Innovations in Dry Eyes: The Truth in the Trenches

Innovations in Dry Eyes: The Truth in the Trenches

Patients with severe dry eye can often feel miserable. Imagine feeling a painful sandy sensation grate over the front of your eye every time you blinked. Any innovation that helps is priceless to these patients and their doctors who yearn for better treatments for this frustrated patients.

I came across this article today about Lipiflow in Europe. It has some interesting points. The key concern I have with Lipiflow is the cost for the treatment. It costs about $1700-$2200 in the Washington DC area. In the last few years I’ve noted of those patients who have had Lipiflow (either before they first saw me or after I referred them to a Lipiflow center–of which I have no stock or financial interest in), about 50% of patients love it but 50% said it did nothing to help their symptoms.

We try to warn patients that there is no 100% money-back guarantee with Lipiflow (we do not own the machine and refer to a center if a patient wants Lipiflow) or any of the innovative dry eye treatments which is frustrating for everyone. Still, though, in cases of desperation, patients are willing to try anything to provide relief.

I have been following over the years patient’s suggestions on dry eye care at Dry Eye Zone.

An easy paper presentation for a med student would be to review Dry Eye Zone and other online sites to see what is the average perception of all the different dry eye treatments. If anyone out there feels compelled to do this research or write the code to extract this information from such sites, please let me know.

I have started a database of my dry eye patients to see what are our successes thus far.
In my 19 year career I have noted the following:

1. I have only 2 patients out of at least 250 who said Autologous Serum did not help at all. The vast majority have had a significant improvement to the point that many have called it their “miracle drop.”Additionally, I used to think that Autologous Serum should only be reserved for severe Sjogrens or Rheumatoid Arthritis patients but I have found it works really well for those patients who do not have autoimmune disorders as the cause of their dry eye. The downside is the need to have a blood draw every 3-4 months and the cost. Currently we charge about $275-$350 depending on amount, & type created.

2. I have been pleasantly surprised by the effectiveness of Intraductal Gland Probing. I was not expecting such a dramatic improvement in some of my patients. 1 out of over 50 patients has said it did not help at all. This was likely due to the extensive scarring present in this patient’s glands that allowed us to show the patient that there is almost no oil production from this patient’s meibomian glands. One of the best things about Intraductal Gland Probing is being able to videotape the procedure to show the patient their meibomian glands, count how many are open or closed, and show the patient the quality of their oil production as it is expressed from the glands.

The biggest downside of IGP is the discomfort involved: I have had to inject lidocaine into the lid in 2 out of the 50 patients due to significant discomfort. The other downside is the cost: range about $250-300 per EYELID. Each eyelid can take between 15-20 minutes and a specialized cannula is used to enter each gland if possible. Again there is no guarantee it will work but it definitely gives the surgeon and patient the most information about the status of the patency and oil production of each gland: this information in my mind is priceless as it gives the patients more information about their long term prognosis.

3. I have not been impressed by Lipiflow and hope more innovations are coming soon.

4. I have been impressed with Testosterone cream & drops (Leiters Pharmacy). Thus far 4 patients out of 4 have felt an improvement.

5. Restasis: again it depends on when patients use it. If patients have truly followed the first 3 steps on my step ladder, particularly the warm/hot compresses & the cleaning with Tea Tree Oil, then the use of Restasis helps in about 70% of my patients. If they have not done the cleaning and steps 1-2, the effectiveness of Restasis is closer to 30% and these patients are much more likely to give up on Restasis before the 3 month mark, which is often truly needed for Restasis to start to have a positive effect on a patient’s symptoms.

So these are some thoughts on some of the treatments we use daily for our dry eye patients.

Lipiflow is definitely on to a great idea.

The best dry eye machine would the likely following:
1. Heat the eyelids even warmer for 10-15 minutes then
2. Use microscopic probes as we use for Intraductal Gland Probing and enter each gland with laser precision and possibly inject a little steroid in those glands that are scarred or were scarred prior to being popped open.
3. Then massage the eyelid with a milking-type apparatus

Still though, we live in the best time in history to have dry eyes!

Sandra Lora Cremers, MD, FACS


An innovative treatment for dry eyes

Could an exciting new procedure – involving the heating of the inside of the eyelids – cure dry eyes? Jake Wallis Simons, whose eyes are constantly itchy and sore, tests it out

Jake Wallis Simons undergoing a new gland cleaning treatment for Dry Eye at Barnard Levit Optomotrists in Golders Green

Jake Wallis Simons undergoing a new gland cleaning treatment for Dry Eye at Barnard Levit Optomotrists in Golders Green Photo: Philip Hollis/The Telegraph
Let me explain why, one wet January afternoon, I’m preparing to have the insides of my eyelids heated up. I suffer from dry eyes – the most common eye disorder in Britain. My eyes are constantly red, itchy and sore. Other symptoms include a sensation of grittiness, eye fatigue, sensitivity to light, discomfort in windy or dry conditions, and even blurred vision.
“It’s certainly the biggest complaint that I treat,” says Dr Simon Barnard, a senior partner at the Barnard Levit optometrists in north London.
Dry eye syndrome affects up to six per cent of the population and may well be exacerbated by the the time spent in front of computer screens and in air-conditioned environments. It occurs when a lack of protective oils causes the tear fluids to evaporate too quickly, leaving the eyes irritated. The meibomian glands on the rim of the eyelids, which normally secrete the oils, become blocked and filled with a waxy substance. This causes inflammation, which only worsens the condition.
To release the blockages, heat must be applied to melt the waxy substance, which is then massaged out of the glands.
Over the years, I have tried several standard remedies for dry eye syndrome – eye-drops, eyelid massage, and the daily application of a heat-pack to the eyelids. But like thousands of other sufferers leading busy lives, I’ve found it almost impossible to sustain such a regime. Now I am trying an innovative treatment called Lipiflow at Barnard Levit, the first optometrist in Europe to offer it.
Two small eyepieces attached to an electric cable are placed over my eyes. Each is attached to a special contact lens, which slips under the eyelids. My eyelids are then warmed to 42Cfrom within, and massaged at the same time, for 12 minutes. It is not exactly comfortable, but afterwards, when the redness caused by the treatment subsides, my eyes feel free of the usual irritation.
Dr Barnard says that for some patients, a single session is enough to “reset” the eyes and cure dryness permanently. Others might need to repeat the treatment, depending on severity.
Lipiflow was developed by Dr Donald Korb, clinical professor at the University of California, Berkeley. “It started in 1980 when I published a paper on the mechanism of obstruction of the glands,” he tells me. “I knew if one could adequately heat the eyelids while applying pressure throughout the procedure, one would liquefy the obstructive material and there would be a high probability that the gland would again function. I then embarked on a project to accomplish this.”
A randomised, controlled trial in 2009 demonstrated that 79 per cent of patients using Lipiflow reported an improvement of their dry eyes within four weeks. Introduced in the United States in 2012, the treatment is not widespread in Europe, partly on account of cost, which is £600 per eye.
Four weeks on, I’m pleased to report that Lipiflow worked for me. I still get red eyes from time to time, but on the whole I am symptom-free. Dr Romesh Angunawela, consultant eye surgeon at Moorfields Eye Hospital, says: “Patients may
wish to try Lipiflow if they have dry eyes with oil gland dysfunction and wish to jump-start their treatment, or where other conventional methods have not produced good results. The treatment is expensive, however, and patients should first see their ophthalmologist for advice.”
Jake Wallis Simons received Lipiflow as a complementary treatment at Barnard Levit optometrists
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