lid cleaning products, such as Cliradex, Oust Demodex Swabstix, and TheraTears SteriLid.
o You may trial hypochlorous acid solutions such as Avenova and Ocusoft HypoChlor that are available over the counter or online.

• For Meibomian gland dysfunction, massage your eyelids after applying a moist warm compress for one minute.

• Wash your hands well with soap and water first; rinse well. The meibomian gland opening are on the edges of your eye lids, and they are long, thin, and run perpendicular to the edges of they eyelid. So, you want to squeeze their thickened oil out by gently using a finger on the eyelid opposite the edge of the lid, then gently roll or slide your finger downward on the upper eyelids and upward on the lower eyelids. Repeat this 5-10 times on each eyelid.

HOW ABOUT CONTACT LENSES AND DRY EYES?

• If you wear contact lenses, use only special daily replacement lenses (such as Acuvue Oasys and Alcon’s Dailies Total-1) designed for dry eyes.
• Therapeutic scleral contact lenses can help severe dry eyes.

PRESCRIPTION TREATMENTS FOR DRY EYES AND LUPUS

• Ask your doctor if you would benefit from medicated dry-eye drops, such as Restasis, Cequa, or Xiidra.
• If Restasis or Cequa irritates your eyes when you first start using it, keep it in the refrigerator. Also, apply it 10–15 minutes after using artificial tears first.
• Restasis comes in single-use tiny vials and a large multidose vial. If you want to save money, ask for the small vials. Do not touch the wet edges of the vial while using it; twist the cap back on the vial to reuse. Get two doses out of each vial (a 3-month supply can last 6 months).
• Ask your doctor for Tyrvaya (varenicline) nose drops to help dry eyes (one spray in each nostril twice daily; can take 4 weeks to work).
• Add NSAID eye drops to your drug intolerance list. They can harm dry eyes.

• Ask your ophthalmologist to insert tear-duct plugs to decrease tear drainage.

• Topical corticosteroid anti-inflammatories such as fluorometholone or loteprednol may be used short-term, or long-term in some cases, to decrease inflammation that can impair tear production. Topical steroids should be used with caution as they may cause elevated eye pressure or cataracts when used long-term without monitoring.

• Oral pilocarpine (Salagen) or cevimeline (Evoxac) may modestly increase secretions of both tears and saliva but is most effective for dry mouth.

IN-OFFICE PROCEDURES

• Blepharoexfoliation (BlephEx): This is a cleaning procedure to remove excess bacteria, biofilm, and the buildup at the eyelid margins more effectively performed by an eye care provider in the office. One time or repeated treatments every 6-12 months will allow the lid scrubs/eye hygiene applied at home to be more effective.
• Thermal pulsation treatment (LipiFlow, Systane iLux MGD, etc.): This in-office procedure combines the heat and therapeutic pressure applied on the each of four eyelids to effectively remove the blockage and improve meibomian gland function. One time or repeated treatments every 6-12 months will allow warm compresses applied at home by the patients to be more effective.

• AUTOLOGOUS SERUM EYE DROPS
  Natural tears are a product of blood filtration made by lacrimal glands. When natural tear production is impaired for any reason, use of autologous serum eye drops is a well-established and often effective treatment for severe dry eye. This involves having blood drawn and processed to create eye drops at the concentration recommended by the eye care provider (20-75%) made from serum part of the blood, which contains many growth factors and biochemicals that are naturally found in tears, which are not found in any artificial tear product.
• PLATELET-RICH PLASMA (PRP) EYE DROPS
  PRP is a blood product similar to autologous serum eye drops but it is prepared using an anti-coagulant separating plasma and platelets from the rest of the blood. Plasma and platelets play an important role in tissue repair. PRP eye drops are rich in growth factors, proteins, and anti-inflammatory cytokines and are used to treat severe dry eye.
• PROSE (PROSTHETIC REPLACEMENT OF THE OCULAR SURFACE ECOSYSTEM) AND SCLERAL CONTACT LENSES
  Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) is a medical treatment system that restores vision, promotes healing, reduces symptoms, and improves the quality of life for patients with severe dry eye. A scleral contact lens is a large, rigid, gas-permeable contact lens with a unique design that can be used to great effect for therapeutic treatment of severe dry eye. These lenses are larger than typical contact lenses in that they rest on the sclera (the white of the eye) and vault over the cornea (the clear front window to the eye, which is the most sensitive area causing pain in severe dry eye conditions). These lenses hold a reservoir of saline in the vaulted area over the cornea. They generate incredibly sharp vision and can correct refractive errors, but most critically, they bathe the cornea in saline constantly to alleviate dryness and remove any eyelid friction from the corneal surface.
• AMNIOTIC MEMBRANE PRODUCTS
  • Amniotic membrane products are made from processed human amnion, found as the innermost layer of the placenta. They have been adopted to accelerate wound healing on the surface of the eye, as well as diabetic skin ulcers and other wounds. Their primary use for the eye is to assist in healing large surface defects by providing a scaffolding matrix that allows easier migration of surface epithelial cells. They are sometimes used in severe dry eyes, as well. Self-retained cryopreserved amniotic membrane (Prokera) is a therapeutic option consists of an amniotic membrane stretched over a ring. It is placed over the eye in the office and the ring is removed after the amniotic membrane completely resolves in 5-7 days. Dehydrated amniotic membrane (AmbioDisk) may be preferred in certain cases, which requires hydration after it is placed over the cornea under a large diameter contact lens.

STIMULATE TEAR PRODUCTION

• Systemic drugs that stimulate saliva and tear secretion, such as bethanechol, pilocarpine (Salagen), and cevimeline (Evoxac) help.

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