Dry Eye Relief: What’s Causing Your Dry, Gritty Eyes (and the Simple Routine That Helps) | Dr. Carly Rose

Carly Rose: [00:00:00] What is mascara really doing to our eyes? The bad mascara will say it. They can disrupt your bling, and that is vital for a healthy tear film. So then you have to dive into the ingredients of the cosmetic and alcohols, the parabens, the fragrances, and it can be so overwhelming. 

Dr. Brighten: Dr. Carly Rose 

Narrator: is the expert patients turn to when dry eye becomes life altering and nothing else has worked with two specialized clinics and a reputation for solving complex cases.

She's changing the way we understand dry eye, including the critical role hormones play. 

Dr. Brighten: What's the one aesthetic treatment you refuse to get and why? 

Carly Rose: Under I filler, I have heard too many cases of sudden blindness from it. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And then number two is. 

Dr. Brighten: Since we've been talking about aesthetics, what's the one aesthetic treatment you refuse to get and why?

Carly Rose: Oh my gosh. Can I give you two? 

Dr. Brighten: Yeah. Go. 

Carly Rose: All right. And I don't, this is not, you can't generalize all aesthetic procedures, right? But under eye filler, I have [00:01:00] not ever done it. It feels very risky to me. Even a great injector can, there can can be things that go wrong. The filler can migrate retrobulbar. This is new.

We didn't know that. The filler itself can go behind the eye. 

Dr. Brighten: That sounds great. 

Carly Rose: In risk of blindness, right? There's this triangle of death. Avoid the triangle of death. I have heard too many cases of sudden blindness from it. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And then number two is crow's feet. Botox, because it fully disrupts the blink.

Dr. Brighten: Really? 

Carly Rose: Mm-hmm. 

Dr. Brighten: Wow. There's a lot of people getting that done. 

Carly Rose: There's a lot of people, 

Dr. Brighten: if people are wanting to still have Botox, they're like, I wanna, I wanna diminish my smile lines. Is there a. Safe application. Like ask them to do less or is it all or nothing, 

Carly Rose: you know? Absolutely. And this is where I actually built a med spa to give safer alternatives.

Mm-hmm. And this is not all neurotoxins are bad, actually. Some dry eye doctors are starting to use neurotoxin to help dry eye [00:02:00] disease. So for example, a unit right here can act like a punctal plug. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so there are ways we can use these beneficially. There are ways that it's very harmful. The same product.

Right. But if you have crow's feet Botox and you wanna minimize that, uh, IPL all day long, intense pulse light actually helps treat dry eye. It came from the aesthetic world. It's a skin treatment. It decreases inflammation, it increases collagen. It's great for the skin health all over. And then radio frequency, great for skin tightening, great for dry eye.

So these have, they're mutually beneficial. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And then there are injectables, like S Sculptra for example. You could get s Sculptra injected in your temples and that generates collagen and almost, it almost acts like a filler, making your own filler over time. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so you can fill out that space and decrease the wrinkles instead.

Dr. Brighten: Okay. It's great to have alternatives. 'cause I think a lot of people, you know, there's people who [00:03:00] judge people for Botox, then there's people who, they love their Botox. And yet we need to find safer alternatives. Because the reality is, is that, you know, some, for some people, the aging process does weigh on their mental health now with the under eye filler.

You're saying it migrates behind the eyes. Why is that so problematic? 

Carly Rose: Well then you can't get it out and at this point we don't know what it's doing. Mm-hmm. Because we just found out it can do that a couple of years ago. 

Dr. Brighten: Gosh. 

Carly Rose: So it's like, what is gonna happen is my question. 

Dr. Brighten: Yeah. 

Carly Rose: But for example, with under eye filler, we have a great alternative.

PRP injections and PRF injections, they are from your own blood. So they are a lot more natural. They don't migrate. They do, they do act very differently. But you can get a, it's almost like building your own under eye instead. So I do see the beauty industry moving towards these regenerative procedures instead of trying to repair and fix and fill.

Dr. Brighten: I feel like we are gonna learn so much more about [00:04:00] fillers in the next 10 years. And I, uh, you know, I don't want anyone to like, feel bad about it, but I do, you know, pause and think like, have we actually done enough research to have released this to the general public in the way that we've been doing extreme 

Carly Rose: quantities?

Dr. Brighten: Yeah, extreme quantities, but also. Not licensed medical providers, you know, providing this. So there are some countries where estheticians are providing this, where, um, I think we need to use caution all around that. I certainly am like, don't let anyone mess with your face who hasn't taken extensive anatomy and who hasn't dissected a cadaver.

Mm-hmm. Because you wanna make sure there's so many blood vessels, there's so many things that can go wrong. And when it comes to the eyes, these are an extension of your brain. And I think that's so important. And we're gonna talk about hormones, we're gonna talk about pots, we're gonna talk about a lot more going into this episode.

What is mascara really doing to our eyes? 

Carly Rose: So the to blanket statement, I usually recommend no waterproof [00:05:00] mascara, no tubing, mascara. And then of course, the lash extensions, the glue-ons, the falsies, those are a whole different ball of wax. The bad mascara, we'll say it, um, multiple things so they can disrupt your blink.

And that is vital for a healthy tear film. That's actually one of the biggest things that I'm seeing. And then the waterproofs are really difficult to get off, so you have to be really abrasive. You're using abrasive makeup removers or a lot of force, and that's not good for the eyes, the eyelids or the tear film.

And then with the tubing mascara, the, the fibers and the tubes themselves go into your eye and disrupt the tear film. Oh, there's so many things, um, powdered. Powdered eyeshadows fall into the tear film and disrupt it. So I always recommend creams, so I try to simplify, no waterproofs, no tubings, and remove them every night.

That is really important. 

Dr. Brighten: Okay. So what about [00:06:00] the, the eyeshadow? You brought that up, you said creams instead, but I know people are gonna be like, well, wait a minute though. Can't there be certain things in the creams that could be disruptive to my eyes, 

Carly Rose: absolutely. But the, the likelihood of them getting into your eyes is lower.

Dr. Brighten: Okay. 

Carly Rose: Because of the physical makeup. Absolutely. So then you have to dive into the ingredients of the cosmetics and, and the alcohols, the parabens, the fragrances, and it can be so overwhelming. And then I know a lot of these platforms that can help you find clean makeups are also. Not always easy to understand or not always true and biased in the medical sense, and so it gets complicated, but there are quite a few ophthalmologists and optometrists and eye care providers getting into the aesthetic and beauty world to try to help clarify what's going on.

Dr. Brighten: What should people look for in their eye makeup, like what are red flags? If you see that ingredient. 

Carly Rose: Always red flags for me are, um, alcohol, parabens, [00:07:00] fragrances. And then you wanna look at, um, like I love a mineral based, right? The more natural, the better. But then you're looking at do they wear well? Do they last long?

Are they efficient? Because from my perspective, I want you to also get the results right? I want you to feel like you look good and not just use a, an inferior product. So the balance is, does it work as well? Is it healthy? Does it work? But the alcohol's, the parabens and the fragrances, those are pretty easy to spot.

Dr. Brighten: Parabens and fragrances. We always think about these in the context of hormones. What are they doing to the eyes? 

Carly Rose: Yeah, they are endocrine disruptors. And I know, um, we're gonna dive into this. Dry eye disease is so androgen deficient, directed, so it can certainly disrupt that, but they're pro-inflammatory.

Your eye is sensing these things as a foreign object, and so it's trying to flush it out. It begins this T-cell activation and this inflammatory cascade on [00:08:00] the surface of the eye, all of these different products, and so it's like we're constantly assaulting our eyes from the outside in and the inside out.

Dr. Brighten: So what is the ideal routine to be removing your makeup at night? 

Carly Rose: My favorite products are actually a two step. I talk to my patients all the time about a, doing a two step makeup removal. Just like with your skincare, I like to first remove with an oil base something my favorite is. Do you want me to say brands?

Dr. Brighten: Yeah. You can 

say, 

Carly Rose: okay. My favorite is something called We Love Eyes. It was made by an optometrist and it also has tea tree oil in it, which will help clean up some other things. So I use that as a dry eye treatment and a fantastic makeup remover. Mm-hmm. It's kind of like a twofer. And then follow it up with something like a micella water or a gentle cleanser after that helps break up and dissolve the hard to remove eye, um, eye products.

Mm-hmm. So you're not rubbing as forcefully. 

Dr. Brighten: I've also seen you recommend baby shampoo for people's eye lives. 

Carly Rose: I recommend [00:09:00] not baby shampoo 

Dr. Brighten: at all. Oh, okay. Okay. 

Carly Rose: So when I was in optometry school, we were taught to treat dry eye with baby shampoo and oral doxy. 

Dr. Brighten: Mm-hmm. 

Carly Rose: This is what I was trained to do and it is so far from what we should be doing.

And there are still eye doctors out there recommending baby shampoo all day long and they have deep fragrances and colors and paraffins and things that are not good for the tear film. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And the thing about the baby shampoo, and I think why it got so much recognition is because it's pH balanced.

So it doesn't burn, but just because it doesn't burn doesn't mean it's good for your eyes. So I'm actually do not do baby shampoo. Use something that's made, uh, made for the eyes instead. 

Dr. Brighten: Okay. Talk to us about falsies because I'm sure people listening are like, but wait, sometimes I just wanna glue on some lashes and call it a day.

Is it always bad? Are there ways to mitigate that? Like what's the line? 

Carly Rose: Everything in moderation. Always. Even I wear waterproof mascara at funerals, right? I, I say don't wear wa waterproof mascara. Don't [00:10:00] wear it regularly. Don't do this routinely. Mm-hmm. Every once in a while is just fine. Make sure you're cleaning the glues off very well.

But the thing with the false season lash extensions, it adds all of the tear film disrupting components. But then there's something called demodex, which is a parasite. It's an arachni that lives in our lashes and brows. These false, uh, lashes. They're almost giving demodex mansions. Demodex just goes crazy living in these, and they're difficult to clean out and they're difficult to maintain.

So I'm a big fan of everything in moderation. Limit the use. 

Dr. Brighten: And what's the best way to remove that glue to protect your eyes? 

Carly Rose: That's where an oil-based is gonna help. 

Dr. Brighten: Okay. 

Carly Rose: Dissolve it. 

Dr. Brighten: Okay. And so, you know, we're talking about like, oh, we don't wanna disrupt the blink. You know, we won't wanna disrupt the, you know, the film of the eyes.

But like, why does this matter? For someone listening right now, why does this matter so much for their eye health? 

Carly Rose: Well, and that's another thing with the [00:11:00] falsies, is you can't get a complete blink if the lashes are so large. And the lid margin is really, really important. And the two lids need to touch together.

Mm-hmm. To squeeze oil out. It's like the pump for your tear film. So we have 60 to 80 oil glands in our upper and lower lids, and they're like. Tubes of toothpaste all stacked up next to each other, and they should be filled with this nice, clear liquid oil like olive oil. And then every time you blink, the gentle pressure of the two lids touching, squeezes that oil out and what's happening.

There's also this side to side self-cleaning. Motion. Mm-hmm. With the lids. So they're squeezing and they're cleaning at the same time. So even things like looking at computer screens, we blink 75% less than we should. And so what we're doing is training an incomplete blink. The two lids are not touching, the oil is getting clogged in there and stuck.

[00:12:00] So then we have to do all of these thermal procedures to evacuate the oil glands. And sometimes we even have to go in and micro probe them back open because they start to scar down. And what we've said for many years is once they're gone, they're gone. They start to atrophy. These glands do. Mm-hmm. And then it takes a lot of work to get them to come back on.

So with dry eye disease prevention is the easiest thing we can do. So that looks like blink exercises, screen breaks, and making sure you're using healthy cosmetics and proper eyelid hygiene. 

Dr. Brighten: What are blink exercises? 

Carly Rose: That's a great question and I, it's not what people think. It's, a lot of times patients will think it's a full squeeze.

You're squeezing with your whole face and you actually wanna separate the frontal muscle from the, or orbital orbital muscles. So what we're starting to do is use our forehead muscles to blink, and that's not helpful at all because we have these tiny little muscles called the [00:13:00] muscle of lin that help also open those oil channels.

At the same time, if you're using your forehead to blink, those oil glands don't open, and so you don't get the same activation. So what I tell patients to do is either raise or relax your eyebrows. And then gently squeeze with just your eyelids. 

Dr. Brighten: Mm-hmm. 

Carly Rose: You can almost hear a sound in your ears when you do this, and that's when you know you're doing it.

Right 

Dr. Brighten: now. I'm like, 

Carly Rose: exactly. I walk. I walk patients through it because we really do need to dissociate these two muscles now. 

Dr. Brighten: Yeah. Well, for everyone, if you're listening to this, I would definitely recommend jumping over to YouTube so you can see what the blink exercise is. Now you mentioned like consequences of the, the.

Things we do to our eyes leading to dry eyes. Why is that so problematic for people? 

Carly Rose: Well, studies show that dry eye disease is more life altering than a fractured hip or angina. And it doesn't sound like a [00:14:00] very serious condition. It sounds like. We'll just use some eyedrops and get over it. But there are so many cases at this point of suicide, suicidal ideation.

I'd say at least half of patients have depression, anxiety. This is almost like a chronic pain condition. And there are cases of patients requesting e enucleation surgically removing the eyeball because it kind of, it, it, it's progressive and it's chronic, so it keeps getting worse. Mm-hmm. Until you intervene and do something about it.

And it can lead to, it almost feels like there's hot sauce in your eyes or sunscreen in your eyes all the time. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And that makes daily living very difficult. And then it starts to involve. You know, the mental health. 

Dr. Brighten: Mm-hmm. And I guess blink exercises are not gonna be enough once you get to that stage.

So for everybody listening, how often should we be doing these blink exercises? Preventatively. 

Carly Rose: I mean, if you're on a screen, you should be doing blink [00:15:00] exercises a few times an hour. 

Dr. Brighten: Okay. 

Carly Rose: And the goal with that is to make a normal blink, your routine and your habit, because we've trained it out, so now we just need to train it back in.

It's like going to the gym for your eyes. Mm-hmm. And getting back to this homeostasis. But yes, once you have dry eye disease, blink exercises are not. Going to be enough. Mm-hmm. They're really the lifestyle intervention, let's get it back on track. But then for patients without dry eye disease on screens, please do blink exercises to just prevent this altogether.

Dr. Brighten: And are you doing like 10 exercises, like 10 blinks every 30 minutes? Or what does it look like? 

Carly Rose: Yeah, I just say a few every 15 minutes. And what I do like to do a lot is habit stacking. So if, um, I, for example, I have a young patient who cracks her knuckles all the time. So I told her every time you crack your knuckles, do some blink exercises.

Mm-hmm. If you drive a lot, every red light and stop sign, do some blink exercises, start to correlate it [00:16:00] with daily things you do frequently. 

Dr. Brighten: Why are we blinking less staring at computer screens? 

Carly Rose: We're locked in. Actually, I was just talking with one of my optometry friends about this. Not only are we stopping blinking, we're shrinking our vi visual field.

We're actually starting to. Suppress our peripheral vision and all of our, uh, visual fields are getting very centralized. Mm-hmm. Which kind of goes along with this disautonomia we're going to touch on, but we're locking in, we're staring, and it's almost like we're in fight or flight all the time, is what our brain is processing.

And then, not to mention the blue light. Right. That's high energy and that's exhausting. But really, truly, we're just staring to focus at the work on the words at the page. Humans aren't meant to do so much extended near work with their eyes. Our visual systems weren't originally designed to do this all day.

And so we're converging, we're locking in, we're focusing and we're staring, and that's all very exhausting. 

Dr. Brighten: Mm-hmm. 

Carly Rose: So I guess we can add on to that, the [00:17:00] 20 20 20 rule. This is visual hygiene. So if you are on a screen. Every 20 minutes look 20 feet away for 20 seconds out a window, down a hall. I tell my patients it's like eyeball yoga.

You need to let the focusing muscles in your eyes relax. You need to reset the whole system. 

Dr. Brighten: Mm-hmm. How are your eyes the first sign that you may have breast implant illness? 

Carly Rose: Oh my gosh, yes. So breast implant illness, um, is controversial, right? There are, there's very few studies about it, but there is one study out there that shows that this patient's chronic dry eye is from her, was from her breast implant, and then she had an explan and the dry eye disease reversed.

And so the rabbit hole I went down is in these communities of women that are experiencing these autoimmune symptoms, is what it's like. Mm-hmm. And I'm from Ohio. In Ohio, we have one of the most. Extensive. The plastic surgeon that's been doing the most extensive work in this, her name is Dr. Lu Jean [00:18:00] Fang, and she has years and years of studies and surveys on this pat.

These patients and the visual system and dry eye disease are top of the symptom list. You know, the eyes are so hungry, nutritionally hungry that they're often the first to show signs of any systemic ill, many systemic illnesses. So to me, it's not a surprise that that's where the systemic inflammation is manifesting.

Dr. Brighten: Mm-hmm. 

Carly Rose: To so much so that I have now started asking all of my dry eye patients. Probably five years ago, if they have breast implants, if they have any other medical device implants. Because what happens is the body film, uh, forms this biofilm around these implants, and that is pre it's inflammatory. So it's causing these systemic inflammatory symptoms.

Dr. Brighten: Mm-hmm. You said that the eyes are so nutrient hungry. What are some of the best foods for our eye health or the best nutrients we should be taking in? 

Carly Rose: I love this. So [00:19:00] prevention is everything. I will say that until I'm blue in the face, uh, macular degeneration, glaucoma, dry eye disease, if we can find it on the front end, it's significantly easier to treat and cheaper to treat.

These diseases get very expensive and so omega threes. Fresh, wild caught fish. The smaller swimming fishes, the better sardines, mackerels, of course, salmon, avocados, nuts, and then avoid inflammatory foods. So I more talk about also things to avoid, like gluten, sugar, dairy, and alcohol. Those are the biggies, especially when you're in a chronic state of inflammation.

Dr. Brighten: Mm-hmm. 

Carly Rose: Of course, any eat the rainbow, right? You want your antioxidants, you want your carotinoids, but zanine, lutein, huge. Those are bigger than the carotinoids. 

Dr. Brighten: Is it true that everyone should eat carrots for their eye health? 

Carly Rose: See, that's what's so funny is they're great, the carotinoids are great, but the zeaxanthin and lutein from shrimp and [00:20:00] salmon is gonna do a lot more for you, 

Dr. Brighten: okay?

Mm-hmm. Yeah. So 

Carly Rose: red peppers, 

Dr. Brighten: but, okay, I was gonna say, oh wait, the vegan are gonna come into the, 

Carly Rose: okay, so for the vegans, I like the seaweeds. 

Dr. Brighten: Mm, 

Carly Rose: those are great. Okay. From the ocean. 

Dr. Brighten: Okay. I love that. And that's also giving you iodine, which, you know, we know a lot of women can have deficiency in even, you know, because like, you know, pink Himalayan salt is like the new trend.

Not everybody's eating iodine, salt. And for women, especially like our ovaries, our breasts are thyroid. It needs iodine so much. 

Carly Rose: Well, in vitamin A, you know, I actually talked to, um, these are the extreme patients that they're doing everything. I'm seeing a lot of vitamin A deficiency and so I do talk about liver and different organ meat too.

Usually in capsule form. Not many people like to eat liver, but yeah, I recommend beef organs quite a bit 

Dr. Brighten: back in the day. So my very first book, I think that came out in like 2014. Um, there were no liver capsules. [00:21:00] So what I used to do with patients, and I put this in my book, is to actually go to the butcher and ask them if they'll cut it up into like little sizes, like the size of your pinky.

If you don't wanna touch it, that would be ideal. Sometimes the butcher's like, no, go figure this out yourself. But to actually put that in the freezer and to freeze it and so well I would have them cook it and then freeze it. 'cause I just am like very anti parasites in anybody. Um, and so I'd be like, just freeze it and then you can just swallow it like a capsule yourself.

Now that's 

Carly Rose: brilliant. 

Dr. Brighten: Yeah. But now you can actually get capsules and you can do it that way because so many people, I mean liver is irrefutably one of the most nutrient dense foods. But you say liver and people say yuck. Like, so you've gotta find ways around it. 

Carly Rose: Yeah. My mom, it was her favorite food and I think she traumatized me.

I can't, I can eat a lot of food, but liver's not on my, not on my menu usually. Yeah. So I take it in pill form. 

Dr. Brighten: I know. I feel like there's a whole generation where like liver and canned beets and like cream of spinach. Like there's these things that like, they're like, Nope. From my [00:22:00] childhood, traumatized.

Can't do it. 

Carly Rose: Yeah. 

Dr. Brighten: Well, let me ask you, you know, for people who are listening, what are this? Signs you should never ignore when it comes to eye health. 

Carly Rose: You know, there's a very common one that gets glazed over a lot and it's contact lens intolerance. 

Dr. Brighten: Oh, okay. 

Carly Rose: So many people I hear say, oh, I just can't wear contact lenses.

My eyes are allergic to them. I, my doctor switched me five times. Five different brands. It's probably your tear film. Mm. And it's just such an early sign that we don't put two and two together. But what happens is when we wear contact lenses, we actually need about double the tear volume because we have these different interfaces now.

So if you're not wearing a contact lens, your tear film just has to coat the cornea. Well now your tear film has to coat the cornea, the back of the contact lens in the front of the contact lens. Mm-hmm. So you, you need more support. 

Dr. Brighten: So do you do eyedrops in that, that situation, or what do you do? I 

Carly Rose: usually jump to heat.

Well, let me give you my favorite. Hot [00:23:00] compresses, blink exercise, lid hygiene, and omega threes. 

Dr. Brighten: Okay. 

Carly Rose: It's where I always start. I tell people you're, that's gonna take about a month or two to see any signs or changes. So it kind of depends on your timeline. How fast do you wanna get there? So there are a lot of different pharmaceutical eye drops that are anti-inflammatory, that work great.

I don't usually reach for an over the counter eye drop. Mm. They don't do a ton. The only time I would really recommend those is, um, extenuating circumstances on flights if you haven't slept all night. Right. You need a little support. They're like a lotion for your eyes, but they don't really treat anything.

Dr. Brighten: Mm-hmm. 

Carly Rose: And then they can have a lot of preservatives in them that can actually irritate the tear film even more. So sometimes they can make the condition worse. Now there are great pharmaceuticals that we can do, and then the light-based therapies. Powerhouses. IPLI see a world where people will start to get ipls preventatively.

So, because we're all on screens. 

Dr. Brighten: Yeah. Well, let me ask you about heat [00:24:00] application. What does that actually look like? Like are you, so I'm gonna tell you one thing that I do love is, um, hot chail tea bags. Yes. But on my eyes, I'm, this is, this is like a little luxury thing that I realize, like you haven't really shared with my audience, but I've like done for decades because it's just so soothing and it feels so great.

Or if my eyes are puffy, it'll be like green tea bags, um, for the caffeine in there. But in terms of heat application, how are we actually going about this? Because they wanna make sure people don't hear this and think, oh, put a hot water bottle on my face for like 30 minutes. 

Carly Rose: Right. Honestly, uh, it's convenience for me.

So I start to dig into the patient's lifestyle. How much free time do you have? Right? Do you have access to a microwave? How, what are your funds like, because the, you can buy. Quite a few different heat masks. Some are microwaveable, some are the snap kind. I educate patients on how to make their own with a clean sock and rice.

If you, one thing I was taught in school is a hard boiled egg if you have a ty, because that gives you a lot of pressure and [00:25:00] it holds heat really long. But now we have so many commercially available hot compresses that you can find about anything that fits your lifestyle. But a caveat to these hot compresses that we did not learn in school is, um, I'm actually guided by the patient's experience with hot compresses.

Mm-hmm. Because I've learned so much now about ocular rosacea and hot compresses can make ocular rosacea worse. Mm. And we absolutely mix the two MGD and ocular rosacea. They usually run together. And so I'll ask the patient, how do your eyes respond to a hot shower or a hot compress? And sometimes.

They'll tell me, you know, my doctor told me to do it, and my eyes flared up like crazy. Okay, don't do it. Do a cold, compress or alternate, because what happens is the oil glands are clogged and we want to melt the oil out and squeeze it out, just like cooking oil. Mm-hmm. The hotter the better. So these in-office thermals, they manipulate that and they heat the oil and [00:26:00] squeeze it out.

But when you're home, you can have clogged oil glands, but also ocular rosacea and that heat is gonna flare the rosacea component. And so that's where we're either gonna alternate or do cold compresses or in-office heat only. 

Dr. Brighten: Okay. What is MGD and ocular rosacea? For people who don't know? 

Carly Rose: MGD is meibomian gland dysfunction, and that's at least 86% of dry eye disease has a meibomian gland dysfunction component.

Mm-hmm. That's from the lack of blinking, it's from demodex, it's from systemic inflammation. There's a lot of causes. And then ocular rosacea is like facial rosacea, and we pick up on it with these little tiny vascular, these little tiny blood vessels, right on the lid margin. Mm-hmm. And so if you, tight lining, we haven't talked about tight lining in cosmetics.

What's 

Dr. Brighten: tight lining 

Carly Rose: when you use a eyeliner on the waterline? 

Dr. Brighten: Oh, 

Carly Rose: big. No, no. I can't believe I've missed that. Don't do that. But the trend right now is I 

Dr. Brighten: feel like we all did that like, um, like [00:27:00] 20 in the nineties, 20 years ago, right? Yeah. Like almost 30 years ago. And, uh, so I forgot all about it, but I'm like, I don't know.

I feel like, um, gen Z's like trying to bring everything back. They 

Carly Rose: are. 

Dr. Brighten: And like, maybe don't also the hair and eighties, like it wasn't a good idea. 

Carly Rose: Well, what I'm seeing is, um, people are tight lining with white liner. 

Dr. Brighten: Oh yeah. 

Carly Rose: Because the rims are red. 

Dr. Brighten: Oh. '

Carly Rose: cause they probably have ocular rosacea and demodex.

Dr. Brighten: Oh my gosh. 

Carly Rose: So please just treat that and then you don't have to tight line with white liner. 

Dr. Brighten: Yeah. Yeah. I've seen that. I thought people were doing it to try to make their eyes look brighter or I don't know. Well, 

Carly Rose: it's, well it's, it's all psychological, right? Because we know that a calm white eye is a healthy eye is a healthy body.

Dr. Brighten: Mm-hmm. 

Carly Rose: And in our subconscious, we wanna partner with someone who is healthy and 

Dr. Brighten: the trickery 

Carly Rose: can reproduce. 

Dr. Brighten: Yeah. 

Carly Rose: Right? So if our eyes are red and our rims are red and everything's swollen, there's something going on there. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so we do want bright white eyes. For evolutionary [00:28:00] purposes. 

Dr. Brighten: Yeah. Okay.

So we've got the heat you recommended twice Now this light therapy. Mm-hmm. Is this something people are doing at home or are they doing it in a practitioner's office? The IPL, 

Carly Rose: so there are a few different light therapies that have made their way to the eye world. Uh, low level light therapy is in office and at home.

I love LLLT. It's like the red lights, the infrared lights. Mm-hmm. They're fantastic and so they're great to calm the inflammation. They, that also helps produce stem cells, so it helps heal the surface of the eye. And there are studies now coming out that it can slow myopia and macular degeneration, so it's helping the front and the back of the eye.

It's a win-win. And then intense pulse light is in office that is physician-based. Do you want a medical provider doing those treatments? It's state to state. Every state is different and every country's different. Mm-hmm. And all of the machines are different and the devices [00:29:00] are different, but they is, it's not a true laser because it is, um, not so focused in light.

Mm-hmm. It's, it's definitely, we play with the filters depending on the depth of the epidermis and dermis. We wanna get to different filters, different wavelengths of light, different energies, target and treat different things. 

Dr. Brighten: Mm-hmm. 

Carly Rose: But that's been around for over 50 years with a great, great safety profile.

Really fantastic results. I've been treating dry eye disease for over a decade now, and when I started implementing intense pulse light I, over five years ago, that's when the game changed for me. Mm-hmm. That's when I really started to see change in. Treatments. 

Dr. Brighten: Yeah. I remember seeing you talk about light therapy and how it's preserving eye health, and that was one of the big factors in me deciding that I was getting a near infrared sauna rather than just a regular sauna.

Because I'm about habit stacking as well. I like to say I'm lazy because I really, because [00:30:00] I'm like, I'm, aren't 

Carly Rose: we all, 

Dr. Brighten: I mean, I'm like, I'm gonna go in the sauna, it's gonna be my red light therapy. I'm gonna do my deep breathing, like I'm gonna do my, I can get it all taking care of in 20 

Carly Rose: minutes. 

Dr. Brighten: Exactly.

I'm gonna hit it all in 20 minutes right before bed so I can get that like one and a half hours of deep sleep. Like it's a whole strategy, but it's also because like when it comes to like caring for your health, I feel. Especially as women and especially as we age, it's always like, one more thing you gotta do.

Mm-hmm. I mean, even as I had a patient recently who was like, I really don't wanna start hormone therapy. Like, I want the benefits of it, but it's just like one more thing. Mm-hmm. I have to remember on my to-do list, I'm like, I, I feel this. So hard. It's so hard. I feel like every, you know, every five years you're like, and next.

Mm-hmm. And what's on the list again? So let me ask you, if people are at home, you know, are looking at their eyes, how can they assess their eye health? What, what is like the pillar of health, what their eyes should look like, and what are the signs of like, you need to go see someone because this is not normal.

So we covered if you've got a red ring mm-hmm. So that [00:31:00] if you feel like you wanna take a white pencil and like line your eyes to get rid of the red 

Carly Rose: normal, 

Dr. Brighten: talk to your eye doctor. Normal. Yeah. Mm-hmm. So what are some of the other things people should be looking for? 

Carly Rose: You know, dry eye causes a lot of intermittent, blurry vision too.

Okay. And, and that gets over. People think that they just need a prescription change. 

Dr. Brighten: Mm-hmm. 

Carly Rose: But it's like looking through a dirty windshield and it comes and goes every time you blink. It's good for a second and then dissolves. Yeah. That is definitely dry eye disease. And then itchy eyes, watery. Watery eyes a lot of people have and don't realize that's actually dry eye disease.

Mm. And then of course, red, swollen, irritated eyes. 

Dr. Brighten: Mm-hmm. And what about staes people who are constantly getting STEs? 'cause you mentioned that before. First, what is ati? In case somebody has been blessed to never have had water? 

Carly Rose: So Tys are, we talked about those oil glands that are like tubes of toothpaste.

It is one singular oil gland that's clogged and really angry. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so what I tell patients, especially [00:32:00] if they've have chronic sty, is this is a chronic disease state. Every single one of these oil glands can turn into a ty. You could have 80 sty at one time if you want. So for a long time treatment was oral doxy.

And removing them and and removing them is still something we have to do from time to time. Mm-hmm. But once you cut it out, you've lost that oil gland forever. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so now steroid injections are helpful. You can do, um, temporary antibiotics, but you really wanna get to the root cause of the meibomian gland dysfunction.

Dr. Brighten: Mm-hmm. 

Carly Rose: You wanna figure out why these oil glands are so unhealthy and liner tattoo people don't even think about puncture. That 

Dr. Brighten: sounds 

Carly Rose: so painful. Puncture these oil glands. 

Dr. Brighten: I can't. 

Carly Rose: No one even knows the oil glands exist. That's what a style is, is an angry oil gland. Well, people don't realize our, our, our visual system is our leading sensory system.

Dr. Brighten: Okay. Talk about 

Carly Rose: that. So it's deeply connected to safety position and space. And if you [00:33:00] can't feel in control of your eyesight and your vision, it is very dis unsettling. And you know, patients that do lose their vision later on in life, they always, always say, I took my eyes for granted. I took my eyes for granted.

And when it's gone or when you're fighting to get it back, it's a big deal. 

Dr. Brighten: Yeah. So, well, let me ask you, because we've talked about like eye health, its itself, but I'm curious, are there signs that people can see in their eyes, around their eyes that are pointing to a deeper disease that should, they should be aware of?

Carly Rose: Absolutely. And so, for example, diabetes, high blood pressure, ms. Thyroid issues, they all affect the eyes pretty quickly. 

Dr. Brighten: Mm-hmm. 

Carly Rose: It's hard to tell as the patient though, because what we need. So even me as a patient, I have something go wrong. I need to, my sister's an eye doctor as well, so that's very handy and I'll call her like, so I think I might have a corneal abrasion, but, um, for example, flashes and floaters, right?

We know it's not good, [00:34:00] but I can't really diagnose it. Someone else needs to look at me. Mm-hmm. I had my own flashes and floaters. I need to go be seen. We need to look in the eye in the microscope sitting here. Me as an eye doctor, you as a patient, I would still need to put you in a microscope to really tell you.

Mm-hmm. So, uh, uh, it, it goes back to annual eye exams. Annual eye exams. Annual eye exams. Yeah. Catch it early. 

Dr. Brighten: What is actually going on if you have floaters in your eyes? 

Carly Rose: Traditional floaters. So the eye is filled with a jelly. Mm-hmm. Called the vitreous. And what happens with the vitreous over time is it separates into its liquid and solid parts, kind of like jello sitting on the counter.

It'll start to get that liquid. It's top gross. 

Dr. Brighten: Okay, 

Carly Rose: gross. Same thing is happening here. Only what is happening with the solid parts is they're floating around in the liquid like a, like a jelly snow globe. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so you're seeing those little floaters and when you look, I mean it's a bright light or a white wall, you can see them more clearly.

What we don't want to happen is a shower of new floaters all at once, like something broke [00:35:00] loose in there. 

Dr. Brighten: Mm-hmm. 

Carly Rose: Because what happens is as this jelly separates, it almost falls into itself. It, it collapses, but it's attached to the retina at very specific strong attachment points. And so when it falls in on itself, we don't want it to take the retina with it.

Dr. Brighten: Mm-hmm. 

Carly Rose: And so that's the big concern with floaters is. A retinal tear hold. Detachment. 

Dr. Brighten: Yeah. So don't ignore that. 

Carly Rose: Do not ignore that. Yeah. Do not ignore that. I've had patients that will sit on lights out, lights out vision for weeks and with retinal issues, timing is huge. Mm-hmm. The quicker you can be seen for proper treatment, the better your visual outcome.

Dr. Brighten: Okay. Since we started talking about hormones, I wanna shift into more hormone talk and we're gonna talk about everything from like your own hormones to being in perimenopause, menopause, hormone therapy, and birth control. But the first one I want to ask you about is estrogen. 'cause we know that affects just about everything in our body, but what is the eye hormone [00:36:00] connection that women should know about?

Carly Rose: It's huge. It's huge because of a mult, many factors, but dry eye disease is gonna be the main thing. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And with dry eye disease, it's, it's an androgen deficiency for sure. We've known that at least since the nineties. We used to have compounded testosterone drops that we could use for this. But it's become such a multidisciplinary, we really have to put together a care team for these patients to dig into their hormone balances, regulating them.

What's going on with the thyroid, right? Because hypo and hyperthyroid affects the eyes. So truly it's it's dysregulation. Mm-hmm. We have to get the whole body back into homeostasis. Too much and too little are both problems with the eyes. 

Dr. Brighten: So what I'm hearing is it's not just one hormone. We need to look at all hormones.

Carly Rose: It's not just one hormone, it's all hormones. It's environment, it's stress. It's what surgeries have you had. Right. Even retinal detachment surgeries can cause dry eye. It is so multifaceted and multidimensional. [00:37:00] Mm-hmm. That we often will even have to bring in, um, you know, psychiatrists. And therapists and endocrinologists and rheumatologists, and these patients end up having dozens of specialty doctors 

Dr. Brighten: talk to us about these testosterone eyedrops, because I think that's gonna be news to a lot of people.

It was to me last night you shared that at dinner and I was like, hold on. Why is this not something that's readily available? 

Carly Rose: It's not. And you know, it's, um, it, it's becoming harder and harder to get. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so much so that it came down to, I think just one state was able to get it and so we can't really use it at this point if we can't get our hands on it.

Dr. Brighten: Mm-hmm. 

Carly Rose: And that's the same with topical insulin. We used to be able to use topical insulin a lot easier. For, um, corneal nerve growth 

Dr. Brighten: mm-hmm. 

Carly Rose: Which we can dig into, but now we can't access that nearly as easily as well. 

Dr. Brighten: What's the problem? Is it FDA regulation? Mm-hmm. Okay. Mm-hmm. I mean, you know, when it comes to the FDA, there's a lot of [00:38:00] things we use off-label, but I feel like the eyes is one of those areas that we really have to be cautious and, um, I'm a fan of compounding pharmacies, but they're not all created equal.

Carly Rose: Right. 

Dr. Brighten: I wanna hear more though about this androgen eye connection and do see people improve if they go on like testosterone injections or using topical testosterone? 

Carly Rose: Absolutely. But my scope is limited, right? Mm-hmm. Um, specifically with optometrists, we are observed often because you mentioned the eyes and the teeth, they're totally different.

So optometrists are really trained to stay in their own lane, don't work outside of your scope. But how do you do that when your scope includes hormone imbalance and central nervous system dysregulation and the gut, oh my gosh, the gut guides so much of the eyes, there's a direct gut eye axis. Mm-hmm. And so it becomes very challenging to stay in compliance and in the scope of practice, but get these patients the treatment they needed to deserve.

It is, it's very [00:39:00] challenging. And then of course, you want it, you need to find a provider that's progressive enough to stay up on the research and not just jump to birth control pill. 

Dr. Brighten: Yeah. 

Carly Rose: That's usually the answer. 

Dr. Brighten: The thing about birth control is that I actually just. Did a episode and I'll link to it.

It tanks your testosterone. Yeah, so it drops the production of testosterone anywhere from 40 to 60%. It takes your ovaries outta the equation, one of the primary sources of your androgens. Then it raises sex hormone binding globulin, so it binds up your free testosterone and then if you're on progestins that are androgenic in their, in how they've been developed.

They will block the receptor sites. And so you are not getting the testosterone you need. And forever medicine was like, who cares? Right? You are a woman. Why do you need testosterone? I mean, actually they still say that. Uh, and you know, I, I have like a laundry list of why women need testosterone. And now talking to you, I'm like, and your eyes, your 

Carly Rose: eyes, 

Dr. Brighten: dry eyes, your eyes like this is insane.

Because if it was a man, it would be like, stop [00:40:00] everything. 

Carly Rose: Well 

Dr. Brighten: get him testosterone. 

Carly Rose: I agree 100%. And so I do, I start, I actually recommend beyond the pill to a lot of my patients to get started in reading this. And I talk about heavy lifting and diet and stress reduction. But what's fascinating is when I was in school, I was, we were taught that this is an older female disease.

It's para, it's postmenopausal. Women have dry eye disease and it just is part of the aging process. And I developed dry eye disease when I was in my early twenties, and I'm like, this doesn't make sense. Right? And mine just kept getting worse. And I was doing the baby shampoo and I was doing punal plugs and it just kept getting worse.

And, um, you know, they blame then the patient is blamed, well, you're not doing it right or you're the, this is just part of aging deal with it. Mm-hmm. Well, what's happening is. Female dominant. It is very female dominant disease until you get to the younger generation. And the younger population is more 50 50 male and [00:41:00] female.

Mm-hmm. In the 20-year-old dry eye patient. And so I think we're gonna start to see some answers now that this is more of a 50 50 male female disease. 

Dr. Brighten: Yeah. I mean it's like the same thing with endometriosis. Like it's been discovered in men and we're like, okay, we just need more men now. 

Carly Rose: Yes. 

Dr. Brighten: Um, and then we'll, 

Carly Rose: and then we'll get 

Dr. Brighten: the 

Carly Rose: research.

Dr. Brighten: Exactly. Yes. That's 

Carly Rose: me with dry eye disease, like the men are finally getting it. 

Dr. Brighten: Yeah. Well, and for people to make the connection here, we know the younger generation of men are producing less testosterone and less. Sperm than their grandfathers. I mean, there was one study that showed 50% reduction in the sperm production of like 20 somethings compared to like their grandfather's generation.

That's 

Carly Rose: shocking. 

Dr. Brighten: Yeah, and it's endocrine disruptors. So what should women know about what birth control can do to their eyes? 

Carly Rose: Well, obviously dry eye disease. And then there's this vascular component, right? Strokes and thrombocytes and clogging [00:42:00] the blood vessels. And we already talked about the iso nutrient dense and vascular dense.

Like it needs a lot of blood flow. It needs a lot of oxygen, which is why diabetes shows up first. One of the first places it can cause damages. The eyes. Mm-hmm. Is this vascular demand And so we already know what. Birth control can do to the vascular system. And the eye is one of the most densely vascular systems out there.

Dr. Brighten: Mm-hmm. Plus, we understand that birth control depletes nutrients that are crucial for eye health. Mm-hmm. It's very interesting too, because there has been some research. We certainly need more showing that you need your own natural estrogen to take the plant-based omegas and actually activate them, them convert in a way that you can utilize.

And so it raises a big question. When you're on the synthetic estrogen and you've shut down your own estrogen, are you actually able to get those omegas in the same way? 

Carly Rose: Right. And that's why I usually, even for my vegans, they don't love it because the plant-based don't need that [00:43:00] conversion. EPA and DHA, if you get a plant-based, then it has to be converted.

Dr. Brighten: Mm-hmm. 

Carly Rose: And you lose a lot of it. 

Dr. Brighten: Yeah. It is. I mean, it's something that I feel like vegans, when they're doing it for the ethical reasons, they never like to hear those kinds of things, but I feel like. 

Carly Rose: I was vegan for a while, so I get it. 

Dr. Brighten: I it, oh, I tried vegan, I failed. I was like, I, it did, it did not, it is not working for me.

Carly Rose: Yes, I agree. 

Dr. Brighten: If nutrition is a medical intervention that we can utilize, informed consent is warranted. And part of that informed consent of you choosing a vegan diet is for you to understand where the pitfalls are in that so that you can, you know, try So like getting algae oil, you know, supplementation, supplements.

Yeah. And going up higher on that may help circumvent that. But it's, it's knowing the information so that you can do something about it. And, you know, as we're in this conversation, not be blindsided by, you know, not having 

Carly Rose: informed consent. Right. Yeah. That's everything. That's the same thing with the aesthetic world.

You need to know that your crow's feet, [00:44:00] Botox and your liner tattoo can cause permanent damage. 

Dr. Brighten: Yeah. 

Carly Rose: You need to know that if you still elect to do it. Perfect. 

Dr. Brighten: Yeah. I don't even feel like liner tattoo really ages well either. Uh, I mean, I, and I'm wondering 

Carly Rose: very rarely 

Dr. Brighten: because, and as you say this, I am like, is it about the skin changing or is it about how it has basically destroyed those glands?

Carly Rose: It it punctures them. Yeah. And, and then it can deliver the pigment into the glands too. 

Dr. Brighten: Yeah. 

Carly Rose: Because the eyelid is only like a millimeter thick. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And most of these tattoo guns are even deeper than that. So you're fully puncturing the entire eyelid. 

Dr. Brighten: Yeah. 

Carly Rose: And everything in it. 

Dr. Brighten: Well, going back to birth control, if someone is on the pill, is there anything that they can be doing to be taking care of their eye health and mitigate some of these side effects?

Carly Rose: Yeah, it's, it's kind of like. High blood pressure medicine causes dry eye, right? Mm-hmm. But we can't just pull you off your high blood pressure medicine. So that's where we just support the tear film as much as we can. Blink, exercise hot, [00:45:00] compress lid hygiene, and omega threes. Mm-hmm. Always the starting point.

But this is where things like AI may help us quite a bit because what I see happening is progression analysis. And predictions. So what I think we will get to is we, we should be able to plug in all of these different metrics, you know, 20 or 30 things about a patient, your your labs, what medications you're on, and your lifestyle.

And it'll spit out your risk of developing dry eye disease. Mm-hmm. And maybe it looks like an IPLA year to prevent or something along those lines. Mm-hmm. Or start on a pharmaceutical before signs and symptoms begin. 

Dr. Brighten: Well, and that would be a great thing that if we did an all medicine before we started a medication, to try to understand who might be at risk for what side effects.

And then be able to prevent that, you know, if it's interesting 'cause when we look as we're talking in the conversation of the pill. We understand that if you have a family history of depression, you have a history of depression, you've ever had postpartum depression, and now if you're neurodivergent, [00:46:00] we understand all of those things make you at higher risk of developing mood symptoms when you start birth control.

And yet. That's still not a conversation happening when that pill prescription is written, we're still not having those conversations regularly in doctor's offices, so they can say, Hey, if your mood tanks, which can be as scary as suicidal ideation, you need to come back and see me because we can switch formulations.

We can do something different here. What about IUDs? The progestin based IUDs and eye health? 

Carly Rose: Well, I feel like those are gonna be lower risk, right? Because they're not an oral absorption, they're more topical. Mm-hmm. So I feel like those are lower risk, but none of this is happening in a vacuum. Mm-hmm. So every patient is so multidimensional and multifaceted.

Some patients are blessed with this great immune response and they can handle anything. And some patients. You know, can't handle fragrances in the store. Mm-hmm. So that's where it gets so complicated is because it is patient to patient dependent as well. And [00:47:00] that's where I think being connected to our own bodies is very helpful.

Pay attention to what your body is telling you. Advocate for yourself. Talk to your healthcare provider provider, and if they're not hearing you, get a second opinion, get a third opinion, because at the end of the day, the medical system is under-resourced as well. And there's only so much time a doctor can spend with you and review all of your medicines and how they work together and what's really going on.

So I do think patient participation and don't, don't get gaslit. Right. 

Dr. Brighten: Yeah. 

Carly Rose: Don't let yourself get gaslit. Listen to what your body's telling you and take care of it. 

Dr. Brighten: Mm-hmm. For women who are in perimenopause, what do you wish they knew about their hormones and their eye health? 

Carly Rose: I wish women in perimenopause would realize that there are alternatives to feel good.

This life should feel good. You can feel better. It does take time. One thing I say often [00:48:00] is put the fire out. Keep the fire out. Mm-hmm. And how big your fire is Depends on the timeline of getting to resolution, but there that resolution is possible. Hope that it doesn't have to feel this bad. 

Dr. Brighten: Mm-hmm. Why is it so many women in their forties are developing dry eyes?

Carly Rose: Oh my gosh. I mean it's now down to twenties. It's crazy. 

Dr. Brighten: Oh my gosh. But that's like the same thing we're seeing like as in the testosterone conversation. Yes. Is like we're seeing 20 year olds. It's who are women who shocking don't have enough testosterone and, and all doctors care about is like PCOS. And do you have too much testosterone?

Carly Rose: Yes. Well, you and I chatted earlier about our, you know, fertility struggles and I probably. A dozen years ago was told, well, you are ovulating, like a postmenopausal woman. We're just gonna have to put you on all these meds. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And that was the only conversation I ever had after one lab with one doctor, and I was like.

Hmm. Really? I think there are things [00:49:00] we can do. 

Dr. Brighten: I just wanna say postmenopausal women don't ovulate. But how often doctors use that phrase? Yes. Because I, because someone might be like, wait, I'm postmenopausal. I don't ovulate. You're right. But this shows you how little doctors understand perimenopause and menopause.

'cause they'll literally say that. Yes. Like you're cycling like a postmenopausal woman. Mm-hmm. You don't cycle when you're 

Carly Rose: postmenopausal. Well, and so many patients see that as a, you know, indictment and this is my forever and it's not. Epigenetics are powerful. We can manipulate our environment. We can manipulate our body.

Dr. Brighten: Mm-hmm. So you mentioned before hyperthyroidism, hypothyroidism affecting people's eyes. I think a lot of people are familiar with the bulging eyes of hyperthyroidism, but hypothyroidism is far more common, especially after the age of 35. How is that affecting the eyes? 

Carly Rose: I mean, it's just a direct correlation to dry eye disease 

Dr. Brighten: really.

Carly Rose: It's almost, yeah. I would challenge you to find a patient with an underactive thyroid. Does not have dry eye disease. 

Dr. Brighten: Mm-hmm. 

Carly Rose: It's just [00:50:00] all of them. And I, I heard a practitioner say that they got tired of treating sick fish who are swimming in poisoned waters. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And it's almost like what isn't causing dry eye disease at this point?

Dr. Brighten: Yeah. 

Carly Rose: Uh, lasik, ble, blepharoplasties, we can talk about in the aesthetic world, our thyroids being completely shot, our stress, our cortisol just spiking. It all ends in these flaming hot eyeballs. Mm-hmm. 

Dr. Brighten: Yes. So let's explain the aesthetic procedure to people who may not be familiar with it. 

Carly Rose: And it's trending it.

I don't know if you, 'cause this is my world. Mm-hmm. But blepharoplasties are viral and trending right now. Can we not make eyelid surgery trend a trend? Mm-hmm. But blepharoplasties are eyelid surgeries. Mm-hmm. And there's a time and a place, and I'm not against a blepharoplasty. One of my good friends is an oculoplastic.

And I'm like, when? When are we doing my bluff? When are, you're doing my bluff? When I'm ready. [00:51:00] But what's happening is a lot of doctors are taking too much of the eyelid. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And then the eye cannot close. So then we're back to the incomplete blinks. 

Dr. Brighten: Yeah. 

Carly Rose: So then we're really doing blink exercises and mitigating all of this.

Mm-hmm. But it's also causing this nerve damage. And, and that's where things like retinal detachment surgery can cause dry eye disease. And you might think how is the back of the eye causing a front of the eye issue? And it's nerve disruption. Any ocular surgery causes nerve disruption. 

Dr. Brighten: Yeah. It's something that I, I definitely have that fear.

My grandmothers as they got older, like they had a very hard time opening their eyes enough to be able to see because Yes. How much skin there was. And 

Carly Rose: that's where insurance will cover a bluff. 

Dr. Brighten: Yeah. Mm-hmm. And so I'm like, that may be in my future. I do laser treatments, I do things to try to prevent that.

But it is something that, um, you know, as we're talking about that, that's always been my concern as you see these, you know, procedures that are done. By the [00:52:00] way, everybody who's listening, I'm talking about when I'm like 80 and function functionally being able to see and, um. But you see these procedures done where like people are completely pulled back.

Mm-hmm. And they can't even close their eyes. Close their eyes. What is happening when they're sleeping? 

Carly Rose: Oh, well, what's the eye is a mucus membrane. You're very familiar with mucus membranes. It has to stay wet to stay healthy. Uh, the cornea. Doesn't have its own blood supply. It gets all of its nutrition from the tear film, and we know how important the cornea is.

Well, when they're sleeping, they're, the wind is just damaging. And if you have nocturnal lag ophthalm, this happens as well. This is 

Dr. Brighten: where the eyelids 

Carly Rose: don't, and this is where the eyelids don't close when you're sleeping. Exactly. And I don't know if you remember the trend on TikTok a couple of years ago where there was the slowmo blink trend and so many people realized they don't close their eyes all the way.

I was like, yes. Find trend. That's helpful now. 

Dr. Brighten: Like, okay, how do we do that? 

Carly Rose: Yes. 

Dr. Brighten: To actually evaluate our eyes. 

Carly Rose: Oh my gosh, that's brilliant. 

Dr. Brighten: Yeah. 

Carly Rose: Yeah. Just record [00:53:00] yourself blinking in slowmo and watch it back. Yeah. Do your eyes close. 

Dr. Brighten: So for 

Carly Rose: everyone that's what you want. Yeah. Is your eyes to close 

Dr. Brighten: for everyone listening, if you go into these apps?

So, uh, I use TikTok more than I use, um, the reels. Uh, so I don't know if they have a slowmo, but the, that. The TikTok has a slowmo cap cut, like a lot of editing programs you can actually put it on. That's brilliant. Actually, your camera has that. Your own camera has it. Yes. And so you can record it in Slowmo and slow the whole thing down.

Mm-hmm. I said I'm gonna do that for sure. 

Carly Rose: Yes. 

Dr. Brighten: But you were talking about how if your eyes don't stay closed at night, they're getting dried out. 

Carly Rose: The wind is damaging it, and then it can scar over and then you can't see. 

Dr. Brighten: Okay. That's right. That's not, it's a big deal. Significant. Yeah. 

Carly Rose: Not to mention, I do not wanna underestimate.

The quality of life impact when your eyes are so irritated. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And if you can't see it's, it's very disorienting. 

Dr. Brighten: Yeah. You know, it's interesting 'cause in this conversation I'm like, I would think low estrogen [00:54:00] Sure. Having dry eyes because everything gets dried out when our estrogen gets low. Same with our thyroid.

So dry skin mm-hmm. Is definitely one of those signs. But the, the androgen piece. You know, I I to come back and harp on it some more because so many doctors think if androgens are low in a woman, it's low libido and it's nothing else. But for women to really understand, that can be a sign of low testosterone as well.

Yes. So we've got these three key hormones. But you also mentioned insulin. Is that involved in dry eyes or is insulin dysregulation doing something else in the eyes? 

Carly Rose: Well, it's complicated, so. Diabetes absolutely affects the eyes. Mm-hmm. And so systemic inflammation, or I'm sorry, systemic insulin doesn't specifically that I know of have this effect on the eyes.

Mm-hmm. But the topical insulin acts as a nerve growth factor. 

Dr. Brighten: Okay. 

Carly Rose: So it actually is neurogenic. 

Dr. Brighten: Okay. 

Carly Rose: Which is fascinating. 

Dr. Brighten: Yeah. And then talk to us about cortisol, because you mentioned that briefly, but we [00:55:00] know HPA dysregulation is running rampant in our society. 

Carly Rose: Yes. 

Dr. Brighten: And it especially gets amplified postpartum and also in the perimenopause through postmenopausal years.

So what are these high levels of cortisol over time doing to our eyes? 

Carly Rose: You know what? It's funny because dry eye disease led me here because I just keep following the rabbit hole of, well, what's going on here? Why? Why is this happening? Why is this happening? And I started to notice a trend of just insane HPA disautonomia and basically patients stuck in fight or flight and not in rest and digest.

Dr. Brighten: Mm-hmm. 

Carly Rose: And of course, if you think about it, evolutionarily, when we're in fight or flight, we can't have watery eyes. 

Dr. Brighten: Mm-hmm. 

Carly Rose: We're running for our lives. Right. Rest and digest is when all of our juices turn on. And so there's a very intimate relationship between the eyes, the corneal nerves, and the parasympathetic and the sympathetic systems.

Dr. Brighten: Mm-hmm. 

Carly Rose: And [00:56:00] how I started learning about it is because there is, there are a few medications now, but. One came out a few years ago, and it's a nose spray and it's a parasympathetic activator. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so I'm like a parasympathetic activator through the nose. This is interesting for the eyes. 

Dr. Brighten: Mm-hmm. 

Carly Rose: So we have a nerve in our nose called the anterior ethmoid, and it is a vagal mediator.

And so what we're doing is stimulating that to send a signal to the brain to turn on the parasympathetic pathway to start making tears. There's a direct parasympathetic tear production mm-hmm. Connection. Well, what we also now note, there are, um, different devices that are, that stimulate that nerve. You can stimulate the nerve externally.

And then there is now a neurogenic eye drop that just came out to start doing this with the corneal nerves. Mm-hmm. And so I started researching and going down this corneal nerve, rabbit hole. And with the corneal nerves there is this. Bidirectional [00:57:00] feedback. So for a long time it was almost like Lasik, for example, slices the corneal nerves in half.

And so we knew that you weren't getting the sensation to tear. But what, what I didn't fully understand is there's this crosstalk and these nerves actually excrete growth factors to support the corneal epithelium. 

Dr. Brighten: Mm-hmm. 

Carly Rose: Okay. So everything in the eye is just a specialized version of the rest of the body.

The corneal is specialized epithelium, the lashes are specialized hair follicles, the eyelids are specialized epidermis, like it's all the body but nuanced. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so the corneal nerves secrete growth factor to help the corneal skin grow. Mm-hmm. So I'm like, well this is fascinating because not only do we not have this, that.

ENT sensation, it's like we're missing something from the efferent side, and we didn't realize how much these nerves support the epithelium. Mm-hmm. And so [00:58:00] then that goes to the central nervous system. So of course our central nervous system senses hot. The environment, that's it's sensory input, but how much of it is actually supporting the surrounding tissue as well by excreting these different growth factors.

Dr. Brighten: Mm-hmm. 

Carly Rose: It's very fascinating. 

Dr. Brighten: Well, let me ask you if LASIK is slicing through nerves. 

Carly Rose: Yes. 

Dr. Brighten: What's the harm that can be done? 

Carly Rose: Oh, the famous cases that you see of suicide from dry eye disease are almost always LASIK related. 

Dr. Brighten: Whoa. 

Carly Rose: They're almost always corneal nerve involved because that's when this disease gets really challenging.

Huge connection. Huge connection. And it's one of those things where either you're fine or you are really not fine. Mm-hmm. There's not a lot of gray area. The risk is fairly low. And it depends on the practitioner, right? And which devices they're using, how deep they need to cut. And that depends on your prescription as well.

So the larger prescription, the deeper they need to cut. And [00:59:00] so there are things that you can do instead of lasik. Like orthokeratology is like braces for your eyes. There's no cutting, there's no nerve involvement. There's no long-term risk. It's a rigid contact lens that you wear at night while you're sleeping.

Dr. Brighten: I'm already, my eyes are already squinting. I'm like, Ooh. Rigid contact lens in my eye. 

Carly Rose: Yeah. 

Dr. Brighten: But it sounds, um, like Invisalign for your eyes. 

Carly Rose: Exactly. 

Dr. Brighten: Yeah. It's 

Carly Rose: exactly like Invisalign for your eyes. 

Dr. Brighten: Is there any way to know who would be at risk before undergoing lasik? 

Carly Rose: Yeah. Obviously a dry eye patient. Okay.

Yeah. Okay. Should get lasik. But identifying the dry eye patients aren't as easy as it seems because you usually do need specialized tools. Mm-hmm. To get the early ones, not the, the, the end stagers that you can see them from a mile away. But the early patients and those are gonna be most of the time the LASIK patients because they're younger usually.

Mm. And so if they have this disease process, it's going to be earlier usually. So you wanna test, um, there are different bio biometrics we can do. We can [01:00:00] test your tear film for inflammatory markers. We can test your tear film for two high of salt. It's called osmolarity. If you're too, if you are hyperosmolar, you probably have dry eye disease.

Mm-hmm. We can look at the lid margins. We can look for demodex. That parasite looking at blinking because the corneal nerves directly impact your blink. 

Dr. Brighten: Are you analyzing my blinking as we speak? 

Carly Rose: I analyze everyone's blinking. I like eye contact is my. My love language. I'm like staring at people. 

Dr. Brighten: Well, I wanna talk more about the gut eye connection, but before we go into that, you mentioned how our lashes are specialized follicles.

People are using lash serums. Yes. To help them grow. Good or bad, let us know. 

Carly Rose: Depends on the lash serum. Okay, so let me give you the buckets. The, the lati of the world, their prostaglandin analogs. Do not, it's like pouring inflammation on your eyes. 

Dr. Brighten: Totally. 

Carly Rose: They work, but not, not without damage. And 

Dr. Brighten: as someone with endometriosis, [01:01:00] I'm like, oh god, no.

No more prostaglandins. 

Carly Rose: No more prostaglandin. They, no, it's, it's really ridiculous. And that's where you see these deep red rims on the lid margin itself because you know, you're just painting inflammation onto there and you're getting this neovascular inflammatory. Blood vessel growth, and then those blood vessels are leaky and they're just leaking more inflammation on the surface of the eye, and then your lacrimal gland starts leaking inflammation and it's this vicious cycle of inflammation.

So please don't do a prostaglandin analog lash serum, but healthy lashes are long. The best way to grow a lash is the healthy way. So that's the omegas, that's the oil-based lid. Cleansers, that's taking care of demodex, but then a castor oil. Mm-hmm. I'm a big fan of castor oil. You want it to be cold pressed organic, hexane free.

And something that isn't mentioned enough with castor oil and the eye is, I like a separate bottle. So if you, if you are one of these that uses castor oil all over your body, don't use that [01:02:00] same bottle on your eyes. 

Dr. Brighten: Hard agree. Yeah. 

Carly Rose: Keep them separate. Keep them separate. And then there are great lash serums that are peptide based or floral essence based.

Right. Different marigold extracts and clovers. And there are ways to grow lashes with a peptide base, lash serum as well. But always start with lid hygiene. Lid hygiene alone can do wonders for your lashes. 

Dr. Brighten: And the lid hygiene is what we talked about. Mm-hmm. With the double cleansing. 

Carly Rose: Yes. 

Dr. Brighten: Okay. 

Carly Rose: It's beautiful how it all goes together.

Dr. Brighten: Yeah. Mm-hmm. Let me ask you, because I actually got somebody who messaged me and said, I, I had done a whole episode on hair loss, and they said, can I start using minoxidil on my lashes? My reply is, 

Carly Rose: no, 

Dr. Brighten: I, okay. Well, you say no. My reply was like, I cannot advise him on this. This is outside my scope. I would not recommend anything on the eyes that an eye doctor has not approved.

Um, because again, I'm like very, very cautious with eyes. I'm like, they're not a mess around. That's why I've always told my patients the same thing. Yeah. I love cast oil for [01:03:00] lash growth and lash health, but it should be separate and your hands should be clean before you. 

Carly Rose: Yes. 

Dr. Brighten: And I think people just kind of like, take that for granted.

Or they think like, oh, I wash my hands when I went to the bathroom like 30 minutes ago immediately. Mm-hmm. Wash your hands before, you know, applying anything 

Carly Rose: but minoxidil on the brows. I'm fine with. 

Dr. Brighten: Okay. Mm-hmm. Okay. Yeah, foam liquid 

Carly Rose: foam is great. 

Dr. Brighten: Okay. 

Carly Rose: And speaking of, um, retinols 

Dr. Brighten: mm-hmm. 

Carly Rose: Retinols can dry your eyes out big time.

Okay. And so with retinols and they migrate, so I was just thinking with the Minoxidil, I just retinol 

Dr. Brighten: last night, so I'm sitting here like, like, 

I 

Carly Rose: mean, I'm a retinol girly too, but just stay away from your orbital bone. 

Dr. Brighten: Yeah. 

Carly Rose: So even farther away with retinol. 

Dr. Brighten: Okay. 

Carly Rose: Because it, it does migrate. 

Dr. Brighten: So like above the eyebrows mm-hmm.

Can you hit your crow's feet? 

Carly Rose: Mm, yeah. 

Dr. Brighten: Okay. More towards the temporal mm-hmm. Area. Mm-hmm. So if people on YouTube can see, I'm pointing at the hairline mm-hmm. And then drop to the cheekbones. Mm-hmm. Okay. Mm-hmm. Good to know. I, I also use that circumference with, um, when we're [01:04:00] doing topical estrogen on the face.

Carly Rose: Amazing. 

Dr. Brighten: And I'm like, you can put it a little bit closer to like the crow's feet, but underneath the eyes, I'm like, the cream is. So thick and heavy that you don't, yeah, it's great for vagina. It's not great for your 

Carly Rose: eye. The other mucus membranes. 

Dr. Brighten: Yeah, underneath your eyelids, like we don't want that so much.

So let's shift gears into the gut eye connection. 'cause I think this is gonna be the first time a lot of people have even heard this. 

Carly Rose: Oh, it's huge. It's huge. It's so one of my colleagues and friends now, she's the expert, right? She just put together a series on the gut for optometrists. Mm-hmm.

Specifically because there are so many direct connections that it's almost like, that's one of the first things I ask about is do you have IBS? Yes. Uh, Crohn's, all of these things because. We are what we eat. Right? It it common sense. It is common sense, but we have so many studies that show this now that it's irrefutable.

So I do talk [01:05:00] about things like intermittent fasting and elimination diets, but again, with hormone balance, intermittent fasting is not as studied in women. So I say don't intermittent fast on your cycle or the week before your cycle, but start to look at reductions and spacing, the eating times. 

Dr. Brighten: Mm-hmm.

Carly Rose: Makes a big difference. And then I'm always talking about the inflammatory diet. I mean, fish oil is my go-to, right? Mm-hmm. So how does that work if you're taking it in through your mouth? Well, everything we eat gets to our eyes eventually. 

Dr. Brighten: Are there connections between the enteric nervous system, the nervous system of the gut and the eye?

Carly Rose: Well, uh, the more I research this, the more I realize that vagal tone runs the eye. Mm-hmm. So how can it not be connected to that? Right. Yeah. 

Dr. Brighten: Well, and we talked about, you know, parasympathetic activity, the health of the eye, cortisol. Now we're talking about the gut and the vagus nerve, which is all about that parasympathetic activity.

Are there tips you share with your patients to help with vagal tone, to help them get in that rest and digest? 

Carly Rose: [01:06:00] We have studies that show that things like meditation and yoga are more effective for dry eye disease than orals, than oral prescription medications. 

Dr. Brighten: Nice. 

Carly Rose: And yet, the go-to for most eye doctors is oral doxy.

That's gonna ruin the gut. Mm-hmm. When we know that things like meditation are more effective and then it's gonna help balance the gut. So I do, I start with guided me or visual visualizations I talk about a lot, especially with my end stagers that are. Dark in a dark head space, we have to somehow find the visualization of your eyes healing.

You have to get there. I, and this is where I say I'm a doctor of hope more than anything, because at this point I'm starting to get just nothing but end stagers and knowing that I've seen improvement. So you were asking about the perimenopausal women. There's hope to feel good. Mm-hmm. That's the same with the dry eyes.

There's hope, the body wants to heal, but [01:07:00] a lot of these patients at. 40 to 50% of them high anxiety, depression, and they start to really ruminate and fix their thoughts on these disease states. And so I just start with a three minute silent meditation. Can you give me three minutes a day? It's going to help so much.

Mm-hmm. It's gonna start to reduce the cortisol and reset the vagal tone. Mm-hmm. Three minutes a day. But again, like your red light therapy, how can I fit one more thing in? And I think that's sym sympathetic activation. Mm-hmm. Because we're just running around like crazy people and we don't even realize what off can feel like reconnecting with our bodies is everything.

Dr. Brighten: Yeah. Partnering that with like the blink and then the deep breathing while you blink and I'm like, yes, you. Are doing so much for your hormones. I mean, we're talking about eyes in this episode, but you've done so much for your hormones. Don't 

Carly Rose: even get me started on wide eye stretches that directly activates your vagus nerves.

Dr. Brighten: Say more. What is this? Okay. Uh, lots of people talk about vagus nerve. No one has 

Carly Rose: said, no one. I mean, starting [01:08:00] to reach my FYP. So people are starting to but wide eye stretches and opening that peripheral field. You know how we were talking about how our generation is just really shrinking our field?

Dr. Brighten: Mm-hmm. 

Carly Rose: Stimulating the peripheral field is vagal toning. Mm-hmm. It's one of the most direct things we can do. And so practicing, um, noticing, practicing, noticing your peripheral vision. If you're looking straight ahead, can you see the wall? If you're looking straight ahead, can you see the window? If you're looking straight ahead, can you see the ceiling?

And there's actually something we use for our macular degeneration patients called an amsler grid. So you can just google an Amsler grid and see this cover one eye at a time, and you're gonna focus on the.in the middle and notice the grid around it. It's a noticing. Mm-hmm. It's subtle. But wide eye stretches do the same thing.

You can, um, look in all four cardinal directions diagonally. You start to put that together with things like, um, by hemisphere tapping [01:09:00] or other things. Um, there are optometrists that specialize in NeuroVisual medicine, and they are the experts at this man. They really understand things like how lights are affecting our sympathetic nervous system.

There's something called syntonic, which is light-based therapy for parasympathetic activation that a lot of vision therapy doctors use. It's fascinating when you get into the world of light-based therapies and what the visual processing system is really doing. It's, it's telling our central nervous system how to respond.

Dr. Brighten: Let me ask you about working in front the window with the light. I'm wondering if that does anything additional 

Carly Rose: Well, yeah. And natural light in general and getting outside in general, direct connection to myopia progression. 

Dr. Brighten: Mm-hmm. 

Carly Rose: There, uh, are lots And 

Dr. Brighten: what's myopia progression? 

Carly Rose: Yeah. So there specifically two hours a day of outdoor time is the magic number for kids to prevent myopia or help it from.

Progressing. 

Dr. Brighten: But what is 

Carly Rose: myopia? Myopia is [01:10:00] nearsightedness and usually, and anatomically it means your eyeball is too long on your prescription. It means you have a minus number in front of it. And most people are a myopic a little bit, but progressive myopia is when you just rapidly get worse and worse and worse every year.

Dr. Brighten: Mm-hmm. 

Carly Rose: And there are lots of things we can do for that. Like orthokeratology that we mentioned, the um, Invisalign for your eyes, that helps quite a bit. But a lot of this myopia progression has to do with your peripheral vision, stimulating your peripheral retina specifically. That's what Orthokeratology does and that's what these different myopia control lenses do is stimulate the peripheral retina.

Mm-hmm. But then getting outside specifically not in a city even. You want to be in nature because think about walking through the woods and all of these trees are stimulating your peripheral retina. 

Dr. Brighten: Mm-hmm. 

Carly Rose: You have less central. Detail and you have more peripheral detail. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And it's, and then the, the natural light, it's huge.

Dr. Brighten: So what the urban [01:11:00] planning in the United States has done to our health extends even to the degeneration of our eye health. 

Carly Rose: Very much so. 

Dr. Brighten: That's wild. 

Carly Rose: Mm-hmm. 

Dr. Brighten: But for people who are like, well, crap, I 

Carly Rose: live in a city. There are studies that show that, um, subdivisions shorten your lifespan. 

Dr. Brighten: What, 

Carly Rose: yes. Living? Yes.

Dr. Brighten: This is wild. 

Carly Rose: And like obviously look at all of the downstream consequences of central nervous system dysregulation. 

Dr. Brighten: Yeah. No, I haven't, I haven't seen that study, but I'm wondering because. People who are listening right now being like, great, I live in, I live, live in the same 

Carly Rose: division, 

Dr. Brighten: or I live in an apartment in New York City.

Mm-hmm. Like what do I do to mitigate this? 

Carly Rose: Get to Central Park. Okay. I love Central Park. Get to Central Park plan, outdoor time. 

Dr. Brighten: Okay. 

Carly Rose: It's so important for our health. 

Dr. Brighten: Okay. 

Carly Rose: In, in Ohio, the u uc is University of Cincinnati. They have an OSHA center, which is the Center for Integrative Health, and they do tons of free community forest bathing guided walks with like a therapist [01:12:00] guiding you through the forest.

Slowing down is huge. Walk slower. Mm-hmm. Notice the leaves smell. Smell things because that anterior ethmoid nerve we were just talking about nose breathing. Is responsible for a third of our tear production. 

Dr. Brighten: Interesting. 

Carly Rose: A third. So nose breathing helps Vagal turn. 

Dr. Brighten: Yeah. We had a, um, Dr. Stacy, uh, 

Carly Rose: I love Dr.

Stacy. 

Dr. Brighten: Yeah. Again, it is funny because, uh, I don't know, you two like remind me of each other, like in some way 

Carly Rose: compliment. 

Dr. Brighten: Um, yeah. But I think it's because like you are, you, you're the eyes and she's the mouth and like you're such geniuses in the area. This, the medicine decided to neglect, like anyhow, and she was talking about how mouth breathing is associated with worsening A DHD worsening nervous system dysregulation as you say this, like it's a full circle moment.

Mm-hmm. I think for a lot of the listeners of like, and mouth breathing is also going to be associated with this dry eye condition because again, how it affects the [01:13:00] nervous system. 

Carly Rose: Yeah. We're not stimulating the vagal nerve. 

Dr. Brighten: Mm-hmm. Let me ask you what's happening When someone says, my eyes feel like they're on fire, but their doctor is telling them everything is normal.

Carly Rose: Oh my gosh. I hear that all the time. All, all the time. Usually by the time patients end up in my chair, they've seen multiple providers. 

Dr. Brighten: Mm-hmm. 

Carly Rose: It's usually inflammation in the eye itself, and that's where we contest for it. And that's where most of the time, the red irritated eyes. But what happens is if you are, if you tear film gets so disrupted, then your body starts to produce inflamed tears.

Mm-hmm. And so that's where we have this cycle. And it depends on how big your fire is, is how much we have to do to put it out, but we have to put it out and then regulate. 

Dr. Brighten: And, and how do we put it out? 

Carly Rose: That is where I talk about heat, fish, oil, blank exercise, lid wash, always my go-to. And then we have the, all the pharmaceuticals.

I often will ask a patient scale of one to 10, ten's the worst your eyes [01:14:00] could ever feel. You're, you wanna cut them out? What number are you? You know, five or six. I go pretty traditional. Okay, we're gonna start here. We're gonna do a couple in-office therapies, maybe clean up your lid margin. But if they're at a 10, outta 10, we need to get there faster.

And so I usually throw the kitchen sink on people. And that's where people will tell me often it feels like I have a newborn again, caring for these eyes. Mm-hmm. And they have to do so much. And one more pill. I can't do one more thing, but we just have to do that initial work and then we start pulling things away.

To see how much you can regulate. So it usually looks like multiple pharmaceuticals, multiple in-office procedures and lifestyle diet and stress changes. 

Dr. Brighten: Mm-hmm. 

Carly Rose: But we're talking about these lifestyle changes at every visit because it's progress over perfection. It's not gonna be overnight. If habit changes were easy, we would all be perfect bodies, perfect finances, perfect sleep.

It's not as easy as that. So yeah, [01:15:00] it's a reminder every time you come in. How are blink exercises going? Oh, I forget. Okay. Well I'm reminding you. Or I will use corneal shields when I do ipls and they're like these, um, metal. Barbaric looking corneal shields. And I can almost tell how strong the eyelid muscles are by how well they can hold them in.

They're like little eyelid weights. 

Dr. Brighten: Yeah. 

Carly Rose: And so after a series of treatments, I'll say, oh, your blink exercises are doing great. You can hold these in so much better. There are also different, um, muscle stimulators we can use on the eyelid muscles themselves to try to bulk the strength of the muscle again.

What 

Dr. Brighten: does that look like? Does that look like a tens unit kind of 

Carly Rose: device? It's, it's, it's a lot like a tens unit. Okay. And again, it comes from the aesthetic world because there are different skin procedures you can do to, it's, they say it's like going to the gym for your face. Mm-hmm. And to rebuild the muscle beneath the skin.

So for so long we were worried about just filling, but now maybe we can fill with muscle instead. 

Dr. Brighten: Mm-hmm. 

Carly Rose: You know? 

Dr. Brighten: Yeah. It's 

Carly Rose: very cool. 

Dr. Brighten: Let me ask you, [01:16:00] what is going on with women who have dry eyes? They can't stand without getting dizzy, and their heart seems to race for no reason. 

Carly Rose: That's where things like electrolytes come into play too, right?

Mm-hmm. So the whole body is so balanced. Or unbalanced that our blood pressure may drop. Um, there's a lot of, um, a lot of my dry eye patients have EDS pots and all kinds of dysautonomia mm-hmm. To where it's like, are we changing our systems? Are we being born with these broken systems? 

Dr. Brighten: Mm-hmm. 

Carly Rose: But it, it, it goes back to central nervous system regulation.

Dr. Brighten: Mm-hmm. Last night, Dr. Ana Sierra, and you were talking and she had mentioned about so, so everybody listening, she is in a ologist, specializes in chronic pelvic pain, and she talked about how you can see. Central pain, sensitization in the eyes when you look at someone, it's 

Carly Rose: the exact same thing. Yeah. 

Dr. Brighten: Yeah.

Carly Rose: Yeah. And, and there are all of these theories about like how wide your palpebral fissure is or [01:17:00] how narrow. Right. A wider palpebral fissure is gonna be a more sympathetic dominance. And the pupils dilate when we're in sympathetic versus, I'm sorry, dilate when we're relaxed and contract, when we're in sympathetic.

So pupil tone and that, and one thing that no one realizes is the field, your visual field shrinks. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And so I think that's where I, I don't know, maybe optometrists are really gonna push this forward in calming everyone's system back down. 

Dr. Brighten: Yeah. 

Carly Rose: Identifying them earlier. 

Dr. Brighten: What is the evolutionary strategy of our field Narrowing though, because there is a reason why.

Mm-hmm. We've adapted for that. When we're under stress, 

Carly Rose: the classic right now is screens. And that we are just, 

Dr. Brighten: well, that's not evolutionarily adaptive. That's how we have screwed ourselves with modern 

Carly Rose: society, with this, this one. Right. Well, I guess that's what I'm saying is these last few generations, our eyes are different than they ever were before.

Dr. Brighten: Okay. Okay. 

Carly Rose: Right. It, it's rapid. So [01:18:00] what is going on? But the screens screen time. Um, when I was in school, I was taught that four hours a day is severe. Screen time. Mm-hmm. Well, now everyone's at like 10, 12 hours. It's our life. So we can't even begin to guess the long-term consequence, but I think that's part of it, is that we're just tunneling in.

And we're locking in. 

Dr. Brighten: Yeah. 

Carly Rose: Well, one thing I think that we don't talk about enough is when we're in fight or flight, our systems locked down because we have to escape. We have to survive, and that's great, but just like animals after a fight, they need to shake it out. Mm-hmm. Right. It's almost like somatic therapy, getting that built up energy out of your body.

Yeah. We're not doing, we're not grounding, we're not moving, we're not screaming, you know, we're not getting as much physical touch as we need. The cracking of the fingers. Right. Yeah. We should be doing a lot more daily practices to get this energy out of our body, because we're like batteries. If we store this [01:19:00] energy, it's gonna fry our systems.

Mm-hmm. We don't have, if we're electric bodies, we don't have enough grounding. 

Dr. Brighten: Jump squats are one of my. Biggest prescriptions for people who have anxiety. And I'm like, because what your body's begging you to do is move. Like it doesn't know when the anxiety signal comes on, whether the threat is real, going to eat you.

Like do you need to run away or do you need to fight? So you need to move the big muscles because that's what it was designed to do. So I want 

Carly Rose: to, and then doing that raises testosterone. 

Dr. Brighten: Well, there you go. It's 

Carly Rose: perfect. 

Dr. Brighten: Well, I wanna ask you too about the connection. What is going on there with this connection between dry eyes and these other conditions?

Carly Rose: I think it's loose right now, and studies are gonna keep coming because, you know, we were taught that things like EDS were so rare. Mm-hmm. And now they are seemingly not nearly as rare as we think. 

Dr. Brighten: Yeah. 

Carly Rose: But if we think about the connective tissue as supporting the central nervous system, right. They're intimately connected there.

Dr. Brighten: Mm-hmm. 

Carly Rose: And then all of [01:20:00] the. Everything's hyper mobile. And so for example, there could be a direct connection to your blink. If you have this like floppy collagen, the two lids won't press together, they'll flare out. That's a very direct example. So your oil glands aren't getting the pressure it needs because the connective tissues can't support it.

Dr. Brighten: Mm-hmm. 

Carly Rose: And then, you know, there are connections to, um, cataracts and vision and lots of other things, but there is this direct inflammatory component that mm-hmm. They almost always have a dry eye. Condition. 

Dr. Brighten: And what do we do about the EDS blink problem? 

Carly Rose: That's what's interesting because we don't know be, for example, one of my favorite treatments in dry eye is radio frequency, and it works with the collagen in, it's called, it does collagen.

It produces collagen. And that's how it came from the aesthetic world. But the question is, well, if my patient has faulty [01:21:00] collagen, is this still gonna do the same thing? And we don't totally know because this radio frequency just came onto the eye world a few years ago. 

Dr. Brighten: Yeah. 

Carly Rose: And so we don't totally know, but we know it's working.

Mm-hmm. So something's happening and my. Opinion is that it is probably stimulating the nervous system and making the nerves around the eyes, the nerves, and the oil gland, the nerves and the lacrimal gland healthier because we know radiofrequency, post-surgical and other parts of the body help collagen and nerve healing.

So. That's my extrapolation, but we don't have that direct connection yet. 

Dr. Brighten: EDS often rides along with histamine issues, huge 

Carly Rose: histamine issues. 

Dr. Brighten: Yeah. What do histamine issues do to the eye? And so this is anywhere from MCAS to like histamine intolerance? 

Carly Rose: Well, you can have these histamine reactions in the eye mm-hmm.

As well. I mean, look at allergic shiners. And so they're rubbing their eyes all the time and they are never getting relief. And rubbing your eyes makes it worse because it breaks the mast cells open and [01:22:00] releases even more histamine. And that's where it goes back to diet. Mm-hmm. You have to decrease your high histamine foods.

You have to get in touch with your body and what's helping and healing it. 

Dr. Brighten: I think a lot of people don't realize that when our hormones become. Imbalanced. So whether that is way too much estrogen and too little progesterone happening because of perimenopause, or it's a situation of, you know, perhaps, you know, you're, you're dealing with being on hormonal birth control or other variables that that can lend itself to more histamine problems.

And so we can see people have cyclical flu-like symptoms before their period that points to histamine. I think the other thing people don't understand is that. Endometriosis itself is a condition that actually like starts a whole histamine party like that. Those misbehaving tissues love to dysregulate those mast cells.

And so, you know, as you're saying all of this, I'm like, there's so many conditions that I can identify. Or like if you have read, like you [01:23:00] say, dry eyes, I have to start thinking about like all of these other things that could possibly be lying underneath. Because as much as medicine likes to compartmentalize every single system of the body and every diagnosis goes to the certain person, every single one of these things are connected.

I think it's one of the biggest disservices we've done in women's health. 

Carly Rose: I agree 100%. And how I said, what isn't causing dry eye, right? Yeah. So oftentimes the patients will ask me what caused this? And it's like, well, you had lasik, you wear waterproof mascara, you've had crow's feet, Botox, you, um, your thyroid's off.

You're eating these foods. All of these things you're, you've wore contact lenses for 20 years that destroys your nerves. Like there are so many things that compile on top of it, which is why dry eye disease is such a complicated one. 

Dr. Brighten: What is the healthy way to wear contacts then? 

Carly Rose: I always love a daily disposable.

Dr. Brighten: Mm-hmm. 

Carly Rose: And not a reusable, and then give your eyes breaks. For sure. [01:24:00] I see a world where. We are testing corneal nerves on all routine patients. Mm-hmm. So in my dream world, all contact lens patients are getting corneal nerve testing. There's a variety of ways to do this. It's pretty easy, but like in the modern healthcare system, how can you add one more?

Dr. Brighten: Mm-hmm. 

Carly Rose: Test. You're, we're up against time and resources, but I, I love a world where we are testing corneal nerves and then when, if we start to see a dip in the nerve function, we pull 'em out for a little bit, we support the nerves, and then it's the balance. 

Dr. Brighten: And what does supporting the nerves look like?

So if somebody's like, oh my God, I've been wearing contacts every day for 20 years. Mm-hmm. What can be done 

Carly Rose: supporting the nerves? Looks like there are a few pharmaceuticals. Topical insulin supports the nerves. There's one called Germin. We, you really usually use this if the nerves are basically shot.

It's, it's a powerhouse of a nerve growth factor. I also love biologics. PRP we were talking about a lot. PRPI drops are [01:25:00] fantastic. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And 

Dr. Brighten: how would you do PRP eyedrops? I'm curious. Yeah. I'm like, I'm gonna stop you right there. 'cause that I'm, I just had a PRP injection like two days ago, but I'm like, how are you keeping this plasma around for eyedrops?

Carly Rose: Yeah. No, it's, it's awesome. So there's autologous serum, there's a few different biologic eyedrops you can use. Mm-hmm. Autologous serums, like the OG PRP seems to be superior over the last couple of years. We're starting to see that it is superior. So that's my preference. I again, see a world where we would use PRP instead of an over the counter artificial tear.

Dr. Brighten: Mm-hmm. 

Carly Rose: Plus, I have a sneaking suspicion that this is a. Good way to grow lashes. 

Dr. Brighten: Yeah. 

Carly Rose: I have no hands down immediate. How could it not? 

Dr. Brighten: Yeah, 

Carly Rose: how could it not? Right. So how cool would it be in a world where we're doing maybe an IPLA year and PRPI drops instead of an artificial tear? Then we are supporting the corneal nerves.

We're calming everything. We're healing everything. We're growing lashes. It's my dream world. 

Dr. Brighten: So PRP, take your blood out, spin it down. Mm-hmm. You get the plasma. Is this a one time office [01:26:00] treatment application? 

Carly Rose: It depends on the stage of the. Of the patient. Mm-hmm. And some patients can get by with a couple times a day using it, and some patients are like eight to 10 hours a day.

Okay. If their cornea is falling off, I mean, they're in ICU basically. 

Dr. Brighten: So eight to 10 times a day 

Carly Rose: is they're using these eye drops. Okay. Okay. Mm-hmm. And it's sometimes forever and sometimes limited, depending on how much your body wants to heal. It's goes back to how big is your fire? 

Dr. Brighten: Yeah. 

Carly Rose: What are we up against?

What are we working with? But PRP eyedrops are fantastic. We can, um, there are also doctors looking into placing PRP into these little oil glands. 

Dr. Brighten: Oh. 

Carly Rose: To, um, regenerate. 

Dr. Brighten: I didn't know this episode. I'd be making so many faces. That sounds brilliant. Also, I'm gonna be put under, if I'm gonna have that done, just like put me to sleep, I will not cooperate.

Carly Rose: And then, um, PRP injected into the lacrimal gland. Right. So if you turn the lacrimal gland on to be inflammatory, well, we have to. Try to turn it back off. Yeah. So things like PRP injected straight into the gland. Mm-hmm. And I [01:27:00] know that these pharmaceutical companies are looking at other, um, injectables into these areas.

Dr. Brighten: Yeah. We know with Parkinson's, Alzheimer's disease, that gut dysfunction, the loss of gut motility is an early sign of that. The eyes are extension of the brain right now. Has science made any connection between these 

Carly Rose: words? 100%. 

Dr. Brighten: Okay. Go. 

Carly Rose: In fact, um, 

Dr. Brighten: you're like, I'm gonna like let you finish that question. I got something to say.

Carly Rose: We are now starting to think how I would love to have all contact lens patients have their nerves tested. Mm-hmm. All Parkinson's MS. And dementia patients need their corneal nerves tested. There's a direct link to decreased corneal nerve function with these other neurological conditions. It makes sense intuitively, but clinically no one is, I mean, I don't wanna say no one, that's a generalization.

It is not standard to test corneal nerve sensitivity on these patients, and I think we're doing them a disservice. 

Dr. Brighten: Mm-hmm. So. In testing this, are we doing this preventatively to have early [01:28:00] interventions? Are we testing it to track disease progression or both? 

Carly Rose: Kind of Neither. So about five years ago you're like 

Dr. Brighten: all wrong.

Carly Rose: About five or so years ago, I was treating all of these dry eye patients and their corneal epithelium just looked terrible. 

Dr. Brighten: Mm-hmm. 

Carly Rose: And I'm like, why? What is going on? Their oil glands are beautiful, their salt is regulated, they're on these anti-inflammatories. Why can't I keep their cornea? It's like a rash, like a scratch on their corneas all the time.

And I'm like, why are these corneas so unhealthy? And it's corneal nerve health. Mm-hmm. So I called a colleague who was, at the time, there were very few of us doing this. And I said, are you testing the corneal nerves on all of your dry eye patients? And he said, uh, just dry eye, just the end stagers. And he said, no, but I think I should be.

So I started routinely checking on the dry eye patients. That's it. Um, because it gives so much insight into the longevity of the treatment. Mm-hmm. [01:29:00] If your corneal nerves are affected, I mean, add months to it and many more. Um, we have something called ProKera amniotic membranes. They're membranes made out of amniotic tissue that we place on the eye.

The biologics, like PRP and autologous serum, the crummins, the topical insulin. So those are all just really mainly nerve health. So we get the dry eye under control. Now we have to heal the nerves. Then the whole system's functioning. Mm-hmm. I. Dare I say, no one's testing corneal nerves on healthy people.

Dr. Brighten: Yeah. I just wonder because you know, it's also something, so I was taught in medical school to always listen to bowel sounds and if the lower left quadrant had diminished or loss of bowel sounds, neurology workup, like we need to figure out what's going on. 

Carly Rose: Oh, I just got cold too. 

Dr. Brighten: How would we not be testing corneal nerves?

All health insurance should be covering this. It shouldn't be an add-on to keep your eyes, because your eye health is going to affect the rest of your health 

Carly Rose: and the rest of your life. [01:30:00] Right. Your whole life. Um, a machine, a device did just come out about a year or so ago is, do you know the airp puff test that everybody hates 

Dr. Brighten: so much, but yes, I know it.

Carly Rose: That's called an NCTA non-contact tonometer. So it checks your eye pressure without touching you. Something just came out that's a non-contact anter, which is a way to test corneal nerve function. Mm-hmm. Without touching. So I. Dreamworld, all eyecare offices have a non-contact anter and it's just baseline.

We should be getting like blood. It should be like blood pressure because I do think it's gonna be a predictive, I think this is where AI can help us out a lot. Mm-hmm. And how do we get them to come back on instead of, are they optimally functioning at this age for this patient? If not, why is there a neurological condition?

Mm-hmm. Is there diabetes that we don't know about? Is there this is there that is there central nervous system dysregulation? I think it could be a predictor of Yeah, that as well. 

Dr. Brighten: Do you ever use [01:31:00] N-Acetylcysteine in 

Carly Rose: Yes. All the time. Yeah. And that's another one that's not used nearly as often because it's also an antioxidant.

Well, no wonder it works so well. I love Mu it's Muco Mist as the brand name, but we get it compounded for the eyes mm-hmm. In specifically these patients that I start to see what I was referring to as this vitamin A deficiency look. Mm-hmm. Um, it's the goblet cells. The goblet cells are like the redheaded stepchild of the dry eye world.

And no one really knows a ton about them when we don't talk about them a lot, but they're this mucus producing, uh, cell and compounded muco mist supports them significantly. 

Dr. Brighten: Mm-hmm. I take oral NAC, there's like. Thousands of reasons, in my opinion, to take NAC. What does this vitamin a deficiency picture look like?

Because you mentioned it, but I'm not sure it's clear for people who are listening. 

Carly Rose: So we use fluorescein the most, but there's a dye called Lissamine green that I love and it stains dead and revitalized cells in the conjunctiva. So Lissamine green is [01:32:00] usually better for the cornea. I'm sorry. Fluorescein is usually better for the cornea, and that's what we use all the time.

But Lissamine green is for, for most areas, but also the conjunctiva, which is where the goblet cells exist. 

Dr. Brighten: Mm-hmm. 

Carly Rose: But lissamine green, if it, if your eye is staining green left to right, there's usually something else going on. Mm-hmm. Like chemotherapy, what I was taught in school, chemotherapy, vitamin A deficiency from alcoholism or an eating disorder.

Dr. Brighten: Mm-hmm. 

Carly Rose: But now what we're starting to see is, um. People who don't have disordered eating, but still nutrient deficient because they're either not absorbing or they're not eating the right foods, then they're starting to get this same appearance. 

Dr. Brighten: What do you think the standard American diet's doing to people?

Oh my gosh. 

Carly Rose: Destroying it. I know. Honestly, it's crazy. It's too, it's, it's too processed and it's too much. 

Dr. Brighten: Mm-hmm. Well, and as you talked about, like the glucose dysregulation and the high glucose [01:33:00] levels affecting the eye, I think that's something people need to be aware of, is that ultra processed food is gonna hit you with a double whammy.

So it's gonna be major glucose swings. Then we've got the problem of omega sixes and we already have a problem in our society of an imbalance of Omega-3 to omega sixes. That's not that omega sixes are bad, but it's just so much easier to get omega six. You 

Carly Rose: know, our ratio is like 50 to one and it should be like three to one.

Dr. Brighten: Yeah. 

Carly Rose: Yes, I know. So when I recommend omegas to patients, I, I tell them this and I say, you can decrease sixes and increase threes. We have to get that ratio back in balance. 

Dr. Brighten: If you could challenge the listeners to do one of those four things starting today, which would it be? 

Carly Rose: I'll go lid hygiene. 

Dr. Brighten: So cleansing it.

Mm-hmm. Making sure that your lids are clean every night. Yes. 

Carly Rose: Yes. 

Dr. Brighten: And what word of caution would you give to the girlies who are just too tired at the end of the night to take their makeup off? 

Carly Rose: You know, I tell people, this is another thing with contact [01:34:00] lenses, they'll be too tired to take them out and I switch them to daily disposables and I say, take them out when you go to bed, put and put 'em.

It's disgusting, but put them on your bedside table instead of sleeping in them. 

Dr. Brighten: Mm-hmm. 

Carly Rose: Keep a good makeup removing wipe on your bedside table. 

Dr. Brighten: Okay. 

Carly Rose: The basics. Right. And this is always progress over perfection. What is something, what's a step in the right direction. 

Dr. Brighten: Mm-hmm. Are there any wipes in particular that are, that are eye doctor approved?

Carly Rose: You know, I like, uh, the, my Cellar Water based. 

Dr. Brighten: Mm-hmm. 

Carly Rose: Those seem to work well, not heavy fragrance. Things like that. The bird's bees are usually great. There are a lot of decent ones. 

Dr. Brighten: Mm-hmm. Yeah. And I actually just use cotton pad in my cell water and yes, 

Carly Rose: that's the best. 

Dr. Brighten: Just wipe it off and call it a day.

Mm-hmm. But yeah, no, I do the double cleanse as well. And for anyone listening who feels like that's extra work, it actually makes it so much easier. Uh, and 

Carly Rose: it feels good. 

Dr. Brighten: My, so when I started recommending that to women, like, you know, years ago my perimenopause patients were like, oh my God, my face is not [01:35:00] completely dried out.

Yes. Like it's hydrating at the same time as it's removing the impurities. It's actually quite lovely. And once you do it, there's no going back. 

Carly Rose: I agree. And I've tried to make for myself, because remember I am a dry eye patient and I'm a single mother and a busy practitioner. So like I fully get it. I fully get the capacity piece.

Dr. Brighten: Should people be doing lymphatic drainage on their face for their eye health? 

Carly Rose: I wouldn't necessarily say eye health, but a question I get a lot from patients is what to do about these hooded eyes. Mm-hmm. Start with lymphatic drainage. You may not need a bluff, you may need gua. Mm-hmm. 

Dr. Brighten: And what about the puffiness that develops into the eye?

Can that also help or do the 

Carly Rose: tips? Absolutely. Absolutely. Um, so I also, I like there are these little tiny cold stainless steel rollers. Mm-hmm. Made by wheel of eyes. The same company that I like their lid wash, keep 'em in the freezer and then go. Into out the cold, the pressure, and then the lymph drainage.

Dr. Brighten: Mm-hmm. [01:36:00] 

Carly Rose: Works wonders. 

Dr. Brighten: Amazing. Mm-hmm. Well, thank you so much for taking the time. 

Carly Rose: Thank you for having me. This was amazing. 

Dr. Brighten: Yeah. This was a great conversation. I think it's, it's gonna be very eye-opening 

Carly Rose: for a lot of people. 

Dr. Brighten: Well, thank you so much. 

Carly Rose: Thank you. 

Dr. Brighten: Thank you so much for joining the conversation.

 

If you could like, subscribe or leave a review, it helps me so much in getting this information out to everyone who needs it. If you enjoyed this conversation, then I definitely want you to check out this.