Doc, my eyes still hurt, now what?

Recently a patient complained to me: ‘Doc, my eyes still hurt.’

I asked: ‘have you tried the artificial tears I recommended to you?

‘Yes, it doesn’t do any good.’

‘How many times did you put in a day?’

‘I just did that once and it did not work.’

‘I see. How about the warm compress?’

‘Not working either.’

‘How long did you do it and how many times a day?

‘Once or twice, I forgot.’

‘Are you taking the fish oil supplement?’

‘Yes. Did not feel any different.’

Here I have a patient who two months ago came to me for dry eye. He reported trying restasis from his previous eye doctor for months but no relief at all. Eye exam showed typical meibomian gland dysfunction (MGD) and poor tear film quality, without blepharitis or corneal staining. So this is a case of MGD-induced dry eye, that’s why I started him on eyelid warm compress 5 min x 2, and fish oil 1000 mg x 2 daily, with artificial tears as needed, up to 4 times daily. I asked him to follow up in 1 month. At which time he was not doing any of the things I asked, and of course his dry eye symptoms continued. After re-education, I asked him to do these consistently and follow up again in 1 month. He has probably done some of this now, but not consistently, and given up very quickly.

Rather than drilling him again for being more compliant with the treatment regimen, I offered him an alternative, which he clearly came looking for. I would like to refer him for a lipiflow treatment. I explained what it is, how it is done, and why it works. Then I told him that it’s not covered by insurance and may cost $1-2,000 for one session.

After a short moment of silence, he told me that he would like to give warm compress another try. And that he just started taking fish oil last week and would like to see if doing this for longer may help. I agreed, and asked him to return in 6 weeks to evaluate on progress.

No one likes having the dryness, foreign body sensation, redness, burning and tearing caused by dry eye. Fortunately there are effective treatments such as warm compress and artificial tears, and often these are enough to control dry eye symptoms. Unfortunately these treatments require consistent and long-term use. There is no cure for dry eye, which is a chronic condition and may require life-long management. When it comes to dry eye treatment, compliance is key. There are certainly those unlucky people who despite doing everything right still suffers from dry eye. But fortunately those are the minority.

For more information on dry eye and treatment, you can visit my previous posts and video.

Dr. Ding | Dry Eye Disease and Treatment

In this video I will talk about dry eye disease and its treatment. Common symptoms of dry eye disease include dryness, irritation, foreign body sensation, redness, tearing and itchiness. There are two causes of dry eye, not having enough tear volume, or having too much tear evaporation, the latter being the main cause of dry eye and mostly due to Meibomian gland dysfunction. I will discuss over the counter and at home remedies for dry eye treatment, including lid hygiene, warm compress, artificial tears. I will talk about nutritional supplement, specifically, omega-3 to help dry eye symptoms. A variety of devices can also help dry eye, including moisture goggles, lipiflow, intense pulsed light therapy, punctal plugs, neurostimulation device and scleral lenses. I will talk about the FDA-approved medication eye drops for dry eye, including Restasis, Cequa and Xiidra. And autologous serum eye drops for severe dry eye.

Drug-induced uveitis or dry eye?

by Juan Ding, OD, PhD

I will try to write about one interesting eye case that I see each day. The purpose is to provide education of eye diseases, vision function and eye care to the public, and maybe to students who study optometry. This is the 2nd of the series.


Woman in her 30s referred by her cancer doctor for red eye. The symptoms were irritation, itchiness, pain, redness, and some crusting, but hardly any photophobia. Cancer doctor informed me that the patient was on two cancer medications, dabrafenib and trametinib, which are known to cause uveitis (inflammation of the middle layer of the eye). Just from the symptoms, it sounded like conjunctivitis or dry eye rather than uveitis. Unexpectedly though, there was indeed inflammation of the iris; the vitreous and retinal were normal, so the inflammation was restricted to the fronter part of the eye, termed iritis. Interestingly, almost all her complaints were actually from the mild dry eye she also had. In contrast, usually iritis would produce a dramatic complaint of pain and photophobia.


My patient had malignant melanoma. She started with chemotherapy with dabrafenib and trametinib for 2 months, followed by surgery, then continued with chemo. About 5 months into the chemo she presented with inflammation of both eyes. Below are the eye side effects of these two medications listed by manufacturer:


“Ocular Toxicities. Retinal vein occlusion (RVO) may lead to macular edema, decreased visual function, neovascularization, and glaucoma. Urgently (within 24 hours) perform ophthalmologic evaluation periodically and at any time for a patient-reported loss of vision or other visual disturbances. Permanently discontinue MEKINIST in patients with documented RVO.

Retinal pigment epithelial detachment (RPED) can occur with MEKINIST administration. Withhold MEKINIST if RPED is diagnosed. If resolution of the RPED is documented on repeat ophthalmologic evaluation within 3 weeks, resume MEKINIST. Reduce the dose or discontinue MEKINIST if no improvement after 3 weeks.

Uveitis (including iritis and iridocyclitis) can occur with TAFINLAR. Perform ophthalmologic evaluation for any visual disturbances. Monitor patients for visual signs and symptoms of uveitis (eg, change in vision, photophobia, and eye pain). Permanently discontinue TAFINLAR for persistent grade 2 or greater uveitis of more than 6 weeks duration.”


Her iritis responded well to prednisolone acetate 1% drops 4 times a day in both eyes, and tapered without incident.


Two months later, she came complaining of bad dry eyes; no uveitis. She got relief with preservative free artificial tears. About the same time, her cancer doctor found sarcoid-like reaction in her lungs.


Another two months later, in a routine follow up eye exam, I found iritis in both of her eyes again, though she had no compliant. It went away again with prednisolone drops.


It is not clear if her two episodes of iritis are due to sarcoidosis, or to drug toxicity; or if her sarcoid is in anyway related to the drugs. It does appear that her symptoms are mostly related to dry eye rather than uveitis. Prior to this she did not have a history of dry eye. Hopefully she can be off of these medications soon and hopefully she will then not suffer from dry eye again.