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formulations. Since most patients have an evaporative component, I usually prescribe a lipid-based product such as Refresh Optive Advanced (Allergan; carboxymethylcellulose [CMC] 0.5% glycerin 1%, polysorbate 80 0.5%), which functionally targets all three layers of the tear flm. Understanding how each drop is designed to work allows me to choose the option that best matches each patient's needs. Manage Lid Flora W h e n p a t i e n t s h a v e m a r g i n a l meibomian gland function, stagnant meibum on the lid surfaces creates an environment conducive to bacterial overpopulation — specifically staph species. Staph adhere to the dictum of survival of the fttest and, as a result, produce pro-infammatory exotoxins. Staph additionally elaborates a variety of enzymes such as lipase, which facilitate penetration and infection. Lipase also breaks down the tear lipid layer, causing saponification which destabilizes the tear flm. To reduce bacterial overpopulation, i n a c t iv at e t h e t ox i ns , an d bl o c k t h e e n z y m e s , I p r e s c r i b e p u r e hypochlorous acid (HOCL), a naturally occurring substance produced by white blood cells to fght microbial invaders. Pure HOCL is found only in Avenova (NovaBay) and has been shown to have fast-ac t ing , bro ad-sp e c t r um activity against overpopulation of microorganisms of the external ocular flora. Avenova is well tolerated and easy for patients to use. They simply spray it on a cotton round or oval; then wipe the upper and lower eyelids. A lt houg h Avenova is ef fe c t ive as part of the regimen for managing blepharitis and meib omian g land dy s f u nc t i on ( MG D ) , re g u l ar u s e a ls o c an pre ve nt t he s e probl e ms f r o m d e v e l o p i n g b y c o nt r o l l i n g bacterial over population. When I find significant demodex infestation, I recommend Cliradex (Bio-Tissue) moist towelettes for home therapy for 6 to 8 weeks to eradicate the mites. Nutritional Support Nutritional suppor t is cr ucial for MGD and dry eye patients. A number o f g o o d p r o d u c t s a r e av a i l a b l e , including HydroEye (ScienceBased Health). HydroEye contains gamma l i nol e n i c a c i d ( G L A ) f rom bl a ck currant seed oil, plus the omega-3 fatty acids EPA and DHA from high quality fish oil, and other important nutrients. In a randomized, controlled t r i a l , Hy d r o E y e w a s s h o w n t o provide significant dr y eye relief, suppress markers of ocular surface inflammation, and maintain corneal surface smoothness. 2 Triglyceride- based pure omega-3 products have als o b een found to b e helpful in managing dry eye and MGD. Address Infammation Nearly every dry eye has concomitant i n f l a m m a t i o n , w h i c h m u s t b e managed. Cyclosp or ine (Rest asis, Allergan) is a time-tested option for addressing infammation, and we have other options, too. In my practice, I frequently prescribe topical steroids, and I use doxycycline when I want to ramp up therapy quickly. Manage Exposure About 20% of my patients who are s i g n i f i c a n t l y s y m p t o m a t i c h a v e nighttime exposure. I can see evidence of this by either direct examination or by observing light from between the lids when I get down beneath the patient and shine a transilluminator on the upper lid sulcus. Rather than asking these patients to use an ocular ointment at night, which can be an exit ramp from therapy, I recommend they wear a silicone eye shield (Onyix, Eye Eco) while they sleep. This creates a moisture barrier and the patients ofen wake without their usual symptoms. Incomplete blinking frequently exacerbates dry eye symptoms, as well. When blinking is incomplete or the blink rate is lowered, meibum isn't properly expressed and/or the auto- cleaning of debris and epithelial cells from the mucocutaneous junction doesn't sufficiently occur. The latter, in particular, causes overgrowth of epithelium and debris, which prevents meibum from getting into the tear film and blocks the glands. This can be seen as the Line of Marx using fuorescein or, better, lissamine green stain. To remedy this situation, I debride the Line of Marx (Figure 3), which is simple using a golf club spud of the BlephEx device. I also coach patients on how to blink properly and sometimes recommend the Donald Korb Blink Training app, available from TearScience. Unblock the Meibomian Glands For a substantial number of patients, regardless of what initial therapies they Figure 3. Debriding the Line of Marx can provide signifcant relief of dry eye symptoms. Continued on p. 14 10 | FEBRUARY 2016