Treatment given for chronic dry eyes fails to improve condition

Dear Dr Roach: I developed chronic dry eyes after having cataract surgery on both eyes. I consulted an ophthalmologist who specialized in treating dry eyes. She prescribed Restasis, but my condition didn’t improve after three months of use. She then switched me to Xiidra and instructed me to use it for two more refills, which lasted nine months.

At the end of my conversation with the dry eye specialist, she said that she had done everything she could for me. I inquired about the Miebo drug that was recently approved or the LipiFlow procedure. She mumbled something, then said “goodbye” and “good luck.” Was she openly admitting her incompetence? — K.J.W.

Dear K.J.W.: It’s hard for me to believe that a dry eye specialist wouldn’t know about the new treatments available in their area of expertise, and I can only guess that there was some kind of miscommunication. As a generalist, I have to know at least a little bit about a whole lot of conditions, rather than a specialist who knows a whole lot about just a few conditions.

For most people with dry eyes, starting with artificial tears is usual and effective for many people, but I certainly have had patients use artificial tears many times daily and still have unpleasant symptoms. I also recommend trying to avoid dry areas, especially with high airflow.

Most people with dry eyes have blockages in the meibomian glands, which secrete an oily substance that helps prevent the eye fluid from drying and forces the lacrimal glands to make more tears. (This leads to the paradox of people having red, watery eyes when they really have dry eye disease.) Trying to unblock the meibomian glands with baby shampoo and warm water is another treatment generalists like me often try. But when these therapies aren’t working, an ophthalmologist is essential.

The ophthalmologist can do an exam to be sure if the meibomian glands are blocked. Among the treatments they have available are the ones you tried: cyclosporine (Restasis), which works well for a minority of people; lifitegrast (Xiidra), which decreases inflammation; varenicline (Tyrvaya), which increases tear production; and Miebo (perfluorohexyloctane), which works by reducing evaporation.

If the problem is the blocked glands, doctors can also consider more powerful treatments to unblock the meibomian glands.

One of these, Lipiflow, is a heat-based treatment. My colleagues in ophthalmology, to whom I refer, tell me that this is often a successful treatment, although the process may need to be repeated, sometimes every six months and sometimes longer. Ophthalmologists can also place plugs to reduce the loss of tears through drainage.

Dear Dr. Roach: We’re told to wash our hands with soap and water for 20 seconds to kill the COVID19 virus. How long should we wash our hands to kill bacteria and other viruses? — C.C.

Dear C.C.: Twenty seconds is the right amount of time for bacteria and viruses. An alternative is an alcohol-based hand-rub, which is fast and effective. Of course, you should wash your hands before and after eating — and after using the restroom. Bacterial spores cannot be easily killed, but they are effectively washed off by soap and water. In cases where spores are a concern (Clostridioides difficile is a big one), then hand-washing is essential, as alcohol is ineffective.