Steven L. Maskin, M.D. is an ophthalmologist who specializes in solving difficult Dry Eye, MGD, and ocular surface disorders. He is the director of the Dry Eye and Cornea Treatment Center in Tampa, Florida and founder of MGDinnovations, a bio-tech company focused on Meibomian Gland Dysfunction.
Do you remember what happened when your doctor was searching for a reason for your chronic eye pain? Did you hear the word “neuropathic”? Maybe your doctor prescribed pain medication. Did you take it? And did the pain stop but then return when you stopped taking the pain meds?
If this scenario sounds familiar, it’s because some doctors, ophthalmologists and optometrists alike, are now saying “neuropathic eye pain” is the cause of mysterious eye pain in the Dry Eye patient. They refer to the phenomenon as “pain without stain.” They explain that it’s a problem with the patient’s nerves. So the brain “feels” pain even when there is nothing there to cause the pain.
Reasons to Doubt Neuropathic Pain Diagnosis
It may sound plausible, but in fact there are plenty of reasons to doubt a diagnosis of neuropathic eye pain. The reasons are numerous. For example, a doctor’s diagnostic techniques may be poor, so they miss a multitude of possible ocular surface comorbidities that might be causing pain or other discomfort.
Test results may be inaccurate so even something simple like aqueous tear deficiency can be easily missed. This can happen when a Schirmer’s test or fluoresceine clearance test (FCT) is improperly administered or too swiftly abandoned (as when a test is administered just once instead of several times in succession, as necessary). Or it can be because the challenge test for pain, instilling anesthetizing drops in the eye, doesn’t actually numb parts of the ocular surface that are diseased, sometimes severely diseased and highly sensitive. So the eye will never go numb with topical eye drops.
It can be due to a reliance on fast and easy but not specific tests. An osmolarity test, for example, may indicate that tear osmolarity is sub-optimal, but what does that actually mean? Is a specific disease indicated? Maybe it is because of aqueous tear deficiency, but maybe it’s because of something else! Similarly, MMP-9 testing may indicate some level of inflammation, but why? What is underlying this positive test for the presence of inflammation, if, in fact, it is accurate?
Successful reversal of neuropathic eye pain
In his recently published paper, Dr. Steven L. Maskin describes three patients who had been diagnosed with ocular neuropathic pain by other doctors. The usual treatments were prescribed, but the patients didn’t improve. When they finally saw Dr. Maskin, and had all of their comorbidities diagnosed and treated with targeted treatments, these patients finally found relief for their debilitating and painful symptoms.
Now, I will admit much of what Dr. Maskin writes is way over my head with technical and medical words I don’t always understand. But that said, I am sure the doctors who need to read this will understand it. And if they do, they will get better at diagnosing and treating these types of patients with massive, chronic pain. If your doctor gave you a diagnosis of neuropathic eye pain, maybe you could take a copy of Dr. Maskin’s article to them and see what they think about it.
Reading research is something of a challenge for a non-scientist, non-medical person like me. What I do first in reading an article of this type is to read the abstract. The abstract is at the beginning of the article. It gives sort of the bottom line of the research. Sort of like what some call an Executive Summary. You can see the whole abstract further below. But first a bit of “my take”.
My biggest takeaway from the abstract, was to give me greater assurance that my decision to have Meibomian gland probing was a good one. I only wish I had learned about it sooner than 10 years plus into my Dry Eye Disease. Then to be honest, I probably would not have done it 10 years ago. At that time the science on the procedure was very thin indeed. I would not have been convinced then. I certainly would not have been desperate enough. After all Restasis was doing well for me in the beginning or so I thought.
The bad news I did not know, and my three well-meaning eye doctors did not tell me, was things were getting worse in the background as time marched on. Their “standard care” was covering the core problem with some symptom relief while the core of the problem, Meibomian gland dysfunction, continued to get worse. Thus, I was one of those, as referred to in the study, who was doing worse in spite of doing a great deal of standard care over the 10 years before I learned about Meibomian gland probing. My story is not an uncommon story. Here is the abstract and see what you think.
Obstructive Meibomian gland dysfunction (MGD) affects millions of patients around the world. Its effective treatment with intraductal Meibomian gland probing (MGP), was first reported in 2010. Since then, MGP has provided relief to thousands of patients globally suffering with refractory MGD. The purpose of Meibomian gland probing is restoring the integrity of the gland’s central duct by entering the gland through the natural orifice, releasing fixed obstruction thought to be periductal fibrosis, thereby establishing and/or confirming the patency of the duct, and concurrently equilibrating intraductal pressure as well as promoting gland functionality with meibum production. There may or may not be immediate secretion of meibum upon successful restoration of ductal integrity depending on the gland’s state of function and degree of atrophy. One double-blind placebo-controlled study has been conducted and, with the accumulated evidence of over 12 other peer reviewed articles in the scientific literature, overwhelmingly indicates that MGP is a safe and effective treatment for the MGD patient refractory to prior standard care and as a first-line treatment. This paper describes relevant fundamental concepts, dispels commonly held misconceptions, and provides an objective review of the current understanding and effectiveness of MGP for the treatment of obstructive MGD. Our analysis will better equip clinicians to draw informed conclusions about both subjective and objective findings reported in MGP studies and researchers to design future robust studies that provide meaningful results.
After reading this post maybe you have further questions. Great! That is what we are here for. To get them answered at no cost to you by a patient advocate via email or by telephone just fill out this short form now.
This ground-breaking book contains a trove information about Meibomian glands and MGD. You will learn about the structure and function of Meibomian glands and discover how MGD develops, how it progresses, and how it can be reversed. You will learn how to decipher puzzling symptoms and Dr. Maskin’s meticulous approach to diagnosis.
One chapter is devoted to common ocular surface and systemic comorbidities. In others you will learn about conventional and newer treatments for MGD, including Dr. Maskin’s own break-through treatment, Meibomian gland probing. Here, he explains why Meibomian gland probing effectively treats MGD and provides step-by-step instructions for correctly administering the treatment.
Throughout, the co-authors dispel myths about Dry Eye and MGD while portraying the devastating effect MGD and comorbidities can have on patient lives.
Uncover the Mystery
“Our collaboration represents the intersection of a doctor’s quest to uncover the mystery surrounding a common but enigmatic eye disease, and his patient’s harrowing journey with a painful, incapacitating disease,” writes Dr. Maskin in the prologue. “We hope our joint effort will shift conventional thought about MGD, its diagnosis, and treatment toward a new paradigm based on clinical evidence that reveals the true nature of this disease, and we offer this book as a beacon of hope for patients needlessly suffering with inadequately diagnosed and treated MGD.”
For information about where you can buy Your Dry Eye Mystery Solved: Reversing Meibomian Gland Dysfunction, Restoring Hope
Since Allergan’s patent protection for Restasis ended several years ago, several companies have entered the Dry Eye market with drops that contain cyclosporine, the active ingredient in Restasis. These newer drops have different formulations than Restasis. Sometimes the concentration of cyclosporine is different and sometimes the vehicle, the liquid in which cyclosporine is suspended, is different. A generic version of the drug is also now available. For information on effectiveness, check the medication’s product information sheet. You can find the product sheet for Restasis here.
Allergan tried to delay competition for Restasis by selling its Restasis patent in 2017 to the Saint Regis Mohawk Tribe in New York. Attempts to protect the patient failed when in 2019, the U.S. Supreme Court rejected Allergan’s argument that the sovereign status of the tribe shielded the Restasis patent from U.S. Patent and Trademark Law.
Allergan loses Supreme Court fight to shield Restasis patents with Native American tribe April 15, 2109 View the full report.
Support Not A Dry Eye Foundation. When you shop at smile.amazon.com, Amazon donates 0.5% of your purchase.
For Dry Eye patients wearing a face mask that doesn’t fit properly can be challenging. That’s because each exhalation that blows over the eyes speeds up tear film evaporation. Then the thinner layer of tear film doesn’t protect the eyes well, so the exhalation feels like a fan blowing at full strength.
It’s a vicious cycle.
If you wear glasses to protect your eyes (or for vision), not only do your eyes feel bad, but your glasses fog up. They get foggier, and your eyes get even more uncomfortable, when you walk down the frozen food aisle of a supermarket.
How to Wear a Face Mask When You Have Dry Eye
Thankfully, we found a simple solution courtesy of a video by Dr. George Yang, a double board certified New York surgeon. Dr. Yang recorded the video for medical and nursing students, but Dry Eye and MGD patients can learn from it too.
In the video, Dr. Yang shows how to get a better fit when wearing a surgical mask. We tried his simple technique with three face masks, all with the metal strip that hugs the nose: procedural masks from CVS, KN-95 (the Chinese version of the N-95), and Dr.K Mask from V-Zero in Korea. (We didn’t have an N-95).
His technique worked with each mask. The masks hugged the nose and cheeks, preventing exhalations from reaching the eyes.
Note: if you can get them, V-Zero brand Dr.K Masks get high marks for comfort.
Wear to Buy Surgical Masks
Not all face masks are made alike, and by now you may have a preferred style and vendor. There are plenty available online: Walgreens, Amazon, and other retailers like 1000bulbs.com.
One great source is Project N95. “Project N95 is a national non-profit working to protect people and their communities during the COVID-19 pandemic and beyond.” Project N95 sells only reliable, high-quality masks that meet required standards. Masks come in a variety of styles and sizes at a variety of price points.
Preventing Air Flow with 7eye Glasses
If you can’t get a good seal between your mask and your face, 7eye glasses may be a solution. 7eye Dry Eye glasses have silicone eye cups that retain moisture and protect the eyes from wind and drafts.
In a previous blog I described ways to direct focus away from the frustrating and painful symptoms of Chronic Dry Eye. This time I’m writing about my experience over the past two years practicing Tai Chi.
Tai Chi is an ancient Chinese exercise created as a fighting art that dates back over 700 years. Although still considered a martial art, today it is no longer practiced for self-defense.
Tai Chi for Dry Eye
There are many styles of Tai Chi; the most notable are Yang, Chen, Wu and Sun. These different styles all consist of a series of exercises that focus on slow movements. The movements are accompanied by deep breathing and the gathering of Qi (pronounced chee) considered the universal life force that present in all living things. Tai Chi can improve strength, flexibility, mood and overall health and reduce inflammation, chronic pain and stress levels. Considered mediation in motion, Tai Chi can also improve concentration, memory and the ability to focus, relaxing both the mind and body.
As a student of Tai Chi, and now an instructor, I have found that focusing on the slow movements of this exercise have reduced my Dry Eye induced anxiety and pain levels. Combined with daily eye care management and an excellent eye doctor, my Dry Eye symptoms, and all the anger and anxiety that goes along with this disease, have significantly decreased. I’m now living an almost normal life again.
Tai Chi might not be for everyone. (You should always check with your doctor first before starting any new exercise program.) Still, I would highly recommend it to anyone who suffers from chronic pain, depression, or anxiety. (If you’re staying at home during Covid-19, there are plenty of Tai Chi videos online.) Even if you don’t have these concerns and just want to feel better overall, you might try this ancient exercise. It helped me tremendously.
California’s Orange County Dry Eye Support Group 2020 meetings will be on May 4 and November 9, 1-3 p.m., P.T.
DUE TO THE CORONAVIRUS PANDEMIC, THE MAY 4, and November 9, 2020 MEETINGS ARE CANCELLED.
Both meetings will be held at Grace Hills Church, Fellowship Hall, 24521 Moulton Parkway, Laguna Woods CA, 92637. The schedule includes a speaker and presentation by the sponsoring organization. For meeting information and to RSVP: call Judi at (949) 933-2417 or email email@example.com.
The featured speaker in May will be Laura Periman, M.D., an ophthalmologist and the “doc with a heart.” Dr. Periman specializes in cornea and external disease. She is a frequent speaker at ophthalmology meetings on various Dry Eye topics and treatments.
Harvey Fishman, M.D., Ph.D., an ophthalmologist who practices in Palo Alto, will address the group in November. He specializes in cornea and external disease, glaucoma, macular degeneration, and same day emergency visits.
Both doctors have experience treating patients with severe Dry Eye.
Jonathan Pirnazar, M.D., an ophthalmologist at the University of California, Irvine, started the Orange County Dry Eye Support Group (OCDESG.) It was and is the only Dry Eye support group in the U.S. In the early days, 10 members would meet at a local library. Since then the group has grown to over 200 members. Today an average of 50 to 60 people attending twice-yearly meetings. The non-profit group is not affiliated with any religious or healthcare organizations.
Meetings are free and open to anyone interested in learning about Dry Eye. A $3 suggested donation covers room rental, printing, and mailing.
OCDESG aims to help Dry Eye patients feel better, to give them hope and a better quality of life. The group answers patients’ questions about how and where they can get help for their symptoms.
For more information visit ocdryeyesupportgroup.org.
Not A Dry Eye Foundation is not affiliated with the OCDESG. Notice of the meetings is provided as a service to Dry Eye patients.
Dr. John A. McAree, a board certified physician of Internal Medicine, first became aware of having eye problems at the age of 18 when he tried wearing contact lenses. He never found them comfortable and could tolerate them only for short periods of time. About 10 years later during his residency program, an astute ophthalmologist offered to administer a few tests. Dr. McAree’s Schirmer’s test result was zero in both eyes but his tear break-up time was normal. The diagnosis was Dry Eye Syndrome. He had no additional Dry Eye tests for the next 25+ years, and the only therapy suggested was giving up his contact lenses. Remarkably, his eyes remained fairly asymptomatic during that entire time.
That all changed on August 21, 2017 when Dr. McAree and some friends were boating on a small inland lake in Michigan. It was the day of the solar eclipse. Although he did not look directly at the sun, its rays reflected off the water directly into Dr. McAree’s eyes. By the next morning, his eyes were extremely painful. He assumed that he had developed solar keratitis (similar to “snow blindness”) and would recover quickly. Still in pain a week later, he sought the care of an ophthalmologist who said that except for dryness there was nothing wrong with his eyes, prescribed a one-week course of a non-steroidal anti-inflammatory drop, and suggested using a lubricating drop. Unfortunately, nothing helped.
Dr. McAree then begged the ophthalmologist for punctal plugs and a RESTASIS prescription. When these treatments didn’t help, the ophthalmologist offered to partially sew his eyes up, at which point Dr. McAree decided to find a different ophthalmologist.
The new ophthalmologist put Dr. McAree on a regimen of steroid drops and resumed RESTASIS. These measures helped a little bit but his eyes remained uncomfortable and his vision blurry. Thankfully, at least the new ophthalmologist was positive and encouraging. Having hope meant a lot.
After several months and no significant improvement in symptoms, Dr. McAree consulted a Dry Eye specialist at a local university who offered little else besides serum tears. One month later there was still no improvement. It was time to takes things into his own hands.
With some understanding of the pathophysiology of his disease, Dr. McAree diagnosed himself with Meibomian gland dysfunction (MGD). After reading reviews and about available treatments, he decided his best option would be Dr. Steven Maskin in Tampa, Florida who had developed intraductal probing of the Meibomian glands and is very well published.
Dr. Maskin thoroughly evaluated Dr. McAree and diagnosed:
possible allergies contributing to the tear deficiency
Dr. McAree first had Meibomian gland probing in August of 2018 which provided subtle but important improvements in symptoms, the most important being increased tear film stability and therefore less visual blurring.
Because of continued foreign body sensations due to conjunctivochalasis, in early 2019 Dr. McAree had amniotic membrane transplant surgery in both eyes. With surgery the comfort in both eyes improved considerably. A second Meibomian Gland probing in June of 2019 improved comfort even more.
Today Dr. McAree accepts that his eyes are not yet “normal” and will require ongoing treatment. However, he is grateful that an extremely painful and disabling condition is now much more manageable. Work requires time at a computer screen and can cause some discomfort, but he is again able to enjoy hobbies like bird watching and kayaking.
These days Dr. McAree uses RESTASIS daily, scrubs his eyelashes with tea tree oil to control demodex mites, rinses his eyes with saline to eliminate allergens, and still uses lubricating drops, but only occasionally. Plus, he is having injections to combat allergies. He is very hopeful that he will continue to experience improvement in his symptoms, and encourages anyone with debilitating Dry Eye symptoms not to give up hope.
Dr. McAree received his medical degree from Duke University School of Medicine in Durham, North Carolina and has practiced medicine for many years in Grand Haven, Michigan. He joined the Not A Dry Eye Foundation Board to emphasize the importance of accurate diagnosis of Dry Eye, MGD, and related comorbidities, and their treatment with targeted, effective therapies.