Dry Eye Relief: What’s Causing Your Dry, Gritty Eyes (and the Simple Routine That Helps) | Dr. Carly Rose

27:12But a caveat to these hot compresses that we did not learn in school is I'm actually guided by the patient's experience with hot compresses because I've learned so much now about ocular rosacea and hot compresses can make ocular rosacea worse. And we absolutely mix the two, MGD and ocular rosacea. They usually run together. And so I will ask the patient, how do your eyes respond to a hot shower or a hot compress? And sometimes they'll tell me, you know, my doctor told me to do it and my eyes flared up like crazy. Okay, don't do it. Do a cold compress or alternate because what happens is the oil glands are clogged and we want to melt the oil out and squeeze it out, just like cooking oil.

27:58The hotter, the better. So these in-office thermals, they manipulate that and they heat the oil and squeeze it out. But when you're home, you can have clogged oil glands, but also ocular rosacea and that heat is going to flare the rosacea component. And so that's where we're either going to alternate or do cold compresses or in-office heat only. Okay. What is MGD and ocular rosacea for people who don't know? MGD is meibomian gland dysfunction. And that's at least 86 % of dry eye disease has a meibomian gland dysfunction component. That's from the lack of blinking. It's from demodex. It's from systemic inflammation.

28:34There's a lot of causes. And then ocular rosacea is like facial rosacea. And we pick up on it with these little tiny vascular, these little tiny blood vessels right on the lid margin. And so if you, tight lining, we haven't talked about tight lining in cosmetics. When you use eyeliner on the waterline, big no, no. I can't believe I've missed that. Don't do that. But the trend right now. I feel like we all did that like 20 years ago. Right. Yeah. Like almost 30 years ago. And so I forgot all about it. But I'm like, I don't know. I feel like Gen Z is like trying to bring everything back. They are.

29:13And I'm like, maybe don't. Also the hair in the 80s. Like it wasn't a good idea. Well, what I'm seeing is people are tight lining with white liner. Oh, yeah. Because the rims are red. Because they probably have ocular rosacea and demodex. Oh my gosh. So please just treat that and then you don't have to tight line with white liner. Yeah. Yeah. I've seen that. I thought people were doing it to try to make their eyes look brighter or I don't know. Well, it's all psychological, right? Because we know that a calm white eye is a healthy eye, is a healthy body. And in our subconscious, we want to partner with someone who is healthy and can reproduce.

29:52Yeah. Right? So if our eyes are red and our rims are red and everything's swollen, there's something going on there. And so we do want bright white eyes for evolutionary purposes. Yeah. Okay. So we've got the heat. You recommended twice now this light therapy. Is this something people are doing at home or are they doing it in a practitioner's office, the IPO? So there are a few different light therapies that have made their way to the eye world. Low-level light therapy is in office and at home. I love LLLT. It's like the red lights, the infrared lights. They're fantastic. And so they're great to calm the inflammation.

30:34That also helps produce stem cells. So it helps heal the surface of the eye. And there are studies now coming out that it can slow myopia and macular degeneration. So it's helping the front and the back of the eye. It's a win-win. And then intense pulse light is in office. That is physician-based. You want a medical provider doing those treatments. And it's state to state. Every state is different and every country is different and all of the machines are different and the devices are different. But it's not a true laser because it is not so focused in light. It's definitely, we play with the filters depending on the depth of the epidermis and dermis we want to get to.

31:17Different filters, different wavelengths of light, different energies target and treat different things. But that's been around for over 50 years with a great, great safety profile, really fantastic results. I've been treating dry eye disease for over a decade now. And when I started implementing intense pulse light over five years ago, that's when the game changed for me. That's when I really started to see change in treatments. Yeah, I remember seeing you talk about light therapy and how it's preserving eye health. And that was one of the big factors in me deciding that I was getting a near-infrared sauna rather than just a regular sauna because I'm about habit stacking as well.

32:01I like to say I'm lazy because I'm like, I mean, I'm like, I'm going to go in the sauna. It's going to be my red light therapy. I'm going to do my deep breathing. Like I'm going to get it all taken care of in 20 minutes. Good sleep is everything. That's why Ali's science back support is made with a blend of melatonin and L-theanine for both kiddos and grownups. So when your mind won't switch off, you've got something that can help. Erasing thoughts and restless nights won't stand a chance. Find Oli Sleep Solutions for the whole family at Oli.com. That's O-L-L-Y.com. Exactly. I'm going to hit it on 20 minutes right before bed so I can get that like one and a half hours of deep sleep.

32:43Like it's a whole strategy, but it's also because like when it comes to like caring for your health, I feel like especially as women and especially as we age, it's always like one more thing you got to do. I mean, even as I had a patient recently who was like, I really don't want to start hormone therapy. be like, I want the benefits of it, but it's just like one more thing I have to remember on my to-do list. I'm like, I feel it's so hard. It's so hard. I feel like every, you know, every five years, you're like, and next, and what's on the list again? So let me ask you, if people are at home, you know, are looking at their eyes, how can they assess their eye health?

33:17What, what is like the pillar of health, what their eyes should look like? And what are the signs of like, you need to go see someone because this is not normal. So we covered if you've got a red ring, so that if you feel like you want to take a white pencil and like line your eyes to get rid of the red. Talk to your eye doctor. Normal. Yeah. So what are some of the other things people should be looking for? You know, dry eye causes a lot of intermittent blurry vision too. And that gets over. People think that they just need a prescription change, but it's like looking through a dirty windshield and it comes and goes.

33:49Every time you blink, it's good for a second and then dissolves. That is definitely dry eye disease. And then itchy eyes, watery eyes. Watery eyes a lot of people have and don't realize that's actually dry eye disease. And then of course, red swollen irritated eyes. And what about styes? People who are constantly getting styes because you mentioned that before. First, what is a stye in case somebody has been blessed to never have had one? So styes are, we talked about those oil glands that are like tubes of toothpaste. it is one singular oil gland that's clogged and really angry. And so what I tell patients, especially if they have chronic styes, is this is a chronic disease state.

34:32Every single one of these oil glands can turn into a stye. You could have 80 styes at one time if you want. So for a long time, treatment was oral doxy and removing them. And removing them is still something we have to do from time to time. But once you cut it out, you've lost that oil gland forever. And so now steroid injections are helpful. You can do temporary antibiotics, but you really want to get to the root cause of the mymobian gland dysfunction. You want to figure out why these oil glands are so unhealthy. In liner tattoo, people don't even think about puncture these oil glands. No one even knows the oil glands exist.

35:13That's what a stye is, is an angry oil gland. Well, people don't realize our visual system is our leading sensory system. Okay, talk about that. So it's deeply connected to safety, position in space. And if you can't feel in control of your eyesight and your vision, it is very unsettling. And, you know, patients that do lose their vision later on in life, they always, always say, I took my eyes for granted. I took my eyes for granted. And when it's gone or when you're fighting to get it back, it's a big deal. Yeah. So, well, let me ask you, because we've talked about like eye health itself, but I'm curious, are there signs that people can see in their eyes, around their eyes that are pointing to a deeper disease that they should be aware of?

35:57Absolutely. And so, for example, diabetes, high blood pressure, MS, thyroid issues, they all affect the eyes pretty quickly. It's hard to tell as the patient, though, because what we need, so even me as a patient, I have something go wrong. I need it. My sister's an eye doctor as well. So that's very handy. And I'll call her like, so I think I might have a corneal abrasion. But for example, flashes and floaters, right? We know it's not good, but I can't really diagnose it. Someone else needs to look at me. I had my own flashes and floaters. I need to go be seen. We need to look in the eye in the microscope.

36:37Sitting here, me as an eye doctor, you as a patient, I would still need to put you in a microscope to really tell you. so it goes back to annual eye exams annual eye exams annual eye exams yeah catch it early what is actually going on if you have floaters in your eyes traditional floaters so the eye is filled with a jelly called the vitreous and what happens with the vitreous over time is it separates into its liquid and solid parts kind of like jello sitting on the counter it'll start to get that liquid top gross okay gross same thing is happening here only what is happening with the solid parts is they're floating around in the liquid like a jelly snow globe.

37:15And so you're seeing those little floaters. And when you look, even if it's a bright light or a white wall, you can see them more clearly. What we don't want to happen is a shower of new floaters all at once, like something broke loose in there. Because what happens is as this jelly separates, it almost falls into itself. It collapses. But it's attached to the retina at very specific strong attachment points. And so when it falls in on itself, we don't want it to take the retina with it. And so that's the big concern with floaters is a retinal tear hole detachment. Yeah. So don't ignore that. Do not ignore that.

37:53Do not ignore that. I've had patients that will sit on lights out vision for weeks. And with retinal issues, timing is huge. The quicker you can be seen for proper treatment, the better your visual outcome. Okay. Since we started talking about hormones, I want to shift into more hormone talk. And we're going to talk about everything from like your own hormones to being in perimenopause, menopause, hormone therapy, and birth control. But the first one I want to ask you about is estrogen, because we know that affects just about everything in our body. But what is the eye hormone connection that women should know about?

38:29It's huge. It's huge because of many factors, but dry eye disease is going to be the main thing. And with dry eye disease, it's an androgen deficiency for sure. We've known that at least since the 90s. We used to have compounded testosterone drops that we could use for this. But it's become such a multidisciplinary. We really have to put together a care team for these patients to dig into their hormone balances, regulating them. What's going on with the thyroid, right? Because hypo and hyperthyroid affects the eyes. So truly, it's dysregulation. We have to get the whole body back into homeostasis.

39:08Too much and too little are both problems with the eyes. So what I'm hearing is it's not just one hormone. We need to look at all hormones. It's not just one hormone. It's all hormones. It's environment. It's stress. What surgeries have you had, right? Even retinal detachment surgeries can cause dry eye. It is so multifaceted and multidimensional that we often will even have to bring in, you know, psychiatrists and therapists and endocrinologists and rheumatologists. And these patients end up having dozens of specialty doctors. Talk to us about these testosterone eye drops, because I think that's going to be news to a lot of people.

39:45It was to me. Last night, you shared that at dinner and I was like, hold up. Why is this not something that's readily available? It's not. And you know, it's becoming harder and harder to get. And so much so that it It came down to, I think, just one state was able to get it. And so we can't really use it at this point if we can't get our hands on it. And that's the same with topical insulin. We used to be able to use topical insulin a lot easier for corneal nerve growth, which we can dig into. But now we can't access that nearly as easily as well. What's the problem? Is it FDA regulation? Okay.

40:23I mean, you know, when it comes to the FDA, there's a lot of things we use off-label, but I feel like the eyes is one of those areas that we really have to be cautious. And I'm a fan of compounding pharmacies, but they're not all created equal. Right. I want to hear more, though, about this androgen eye connection. And do you see people improve if they go on, like, testosterone injections or using topical testosterone? Absolutely. But my scope is limited, right? Right. Specifically with optometrists, we are observed often because you mentioned the eyes and the teeth. They're totally different.

40:58So optometrists are really trained to stay in their own lane. Don't work outside of your scope. But how do you do that when your scope includes hormone imbalance and central nervous system dysregulation and the gut? Oh, my gosh. The gut guides so much of the eyes. There's a direct gut eye axis. And so it becomes very challenging to stay in compliance and in the scope of practice, but get these patients the treatment they need and deserve. It is. It's very challenging. And then, of course, you need to find a provider that's progressive enough to stay up on the research and not just jump to birth control pill.

41:36That's usually the answer. The thing about birth control is that I actually just did an episode and I'll link to it. It tanks your testosterone. so it drops the production of testosterone anywhere from 40 to 60 percent it takes your ovaries out of the equation one of the primary sources of your androgens then it raises sex hormone binding globulin so it binds up your free testosterone and then if you're on progestins that are androgenic in their in how they've been developed they will block the receptor sites and so you're not getting the testosterone you need and forever medicine was like who cares right You're a woman.

42:13Why do you need testosterone? I mean, actually, they still say that. And, you know, I have like a laundry list of why women need testosterone. And now talking to you, I'm like, and your eyes, your eyes, your eyes, your eyes, this is insane. Because if it was a man, it would be like, stop everything. Well, him testosterone. I agree 100%. And so I do I start I actually recommend beyond the pill to a lot of my patients to get started in reading this. And I talk about heavy lifting and diet and stress reduction. But what's fascinating is when I was in school, we were taught that this is an older female disease.

42:49It's postmenopausal women have dry eye disease and it just is part of the aging process. And I developed dry eye disease when I was in my early 20s and I'm like, this doesn't make sense, right? And mine just kept getting worse and I was doing the baby shampoo and I was doing pungdil plugs and it just kept getting worse and then the patient is blamed, well, you're not doing it right or this is just part of aging, deal with it. Well, what's happening is female dominant. It is very female dominant disease until you get to the younger generation. And the younger population is more 50-50 male and female in the 20-year-old dry eye patient.

43:32And so I think we're going to start to see some answers now that this is more of a 50-50 male-female disease. Yeah. I mean, it's like the same thing with endometriosis. Like it's been discovered in men and we're like, okay, we just need more men now. Yes. And then we'll get the research. Yes. That's me with dry eye disease. The men are finally getting it. Well, and for people to make the connection here, we know the younger generation of men are producing less testosterone and less sperm than their grandfathers. I mean, there was one study that showed 50 % reduction in the sperm production of like 20-somethings compared to like their grandfather's generation.

44:08That's shocking. Yeah. And it's endocrine disruptors. So what should women know about what birth control can do to their eyes? Well, obviously dry eye disease. And then there's this vascular component, right? Right? Strokes and thrombocytes and clogging the blood vessels. And we already talked about the ISO, nutrient dense and vascular dense. Like it needs a lot of blood flow. It needs a lot of oxygen, which is why diabetes shows up first. One of the first places it can cause damage is the eyes, is this vascular demand. And so we already know what birth control can do to the vascular system. And the eye is one of the most densely vascular systems out there.

44:54Plus, we understand that birth control depletes nutrients that are crucial for eye health. It's very interesting, too, because there has been some research, we certainly need more, showing that you need your own natural estrogen to take the plant-based omegas and actually activate them in a way that you can utilize. And so it raises a big question when you're on this synthetic estrogen and you've shut down your own estrogen, are you actually able to get those omegas in the same way? Right. And that's why I usually, even for my vegans, they don't love it because the plant-based don't need that conversion, EPA and DHA.

45:29If you get a plant-based, then it has to be converted and you lose a lot of it. Yeah. It is. I mean, it's something that I feel like vegans, when they're doing it for the ethical reasons, they never like to hear those kinds of things. But I feel like... I was vegan for a while. So I get it. I tried vegan, I failed. I I was like, it's not working for me. Yes, I agree. If nutrition is a medical intervention that we can utilize, informed consent is warranted. And part of that informed consent of you choosing a vegan diet is for you to understand where the pitfalls are in that so that you can try.

46:06So like getting algae oil, you know, supplementation and going up higher in that may help circumvent that. But it's knowing the information so that you can do something about it. And, you know, as we're in this conversation, not be blindsided by, you know, not having informed consent, right? That's everything. That's the same thing with the aesthetic world. You need to know that your crow's feet Botox and your liner tattoo can cause permanent damage. You need to know that if you still elect to do it. Perfect. Yeah. I don't even feel like a liner tattoo really ages well either. I mean, I, and I'm wondering very rarely because, and as you say this, I'm like, is Is it about the skin changing or is it about how it has basically destroyed those glands?

46:50It punctures them. And then it can deliver the pigment into the glands too. Because the eyelid is only like a millimeter thick. And most of these tattoo guns are even deeper than that. So you're fully puncturing the entire eyelid. Yeah. And everything in it. Well, going back to birth control, if someone is on the pill, is there anything that they can be doing to be taking care of their eye health and mitigate some of these side effects. Yeah, it's kind of like high blood pressure medicine causes dry eye, right? But we can't just pull you off your high blood pressure medicine. So that's where we just support the tear film as much as we can.

47:26Blink exercise, hot compress, lid hygiene, and omega-3s, always the starting point. But this is where things like AI may help us quite a bit because what I see happening is progression analysis and predictions. So what I think we will get to is we should be able to plug in all of these different metrics, you know, 20 or 30 things about a patient, your labs, what medications you're on, and your lifestyle, and it'll spit out your risk of developing dry eye disease. And maybe it looks like an IPL a year to prevent or something along those lines or start on a pharmaceutical before signs and symptoms begin.

48:05eczema is unpredictable but you can flare less with epglyss a once monthly treatment for moderate to severe eczema after an initial four month or longer dosing phase about four in ten people taking epglyss achieved itch relief and clear or almost clear skin at 16 weeks and most of those people maintain skin that's still more clear at one year with monthly dosing epglyss lebrikizumab lbkz a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema. Also called atopic dermatitis that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies.

48:43EBCLIS can be used with or without topical corticosteroids. Don't use if you're allergic to EBCLIS. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EBCLIS. Before starting EBCLIS, tell your doctor if you have a parasitic infection. Ask your doctor about EBCLIS and visit ebglis.lily.com or call 1-800-LILY-RX or 1-800-545-5979. Well, and that would be a great thing that if we did an all-medicine before we started a medication to try to understand who might be at risk for what side effects and then be able to prevent that.

49:15You know, it's interesting because when we look as we're talking in the conversation of the pill, we understand that if you have a family history of depression, you have a history of depression, you've ever had postpartum depression, and now if you're neurodivergent, we understand all of those things make you at higher risk of developing mood symptoms when you start birth control. And yet that's still not a conversation happening when that pill prescription is written. We're still not having those conversations regularly in doctor's offices so they can say, hey, if your mood tanks, which can be as scary as suicidal ideation, you need to come back and see me because we can switch formulations.

49:51We can do something different here. What about IUDs, the progestin-based IUDs and eye health? Well, I feel like those are going to be lower risk, right? Because they're not an oral absorption. They're more topical. So I feel like those are lower risk, but none of this is happening in a vacuum. So every patient is so multi-dimensional and multifaceted. Some patients are blessed with this great immune response and they can handle anything. And some patients, you know, can't handle fragrances in the store. So that's where it gets so complicated is because it is patient-to-patient dependent as well.

50:27And that's where I think being connected to our own bodies is very helpful. Pay attention to what your body is telling you. Advocate for yourself. Talk to your healthcare provider. And if they're not hearing you, get a second opinion. Get a third opinion. Because at the end of the day, the medical system is under-resourced as well. And there's only so much time a doctor can spend with you. and review all of your medicines and how they work together and what's really going on. So I do think patient participation and don't get gaslit, right? Don't let yourself get gaslit. Listen to what your body's telling you and take care of it.

51:06For women who are in perimenopause, what do you wish they knew about their hormones and their eye health? I wish women in perimenopause would realize that there are alternatives to feel good. This life should feel good. You can feel better. It does take time. One thing I say often is put the fire out, keep the fire out. And how big your fire is depends on the timeline of getting to resolution, but that resolution is possible. Hope that it doesn't have to feel this bad. Why is it so many women in their 40s are developing dry eyes? Oh my gosh. I mean, it's now down to 20s. It's crazy. Oh my gosh.

51:51That's like the same thing we're seeing in the testosterone conversation is like we're seeing 20-year-olds who are women who don't have enough testosterone and all doctors care about is like PCOS and do you have too much testosterone? Yes. You and I chatted earlier about our, you know, fertility struggles. And I probably a dozen years ago was told, well, you are ovulating like a postmenopausal woman. We're just going to have to put you on all these meds. And that was the only conversation I ever had after one lab with one doctor. And I was like, really? I think there are things we can do. I just want to say postmenopausal women don't ovulate, but how often doctors use that phrase.

52:33Because someone might be like, wait, I'm postmenopausal, I don't ovulate. You're right. But this shows you how little doctors understand perimenopause and menopause because they'll literally say that. You're cycling like a postmenopausal woman. You don't cycle when you're postmenopausal. And so many patients see that as a indictment and this is my forever. And it's not. Epigenetics are powerful. We can manipulate our environment. We can manipulate our body. Mm-hmm. So you mentioned before hyperthyroidism, hypothyroidism affecting people's eyes. I think a lot of people are familiar with the bulging eyes of hyperthyroidism, but hypothyroidism is far more common, especially after the age of 35.

53:12How is that affecting the eyes? I mean, it's just a direct correlation to dry eye disease. Really? It's almost, I would challenge you to find a patient with an underactive thyroid that does not have dry eye disease. It's just all of them. And I heard a practitioner say that they got tired of treating sick fish who were swimming in poisoned waters. And it's almost like what isn't causing dry eye disease at this point? LASIK, blepharoplasties, we can talk about in the aesthetic world. Our thyroids being completely shot, our stress, our cortisol just spiking. It all ends in these flaming hot eyeballs.

53:58Yes. So let's explain the aesthetic procedure to people who may not be familiar with it. And it's trending. I don't know if you, because this is my world, but blepharoplasties are viral and trending right now. Can we not make eyelid surgery a trend? But blepharoplasties are eyelid surgeries. And there's a time and a place, and I'm not against a blepharoplasty. One of my good friends is an oculoplastic, and I'm like, when are we doing my bleph? You're doing my bleph when I'm ready. But what's happening is a lot of doctors are taking too much of the eyelid, and then the eye cannot close. So then we're back to the incomplete blinks.

54:38So then we're really doing blink exercises and mitigating all of this. But it's also causing this nerve damage. And that's where things like retinal detachment surgery can cause dry eye disease. And you might think, how is the back of the eye causing a front of the eye issue? And it's nerve disruption. Any ocular surgery causes nerve disruption. Yeah. It's something that I definitely have that fear. My grandmothers, as they got older, they had a very hard time opening their eyes enough to be able to see because of how much skin there was. And that's where insurance will cover a bleph. Yeah. And so I'm like, that may be in my future.

55:17I do laser treatments. I do things to try to prevent that. But it is something that, you know, as we're talking about that, that's always been my concern as you see these procedures that are done. By the way, everybody who's listening, I'm talking about when I'm like 80 and functionally being able to see. But you see these procedures done where like people are completely pulled back and they can't even close their eyes. What is happening when they're sleeping? Oh, well, the eye is a mucous membrane. you're very familiar with mucous membranes, it has to stay wet to stay healthy. The cornea doesn't have its own blood supply.

55:51It gets all of its nutrition from the tear film. And we know how important the cornea is. Well, when they're sleeping, the wind is just damaging. And if you have nocturnal lagophthalmos, this happens as well. This is where the eyelids don't close. This is where the eyelids don't close when you're sleeping. Exactly. And I don't know if you remember the trend on TikTok a couple of years ago where there was the slow-mo blink trend and so many people realize they don't close their eyes all the way. I was like, yes, finally a trend that's helpful. Okay. How do we do that to actually evaluate our eyes?

56:25Oh my gosh. That's brilliant. Yeah. Just record yourself blinking in slow-mo and watch it back. Do your eyes close. That's what you want is your eyes to close. For everyone listening, if you go into these apps, so I use TikTok more than I use the reels. So I don't know if they have a slow-mo, but the TikTok has a slow-mo, CapCut, like a lot of editing programs. You can actually put it on. That's brilliant. Actually, your camera has that. Your own camera has it. And so you can record it in slow-mo and slow the whole thing down. I'm going to do that for sure. Yes. But you were talking about how if your eyes don't stay closed at night, they're getting dried out.

57:03The wind is damaging it and then it can scar over and then you can't see. Okay. That's a big deal. Not to mention, I do not want to underestimate the quality of life impact when your eyes are so irritated. And if you can't see, it's very disorienting. Yeah. You know, it's interesting because in this conversation, I'm like, I would think low estrogen, sure, having dry eyes because everything gets dried out when our estrogen gets low. Same with our thyroid. So dry skin is definitely one of the signs. But the androgen piece, to come back and harp on it some more, because so many doctors think if androgens are low in a woman, it's low libido and it's nothing else.

57:45But for women to really understand, that can be a sign of low testosterone as well. So we've got these three key hormones. But you also mentioned insulin. Is that involved in dry eyes or is insulin dysregulation doing something else in the eyes? Well, it's complicated. So diabetes absolutely affects the eyes. And so systemic inflammation, or I'm sorry, systemic insulin doesn't specifically that I know of have this effect on the eyes, but the topical insulin acts as a nerve growth factor. Okay. So it actually is neurogenic, which is fascinating. Yeah. And then talk to us about cortisol because you mentioned that briefly, but we know HPA dysregulation is running rampant in our society.

58:31Yes. And it especially gets amplified postpartum and also in the perimenopause through postmenopausal years. So what are these high levels of cortisol over time doing to our eyes? You know what? It's funny because dry eye disease led me here because I just keep following the rabbit hole of, well, what's going on here? Why is this happening? Why is this happening? And I started to notice a trend of just insane HPA, dysautonomia, and basically patients stuck in fight or flight and not in rest and digest. And of course, if you think about it evolutionarily, when we're in fight or flight, we can't have watery eyes.

59:11We're running for our lives, right? Rest and digest is when all of our juices turn on. And so there's a very intimate relationship between the eyes, the corneal nerves, and the parasympathetic and the sympathetic systems. And how I started learning about it is because there are a few medications now, but one came out a few years ago, and it's a nose spray, and it's a parasympathetic activator. And so I'm like, a parasympathetic activator through the nose, this is interesting, for the eyes. So we have a nerve in our nose called the anterior ethmoid, and it is a vagal mediator. And so what we're doing is stimulating that to send a signal to the brain to turn on the parasympathetic pathway to start making tears.

1:00:00There's a direct parasympathetic tear production connection. Well, what we also now know, there are different devices that stimulate that nerve. You can stimulate the nerve externally. And then there is now a neurogenic eye drop that just came out to start doing this with the corneal nerves. And so I started researching and going down this corneal nerve rabbit hole. And with the corneal nerves, there is this bidirectional feedback. So for a long time, it was almost like LASIK, for example, slices the corneal nerves in half. And so we knew that you weren't getting the sensation to tear. But what I didn't fully understand is there's this crosstalk and these nerves actually excrete growth factors to support the corneal epithelium.

1:00:49Okay. So everything in the eye is just a specialized version of the rest of the body. The corneal is specialized epithelium. The lashes are specialized hair follicles. The eyelids are specialized epidermis. Like it's all the body but nuanced. And so the corneal nerves secrete growth factor to help the corneal skin grow. So I'm like, well, this is fascinating because not only do we not have the afferent sensation, it's like we're missing something from the efferent side and we didn't realize how much these nerves support the epithelium. And so then that goes to the central nervous system. So of course, our central nervous system senses hot, the environment, it's sensory input.

1:01:36But how much of it is actually supporting the surrounding tissue as well by excreting these different growth factors? It's very fascinating. Well, let me ask you, if LASIK is slicing through nerves, what's the harm that can be done? Oh, the famous cases that you see of suicide from dry eye disease are almost always LASIK related. Whoa. They're almost always corneal nerve involved because that's when this disease gets really challenging. Huge connection. Huge connection. And it's one of those things where either you're fine or you're really not fine. There's not a lot of gray area. The risk is fairly low.

1:02:14And it depends on the practitioner, right, and which devices they're using, how deep they need to cut. And that depends on your prescription as well. So the larger prescription, the deeper they need to cut. And so there are things that you can do instead of LASIK like orthokeratology is like braces for your eyes. There's no cutting. There's no nerve involvement. There's no long-term risk. It's a rigid contact lens that you wear at night while you're sleeping. My eyes are already squinting. I'm like, oh, rigid contact lens in my eye. But it sounds like Invisalign for your eyes. Exactly. It's exactly like Invisalign for your eyes.

1:02:51Is there any way to know who would be at risk before undergoing LASIK? Yeah, obviously a dry eye patient shouldn't get LASIK. But identifying the dry eye patients aren't as easy as it seems because you usually do need specialized tools to get the early ones. The end stagers, you can see them from a mile away. But the early patients, and those are going to be most of the time the LASIK patients because they're younger usually. And so if they have this disease process, it's going to be earlier usually. This episode is brought to you by Fox One. Watch all 104 matches of the FIFA World Cup live in 4K for just$19.99 a month with three days free.

1:03:35Build your own multi-view, choose up to three streams, and follow player spotlights. Stay on top of every moment with live stats, highlights, and instant replays. The FIFA World Cup, streaming live on Fox 1, offers a subject to change. See fox.com for complete terms and conditions. So you want to test, there are different biometrics we can do. We can test your tear film for inflammatory markers. We can test your tear film for too high of salt. It's called osmolarity. If you're hyperosmolar, you probably have dry eye disease. We can look at the lid margins. We can look for demodex, that parasite, looking at blinking because the corneal nerves directly impact your blink.

1:04:17Are you analyzing my blinking? I analyze everyone's blinking. Eye contact is my love language. I'm like staring at people. Well, I want to talk more about the gut-eye connection. But before we go into that, you mentioned how our lashes are specialized follicles. People are using lash serums to help them grow, good or bad. Let us know. Depends on the lash serum. Okay. So let me give you the buckets. The Latises of the world, they're prostaglandin analogs. Do not. It's like pouring inflammation on your eyes. Totally. They work, but not without damage. As someone with endometriosis, I'm like, oh God, no.

1:04:58No more prostaglandins. No more prostaglandins. No, it's really ridiculous. And that's where you see these deep red rims on the lid margin itself because, you know, you're just painting inflammation onto there and you're getting this neovascular inflammatory blood vessel growth. And then those blood vessels are leaky and they're just leaking more inflammation on the surface of the eye. And then your lacrimal gland starts leaking inflammation and it's this vicious cycle of inflammation. So please don't do a prostaglandin analog lash serum. But healthy lashes are long. The best way to grow a lash is the healthy way.

1:05:34So that's the Omegas. That's the oil-based lid cleansers that's taking care of Demodex. But then castor oil. I'm a big fan of castor oil. You want it to be cold-pressed, organic, hexane-free. And something that isn't mentioned enough with castor oil in the eye is I like a separate bottle. So if you're one of these that uses castor oil all over your body, don't use that same bottle on your eyes. Hard agree. Keep them separate. Keep them separate. And then there are great lash serums that are peptide-based or floral essence-based, right? Different marigold extracts and clovers. And there are ways to grow lashes with a peptide-based lash serum as well.

1:06:15But always start with lid hygiene. Lid hygiene alone can do wonders for your lashes. And the lid hygiene is what we talked about with the double cleansing? Yes. Okay. It's beautiful how it all goes together. Yeah. Let me ask you, because I actually got somebody who messaged me and said, I had done a whole episode on hair loss, and they said, can I start using minoxidil on my lashes? My reply is... No. Okay. Well, you say no. My reply was like, I cannot advise them on this. This is outside my scope. I would not recommend anything on the eyes that an eye doctor has not approved. improved because again, I'm like very, very cautious with eyes.

1:06:52I'm like, they're not a mess around. That's why I've always told my patients the same thing. I love castor oil for lash growth and lash health, but it should be separate and your hands should be clean before you. And I think people just kind of like take that for granted or they think like, oh, I washed my hands when I went to the bathroom like 30 minutes ago. Immediately wash your hands before, you know, applying anything. But midoxidil on the brows, I'm fine with. Okay. Okay. Yeah. foam liquid foam is great and speaking of um retinols retinols can dry your eyes out big time and so with retinols and they migrate so i was just thinking with the minoxidil like i just brow last night so i'm sitting here like like i mean i'm a retinol girly too but just stay away from your orbital bone yeah so even farther away with retinol okay because it does migrate so like above the eyebrows can you hit your crow's feet yeah okay a little more towards the temporal area.

1:07:48So if people on YouTube can see I'm pointing at the hairline and then drop to the cheekbones. Okay. Good to know. I also use that circumference with when we're doing topical estrogen on the face. Amazing. And I'm like, you can put it a little bit closer to like the crow's feet, but underneath the eyes, I'm like, the cream is so thick and heavy that you don't, yeah, it's great for vagina. It's not great for the other mucous membranes. Yeah. Underneath your eyelids. Like we don't want that so much. So let's shift gears into the gut eye connection, because I think this is going to be the first time a lot of people have even heard this.

1:08:22Oh, it's huge. It's huge. It's so one of my colleagues and friends now, she's the expert, right? She just put together a series on the gut for optometrists specifically, because there are so many direct connections that it's almost like that's one of the first things I ask about is, Do you have IBS? Yes. Crohn's, all of these things because we are what we eat, right? Common sense. It is common sense, but we have so many studies that show this now that it's irrefutable. So I do talk about things like intermittent fasting and elimination diets, but again, with hormone balance, intermittent fasting is not as studied in women.

1:09:06So I say don't intermittent fast on your cycle or the week before your cycle, but start to look at reductions and spacing the eating times, makes a big difference. And then I'm always talking about the inflammatory diet. I mean, fish oil is my go-to, right? So how does that work if you're taking it in through your mouth? Well, everything we eat gets to our eyes eventually. Are there connections between the enteric nervous system, the nervous system of the gut, and the eye? Well, the more I researched this, the more I realized that vagal tone runs the eye. So how can it not be connected to that, right?

1:09:41Well, and we talked about, you know, parasympathetic activity, the health of the eye, cortisol. Now we're talking about the gut and the vagus nerve, which is all about that parasympathetic activity. Are there tips you share with your patients to help with vagal tone, to help them get in that rest and digest? We have studies that show that things like meditation and yoga are more effective for dry eye disease than orals, than oral prescription medications. Nice. And yet the go-to for most eye doctors is oral doxy. That's going to ruin the gut when we know that things like meditation are more effective and then it's going to help balance the gut.

1:10:22So I do. I start with guided visualizations I talk about a lot, especially with my end stagers that are dark in a dark headspace. We have to somehow find the visualization of your eyes healing. You have to get there. And this is where I say I'm a doctor of hope more than anything, because at this point, I'm starting to get just nothing but end stagers. And knowing that I've seen improvement. So you were asking about the perimenopausal women. There's hope to feel good. That's the same with the dry eyes. There's hope. The body wants to heal. But a lot of these patients, you know, 40 to 50 percent of them, high anxiety, depression, and they start to really ruminate and fix their thoughts on these disease states.

1:11:09And so I just start with a three-minute silent meditation. Can you give me three minutes a day? It's going to help so much. It's going to start to reduce the cortisol and reset the vagal tone. Three minutes a day. But again, like your red light therapy, how can I fit one more thing in? And I think that's sympathetic activation because we're just running around like crazy people and we don't even realize what off can feel like. Reconnecting with our bodies is everything. Yeah. Partnering that with like the blink and then the deep breathing while you blink. And I'm like, you are doing so much for your hormones.

1:11:43I mean, we're talking about eyes in this episode, but you've done so much for your hormones. Don't even get me started on wide eye stretches. That directly activates your vagus nerve. Say more. What about this? Okay, lots of people talk about vagus nerve. No one has said this. No one. I mean, it's starting to reach my FYP. So people are starting to, but wide eye stretches and opening that peripheral field. You know how we were talking about how our generation is just really shrinking our field? Stimulating the peripheral field is vagal toning. It's one of the most direct things we can do. And so practicing noticing, practicing noticing your peripheral vision.

1:12:20If you're looking straight ahead, can you see the wall? If you're looking straight ahead, can you see the window? If you're looking straight ahead, can you see the ceiling? And there's actually something we use for our macular degeneration patients called an Amsler grid. So you can just Google an Amsler grid and see this. Cover one eye at a time, and you're going to focus on the dot in the middle and notice the grid around it. It's a noticing. It's subtle. But wide eye stretches do the same thing. You can look in all four cardinal directions diagonally. You start to put that together with things like bi-hemisphere tapping or other things.

1:12:59There are optometrists that specialize in neurovisual medicine, and they are the experts at this, man. They really understand things like how lights are affecting our sympathetic nervous system. There's something called Syntonics, which is light-based therapy for parasympathetic activation that a lot of vision therapy doctors use. It's fascinating when you get into the world of light-based therapies and what the visual processing system is really doing. It's telling our central nervous system how to respond. Let me ask you about working in front of the window with the light. I'm wondering if that does anything additional.

1:13:36Well, yeah, and natural light in general and getting outside in general. Direct connection to myopia progression. And what's myopia progression? Yeah. So specifically two hours a day of outdoor time is the magic number for kids to prevent myopia or help it from progressing. But what is myopia? Myopia is nearsightedness. And usually anatomically, it means your eyeball is too long. On your prescription, it means you have a minus number in front of it. And most people are myopic a little bit. But progressive myopia is when you just rapidly get worse and worse and worse every year. And there are lots of things we can do for that, like orthokeratology that we mentioned, the Invisalign for your eyes.

1:14:18That helps quite a bit. But a lot of this myopia progression has to do with your peripheral vision, stimulating your peripheral retina specifically. That's what orthokeratology does. And that's what these different myopia control lenses do is stimulate the peripheral retina. But then getting outside specifically, not in a city even, you want to be in nature because think about walking through the woods and all of these trees are stimulating your peripheral retina. You have less central detail and you have more peripheral detail. And it's in the natural light. It's huge. so what the urban planning in the united states has done to our health extends even to the degeneration of our eye health very much so that's wild but for people who are like well there are studies that show that um subdivision shorten your lifespan what yes living yes this is wild and like obviously look at all of the downstream consequences of central nervous system dysregulation.

1:15:22Yeah. No, I haven't seen that study, but I'm wondering because people who are listening right now being like, great, I live in an apartment in New York City. What do I do to mitigate this? Get to Central Park. I love Central Park. Get to Central Park. Plan outdoor time. It's so important for our health. In Ohio, the UC is University of Cincinnati. They have an Osher Center, which is the Center for Integrative Health. And they do tons of free community forest bathing, guided walks with like a therapist guiding you through the forest. Slowing down is huge. Walk slower. Notice the leaves. Smell. Smell things because that anterior ethmoid nerve we were just talking about, nose breathing is responsible for a third of our tear production.

1:16:16Interesting. A third. So nose breathing helps vagal turn. Yeah. We had a Dr. Stacey. I love Dr. Stacey. Yeah. It's funny because, I don't know, you two, like, remind me of each other, like, in some way. Compliment. Yeah. But I think it's because, like, you're the eyes and she's the mouth and, like, you're such geniuses in the area that the medicine decided to neglect. Like, anyhow, and she was talking about how mouth breathing is associated with worsening ADHD, worsening nervous system dysregulation. And so as you say this, like it's a full circle moment, I think for a lot of the listeners of like and mouth breathing is also going to be associated with this dry eye condition because again, how it affects the nervous system.

1:16:58Yeah, we're not stimulating the vagal nerve. Let me ask you, what's happening when someone says my eyes feel like they're on fire, but their doctor is telling them everything is normal? Oh my gosh, I hear that all the time. All the time. Usually by the time patients end up in my chair, they've seen multiple providers. It's usually inflammation in the eye itself, and that's where we can test for it. And that's where most of the time the red irritated eyes. But what happens is if your tear film gets so disrupted, then your body starts to produce inflamed tears. And so that's where we have this cycle.

1:17:35And it depends on how big your fire is, is how much we have to do to put it out. But we have to put it out and then regulate. And how do we put it out? That is where I talk about heat fish oil, blank exercise, lid wash, always my go-to. And then we have all the pharmaceuticals. I often will ask a patient, scale of 1 to 10, 10 is the worst your eyes could ever feel. You want to cut them out. What number are you? You know, 5 or 6, I go pretty traditional. Okay, we're going to start here. We're going to do a couple in-office therapies, maybe clean up your lid margin. But if they're at a 10 out of 10, we need to get there faster.

1:18:15And so I usually throw the kitchen sink on people. And that's where people will tell me often, it feels like I have a newborn again caring for these eyes and they have to do so much. And one more pill, I can't do one more thing. But we just have to do that initial work. and then we start pulling things away to see how much you can regulate. So it usually looks like multiple pharmaceuticals, multiple in-office procedures, and lifestyle, diet, and stress changes. But we're talking about these lifestyle changes at every visit because it's progress over perfection. It's not going to be overnight. If habit changes were easy, we would all be perfect bodies, perfect finances, perfect sleep.

1:18:55It's not as easy as that. So it's a reminder every time you come in. How are blink exercises going? Oh, I forget. Okay, well, I'm reminding you. Or I will use corneal shields when I do IPLs and they're like these metal, barbaric looking corneal shields. And I can almost tell how strong the eyelid muscles are by how well they can hold them in. They're like little eyelid weights. And so after a series of treatments, I'll say, oh, your blink exercises are doing great. You can hold these in so much better. There are also different muscle stimulators we can use on the eyelid muscles themselves to try to bulk the strength of the muscle again.

1:19:34What does that look like? Does that look like a TENS unit kind of device? It's a lot like a TENS unit. And again, it comes from the aesthetic world because there are different skin procedures you can do to, they say it's like going to the gym for your face, and to rebuild the muscle beneath the skin. So for so long, we were worried about just filling, but now maybe we can fill with muscle instead. You know? It's very cool. Let me ask you, what is going on with women who have dry eyes, they can't stand without getting dizzy, and their heart seems to race for no reason? That's where things like electrolytes come into play too, right?

1:20:08So the whole body is so balanced or unbalanced that our blood pressure may drop. There's a lot of my dry eye patients have EDS, POTS, and all kinds of dysautonomia to where it's like, are we changing our systems? Are we being born with these broken systems? But it goes back to central nervous system regulation. Last night, Dr. Ana Sierra, and you were talking and she had mentioned about, so everybody listening, she is a neuropelviologist, specializes in chronic pelvic pain. And she talked about how you can see central pain sensitization in the eyes when you look at someone. Exact same thing. Yeah.

1:20:51Yeah. And there are all of these theories about like how wide your palpebral fissure is or how narrow, right? A wider palpebral fissure is going to be a more sympathetic dominant. And the pupils dilate when we're in sympathetic versus, I'm sorry, dilate when we're relaxed and contract when we're in sympathetic. So pupil tone. And one thing that no one realizes is the field, your visual field shrinks. And so I think that's where, I don't know, maybe optometrists are really going to push this forward in calming everyone's system back down. Study and play. Come together on a Windows 11 PC. And for a limited time, college students get the best of both worlds.

1:21:38Get the Unreal College Deal. Everything you need to study and play with select Windows 11 PCs. Eligible students get a year of Microsoft 365 Premium and a year of Xbox Game Pass Ultimate with a custom color Xbox wireless controller. Learn more at windows.com slash student offer. While supplies last, ends June 30th. Terms at aka.ms slash college PC. Yeah. Identifying them earlier. What is the evolutionary strategy of our field narrowing though? Because there is a reason why we've adapted for that when we're under stress? The classic right now is screens and that we are just... Well, that's not evolutionarily adapted.

1:22:16That's how we have screwed ourselves with modern society. With this one, right? Well, I guess that's what I'm saying is these last few generations, our eyes are different than they ever were before. Okay, okay. Right? It's rapid. So what is going on? But the screen time, when I was in school, I was taught that four hours a day is severe screen time. Well, now everyone's at like 10, 12 hours. It's our life. So we can't even begin to guess the long-term consequence, but I think that's part of it is that we're just tunneling in and we're locking in. Yeah. Well, one thing I think that we don't talk about enough is when we're in fight or flight, our system's locked down because we have to escape.

1:22:57We have to survive and that's great. But just like animals after a fight, they need to shake it out, right? It's almost like somatic therapy. Getting that built-up energy out of your body, we're not doing. We're not grounding. We're not moving. We're not screaming. We're not getting as much physical touch as we need, the cracking of the fingers, right? We should be doing a lot more daily practices to get this energy out of our body because we're like batteries. If we store this energy, it's going to fry our systems. We don't have, if we're electric bodies, we don't have enough grounding. Jump squats are one of my biggest prescriptions for people who have anxiety.

1:23:38And I'm like, because what your body's begging you to do is move. Like it doesn't know when the anxiety signal comes on, whether the threat is real, going to eat you. Like, do you need to run away or do you need to fight? So you need to move the big muscles because that's what it was designed to do. So I want to - And then doing that raises testosterone. Well, there you go. Perfect. Well, I want to ask you too about the connection. What is going on there with this connection between dry eyes and these other conditions? I think it's loose right now and studies are going to keep coming because, you know, we were taught that things like EDS were so rare and now they are seemingly not nearly as rare as we think.

1:24:18Yeah. But if we think about the connective tissue as supporting the central nervous system, right? They're intimately connected there. And then all of the, everything's hypermobile. And so, for example, there could be a direct connection to your blink. If you have this like floppy collagen, the two lids won't press together. They'll flare out. That's a very direct example. So your oil glands aren't getting the pressure it needs because the connective tissues can't support it. And then, you know, there are connections to cataracts and vision and lots of other things. But there is this direct inflammatory component that they almost always have a dry eye condition.

1:25:04And what do we do about the EDS blink problem? That's what's interesting because we don't know. For example, one of my favorite treatments in dry eye is radiofrequency. And it works with the collagen. it's called it does collagen it produces collagen and that's how it came from the aesthetic world but the question is well if my patient has faulty collagen is this still going to do the same thing and we don't totally know because this radio frequency just came onto the eye world a few years ago and so we don't totally know but we know it's working so something's happening and my opinion is that it is probably stimulating the nervous system and making the nerves around the eyes, the nerves in the oil gland, the nerves in the lacrimal gland healthier.

1:25:52Because we know radiofrequency, post-surgical, and other parts of the body help collagen and nerve healing. So that's my extrapolation, but we don't have that direct connection yet. EDS often rides along with histamine issues. Huge histamine issues. Yeah. What do histamine issues do to the eye? And so this is anywhere from MCAS to like histamine intolerance. Well, you can have these histamine reactions in the eye as well. I mean, look at allergic shiners. And so they are rubbing their eyes all the time and they are never getting relief. And rubbing your eyes makes it worse because it breaks the mast cells open and releases even more histamine.

1:26:29And that's where it goes back to diet. You have to decrease your high histamine foods. You have to get in touch with your body and what's helping. and healing it? I think a lot of people don't realize that when our hormones become imbalanced, so whether that is way too much estrogen and too little progesterone happening because of very menopause, or it's a situation of, you know, perhaps, you know, you're dealing with being on hormonal birth control or other variables, that that can lend itself to more histamine problems. And so we can see people have cyclical flu-like symptoms before their period, that points to histamine.

1:27:06I think the other thing people don't understand is that endometriosis itself is a condition that actually like starts a whole histamine party. Like that, those misbehaving tissues love to dysregulate those mast cells. And so, you know, as you're saying all of this, I'm like, there's so many conditions that I can identify or like, if you have read, like you say dry eyes, I have to start thinking about like all of these other things that could possibly be lying underneath because as much as medicine likes to compartmentalize every single system of the body and every diagnosis goes to the certain person, every single one of these things are connected.

1:27:43I think it's one of the biggest disservices we've done in women's health. I agree 100 % and how I said, what isn't causing dry eye, right? So oftentimes the patients will ask me, what caused this? And it's like, well, you had LASIK, you wear waterproof mascara, you've had crow's feet Botox, your thyroid's off, you're eating these foods, all of these things. You've wore contact lenses for 20 years. That destroys your nerves. There are so many things that compile on top of it, which is why dry eye disease is such a complicated one. What is the healthy way to wear contacts then? I always love a daily disposable and not a reusable.

1:28:24And then give your eyes breaks for sure. I see a world where we are testing corneal nerves on all routine patients. So in my dream world, all contact lens patients are getting corneal nerve testing. There's a variety of ways to do this. It's pretty easy, but like in the modern healthcare system, how can you add one more test? We're up against time and resources, but I love a world where we're testing corneal nerves. And then if we start to see a dip in the nerve function, we pull them out for a little bit. We support the nerves. And then it's the balance. And what does supporting the nerves look like?

1:29:03So if somebody's like, oh, my God, I've been wearing contacts every day for 20 years, what can be done? Supporting the nerves looks like there are a few pharmaceuticals. Topical insulin supports the nerves. There's one called Sinedgerman. We really usually use this if the nerves are basically shot. It's a powerhouse of a nerve growth factor. I also love biologics. PRP, we were talking about a lot. PRP eye drops are fantastic. How would you do PRP eye drops? I'm curious. I'm going to stop you right there because I just had a PRP infection like two days ago, but I'm like, how are you keeping this plasma around for eye drops?

1:29:39Yeah, no, it's awesome. So there's autologous serum. There's a few different biologic eye drops you can use. Autologous serums like the OG, PRP seems to be superior. Over the last couple of years, we're starting to see that it is superior. So that's my preference. I, again, see a world where we would use PRP instead of an over-the-counter artificial tier. Plus, I have a sneaking suspicion that this is a good way to grow lashes. Yeah. No, hands down. How could it not? Yeah. How could it not, right? So how cool would it be in a world where we're doing maybe an IPL a year and PRP eye drops instead of an artificial tier?

1:30:15then we are supporting the corneal nerves. We're calming everything. We're healing everything. We're growing lashes. It's my dream world. So PRP, take your blood out, spin it down, you get the plasma. Is this a one-time office treatment application? It depends on the stage of the patient. And some patients can get by with a couple times a day using it. And some patients are like eight to 10 hours a day. If their cornea is falling off, I mean, they're in ICU basically. Eight to 10 times a day? Is they're using these eye drops. And it's sometimes forever and sometimes limited, depending on how much your body wants to heal.

1:30:49It goes back to how big is your fire? Yeah. What are we up against? What are we working with? But PRP eye drops are fantastic. We can, there are also doctors looking into placing PRP into these little oil glands to regenerate. I didn't know this episode I'd be making so many faces. That sounds brilliant. And also I'm going to be put under if I'm going to have that done. They're just like, put me to sleep. I will not cooperate. And then PRP injected into the lacrimal gland, right? So if you turn the lacrimal gland on to be inflammatory, well, we have to try to turn it back off. So things like PRP injected straight into the gland.

1:31:27And I know that these pharmaceutical companies are looking at other injectables into these areas. Yeah. We know with Parkinson's, Alzheimer's disease, that gut dysfunction, the loss of gut motility is an early sign of that. The eyes are extension of the brain. Right now, has science made any connection between these? 100%. Okay, go. In fact... You're like, I'm going to let you finish that question. I got something to say. We are now starting to think how I would love to have all contact lens patients have their nerves tested. All Parkinson's, MS, and dementia patients need their corneal nerves tested.

1:32:04There's a direct link to decreased corneal nerve function with these other neurological conditions. It makes sense intuitively, but clinically, no one is, I mean, I don't want to say no one. That's a generalization. It is not standard to test corneal nerve sensitivity on these patients, and I think we're doing them a disservice. So in testing this, are we doing this preventatively to have early interventions? Are we testing it to track disease progression or both? Kind of neither. So about five years ago, about five or so years ago, I was treating all of these dry eye patients and their corneal epithelium just looked terrible.

1:32:43And I'm like, why? What is going on? Their oil glands are beautiful. Their salt is regulated. They're on these anti-inflammatories. Why can't I keep their cornea? It's like a rash, like a scratch on their corneas all the time. And I'm like, why are these corneas so unhealthy? And it's corneal nerve health. So I called a colleague who was at the time, there were very few of us doing this. And I said, are you testing the corneal nerves on all of your dry eye patients? And he said, just dry eye, just the end stagers. And he said, no, but I think I should be. So I started routinely checking on the dry eye patients.

1:33:21That's it. because it gives so much insight into the longevity of the treatment. If your corneal nerves are affected, I mean, add months to it and many more. We have something called Prokera amniotic membranes. They're membranes made out of amniotic tissue that we place on the eye. The biologics like PRP and autologous serum, the senedrumins, the topical insulin. So those are all just really mainly nerve health. So we get the dry eye under control. now we have to heal the nerves then the whole system's functioning i dare i say no one's testing corneal nerves on healthy people yeah i just wonder because you know it's also something so i was taught in medical school to always listen to bowel sounds and if the lower left quadrant had diminished or loss of bowel sounds neurology workup like we need to figure out what's going on why would we not be testing corneal nerves all health insurance should be covering this, it shouldn't be an add-on to keep your eyes because your eye health is going to affect the rest of your health and the rest of your life, right?

1:34:28Your whole life. A machine, a device did just come out about a year or so ago. Do you know the air puff test that everybody hates? Yes, I know so much, but yes, I know it. That's called an NCT, a non-contact tonometer. So it checks your eye pressure without touching you. Something just came out that's a non-contact non-contact asthesiometer, which is a way to test corneal nerve function without touching. So I, dream world, all eye care offices have a non-contact asthesiometer and it's just baseline. We should be getting, it should be like blood pressure because I do think it's going to be predictive.

1:35:04I think this is where AI can help us out a lot. How do we get them to come back on instead of are they optimally functioning at this age for this patient? If not, why? Is there a neurological condition? Is there diabetes that we don't know about? Is there this? Is there that? Is there central nervous system dysregulation? I think it could be a predictor of that as well. Do you ever use N-acetylcysteine? Yes, all the time. And that's another one that's not used nearly as often because it's also an antioxidant. Well, no wonder it works so well. I love, it's mucomast is the brand name, but we get it compounded for the eyes.

1:35:41And specifically, these patients that I start to see what I was referring to as this vitamin A deficiency look, it's the goblet cells. The goblet cells are like the redheaded stepchild of the dry eye world. And no one really knows a ton about them when we don't talk about them a lot, but they're this mucus producing cell. And compounded mucomast supports them significantly. I take oral NAC. There's like thousands of reasons, in my opinion, to take NAC. What does this vitamin A deficiency picture look like? Because you mentioned it, but I'm not sure it's clear for people who are listening. So we use fluorescein the most, but there's a dye called lysamine green that I love, and it stains dead and devitalized cells in the conjunctiva.

1:36:26So lysamine green is usually better for the cornea. I'm sorry, fluorescein is usually better for the cornea and that's what we use all the time. But lysamine green is for most areas, but also the conjunctiva, which is where the goblet cells exist. But lysamine green, if your eye is staining green left to right, there's usually something else going on. Like what I was taught in school, chemotherapy, vitamin A deficiency from alcoholism or an eating disorder. But now what we're starting to see is people who don't have disordered eating, but still nutrient deficient because they're either not absorbing or they're not eating the right foods.

1:37:06Then they're starting to get the same appearance. What do you think the standard American diet's doing to people? Oh my gosh. Destroying it. I know. Honestly, it's crazy. It's too processed and it's too much. Mm-hmm. Well, and as you talked about like the glucose dysregulation and the high glucose levels affecting the eye, I think that's something people need to be aware of is that ultra processed food is going to hit you with a double whammy. So it's going to be major glucose swings. And then we've got the problem of omega-6s and we already have a problem in our society of an imbalance of omega-3 to omega-6s.

1:37:45That's not that omega-6s are bad, but it's just so much easier to get omega-6? You know, our ratio is like 50 to 1 and it should be like 3 to 1. Yes. I know. So when I recommend omegas to patients, I tell them this and I say, you can decrease sixes and increase threes. We have to get that ratio back in balance. If you could challenge the listeners to do one of those four things starting today, which would it be? I'll go lid hygiene. So cleansing it, making sure that your lids are clean every night. Yes. And what word of precaution would you give to the girlies who are just too tired at the end of the night to take their makeup off?

1:38:24You know, I tell people, this is another thing with contact lenses. They'll be too tired to take them out. And I switched them to daily disposables. And I say, take them out when you go to bed and put them, it's disgusting, but put them on your bedside table instead of sleeping in them. Keep a good makeup removing wipe on your bedside table. The basics, right? And this is always progress over perfection. What's a step in the right direction? Are there any wipes in particular that are eye doctor approved? I like the micellar water-based. Those seem to work well. Not heavy fragrance, things like that.

1:39:00The Burt's Bees are usually great. There are a lot of decent ones. Yeah. And I actually just use cotton pad and micellar water. Yes. That's the best. Just wipe it off and call it a day. But yeah, no, I do the double cleanse as well. And for anyone listening who feels like that's extra work, it actually makes it so much easier. And it feels good. So when I started recommending that to women, like, you know, years ago, my perimenopause patients were like, oh my God, my face is not completely dried out. Like it's hydrating at the same time as it's removing the impurities. It's actually quite lovely.

1:39:34And once you do it, there's no going back. I agree. And I've tried to make for myself, because remember, I am a dry eye patient and I'm a single mother and a busy practitioner. So like I fully get it. I fully get the capacity piece. Should people be doing lymphatic drainage on their face for their eye health? I wouldn't necessarily say eye health, but a question I get a lot from patients is what to do about these hooded eyes. Start with lymphatic drainage. You may not need a bleph. You may need gua sha. And what about the puffiness that develops under the eye? Can that also help? Absolutely. Absolutely.

1:40:10Absolutely. So I also, I like, there are these little tiny cold stainless steel rollers made by We Love Eyes, the same company that I like their lid wash. Keep them in the freezer and then go into out. The cold, the pressure, and then the lymph drainage. Works wonders. Amazing. Well, thank you so much for taking the time. Thank you for having me. This was amazing. Yeah, this is a great conversation. I think it's going to be very eye-opening for a lot of people. Well, thank you so much. Your call has been forwarded to voicemail. Hi, this is Zoe Deutsch. And Nick Robinson. Our brand new movie, Voicemails for Isabel, is all about those little moments that feel like the universe is looking out.

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