Published in Ocular Surface

Ümay: At-Home Compliance with Parasympathetic Activation & Intentional REST

This post is sponsored by Umay
12 min read

In this session from Eyes on Dry Eye 2023, learn how the Ümay REST® device supports the benefits of parasympathetic activation for patients with dry eye disease (DED) and enhances at-home compliance.

Are your patients struggling with eye strain?

Ümay REST uses patented technology to deliver a Thermal Meditation experience using precisely engineered cooling or warming at the touch of a button for relief from eye strain and a busy mind.
Benefits of daily use include:
  • Better Blinks. Designed to help produce and protect tears while improving eye comfort from digital eye strain. Gentle heat waves soothe and protect tired eyes, while cooling sensations restore natural tears.
  • Better Sleep. Designed to trigger sleep signals through calm thermal waves, REST helps individuals fall asleep faster and for up to an hour longer.

Proof in the results

At the beginning of 2022, Umay completed a six-week market study of 500 office workers across Canada who were given unlimited access to REST.1 Digital strain and its range of symptoms were assessed by administering five well-validated questionnaires at the beginning and end of the study:
  • Eye comfort: Ocular Surface Disease Index (OSDI), Computer Vision Symptom Scale Questionnaire (CVSS-17), and Contact Lens Dry Eye Questionnaire-8 (CLDEQ-8)
  • Sleep quality and patterns: Pittsburgh Sleep Quality Index (PSQI)
  • Wellbeing and response to stress: State-Trait Anxiety Inventory (STAI)1
Study findings revealed that using REST for six weeks produced statistically significant benefits for:
  • Sleep quality
  • Response to stress
  • Digital eye strain1
Participants reported falling asleep faster and staying asleep longer with better quality sleep. While 85 percent felt eye comfort had improved and 44 percent of participants reported a 10+ point improvement on the OSDI score.1
REST in the Workplace: An Intervention Case Study
REST in the Workplace: An Intervention Case Study1

How does parasympathetic activation play a role in dry eye management?

When asked why parasympathetic activation is important in dry eye management and how it can be integrated into the treatment approach, Mila Ioussifova, OD, FAAO noted that the lacrimal gland is primarily innervated by the parasympathetic nervous system.
“We have pharmaceuticals and some external neurostimulators that address that, but that's done at the local level,” she explained. “For patients with neuropathic pain in which the central nervous system may be involved, those may not be enough.”
Plus, she said the stressors of modern life “really leave us in more of a sympathetic tone, which down-regulates the parasympathetic nervous system.”
Noting that overall, the parasympathetic nervous system supports resting and digesting, Dr. Ioussifova said it also supports secreting.
“So, our lacrimal gland secretes when the parasympathetic nervous system is activated,” she explained. “Some of the ways you can activate the parasympathetic nervous system is through the use of yoga, meditation, and mindfulness practices.”
But Dr. Ioussifova said the most important activator is sleep.
“When we sleep, our parasympathetic nervous system is on,” she said. “So that's where the importance of sleep comes in. That's why we ask our patients about their sleep habits when we're taking their case histories. Because if they are only sleeping a couple of hours a day, their parasympathetic nervous system isn’t functioning correctly, and when that happens, the lacrimal glands aren’t either.”
Based on that correlation, she said a device like REST helps to open the dialogue with patients about the importance of incorporating certain practices to help them relax, unwind, take breaks from their screens throughout the day, and have “that good habit at night, as well.”
When asked what she sees possibly evolving in home management as a result of the upcoming TFOS Lifestyle Workshop, Dr. Ioussifova said she’s hoping it will shift the approach to treating patients with dry eye disease by incorporating at-home treatments so patients can benefit more from treatments performed in the office.
“I think this is going to shift the way we prescribe these mental breaks to activate the parasympathetic nervous system,” she said. “And help us take sleep seriously enough to prescribe it to our patients.”

How REST supports in-home compliance with dry eye protocols

Noting that she uses REST personally, Dr. Ioussifova said that in her practice, she appreciates how compliance is increased with patient use at home.
“We perform a lot of advanced in-office treatments, but what's been lacking is the patient compliance with home treatments that could help optimize what we’re doing in the office,” she explained. “Even if we do a lot of fancy treatments, if the compliance is not there, treatment efficacy and duration may be limited.”
Saying that REST is “not just a heating device,” Dr. Ioussifova emphasized that it “actually activates the parasympathetic nervous system,” which is what she finds most exciting about the technology.
When asked to describe his experience and research regarding the importance of the blink beyond implications for the ocular surface, Dr. Gradisar referred to blinking as “quite fascinating, especially when it comes to alertness and sleepiness.”
“For example, some of the research indicates that when people are sleep deprived, there’s a change in the blink rate,” he explained, noting that the impact on blink duration can be “quite significant.”
He added that he’s been interested in the relationship between sleep and alertness, methods for measuring attention and concentration, and the impact on performance.
“And that relates in some ways to alertness and attention,” Dr. Gradisar said. “For many, when they’re engaged in some sort of task—such as digital devices—the blink rate will decrease. But when they do blink, there's almost a pause in their attention. So, in addition to moistening the eyes, blinking seems to be linked to some sort of attentional brain relaxation or pause in the background that allows our brains to have a moment to breathe.”

Can dry eye disease impact mental health?

Regarding the connection between DED and mental health, Dr. Ioussifova said the relationship between screen time, blink quality, the ocular surface, and dry eye are well established.
“We know that screen use is one of the contributing factors to dry eye, which is now the number one reason patients see their doctors,” she explained. “But screen time also impacts our mental health and sleep habits. Research indicates a link between mental health issues—such as anxiety and depression—and dry eye. In fact, a 2022 study indicated that among patients with dry eye disease, up to 30 percent also had anxiety and depression.”
Dr. Ioussifova said when patients experience depression and anxiety, an overactivation of the sympathetic nervous system takes place, aka, the “fight or flight” response.
“There are also increased cortisol levels and inflammatory markers, which can influence the way we process pain,” she added. “That’s why patients who have neuropathic pain are also some of our most challenging dry eye patients to treat. Traditional in-office treatments or pharmaceuticals may not be beneficial to these patients because those other issues are not being addressed. So, we may be missing the target if we're not addressing mental health and sleep habits when treating our patients with dry eye disease.”

How does thermoregulation impact sleep quality?

Noting that treatments for dry eye and meibomian gland dysfunction (MGD) are often based on heat, Dr. Dierker asked Dr. Gradisar about his work related to thermoregulation and how it impacts patients’ sleep quality and routines.
Dr. Gradisar said thermoregulation, sleep, insomnia, and circadian rhythms were part of his PhD research in the early 2000s, and he was “fascinated by the minute-to-minute changes occurring related to thermoregulation when a person is trying to fall asleep.”
In order to fall asleep, the core body temperature must be reduced, which is accomplished through the release of heat through the skin in certain areas. Noting that he and other researchers focused on various parts of the body to assess the release of heat, he said eventually, “it really boiled down to the fact that there was something going on with the eyes.”
“When the eyelids were shut, you would see this really rapid increase in skin temperature from the hands in helping to cool the body to help facilitate sleep,” Dr. Gradisar explained.
Although additional factors may also play a role, he said changes in thermoregulation took place when individuals shut their eyes.
“There's an obscure study that examined the correlation between hand temperature and corneal temperature at the surface,” Dr. Gradisar said. “The correlation was significant, so it's very clear there's a connection between what's happening with our eyes, thermoregulation, and falling asleep.”

Discussing thermoregulation and a Ümay REST Routine with Patients

When eyecare providers are discussing the role of thermoregulation and a rest routine with patients, Dr. Gradisar said it’s about more than having an evidence-based discussion about at-home treatments. Rather, it’s about whether the patient will be compliant with the recommendations that are made.
“In some ways, the client has to go home and do their homework,” he said.
Underscoring the importance of taking a pause during the day, Dr. Gradisar said research supports the effectiveness of a power nap to increase performance—and that when he tried the REST device for the first time, it was almost like taking one.
“But it’s more of a power-power nap because it only takes a few minutes and you don't actually have to be reliant upon falling asleep,” he added, noting that REST provides additional value because it can be used throughout the day.
“With its thermoregulation capabilities, it provides both warmth and coolness,” Dr. Gradisar explained. “So it can be used to warm the eyes to support relaxation during the day and before bed—and to cool the eyes to help facilitate alertness in the morning and as needed.”
Based on the initial data he’s viewed about how REST improves sleep quality, Dr. Gradisar said it’s “actually a bit of a reward,” which should help to improve compliance.
“And if you have better compliance, then you can be more effective as a clinician,” he said.
Referring to convenience as “the biggest thing,” Dr. Ioussifova said that with one button, patients can activate both heating and cooling.
“We’re very familiar with treating MGD with heat, but we haven’t had that cooling component for treating our patients with dry eye,” she explained. “So, for patients who wake up with irritated and inflamed eyes, this has been a great addition.”
Dr. Ioussifova said the Ümay REST offering provides the opportunity to both talk about the technology with patients and integrate a holistic approach to incorporate additional factors that are important to activating the parasympathetic nervous system.
“So it's a perfect blend of treating dry eye, as well as the mental health and sleep component,” she said.
1. REST in the Workplace: An Intervention Case Study. Ümay.
Mila Ioussifova, OD, FAAO
About Mila Ioussifova, OD, FAAO

Mila Ioussifova, OD, FAAO, is the owner and an optometrist at South Waterfront Eye Care in Portland, Oregon. She studied at University of Oregon before obtaining her Doctor of Optometry degree at the New England College of Optometry.

Dr. Ioussifova currently is an adjunct clinical faculty member and attending doctor at Pacific University in Portland, Oregon.

Mila Ioussifova, OD, FAAO
Michael Gradisar, M.Psych, PhD
About Michael Gradisar, M.Psych, PhD

Michael Gradisar, M.Psych, PhD, is the Head of Sleep Science at Sleep Cycle AB. Dr. Gradisar earned his Master of Psychology in Paediatric Sleep before obtaining his PhD in Psychology, both at Flinders University.

Dr. Gradisar is also the CEO and Founder of WINK Sleep, as well as the Director of the Child & Adolescent Sleep Clinic in Adelaide, Australia.

Michael Gradisar, M.Psych, PhD