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Many of you now by now that my dad was an ophthalmologist, so I guess there's a certain place in my heart for eye issues. However, when we talk about skin on the show, we might not think about the connection to our eyes, but a lot of people struggle with eye issues, especially since some medications that are taken to help skin conditions sometimes exacerbate eye issues.
Today's guest is an optometrist, Dr. Carly Rose, who received a Bachelor of Science in Biology from Northern Kentucky University before heading off to optometry school in Chicago. She then chose to complete a year-long residency at the Cincinnati VAMC Eye Clinic.
Dr. Rose owns a comprehensive primary eye care practice called Eyecare on the Square and a dry eye medspa, Clear Eyes + Aesthetics in Cincinnati OH. She is a current member of the American Optometric Association, the Ohio Optometric Association, and the American Academy of Optometry.
Have you ever dealt with dry eye or eye-related side effects from medications? Let me know in the comments below!
Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android
In this episode:
- What is dry eye + what are the symptoms?
- What can cause an ocular surface condition?
- How screens + breathing can mess up tear production
- What you need to know about Demodex mites + eyes… yikes!
- Possible medications that can dry out your eyes
- Tips for dry eyes- at home or in a professional's office!
Quotes
“Tears are a lot more than just water. They're very, very complex. And it's really cool because it's also kind of like breast milk in that it, it changes percentage of components depending on what's going on in the environment. So they're reactive.” [2:52]
“There are more dry eye patients than all macular degeneration and glaucoma patients combined. And that number is growing exponentially.” [03:57]
Links
Follow Dr. Rose and her practices on Instagram here, here, and here | Facebook | tiktok
Check out Dr. Rose on her website
Healthy Skin Show ep. 210: How Steroid Creams Impact Your Eyes w/ Dr. Brian Boxer Wachler
Healthy Skin Show ep. 201: Before You Put Anything Around Your Eyes…w/ Rachael Pontillo
285: Got Dry, Irritated, Red Eyes? Sneaky Triggers You Wouldn't Think Of w/ Dr. Carly Rose FULL TRANSCRIPT
Jennifer Fugo: Dr. Rose, thank you so much for being here on the show. I really appreciate it.
Dr. Carly Rose: Thanks for having me. I'm super excited.
Jennifer: So I was really excited to be introduced to you because as you know, we were talking about before my dad was an ophthalmologist, and I, I guess there's a certain place in my heart for eye issues as a result of that <laugh>. And that's one reason why I like to talk about this on the Healthy Skin Show because while we aren't necessarily dealing with, when we're talking about skin, we don't think about the connection to our eyes. But a lot of people struggle with eye issues, especially like, you know, as you guys might remember, we had another episode on like steroid creams and placing them on the face and especially around the eye area. And so when it comes to dry eye, this is an issue that some people have. Sometimes medications can make it work. Like some, some of you guys know, Dupixent is one of those things that can sometimes exacerbate eye issues. What is dry eye?
Dr. Rose: It's a complicated, confusing condition, honestly. And you hit the nail on the head because we often just forget. So in optometry school, let me summarize. You had just mentioned that we often remember that the eyes are a connection to the brain. They're just an extension of brain tissue. The eyelids are an extension of the skin. They're a very complex, it's a modified skin. We have modified hair cells as eyelashes. You have modified oil glands as meibomian glands, but they're truly an extension of the skin. So everything how you can imagine inflammatory skin conditions, you get inflammatory eyelid eye conditions. So it is really, really similar. Um, dry eye in a nutshell is something that is causing a lack of homeostasis in the tear film. So the tear film is really complex. It's over 2000 different molecules, oils, mucus water antibodies, lipids, growth factors, awesome stuff, right?
To keep the cornea really healthy. And anything that causes a disruption in that balance causes an ocular surface condition. So it could be blocked oil glands, it could be an incomplete blanket, could be a complication of medications like high blood pressure meds. It could be an inability to digest lipids. If you say have a diabetic or a pancreatic digestive enzyme problem, it's really complex, but when you nail down to the root of it, it's getting your tears back to where they should be. So how do we do that? It depends on what you have going on.
Jennifer: Yeah, well I was just thinking that it sounds like tears are a lot more than just water.
Dr. Rose: Oh, they're a lot more than just water. They're very, very complex. And it's really cool because it's also kind of like breast milk in that it, it changes the, the, the percentage of components depending on what's going on in the environment. So they're reactive.
Jennifer: Oh my gosh. And then two, isn't there, like I would imagine like a microbiome too in the eye area.
Dr. Rose: You're just, you're exactly right. You're exactly right. And so actually, specifically demodex is a skin bug, you know? Mm-hmm. <affirmative> that also lives in lashes and brows. And it is a big contributor to this ocular surface disease. So we have to worry about bacterial overload. We have to worry about your mechanical blink. So for example, we're all on screens when we look at screens, we blink 75% less than we should, and that's the pump for the oil portion of our tiers. So all of our pumps are going out, and then we have all of these other things going on. It's just a recipe for disaster. In fact, there are, we've all heard of glaucoma and macular degeneration. There are more dry eye patients than all macular degeneration and glaucoma patients combined. And that number is growing exponentially. It, it's just, uh, I used to call it an epidemic. It, I can't really use that word anymore, but it, it is a big deal right now.
Jennifer: And I would imagine since, um, with Covid and everyone shifting to screens and using Zoom and whatnot, and, and it's become more accepted essentially. Mm-hmm. <affirmative>, I would imagine that it's got potentially gotten worse because you did say that
Dr. Rose: It's been confirmed that it's getting worse.
Jennifer: Wow.
Dr. Rose: Plus there's this weird component with breathing and tear production and specifically nose breathing. And so there was a mask associated dry eye condition that we saw come out. And that was because we were forcing air directly into the eyes, kind of like a CPAP. But then also there's this component of a, it's actually trigeminal parasympathetic stimulation. Nose breathing produces up to a third of our tears. So it's been fascinating to watch this condition change just in the past couple of years.
Jennifer: So even just the way you breathe, like if you start to pay attention to how you breathe, if you find that your mouth breathing a lot, or, I mean, we've talked about mouth breathing versus nose breathing during sleep. <laugh>, here on the show, that could be a, a part of the solution potentially for someone listening.
Dr. Rose: Exactly. And there are companies like taking advantage of that pathway as well to try to turn the system back on. It's fascinating.
Jennifer: So, um, for somebody who does have dry eye, I think it would be helpful. You know, because sometimes like we assume, because we know what it is, and, and I sort of like, it's the, the semi osmosis thing because my dad had was an eye doctor. I'm like, oh yeah, I know what dry eye is, but what if someone's listening to this? And this is like, my eyes feel scratchy. Like what is dry eye?
Dr. Rose: So for the patient, what they usually experience is red, irritated, watery eyes. That's one most people get confused by because why would my eyes water if they're dry? But watery eyes for sure. Um, if your vision comes and goes and blinking kind of changes it, that could be dry eye. Uh, dry eye actually often gets misdiagnosed as a contact lens intolerance or allergies. So also if your contact lenses are bothering you like crazy, it's probably an insufficient tear film.
Jennifer: Okay. And what about is dry eye the same or connected to when like you have conjunctivitis or blepharitis or when even if just the whites of the eyes are getting more like pink or tend to stay pink more often? Yes,
Dr. Rose: Absolutely. So that's technically called injection. When your eyes are injected, the red, swollen, irritated and that is one of the most common complaints I get from my dry eye patient. So that's a biggie. Conjunctivitis is like a global term of conjunctival irritation. We usually with the syntax we use, right? When we call something conjunctivitis, most people associate that with a bacterial conjunctivitis that's not usually directly linked to dry eye, but blepharitis for sure is. So blepharitis is just an inflammation in the lashes basically. And that is inflammation or you know, buildup that demodex we were talking about. All of that's kind of lumped together in this blepharitis that feeds right into the ocular surface disease. Mm. It's this vicious cycle of something is disrupting our system.
Jennifer: Okay. Now with the demodex mites, which my audience is somewhat familiar about, they, we've talked about demodex in terms of rosacea and potentially finding them sometimes in other conditions like eczema on the face, is it normal to have demodex mites living in the eye area? So there are like a commensal essentially,
Dr. Rose: Basically. And what happens is, so we all have 60 to 80 oil glands per eye in our upper and lower lids. And they open along the lid margin. So that water line where people tight line and put eyeliner right on that lid line, you shouldn't because that's where the oil glands open. And so what happens is the two lids touch together during a blink and that oil should be nice and clear and liquid like olive oil and it should squeeze easily out and lubricate the surface of your eye. All kinds of things are clogging those oil glands, including lack of blinking and putting cosmetics on the lid line and demodex. But what happens is they get obstructed and that nice clear, healthy liquid oil turns into more solid insidious, thick cruddy oil. And Demodex loves that. It turns into junk food for them. And so then they get overpopulated and now we have a demodex problem.
Jennifer: Oh wow. That is fascinating,
Dr. Rose: Isn't it?
Jennifer: So, okay, so we've got this issue and you mentioned makeup too, which for many women, especially as we're going back to the office and you go out to events, you know, it's always nice to be like, oh, I'm gonna put on, you know, like really nice eyeliner, right? Eyeliner or mascara, whatever. What, so what are your thoughts on that in terms of like what do you recommend to your patients to be cautious of or to be mindful of? It sounds like you have to be careful of where you're, where you're actually applying it, even despite the trendiness of putting, um, applying eye makeup, especially very close to the eye.
Dr. Rose: Exactly. You're exactly right. It goes, starts at application, right? And then type and ingredients and then removal. All of those things are important for the ocular surface. So the best way to summarize it is you really do wanna avoid the waterline. Um, the healthier options for things like mascara's would be not waterproof, not fibers. Then we could talk about lash extensions and falsies and lash serums. All of those things could potentially do damage specifically with lash growth serums. You wanna look for something called a prostaglandin analog- that's going to cause inflammation. So you wanna avoid prostaglandins, right? There's those, it's, it's, it's Pandora's box and then you wanna make sure you're cl you want healthy, clean ingredients, right? But then you wanna make sure you remove them properly. That's a big piece too that a lot of people don't think about. So what are you using in your removers are, how much force are you needing to use on the lashes and are you doing it? Are you keeping your cosmetic brushes clean? Those are proven to carry bacteria. So you wanna make sure everything's clean, cleaned off at the end of the day.
Jennifer: Yeah, I know that one thing that I have probably not been so good about is cleaning the brushes and all you need is soap and water. You don't need a whole lot in order to clean things appropriately. But it is important to keep things, especially I think like my dad just, we saw so many different issues in his office. It was instilled in me that you wanna protect your eyes as much as as possible.
Dr. Rose: We take, we take them for granted for sure. And then when I, I see it all day, every day when something does go wrong you're like, oh my gosh, I should have been more careful. It happens every time.
Jennifer: So beyond makeup, what else could potentially cause dry eye issues? Like we mentioned the screen time, we mentioned an incomplete blink, makeup. What are some other things that people might not realize or connect the dots on?
Dr. Rose: A huge kind of bucket of dry eye patients are autoimmune type patients and connective tissue disorder patients. There's usually a faulty uh, kind of like chronic inflammation brewing throughout the body that manifests as really irritated, uncomfortable red eyes.
Jennifer: Okay. And any other issues with like food or out, like could it be due to maybe an IgE allergy to something in your environment or maybe even something that you're using in your skincare or or your makeup?
Dr. Rose: All, all of the above. Plus some, you know, is there mold in your house? Um, is it screens like we mentioned, is it sometimes, uh, device implants right throughout the body? Cause this inflammation. So it really is treating the underlying condition is going to be digging down and seeing what exactly is causing your specific source. Um, it could also be hormone imbalances. There's a whole, we, it's, it's uh, it's research. Every dry eye patient is research.
Jennifer: And you mentioned too, I had mentioned Dupixent as a potential issue. It's a side effect of the drug for some individuals about I think about 10% um, of users if that medication. But are there any other medications that could actually contribute to dry eye issues?
Dr. Rose: Yeah, there are quite a few most anxiety meds, depression meds, ADHD meds and then also high blood pressure meds. Those are huge allergy meds. Anything that dries you out, dries out the system.
Jennifer: The oh wow system. Wow.
Dr. Rose: So, so that's why it's confusing when dry eye is misdiagnosed as allergies because you're treating it as allergies and it's making the problem worse.
Jennifer: So, and in terms of allergy medications, would this be something like Benadryl or are we looking To maybe like Allegra or Zyrtec or one of these other over-the-counter type medications that are non-drowsy?
Dr. Rose: Correct. All of them. Plus allergy eyedrops. So a lot of people self-medicate with an allergy drop and it's making their dry eye worse.
Jennifer: Okay.
Dr. Rose: Or a lot of patients even self-medicate with over-the-counter artificial tears and that's usually not even the answer. The answer is figuring out what's causing your inflammation and treating it appropriately.
Jennifer: Yeah. And and that was something I was gonna ask you is, you know a lot, there's a lot of dry eye medication, well not even medication, I don't know what they're over the counter for most of them. Um, I mean I know that when my dad was practicing there was like one or two I think that were prescriptive. Um, but at that's not the greatest option. And, and I do think if I recall, I believe the other ophthalmologist I had on mentioned perhaps that they might be possibly like almost addictive in a sense or there could be a compounding effect if somebody wants to try something that might maybe is less invasive, maybe they don't wanna go a medication route. Um, are there any other options to help with the dry eye issue beyond like blink more, don't look at your screen all day…
Dr. Rose: <laugh>. Yeah, absolutely. I'll give you my homework that I tell everybody that'll listen even if they don't have dry eye because from my perspective everyone is a potential dry eye patient waiting to happen because the worlds we're just migrating through. It's kind of a side effect of these unnatural environments. And so I tell everyone to do hot compresses. So hot hot cloth or a microwavable eye mask, five or 10 minutes, a couple times a day. What that's going to do is melt those clogged oil glands and then get the oil flowing like it's supposed to. I also think everyone should be doing blink exercises. . And specifically, the way I tell people to do it is either raise or relax your eyebrows and squeeze just with your eyelids. So raise your eyebrow, relax your literally eyebrows. It's tricky. It's tricky right? Yeah, that's perfect. You just wanna squeeze with your eyelid muscles. Okay. Not the other facial muscles. And you wanna do that two to three times an hour
Jennifer: And do you hold for like five seconds or
Dr. Rose: 10 seconds? Just a couple of seconds. Okay. Yeah, not too long. Just squeeze, hold open, squeeze hold open. And then supplementing with an omega, I particularly look for a triglyceride formed um, omega three. So I don't necessarily look at omega six s or omega nine s I look at omega three s. You want it to be the triglyceride backbone, not the ethyl ester formulation. It absorbs a lot better. And you want your EPA and DHA to be over 2000. I'm not so particular on the ratios. Um, some people are, I think if you can get above 2000 in any ratio, um, we're better off than we were with food that's a fat soluble and then a good lid wash. So the goal is we're filling the glands back up with the right kind of oil, some type of omega you wanna heat it and melt it out with the hot compress, you wanna blink it out, squeeze it out, and then you wanna wash it all away.
So that's for everyone. Next level stuff, that's where you would wanna look at. If you really have dry eye and you're doing heat, fish oil, blink exercises, lid wash, and you're still reaching for teardrops and you're finding no relief, you really wanna find a dry eye specialist that can do things like meibography, which is a picture of your oil glands or osmolarity or we can do biometric testing of your tear film. So we can take a little tear film sample and see what type of inflammatory agents are in there and salt. So, so there's a lot more we can do outside of a traditional comprehensive eye care like room that you would think of with a better one or two. There's a lot of diagnostics behind it that are super cool.
Jennifer: That is really neat. Is this something that you could go to any eye doctor to have done?
Dr. Rose: No. So, um, a lot of eye doctors can look at, they look at the surface of your eye, right? But not all of them do the biometric testing where they take the tear samples or something called meibography is flipping the lids and getting an infrared picture of the oil glands, the structure of the glands. And so if, if you do have a condition that you're not finding relief from, for sure find a specialist that has have these technologies and your eye care provider should be able to refer you to that specialist. Just like referring out for cataract surgery. They should have a referral in their head.
Jennifer: Okay. That's good to know because sometimes if you don't know who to ask, you know, and it sounds like too, maybe you could even ask, maybe you're like primary care doctor if you're not currently seeing an ophthalmologist or an optometrist. Um, but looking for somebody that specializes in this sounds like that would be really important. Cause as I'm thinking about all of these, this testing, I'm like, my dad didn't do that. <laugh>. No, that was not in his
Dr. Rose: Wheelhouse. That didn't exist, you know, five years ago it didn't even exist.
Jennifer: Wow. This is a huge, this is a huge change in how things are are being done to help people, which I think is a good thing. So, um, in terms of like other treatment options, you had mentioned something, uh, called IPL. Do you wanna share a little bit about like what that is, how it came about? Yeah,
Dr. Rose: For sure. So, so then you're, we're jumping basically from next level treatments, right? So you have the homework, the home therapy. What would you do if you were a dry eye patient then you were coming in for in-office procedures? In my practice we usually do packages of multiple procedures because you have multiple different things going on. So, um, most people need some type of IPL, which is stands for intense pulse light, which is actually a photofacial that was developed in skincare derm aesthetics for rosacea. And on accident around 20 years ago, an ophthalmologist in Tennessee discovered that it was helping his dry eye patients. So now we have over a hundred peer reviewed studies and FDA approval that came out in like 19 or 20 that shows how effective IPL is for dry eye. So that usually cuts the, it kills demodex, it cuts the inflammatory agents, it cuts it so inflammation, it has a little bit of thermal.
Um, I don't talk about the thermal much cuz we'll get into that in a second. It, it does all kinds of cool things. So usually we do a series of four IPL and something called a thermal evacuation. So we have a lot of different ways to heat up and express out those oil glands in office. So usually we cut the inflammation, get the oil glands unclogged, it's like plumbing for your oil glands. We make sure that you don't have some type of corneal neuralgia or some nerve problems too, and get you back on track to where then heat, fish oil, blink exercise, lid wash actually works for you. So we put the fire out and then keep the fire out.
Jennifer: Okay. So I'm gonna ask you some basic questions that I remember when I worked for my dad, he would go in the room and he'd be talking about doing some sort of laser and he'd walk out and the person would be sitting there like terrified because they don't understand. They're like, is he gonna burn my eye? Like they just didn't understand. So, so if we're talking about I P L, which is you said this pulse, this pulse light mm-hmm. <affirmative>, is this something where you're touching the eye or is this just like a literally a light treatment?
Dr. Rose: It is light. Uh, we do laser grade corneal shields, so we, the eyes protected ultrasound jelly all over the face and it's, I do basically a full face treatment. It's, it's, um, it's a machine that I mix all my settings in there. Right. And I go through the face with these very strategic areas and target different lesions, um, different vascular, like broken blood vessels because those are weak leaky blood vessels. So they blood vessels shouldn't be there and they're leaking inflammation basically. So we wanna target the, the abnormal vasculature and do that about every two to four weeks.
Jennifer: Okay. And you said this was developed for rosacea patients
Dr. Rose: Originally? Yes. So it really helps reds and browns. There's a little bit of collagen production, but it really targets freckles, age spots, sunspots, um, rosacea, things like that…
Jennifer: And if somebody had like active rashes, so active eczema or psoriasis spots on the face, would that be contraindicated?
Dr. Rose: We would couple with their derm with that. Okay. We've had a handful of patients that were not your typical Right. And so we partnered with their derms or one patient, we partnered with her OBGYN just to go through it in a specific fashion. Okay. Those are the outliers.
Jennifer: Yeah. And I, I think it's helpful for people to hear just so that they know the options and they can ask the right questions. I always think that's
Dr. Rose: Important. Well, and what's great about this is it really does rebuild your skin barrier. And so it would only help all of it as long as you didn't have active lesions and, and other complications.
Jennifer: Okay. Um, in terms of dry eye, just long term, is this something that you're doomed to have for your entire life if you have it now?
Dr. Rose: I, I'm a glass half full type of girl, so I don't, I'm gonna say no, but it's gonna take a lot of education on the eye care provider side to tell patients to look out for this, to take blink exercises, to drink enough water to get enough sleep and prevent it. Our mission will be on prevention, I think because the numbers are skyrocketing. So it's our job to do things like these podcasts. So thank you for having me because the more people I can tell, the more we'll prevent it.
Jennifer: Yeah. And, and I also know that this is a frustration that clients have and my, my advice is always, well, I would recommend you go see an eye doctor. Just that's what my dad would say. So <laugh>, that's what I recommend. But this is very specific. This is different than other issues. And as you said, there's newer treatments out that could be helpful that depending, you know, some people are uncomfortable doing more medications, they've had bad experiences with meds, so maybe this light treatment might be a better option. Or they could find some other piece of the puzzle that could be going wrong that you wouldn't normally think about or consider, like you said, it could be demodex issues, it could be screen time, any number of things. And so I think educating people is always the first step in this process. And I also know that there are people that are really squeamish about anything that comes to their eyes, <laugh>. Um, so
Dr. Rose: And that's fair. That happens too, right? And we have work arounds…
Jennifer: It does. Exactly. And so it's my hope that by having this conversation, if you've been on the fence or you've been uncomfortable about going to get help, you now know there are options and there are people, especially in, so Dr. Rose is an optometrist, um, who works with patients like this. Um, Dr. Rose, where are you located and are you currently seeing patients?
Dr. Rose: I am in Cincinnati, Ohio. We actually have two different locations. One is primary care, kind of like comprehensive full scope. And then the second location is a dry eye med spa specific for dry eye treatment, dry eye diagnostics, and then also aesthetic services that won't cause dry eye. Right. So the healthy patients that want to get different things that don't wanna end up as a dry eye patient. So those are both in Cincinnati, I have multiple associates that are fabulous and we are at both locations accepting new patients.
Jennifer: Well we'll put all of your contact information right into the show notes. Is there a website that
Dr. Rose: Anyone, Leslie just can check out? The, the one that's most related to Dry Eye would be the clear experience.com and then are other website also has lots of dry eye info on there. And that's called eye Care on the square.com. And eye care is E Y E C A R.
Jennifer: Perfect. Thank you so much for sharing today. I really appreciate it. It's been a pleasure.
Dr. Rose: Thank you for having me.
Jennifer: Yeah, it's been a pleasure talking about this and I hope that, like I said, either this is gonna entice someone to go actually get help who's really been putting it off and who was afraid that they were only gonna end up with eyedrops. Mm-hmm. <affirmative>, um, or potentially someone is now having an aha moment realizing, oh, this is not just
Dr. Rose: My, the whole time this is, is dry eye.
Jennifer: This was dry eye and I actually need to go get this checked. So thank you so much for being here today. I really appreciate it.
Dr. Rose: You're so welcome. Thank you.
Is stringy eye mucus a sign of dry eye? My eyes aren’t red and irritated, but I keep getting stringy mucus. Also, is there a specific lid wash that’s recommended?