The Dry Eye Zone

Rebecca's Blog

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Dry Eye Awareness & Prevention, Week 2: Medical causes of dry eye

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It's all about prevention. (All month.)

A not-so-secret-secret: I'm not the greatest planner-aheader.

When there's a project that needs brainstorming and executing, I plan.

But stuff like Dry Eye Awareness Month? I stood at my whiteboard (one of many covering most of my office walls) at least a dozen times in June and simply couldn't do it. By the end of the month, I had a concept. but it was still changing daily. Then I thought I had the whole thing taped. I mean, it was Right.

But then, something happened. I got to the end of week 1 - Prevention - and it hit me. 

It's ALL about prevention. 

We're either preventing disease,

Or we're preventing escalation of disease,

Or we're preventing symptoms,

Or we're preventing an escalation, a cascading process of symptoms,

Or we're trying to prevent other sequellae of dry eye, like depression, anxiety and so on.

It all comes back to prevention in some form or another.

So that's what I decided to run with. It's nice to finally have a plan, now that we're already into week 2.

Medically induced dry eye: How do we approach these interminable and sometimes prickly issues?

There is a TON to talk about this week. We're going to be looking at a very important facet of prevention: all the medical treatments and products that can cause or contribute to dry eye.

But... how are we going to look at them? I think that's key. 

One thing I know is that we do NOT need these things:

  • A new list of things to be afraid of
  • Or more things to worry about
  • Or more risks to be overwhelmed by
  • Or more things to resent somebody (industries, doctors, etc) for

I really don't want this to become an exercise in learning more things to be afraid of or angry at. We all have more than enough stuff in our lives to spend our emotions on! And the fact is, the list of things that "can" cause dry eye is beyond intimidating. Poring over a list is not necessarily a helpful exercise. 

So today's post is meant as a preface to the specific medical topics - more, as an exhortation to being intentional, to navigating knowingly and wisely and calmly in a world of medical care that is overwhelming and scary at times.

It's about pausing, asking just a little more, and reading just a little more.

Remember when we first started talking about prevention?

It's not about barricading your life against all the things that "might" happen.

It's about just a little more of this, and just a little less of that. 

There are an awful lot of drugs, surgeries and other procedures that can cause dry eye or make it worse. But... how do we process that fact, when we are all so terribly jaded, not just by the endless lists of side effects that we read and hear in commercials for every drug, but by an entire world full of warnings and disclaimers.

What happens when we have "warning fatigue"? We quite naturally tune it all out and, when the chips are down, we rely upon professionals to tell us which warnings actually matter. This is what lawyers, and doctors, and financial advisors are for. Tell us what to sweat, and what not to sweat.

Unfortunately, some risks fly under the radar even of the professionals. They can't know it all. With dry eye, we get the double whammy: that most eye doctors really don't know all the things that are linked to dry eye, and even if they did, they would not necessarily interpret them the same way we do, because the vast majority of them have not had to live with the physical, emotional, or practical realities of moderate to severe dry eye.

So we have to take a few extra steps. 

When considering a medical decision, whether it's an elective or cosmetic procedure, or a surgery, or a drug, there are simple things you can do:

  • Pause. Don't just leap in with blind faith.
  • Read the warnings. Try to re-frame them in your head from obligatory blather to data: data gleaned from actual clinical trials. If it's included in the side effects list, it's because it happened to real people in significant numbers. It doesn't mean it's a bizarre anomaly that happens to "other people".
  • Ask questions. It's not just about the fact that it is a risk. It's about the percentage of people who it happens to, and it's about the predisposing factors. Your doctor may not have the answers, but s/he may be able to help you find the answers. And perhaps the most important part of the process is giving yourself permission to question, in general.
  • Think about your priorities.

It's about being a little less willing to believe in glitter. (And knowing what glitter is.)

This is critically important in the case of elective surgeries. And I want to be clear: By glitter, I do not mean any form of advertising. We're all too savvy these days to be drawn in only by that.

What I mean by glitter is the allure of having The Best Surgeon do your surgery.

We are all alike in that. We seek out the best, and, well, while we are human, that will be partly for the brag factor. But really, seeking out the best is our way of assuring ourselves that we are doing The Right Thing. That we are, in fact, making A Good Choice.

But... what if it's not always about that glitter-bespattered best surgeon?

What if... you can go to the best, or one of the best, LASIK surgeons in your region, like I did, and still have an outcome like I did?

What if... you can go to the best plastic surgeon in your region for your blepharoplasty, and come out like the women I talk to every week who are in constant pain from a slight lid retraction or non closing eyelids? What if you can even be smart and choose an oculoplastic surgeon, and still come out unhappy because of unremitting eye pain?

What if... you can go to the best cataract surgeon anywhere, and still get dry eye afterwards?

What if... you can go to the best glaucoma specialist in your city, and still find your eyes fried after ten years of daily BAK-preserved glaucoma eyedrops - the very ones that were doing such a great job of keeping  your intra-ocular pressure under control?

What if... you can take your teenager to the best dermatologist in town, and follow their advice to the letter, only to find out only years later that the Accutane they prescribed slowly shriveled up your youngster's meibomian glands, crippling their college and young adult years with pain, disability and socially awkward persistent redness?

Sometimes, the risks are inherent in the procedure or the drug itself, not the professional carrying it out or recommending it.

Sometimes the risks are glossed over by those who have a financial interest and who genuinely do not understand the real life impact of what the risks might actually mean to real people.

The era of Doctor = God is finished. Period. Done. For good.

The era of Medicine = Profession (not business) is finished. Period. Done. For good. We live in a complex, confusion world with a lot of grey area.

Get over it. Move on, step up, and take responsibility for health care. Not just by joining a Facebook group and absorbing the chatter, but by learning what you need to learn.

Don't. Cop. Out. Do your own homework. We have access to data and we need to make use of it. You do not need to learn everything. But you can learn more than you know now, and you need to.

It's about sweating risks a little less, or a little more, depending on circumstances.

I have spoken with so many people over the years who said something like "Well, I would have taken X drug, but I know it can cause dry eye." (Hint: It's usually an anti-depressant.) Here's what I think about that:

  • "Can cause" does not mean "Will cause".
  • Is there a lower risk version? Just as minocycline *might* be less likely to cause less stomach upset than doxycycline, buproprion (Wellbutrin) *might* be less likely to cause more drying than escitalopram (Lexapro). Experimenting is costly - physically, emotionally, financially. But so is doing nothing.

On the other hand, I have heard so many others think nothing of doing a surgery or taking a drug simply because the recommending doctor was such a bigshot.

No doctor is a big enough shot for you to take their word as gospel. Do. Your. Homework. At least a little bit. Because the most important thing is giving yourself permission to question.

It's about establishing priorities.

What is going on with you right now? Step back and look at the big picture.

I have seen people become progressively crippled by depression and anxiety, refusing medications not because they have issues with the medications themselves (many do, and I respect that) but because they are so consumed by fear of anything that could make the dry eye worse, that they do not understand that fear is causing them more harm than dry eye.

Please don't misunderstand me: I know that when you're barely hanging on, the idea of something that might make the pain, or anything, worse, truly is unendurable. But I think that the error that creeps in is when you're convinced it's all about the eyes. It isn't. It all starts with the eyes - absolutely. But there comes a point for many of us where the global mental health impact eclipses the dry eye impact. That's when it's time to re-evaluate your relationship to "risk". 

I fault eye doctors for their poor service to severe dry eye patients in this area, through two distinct channels:

  • They may so badly discredit the idea that our dry eye and our depression or anxiety are related, that we patients end up fighting to defend the reality of our experiences by insisting to them and ourselves that it's all about our eyes and not our messed up heads. And we convince ourselves more effectively than our doctors, to our own detriment. But the fact is, dry eye DOES mess with our heads. Just not the way our doctors think.
  • They may give us rote cookie-cutter advice: "Don't take anti-depressants, they're drying." Ophthalmologists are NOT psychiatrists, and there's good reason why not. No ophthalmologist should be making your mental health care decisions for you. If they can give you comparative data on different drugs, or practically helpful experience, great, but if not, discount or discard what they say. No eye doctor who simply says "Don't take those drugs" is serving  you well, no matter how well intentioned. They should be referring you to an expert, and equipping you with informing, not usurping a role for which they are not trained.

For the record, I personally hate psychotropic drugs, while at the same time acknowledging the critical role they may play in our wellbeing. I am a reluctant yet determined fan.

It's about honoring yourself as a whole person.

While your eyes might, at times, feel like they are running your life, the fact remains that you are not a pair of disembodied eyeballs. Make your decisions on a broader picture of wellness. 

It's about making balanced, informed decisions and plans.

It's hard, maybe impossible, to separate information from emotion.

Prevention and self-care are about the conversations we hold with ourselves and others as we discover the difference.

So... On to Week 2!

Loads to talk about this week! Drugs, drops, surgeries, procedures... bring it on!

Oh, and do you want the big bad ugly list anyway?

If you're a glutton for punishment and delight in all things dry eye, or want to look up something specific, here is the Bible on medically induced dry eye: TFOS DEWS II Iatrogenic Dry Eye report, published 2017. But please, exercise caution and reasonableness. If you have an innocent nerd's delight in details, like me, go for it. If you have a lot of anxiety about your eyes right now, reading this stuff will hurt and not help, so give it a pass.