 Thanks for coming out, everyone. I know dry eye is not necessarily the most sexy topic. We're talking about autoimmune disease, cardiovascular disease, all these things that are going to kill you. Dry eye disease isn't going to kill you unless you crash your car and do something like that. But the thing about dry eye is that it's been kind of pigeonholed into this narrow definition where people think that the only manifestation of dry eye is that my eyes itch, burn, sting. When really the biggest manifestation, and one that is overlooked a lot, is visual fluctuation. So the first thing that the light entering your eye has to go through is the tear film. It's not your cornea, it's not your lens inside your eye. It's the tear film. So if the tear film is junky, what you see, the image on the back of your retina that's formed is going to be junky as well. And we know based on a internet search that the practice that I work for is one of the biggest, most asked questions that led people to our site is why does my vision fluctuate? And a lot of people think that it's due to their focusing system, the lens inside their eye, what we call the accommodation. But more often than not, that's not the case. It's actually the fluctuation of the tear film. And that's kind of why I wanted to talk to you guys about this topic because I want to set the record straight and explain a few little things about it. And then we'll talk about some things that we can do pallatively to help increase the quality of the tear film and decrease those visual fluctuations, that itching, burning feeling, and get you doing better with your eyes. So first thing we're gonna start with is basically a little bit of anatomy as far as the tear film goes. So this is a relatively simple schematic of the tear film. Much more complicated than this, but for the sake of today, we'll just kind of go with this. The first layer at the top, that's the lipid layer, okay? This lipid layer is composed of, can anybody guess what it's composed of? Lipids, fats, cholesterol, those kind of things. And what it does is it acts as an anti-evaporative agent for the aqueous layer, the watery layer underneath. So if you guys can imagine putting water in a glass and then putting olive oil on top, the amount of evaporation you get is going to be much reduced if you have that olive oil. The water's not gonna be able to evaporate. Same thing happens with the tear film. That lipid layer protects the aqueous layer, the watery layer from evaporating. So the muco aqueous layer used to be that we thought it was the mucin layer and the aqueous layer, and those are two totally separate things. Now we're finding more that the two are so intimately connected that we can't really think of it as two separate layers. It's more of a matrix that we have. So these little squiggly lines that I drew in there are the mucin components, the proteins that basically attach the aqueous layer to the corneal epithelium. The corneal epithelium is just like any other epithelium on your body. It regenerates from basal cells, but the cells themselves are not inherently photo, are inherently photophobic. So you need these mucins to kind of connect the two, the cells in the aqueous layer. So this is what it looks like when we have a healthy tear film. Everything is nice and uniform and distributed uniformly as well. So where do those substances come from is the next question. And so we'll start with the lip, since we talked about the lipid layer first, we'll talk about where they come from. And those come from the mybomian glands. So these mybomian glands that we have in our eye, we have about 20 to 30 on the upper and the lower lid. And those are designated by the black lines up there. And so they sit just behind the tear, or the lid follicles. So where your lashes come out, these mybomian glands sit right behind there. And when we blink, we have muscles in the orbicularis oculi that basically squeeze those mybomian glands. So every time you blink, it's excreting a little bit of that lipid layer that coats the front surface of the eye, okay? So that's where the lipid comes from. Now the lacrimal gland is located in the superior temporal portion of the upper lid. And what it does is it creates the aqueous layer, so that watery layer that mixes with the mucin and attaches to the front of the cornea. So what I always tell my girlfriend is that I have a lacrimal gland over activation because that's why I'm crying during the sad movies, but that is true that the lacrimal gland is the portion that makes your tears when you cry, emotional tears. Then we have these third kind of little things that are interspersed in what we call the conjunctiva, the clear layer on the outside of the white part, which is the sclera, and that produces that mucin, that connecting block between the epithelium and the aqueous layer, okay? So that's the normal anatomy that produces a normal tear film. So let's get into this relatively simple schematic of what causes dry eye here. There is a group called T-Fos, a tear film and ocular surface society. And if there's any worse society to belong to, I don't know what it is. But they basically spend millions of dollars every year to come up with this report and develop cool schematics like this that no one can really read too well if you kinda look at it and squint, maybe that works out. But what I think we should do is kinda distill all of this down, and if you read through their reports that are thousands of pages long, you end up getting to a more easily read schematic, which is the one that I've developed that it will kinda go through step by step. Okay, so in the first 100 pages of this T-Fos report, it basically tells us that the loss of tear film homeostasis is the cause of dry eye, okay? That's all you guys need to know. You're 100 pages in, you're in good shape. So why do we lose this homeostasis? What is it that causes these feedback, positive and negative mechanisms to break down and for us to lose the structure of the tear film? Well, the first thing is we get these internal and external factors, obviously very specific, but we'll go through those in a little bit. But those can lead to two problems. And those two problems are primarily first, an unstable lipid layer, okay? If you have an unstable lipid layer that front surface, you're gonna get an increased amount of evaporation in that tear film. So imagine how we were talking about with a water glass and olive oil on top. Now we're thinking more of oil on top of a lake. It's all spread out, splotchy, patchy, things like that. There's not an even surface over the water to prevent that evaporation. So all the spots where that oil is broken up, that's where you're gonna get that increased evaporation. The second problem that we run into with these internal and external factors is a potential reduced production of aqueous. So that lacrimal gland is no longer producing the aqueous layer like we would like it to. And that comes from another number of different issues that we'll get into, but both the unstable lipid layer and the reduced production of aqueous lead to an increased tear film osmolarity. So that means there's more dissolved in the water than there is water, essentially, or aqueous, I should say. And that increase in osmolarity is the hallmark. This is what this TFOS group in their dues report said is the hallmark of any dry eye disease. Any at all is this increased tear film osmolarity. And we can measure that clinically with a few different instruments, but what that leads to is an increase in ocular surface inflammation. So we get all of these inflammatory factors released that causes basically this giant feedback loop of inflammation and leads to a decreased quality of these tear components that are produced. And it can work both ways. It's kind of a two-way street in that an increase in ocular surface inflammation, it can be caused by systemic issues, can then increase the tear film osmolarity by producing these inflammatory factors. And that's how you get an increase in the tear film osmolarity. So it kind of works both ways and they feed each other and it's a bit of a vicious cycle. So let's get on to the infamous factors, the internal and external. I was gonna put an animation, but I couldn't figure out how to do it, so you guys just get all of them. It's no surprise here. First is environment. They're not in any particular order. Diet is another big one. Hormone level systemic disease and systemic and topical medications also factors that we can talk about. But today we're really gonna focus just on the top four because our goal in looking at health in an ancestral way is to use diet and movement and all those kinds of things to reduce the number of systemic medications and topical medications that we are dependent on. We use them when we need to and they're very important, but we want to try to first build a base just like Tim was saying in his earlier lecture on auto-immunity, build a base of these other behaviors that we can do, changing the environment, changing the diet in order to increase our ability to need the systemic and topical medications less. All right, so now we're gonna get interactive. I want you guys to just kinda shout out things that are different between the photo on the left and the photo on the right. Just give me, just doesn't matter what you say, you'll be right. There's no right or wrong answer. Okay, good. Computer, good. Positive ions, okay. That was not what I was expecting, but that's good. Location, light, good. Sunlight. Focal distance, that's a good one. Sitting, good. Yeah, you guys nailed it. 100%. I was not expecting focal distance, but that's a good one. But we'll talk about a few other ones before we get into that. So humidity level, okay. Most of the time we're in air conditioned environments. We might have a desktop fan, something blowing on our face. Bad news for dry eyes, okay. That's just gonna exacerbate things because it's increasing that evaporation that takes place. Altitude can have an effect on it. These, we don't know where the guy in the desk is, but can have an effect on things. Temperature, higher temperatures, higher rates of evaporation. But really the biggest thing that it comes down to is, yes, this focal distance. What are we looking at during our day? And why that's important is because it changes how we blink. And it sounds a little weird, but how we blink is one of the most important things when it comes to dry eye, okay. And so the reason how we blink is so important is because there are rate of blink changes and our completeness of blink changes, okay. When we are just sitting out watching the sunset tonight over the mountains here in Bozeman, we're blinking at about 15 blinks per minute, okay. And that's the variation. There is some variation, but it's not that large. But when we start doing things on the computer or reading books, our rate goes down and it becomes much more variable. So we don't get as consistent of a blink pattern as we get when we're out looking at something. And actually as we talk to people as we're having a conversation, the blink rate skyrockets. So we go from 15 to about 26 to 30 blinks per minute. So just talking to people, having conversations instead of being stuck in an office is actually gonna increase your blink rate, which is interesting. The second component is the completeness of the blink. So what we find is when people are just out running around, most of their blinks are complete. That means the eye, the two lids come down, touch each other and then release. When we start to use computers and read and everything like that, the variation in the amount of complete blinks is hugely influenced. So the way that we spread to your film across our eye, if my arms are my eyelids, I have a tear reservoir that's created from those glands right here. It sits on the lower eyelid. It's called the lacrimal lake. And what happens is that upper lid comes down and it actually acts like a windshield wiper, but in reverse. It actually picks up those tear films and spreads them vertically over the eyeball. So if you have an incomplete blink, here's what happens. You don't pick up that lacrimal lake. The lid goes up and there's no spreading of that tear film uniformly across your eye. So this completeness issue is a huge one and we're just starting to finally get some clinical devices that help us measure and quantify this. So what happens when we have these incomplete blinks? Well, on your guys' left, that's a picture of healthy mybomian glands. You can see those black arrows pointing to these little orifices where the mybum comes out. On the right, we see these clogged or these caps on the glands as we call them in the clinic. And what happens is when you don't have those complete blinks, it doesn't get excreted and it becomes kind of like when you don't put the cap on the top of your toothpaste, it gets hard and anytime you fully blink, then you're not getting that expression of the mybomian glands. You're not getting a good quality lipid. And it's not only from blinking, there's a number of other things we'll talk about with this quality, but it's a huge, huge component of it because every time you blink, that's what's causing that expression of the mybomian glands. So in the clinic, what we do is we put a topical anesthetic on there, we do what's called debridement, we take a little broken off, a little broken off cotton swab, scrape it all off, and then we take big paddles and we squeeze them and squeeze all that nasty clogged up toothpaste stuff out and it provides a lot of immediate relief. Helps with symptoms, but it doesn't fix the problem, which is the poor mybomian gland function and the incompleteness of the blink. So what can we do with our environment? We can blink better, we can blink more often, so I want everyone to do blink exercises with me. These are literally things that we prescribe to our patients. So what I want you to do is I want you to open your eyes and then close them, not hard, just like you're closing them like you would go to sleep and sit for two seconds and then open them and then close them again and squeeze as hard as you can and then open. And what some of you might have felt or might feel is after you've done that big blink, you might feel like your eyes are a little bit watery and that's because you had this massive excretion of that lipid layer and so just remembering to do that. People sit on computers for eight, 10 hours a day and if they're the three blinks per minute person, they're gonna be pretty uncomfortable pretty quick. Other things, like I said, limit direct fan use. You can use a desktop humidifier if you're in an office to help increase the amount of moisture in the air, decrease the amount of evaporation and just don't work as much. Just don't be on the computer, right? We all can tell our bosses that I just wanna work less. I only wanna be here half the day. And the tongue in cheek with that is that as you increase the cognitive demand of what you're doing, you're going to decrease the amount of blinking you do. So if you're reading comic books, maybe not the most cognitively demanding thing in the world, you're gonna be blinking more than you would be staring at Excel spreadsheets that you've made so small to fit as much as you can in that you're trying to squint to see what you're trying to do. So things you can do is increase font size just to reduce the amount of stress that you have cognitively. So now we have another one. All right, let's hear some things about what's the difference between the left and the right picture. Delicious, that's a good one. They're both delicious, I agree. Process and non-process, good. Seed oils, carbs, good. Good. Can I hear dairy? That's good, I love dairy, so I'm good with that. So you guys are all right, you know, refined carbohydrates, refined sugars, really high gluten content in the pizza crust versus a lot of natural stuff. There's some nightshades on the plate on the left and some people obviously have problems with that, but on the whole, pretty low as far as obvious inflammatory foods. But the biggest, the reason I put the picture on the left up is because it contains omega-3s. And omega-3s have been this kind of holy grail of dry eye for a long time. That's where everybody focuses their research when it comes to dry eye. So if you just type in dry eye omega-3 on the university that I was previously working for, you get 2,500 peer reviewed, full text online papers. Half of them say that omega-3s are awesome, they work perfect, let's do it. And half of them say they don't work at all, they don't do anything. So we've spent all this time in this money trying to figure out what it is, why is it a conflict? What's the issue with omega-3 versus not omega-3? Well, I think the answer lies somewhere in the fact that the mechanism of action of the omega-3 is that it reduces, it's an anti-inflammatory, which it is. But if you're just putting on a substance that's slightly anti-inflammatory onto a bunch of a huge population that you don't know how much inflammation that they have to begin with, how are you going to be able to control those variables in order to say this works or this doesn't work? We have no understanding of what is going on inside of them systemically. All we're telling them to do is keep eating McDonald's, but just use these omega-3 supplements. So is there a tie then between what we eat, our gut, and this dry eye? And I believe that there is. And so there's a couple of studies out there, they're pretty few and far between, because like I said, dry eye, not a very sexy issue in the world. But we find that people with irritable bowel syndrome tend to have objective, so lower tear quality and subjective, higher amounts of complaints about burning, itching, those kind of thing, visual fluctuation. And people are, it's higher in those with IBS than those without IBS. And thank you. In folks who have shogrens, which is an autoimmune disease, and it's one of the primary complaints of that is dry eye, we find that 70% of them have a low level of gut inflammation. So we look at, we see as an optometric community shogrens as this autoimmune disease that you can't do anything about, so let's just mask the symptoms. But what we find is probably that by changing some of these environments in these diets, we could actually lower the amount of symptoms in these shogrens patients by decreasing systemic inflammation. So what can we do to manage this with diet? We can remove inflammatory foods, that's different for every single person. I'm not gonna say we need to cut this or add that or anything like that. You guys are all smart enough to know that it's a complex issue and it's an N of one. So you need to find what works for the N of one, you, and remove those foods and reduce that inflammation. Maintaining hydration is kind of an easy one. There's been, believe it or not, there's been studies that have cost a lot of money where people go in and say, you should drink, if you drink more water and you don't drink as much water, do you get more dry eye or not? The people who drink more water, as it makes sense, get less dry eye. And then I still recommend omega-3s and that's because it's something that they can do that will reduce inflammation. And the reason that it's become controversial is there's a big issue. They had a big clinical trial where they said they did a omega-3 supplement and an olive oil supplement and they found that there was no difference between the two, but they both increased comfort and reduced symptoms and increased quality of objective markers. So we know that omega-3s themselves are not this holy grail, but there's something going on there that we need to look further into. So I still get folks on that just because in some patients it really does help. So androgens, doesn't this kind of look like a one of those commercials where it's like black and white and it's like this is the bad thing and then they have like everything saturated and some lady is like stoked because she opened a pickle jar with her little thing that she bought. So anyways, you guys tell me what's the difference, what's kind of going on between these two images here. Yeah, sedentary, active, both patients are a little bit older, okay? And so what we find is that those glands, the mybomian glands and the lacrimal glands are highly, highly influenced by these androgens. Testosterone, estrogen, progesterone. Those are highly, highly specific targets of these androgens. And what we see is as we get older, there is, it's an undeniable fact that those levels will start to get out of balance and be decreased. And so what we see in postmenopausal women and men with andropause or low T is this huge increase in dry eye. And that's simply because the glands are not being stimulated enough, okay? We're not getting that signal to produce high quality and the amount of tear components that we need. So what can we do about that? Well, there's some evidence in the literature that resistance training can kind of balance those levels. It's not gonna, you're not gonna, by doing resistance training, get back to where you were at 20 but it's going to help. You can prioritize sleep. We know how important sleep is in our life with getting all our androgens and cortisol and everything like that straightened out. And then we can supplement if needed. Like I said, there are cases where we can't get those levels back to where they need to be. So we need to do some supplementation or even topical supplementation. Some of our patients are on topical steroid creams on their eyelids that actually increase the quality of their tears and production of the tears. So the whole goal with what we talked about today is to get folks out of here. So at every big box store, Walmart and everything like that, there's an entire aisle dedicated to artificial tears, eye drops, things like that. And there is a huge need for these. Don't get me wrong. I have patients use them every single day but I think we're putting the cart before the horse a little bit. I think there's other things that we can do before we just go, hey, your eyes are dry, go pick up some artificial tears and use them four times a day and then everything will be great because that's typically not what happens. We're just masking symptoms instead of getting at the root cause of everything. So we wanna get everyone here. We wanna get them to the point where they can be happy, be healthy, have consistent vision and not be burdened by these kind of annoyances of this dry eye. So thank you guys very much for listening to me today and I'm happy to answer any questions you guys have. And those are references. A dry eye is my number one health problem. So I'm glad you're here. I'm interested in the mechanism of when you have an allergy, like to me at Desert Flowers, why does your eyes dry up? I don't understand why that would occur. So it comes down to that increase in osmolarity or at least part of it does. When you have a reaction to those allergens, you get a bunch of anti-inflammatory cytokines, things like that released onto the ocular tissue and that increases the osmolarity, increasing the potential for evaporation. And then it also, anytime you have inflammation or anything like that, you're going to get that neurosensory feedback. And so it's partially that evaporation component and partially just that the inflammation is causing pain, which is experienced as dryness, itching, burning that kind of thing. Yeah, I can take an antihistamine and boom. And it's fine, right, exactly. Yeah, you have antihistamines, you have mass cells that are broken, releasing more histamine. So oftentimes if that is the source of the dry eye, we hit it with exactly that an antihistamine because there's just not much we can do. Cool compresses is a palliative treatment just to reduce that overall inflammation, but. So you recommend staying away from our artificial tours, tears, if you can? If you can, but it's certainly, like I said, it's something that I recommend to my patients all the time as long as it sounds like you are the kind of person who has your health pretty straight, your diet pretty straight, your exercise. There's 98% of the population who doesn't have that. So if we can get folks doing that more, and as the whole conference is here to talk about, those increase all kinds of health markers. If we can get them doing that first to help their dry eye, then sometimes patients are like, oh yeah, I have, I'm obese and have diabetes, but I'll get in shape because I want my eyes to be less dry. Thanks. Yep. Steve, nice talk, a couple of comments. One is the research that showed these kids, particularly like in India, for example, they're living mostly on rice and they're extremely vitamin A deprived and that's how they lose their vision and they usually die as a result and just really small amounts of vitamin A will recover their vision and save their vision and now this is purely anecdotal, but when I learned about Weston A Price and I started the first time I ate liver, my dry eye problems resolved and I recommended this to scores of people since and every single one of them has had either complete or moderate relief from dry eyes just from increasing their vitamin A consumption in a natural way, usually some kind of liver or maybe even fish eggs and so I would just encourage any or all of you to consider that and try that. Like I said, that's totally anecdotal. I couldn't find any research that is good support for that but we all know that vitamin A is critical to tear production and then my other comment is, I just wanna make a comment about the Omega-3 supplementation is that the Omega-3s are polyunsaturated fatty acids and they're unstable and they oxidize really easily as soon as you pull them out of the natural food that they're eating so when you put them into a bottle or into a pill they're going to oxidize and this contributes to our consumption of oxidized polyunsaturated fatty acids and I say, this is my recommendation is, get it from the food, get it from the fish, I think is the best way to go, go to the fatty fish and avoid the capsules. Yeah, thank you. That's just my performance. Thank you Chris, I appreciate that and that's one thing that I forgot to kind of really dig into is I feel the exact same way on the Omega-3s with you as far as prioritizing, making sure you're getting those oily fish, the sardines, if you can stomach on which some people can't, I force myself to and that's really the best way to do it and I think would, everyone here would agree as far as looking through it from an ancestral way that the food would be the best way to get those Omega-3s. Hey there, hey there, thanks, that was great. Love the pictures. Oh sure. So when I read the blurb for this talk, I thought I'd mentioned something about blurriness as well as dryness and that caught my attention because that caught my attention because the past few months, sometimes I'll get a little bit of blurriness for no apparent reason, just randomly, it'll be there for a second, I'll blink and it'll go away and I'd never experienced that before but I don't recall that you mentioned anything about that, does that fit into this conversation? Totally, and we kinda got into that a little bit right at the very beginning of the talk. And I would submit it a little bit. But that's totally fine. So imagine you have a nice uniform, if you're in your car, you have a nice uniform, thin layer of water over your windshield. That's not going to distort the image that you see the road in front of you, the signs or anything like that. As soon as it starts to evaporate or you get what we can, you know, you would say rainfall, something that's irregular, irregular water distribution across that surface, things are gonna look a lot blurrier. So that's what kinda happens on our eyes but happens with evaporation. If we don't have that uniform, that nice uniform thickness of tear on the front and you have this increased evaporation, it's gonna get really, the tear film's gonna get junky and that's what image you're gonna see because the light has to go through that junky tear film before it gets to the back of your eye. So what you're seeing is junky and that's why it looks blurry. Yeah, because the tear film is not uniformly distributed on the surface of your cornea. And is that always correlated with the eye drying with the evaporation? Or could there be another reason for a blurriness? We kinda talked about that. There can be some issues with your accommodative system and that's what help us see up close when we're young. We can bend and stretch the lens inside of our eye and that can account for some blurriness but typically almost never when we're looking out in a distant environment, farther than about 10 feet, almost all of that kind of visual fluctuation comes from that tear film breakup or that junkiness in the tear film. Yeah, because I'm not experiencing the feeling of dryness, just the blurriness but maybe just because that's what I'm sensing. Right, oftentimes it probably is happening. Yeah, oftentimes the blurriness or the inconsistent vision, the visual fluctuation is the first sign of dry eye and then as it gets more a bigger problem then you start to actually expose tissue to the air and bring in friction forces that actually cause that itching burning feeling. Right, okay, thank you. Sure, sure, of course. What would be your recommendations on doing those exercises that you talked about? Every, I mean, if you're sitting on a desk all day long, one of the recommendations we make just to not only do dry eye but just that accommodative strain too is what we call the 2020 rule. So every 20 minutes, look in the distance, 20 feet for at least 20 seconds and there's some more information coming out that it needs to be probably longer than 20 seconds, maybe a minute or two and during that time, you can do those blink exercises. So a couple of times an hour, I forget. So I try to, if I get them once every hour, once every 45 minutes, then that's kind of where I'm at. Sure.