Acid Reflux & Eyes (GERD & LPR): Pain & Burning Sensations

Can acid reflux affect the eyes? Yes. It is most common with extra-esophageal (i.e. supra-esophageal) variants such as laryngopharyngeal reflux (LPR) or nasopharyngeal reflux (NPR).

In some cases, severe GERD may cause eye-related symptoms as well.

That said, GERD will not typically cause eye symptoms of the same severity and/or frequency as LPR/NPR.

Disclaimer: You should NOT automatically assume that your eye-related symptoms are a result of a reflux condition. Consult an ophthalmologist for evaluation to ensure that nothing more serious is affecting your eyes.

How acid reflux affects the eyes

Put simply, one or both of the esophageal sphincters (UES & LES) end up damaged and/or dysfunctional (for various reasons).

A person might also have biomechanical confounds such as hiatal hernia (causing food to get trapped and increasing odds of reflux).

In any regard, material from the stomach “refluxes” or backflows into the upper esophagus, including (but not limited to):

  • Acid: Hydrochloric acid.
  • Pepsinogens: Most refluxers are familiar with “pepsin” but there are many types of pepsinogens.
  • Gastrin: Such as G-34, G-17, G-71, G-6.
  • Bile salts: Conjugated and unconjugated.
  • Trypsin: An enzyme that facilitates digestion.
  • Other materials: Other stomach contents (e.g. digestive enzymes), food particulates, bacteria (e.g. H. Pylori), etc.

In some cases, these materials may reach the backs of the eyes – leading an individual to experience ocular symptoms.

Related: Acid Reflux & Ears (Pain & Burning)

Signs & Symptoms of Eye Reflux

Included below are some signs and symptoms of eye-related reflux.

As always, do NOT assume that these symptoms are from reflux until other conditions have been ruled out.

Blurred vision: Some people may experience bouts of blurred vision.

Burning sensation behind eyes: Many people report that they feel a burning sensation behind the eyes. This is typically mild – but not usually severe.

Conjunctivitis: Inflammation of the transparent membrane that lines the eyelid/eyeball.

Dry eyes: Your eyes may feel drier than usual.

Eye pain: Severe cases of ocular reflux may cause eye pain.

Foreign body sensation: Feels like a foreign object is scratching the eye – typically originating from the cornea.

Gritty in eyes: Feeling as though there’s material like sand in your eyes.

Itchy eyes: In some cases, people have complained that their eyes become itchy.

Squeaking noises from eyes (when blinking): This is due to blockages in the lacrimal ducts as a result of dryness and/or inflammation.

Stinging behind eyes: Some people may describe their symptoms as “eye stinging.”

Uveitis: Inflammation of the middle layer of tissue in the eye wall.

Watery eyes: Some people may react to ocular reflux with bouts of watery eyes (essentially the refluxate is irritating the backs of eyes and causes them to water).

Note: Many of these symptoms are misattributed to other conditions such as allergies, dehydration, low humidity, etc.

Research of Eye Manifestations of Reflux

Involvement of LPR in Ocular Diseases: A State-of-the-Art Review (R)

  • Authors: Mayo-Yanez et al. (2021)
  • Methods: A systematic approach (based on preferred reporting items for a systematic review & meta-analysis checklist with a modified population, intervention, comparison, and outcome framework) was utilized to structure a review process of studies that examined the association (with clear diagnostic methods) between LPR & ocular diseases.
  • Results: 7 studies met inclusion criteria in which the primary acquired nasolacrimal duct obstruction and ocular surface disease (OSD) were evaluated.
    • Local increase in eye pepsin concentration (above 2.5 ng/mL) may affect the ocular surface via proteolytic & inflammatory actions.
    • Pylori could also reach the nasolacrimal duct causing mucosal injury and inflammation.
    • Reflux severity correlates directly with the Ocular Surface Disease Index (OSDI).

What are the takeaways from this study?

The severity of LPR seems to correlate well with scores on the Ocular Surface Disease Index (OSDI).

The role of LPR in the pathogenesis of ocular disorders has NOT yet been demonstrated and data are limited and heterogeneous.

Researchers suggest that, in theory, substances like pepsin or bacteria like H. Pylori could reach the lachrymal duct area through hypopharyngeal-nasal gaseous reflux events – causing chronic inflammation and disease onset.

Future research utilizing objective testing for diagnosis and pepsin detection into the tear and nasal mucosa are needed in order to explore this potential relationship.

(I would add that it may be worth testing for other compounds besides pepsin that have potential to cause inflammation as well.)

Association of Dry Eye with LPR in Clinical Practice (R)

  • Authors: Bonini et al. (2021)
  • Aim: Determine prevalence and relevance of suspected LPR in patients with Dry Eye Disease (DED) vs. patients with refractive problems (RP) without DED.
  • Methods: Retrospective study with 245 patients. 152 DED patients compared with 93 sex-matched and age-matched controls.
  • Results: Pathological RSI score (13+) was detected in 80 patients (32.6%): 68 with DED (68%) vs. 12 in the control group (15%). In the control group, pathological RSI was associated with higher SANDE; OSDI; and Schirmer scores – and in the DED patients, pathological RSI was associated with higher OSDI scores.

What were the takeaways from this study?

DED patients are 8-fold higher risk for having pathological RSI scores (indicative of LPR) relative to non-DED patients.

Pathological RSI was associated with more severe ocular symptoms in both DED & non-DED patients – suggesting that LPR symptoms correlate well with both dry eye and severities of all eye problems.

That said, this study was limited by its retrospective design and lack of testing for

Evidence of Pepsin-Related Ocular Surface Damage & Dry Eye (PROD Syndrome) in Patients with LPR (R)

  • Authors: Plateroti et al. (2020)
  • Aim: Examine whether LPR patients show ocular surface changes and determine the relationship between lacrimal pepsin & ocular alterations.
  • Methods: 50 patients with LPR (positive endoscopic signs & adequate RSI/RSF scores) were compared to 20 healthy patients with no reflux disease and dry eye (control group). Tear pepsin levels were measured via Pep-Test kits.
  • Results: LPR patients exhibited ocular surface changes including: epithelial damage (48%) & impaired lacrimal function (72%). 32 of 50 LPR patients (64%) had pepsin detected in tears (average levels ~67.5 ng/mL) versus zero in control subjects. LPR patients complained of: itching (38%); redness (56%); or foreign body sensation (40%).

What are the takeaways from this study?

LPR disease severity is significantly correlated with: (1) tear pepsin content & (2) ocular surface changes & (3) severity of ocular symptoms (conjunctival hyperemia; Oxford score; reduced tear film stability).

Evidence indicates that local increases in pepsin may affect ocular surface structures and functionality through proteolytic and/or inflammatory actions.

Tear instability and pH changes might also contribute to ocular manifestations of LPR.

These manifestations are dubbed PROD (pepsin-related ocular damage) syndrome.

Researchers recommend consideration of ophthalmological evaluation in order to improve the management of patients with LPR.

Eye Reflux: An Ocular Extraesophageal Manifestation of Gastric Reflux (R)

  • Authors: Mazzacane et al. (2018)
  • Aim: Determine occurrence of laryngopharyngeal reflux (LPR) among patients with ocular surface disease (OSD).
  • Methods: Evaluate 290 patients (~60 years of age) with confirmed OSD at ophthalmologists offices and assess Ocular Surface Disease Index (OSDI) and Reflux Symptom Index (RSI).
  • Results: 101 of 290 patients (34%) had pathological RSI (above 13) and suspected LPR.

What are the takeaways from this study?

There was a moderate correlation between total OSDI score and RSI.

Pain, poor vision, and problems using a computer or watching TV were almost 5-fold more frequent in RSI positive patients (LPR suspected) than RSI negative patients (LPR not suspected).

Researchers noted that there is evidence LPR can cause inflammation in the larynx, pharynx, paranasal sinus, and middle ear – and that pepsin can cause otitis media (middle ear infection).

The presence of pepsin in tears has been documented – and pepsin can move through lacrimal film passing through the nasal cavity, the inferior meatus, and nasolacrimal duct.

The outcome of this study suggests that LPR can likely affect the eyes – mainly the anterior segment area and general function.

Researchers also mentioned that older age is strongly correlated with LPR – and the average age of participants in this study was ~60.

This study has some notable limitations: (1) cross-sectional design; (2) lack of functional & macroscopic investigation of the upper GI/respiratory tract; (3) lack of tear composition analysis (e.g. pepsin test); (4) lack of follow up; (5) sample age; (6) unconfirmed LPR (not formally diagnosed).

Obviously it would’ve been better to have these patients undergo analysis from an ENT or gastroenterologist (GI) to confirm a high suspicion of LPR via other modalities (e.g. flexible laryngoscopy, endoscopy, impedance testing, etc.).

Moreover, it would be interesting to determine whether treatment for LPR would’ve improved ocular-related symptoms in the subgroup of patients with high RSI scores (LPR likely).

Investigation of Pepsin in Tears of Children with LPR (R)

  • Authors: Iannella et al. (2015)
  • Aim: Determine whether gastric acid or stomach secretions (e.g. pepsin) – which have inflammatory potential – are present in tears.
  • Methods: Evaluate the composition of tears from 20 patients suffering from LPR (confirmed by 24-hour multi-channel intraluminal impedance (MII)-pH monitoring) + 20 patients in a control group (non-LPR controls).
  • Results: 4 of 20 (20%) children with LPR had pepsin present in tears – whereas control group (non-LPR patients) had zero pepsin present in tears. There were no differences in the total number of reflux episodes and number or weakly basic reflux in pepsin positive vs. pepsin negative children.

What were the takeaways from this study?

20% of children with LPR in this study exhibited pepsin levels above 2.5 ng/mL in tears.

The level of pepsin in the 4 “positive” children with LPR was relatively low (~4.2 ng/mL) and likely insufficient for inducing inflammatory activity in the nasolacrimal duct and precorneal conjunctival cavity.

Researchers admit that they cannot exclude possible endogen pepsin production or its coming from plasma (such that it would end up in the tears).

That said, local production or plasma migration would make it difficult for the pepsin level to reach 4.2 ng/mL (on average) – making it more likely that the pepsin refluxes up and reaches the eyes.

Interestingly, there was zero correlation between pepsin in tears and: (A) total number of reflux episodes and (B) types of reflux episodes. Pepsin-positive patients actually had a lower average number of acid reflux versus the pepsin negative group (27.5 vs. 62).

Researchers speculate that pepsin could cause chronic inflammation in the nasopharynx, nasolacrimal ducts, and may contribute to chronic sinusitis, dacryostenosis, or otitis media with effusion (OME).

This study is limited by the age-specific (young) and small number of participants. It’s possible that results would differ with a larger sample and/or among adults with LPR (due to anatomical and biological changes with aging).

Note: There are other studies/papers that have discussed or investigated the potential relationship between reflux and eye (i.e. ocular) symptoms. These papers are discussed in the “state-of-the-art” review presented by Bonini et al. (2021).

How to Manage & Treat Eye Reflux

Realize that most medical doctors are not familiar with ocular manifestations of acid reflux – and will often misattribute eye-related symptoms to other (suspected) medical conditions.

Targeting the eyes

These are temporary things you can do until your reflux is under control.

Consult a medical doctor to confirm safety of these interventions before implementation.

  • Eye drops: Talk to an ophthalmologist about safe eye drops to help keep your eyes as moist as possible. Reflux may dry out the eyes and/or coat them with “refluxate.” In some cases it may be best to use eye drops with an alkaline pH – whereas in other cases the pH won’t matter (this is individual-specific).
  • Alkaline water + baking soda: Mark Noar (MD) recommends mixing purified alkaline water and baking soda into both a glass and spray bottle. The glass should be used for gargling (throat area) and the spray bottle can be squirted up into the nostrils and throat while inhaling. (This will not work for every case – but will likely help those affected by acid).
  • Saline spray: Arm & Hammer purified saline nasal spray with sodium bicarbonate may help (sprayed up into the nose and/or throat after meals).
  • Humidification: Ensure that your living environment is adequately humidified (30-50%).
  • Optimize temperature: If the temperature is too cold or hot – this may exacerbate symptoms.
  • Air purification: Some people may benefit additionally from an indoor air purifier to get extra dust/debris out of the air.
  • Cleaning: Ensure that your living environment is clean and devoid of significant dander/dust (as these may better explain your symptoms).

Targeting the reflux condition

If ocular symptoms are resulting from reflux – you need to aggressively treat the reflux before these will improve.

This may involve a combination of the following:

  • Proton-Pump Inhibitors (PPIs): Twice daily before breakfast & dinner.
  • H2 antagonists: If you don’t use PPIs. (Can sometimes be combined with PPIs.)
  • Alginates: After every meal (something like Gaviscon Advance Aniseed).
  • Fat loss: May improve esophageal sphincter function. (Read: Weight loss & acid reflux).
  • Low calorie, low acid diet: This will help with fat loss and should decrease acid exposure.
  • Elevating the head of your bed: 6+ inches with bed risers.
  • No food 4-5 hours before bed: For obvious reasons.
  • Loose fitting clothing: To avoid increasing intra-abdominal pressure.
  • Sleep on left side only: Avoid sleeping on the right side and stomach.
  • Zero nicotine, caffeine, carbonation, alcohol: All of these increase reflux events.
  • Surgery: If nothing else works and you’ve tried “everything” with near perfect execution for ~6-12 months – then surgery is necessary.

Gastroftal (oral formula & eye drops)

A medical product called gastroftal may help indivdiuals with reflux and ocular manifestations.

This product contains one component that targets reflux conditions and another that improves eye status.

A New Therapeutic Approach for the Dry Eye Syndrome (DES) in Patients with LPR (R)

  • Authors: Balestrazzi et al. (2020)
  • Aim: Compare the effectiveness of (A) hyaluronic acid (0.2%) eye drops (Atlantis) to (B) combination therapy: eye drops (hyaluronic acid, magnesium alginate, & Camellia sinensis extract) & oral therapy (Gastroftal tablets: containing magnesium alginate & simethicone).
  • Subjects: 21 patients (18-80 years old) who met diagnostic criteria for Ocular Surface Disease (OSDI above 13) & LPR (RSI score above 13)
  • Methods: Examine patients at baseline; divide patients into 2 groups (10 in Group A and 11 in Group B); re-examine patients post-treatment. Tests included: OSDI; RSI; RFS; T-BUT; Schirmer.
  • Results: Both treatments were well-tolerated with no adverse events recorded during the study. Gastroftal combined treatment significantly improved OSDI; RSI; RFS; and T-BUT – and was superior to hyaluronic acid eye drops in OSDI, RSI, and RFS.

What are the takeaways from this study?

Using a combination of Gastroftal eye drops (hyaluronic acid, magnesium alginate, & Camellia sinensis) PLUS oral Gastroftal (magnesium alginate & simethicone) seemed to provide significant therapeutic benefit among patients with LPR & Dry Eye Syndrome – and was safe.

Rationale for ingredients in the Gastroftal eye drop formula…

  • Hyaluronic acid: Modulates inflammatory response, cellular proliferation, and remodeling of extracellular matrix.
  • Magnesium alginate: Topically applied scavenges substances like pepsin and inhibits proteolytic activity.
  • Camellia sinensis: Has potent antioxidant and anti-inflammatory effects.

Rationale for ingredients in Gastroftal oral formula…

  • Magnesium alginate: Precipitates as a gel after exposure to gastric acid and forms a raft or barrier to the reflux of gastric content in the esophagus.
  • Simethicone: An anti-foam agent able to reduce the severity of symptoms caused by excessive gas overload in the stomach.

Nevertheless, there are significant limitations here, including: (1) unfair comparison (a basic eye drop compared to a combination eye drop PLUS oral formula); (2) unclear as to whether all ingredients are needed (perhaps just the oral formula was needed to treat LPR); (3) small sample size; (4) confounds; (5) cross-sectional design; (6) lack of functional/macroscopic investigation; (7) no tear analysis (e.g. for pepsin); (8) no follow up.

In sum, patients with “dry eye” due to LPR may benefit from Gastroftal supplements (eye drops & oral formulation).

How to know whether you have eye reflux… (Questions)

The way to determine whether you are legitimately experiencing eye reflux is to first rule out other medical conditions that may be causing these symptoms (e.g. allergies) and observe whether the times you experience eye burning/stinging are in sync with your other reflux symptoms.

  1. Have you been formally diagnosed with acid reflux?
  2. Do you have an extra-esophageal variant (e.g. LPR/NPR)?
  3. Do you experience burning in your upper throat, sinuses, and ears?
  4. Do your eyes sting, burn, or water after eating?
  5. Are the eye symptoms in sync with your reflux?
  6. Is pepsin present in your tears? (Could test for this)
  7. Has an ophthalmologist ruled out other ocular conditions?

If you answered “YES” to many of the above questions – there’s a good chance that you are dealing with reflux-induced ocular symptoms.

For example, if your eyes tend to burn/sting within 1-2 hours after every meal – and the burning eventually fades until your next meal, you probably have eye reflux.

If your eye-related symptoms correlate extremely well with your reflux episodes such that they intensify when reflux is bad – and completely subside when your reflux is well-controlled, then you can likely be confident that reflux is affecting your eyes.

Note: It is important to mention that a person might have a preexisting eye condition AND experience ocular symptoms from reflux – and there might be some overlap or difficulty distinguishing which condition is causing the symptoms.

Can acid reflux damage the eyes?

It’s unclear as to whether acid reflux can legitimately damage the eyes such as to permanently alter vision or cause eye disease.

Gastric acids, bile salts (conjugated/unconjugated), pepsinogens, trypsin, and other materials or bacteria (e.g. H. Pylori) may end up frequently “refluxed” into ocular structures, thereby facilitating:

  • Inflammation
  • Proteolytic effects
  • Mucosal injury
  • Altered pH
  • Tear instability

One or more of these effects (e.g. a combination) could result in damage. If the reflux becomes severe and is long-lasting without being properly managed – the damage could become significant and/or irreversible.

If the reflux is properly treated in an effective manner – it’s possible that ocular structures may fully recover.

Note: Damage may be contingent upon the magnitude of reflux, number of reflux episodes, chronicity of reflux (e.g. long-term vs. short-term), preexisting eye health, age, and specific type of reflux (acid vs. mixed vs. non-acid).

What should you do if you are worried about eye damage from reflux?

Treat your reflux aggressively and properly under the care of: a gastroenterologist (GI doctor); ENT (otolaryngologist); and/or an allergist/immunologist.

If reflux is unresponsive to conventional therapies – schedule a surgery (e.g. Nissen fundoplication; LINX; Stretta).

Monitor eye health and function under the care of an ophthalmologist.

Ophthalmologists will likely be able to recommend various safe treatments and/or prophylactic measures to prevent pepsin-related eye damage.

My personal experience with eye reflux symptoms

I have LPR (laryngopharyngeal reflux) and it affects my upper throat, sinuses, ears/eustachian tubes, and my eyes.

In fact, my eye-related symptoms were one of the very first symptoms I experienced besides “globus sensation” in my throat.

I suspect that my case of reflux either: (1) has an easier time reaching my eyes (than sinuses/ears) OR (2) the eyes are more reactive to smaller amounts of reflux than other areas (sinuses, ears, etc.) – although both 1 & 2 could co-exist.

The best way I’d describe my ocular symptoms resulting from reflux is as follows: like an extremely mild burning sensation behind the eyes… almost akin to a mild allergy but without the eye watering.  For me it’s more of a burning plus dryness.

I’ve noticed that the eye burning tends to be worse in the morning than the evening – but this may be related to the specifics of my particular reflux.

Increasing humidity and moisture does seem to help a bit.

I’ve also noticed that when waking up in the mornings, my eyes sometimes make “squeaking noises” due to air escaping that was trapped in the lacrimal ducts.

Massaging the outsides of the eyes and tear ducts seems to help with this.

Have you experienced eye problems as a result of reflux?

Feel free to share your experience with eye-related manifestations of reflux.  Evaluate whether you’ve ruled out other medical conditions that may be causing your eye problems.

Have you figured out any solutions that seem to help with eye-related symptoms of reflux? (Note any solutions in the comments section below).

If you were ever able to get your reflux under control – did the eye symptoms improve in sync with the reflux?

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