Quick Review of Dry Eye Treatments:

Review of Dry Eye Treatments:

There are 2 key paths to help dry eye symptoms: 

The most important is to save the Meibomian Glands which are crucial in producing the priceless oil that keeps the watery part of the tear (the aqueous) on the eyeball. 

The second path is to get rid of your symptoms: New 2020 Step Ladder Sheet of all the treatments available is coming soon. 

The best ways to save the Meibomian Glands are:

1. Warm compresses and lid massaging & eye blinking; 15min of warm heat (can be wet or dry heat) 2x per day. Heat is the best way to open the Orifice of the Meibomian Gland and to get the oil to melt a bit to stream out.

2. Thermo Pulsation: Heat with Pressure on all 4 eyelids:

A. LipiFlow (Johnson & Johnson Vision) is the first type of FDA-approved thermal pulsation. It is approved for the treatment of DED caused by meibomian gland dysfunction (MGD). LipiFlow applies localized heat and pressure to the meibomian glands of all 4 eyelids at the same time in a 12-minute procedure with minimal or no pain. Lipiflow attempts to heat the oil glands and open the orifice with its heat and pressure to express as much meibum oil from the glands as an attempt to make the body produce more meibum oil. The best analagy is the milking of a cow: if you do not milk the cow, the milk will dry up. 
LipiFlow has been used in 100,000 procedures and has been published in many clinical studies noting its ability to save meibomian gland structure and function over the long term. Lipiflow has been shown to improve mean meibomian gland secretions and reduce mean dry eye symptoms to approximately half of the pre-procedure level (Blackie et al., Greiner, Satjawatcharaphong, et al.). Another study study showed that 1 LipiFlow treatment was as effective as 3 months of twice-daily lid warming and massage (Finis et al.). LipiFlow is a great option if a patient has Meibomian Glands: Thus a Meibography must be done before LipiFlow is approved. If there are no Meibomian Glands left, LipiFlow will not help. If there is 1 meibomian gland left in an eyelild, LipiFlow will help save that gland, but it will not bring back to life the other atrophied glands. 
B. The FDA 510(k)-cleared iLux system (Tear Film Innovations) uses a Light-Based Heating source to treats MGD with compression under direct visualization. The eye care provider can view the eyelid margin through the magnifier, warm the eyelid tissue within a therapeutic range to melt meibum, then apply compression to the eyelid to express the meibum through the orifices. It can treat both upper and lower eyelids. When I had this done, the rep performing the procedure could not see any oil coming out of my glands. Since I do not have severe MGD, I was concerned it was not really working despite the discomfort. 
The procedure took about 8 minutes. I found this to be more uncomfortable than the Lipiflow with the light being particularly uncomfortable. iLux, though is less expensive than Lipiflow. 
3. Non-FDA Approved Options;
A. Intense pulsed light therapy (IPL) has been FDA-approved for more than 15 years to treat rosacea, scars, and hair removal. It is commonly used in dermatology practice. Ophthalmologist Rolando Toyos, MD, originated the idea of using IPL in eye care after a series of DED patients presented in his office demonstrating improved tear film characteristics without any change in their treatment regimen; all had been treated for rosacea with IPL (Toyos et al.). There are many papers reporting improvement in MGD symptoms with IPL (ie Gupta et al., Craig et al.).
IPL is contraindicated in patients with darker pigmentation, it is a 10-minute procedure, and patients generally have 6-8 treatments every 1-2 weeks depending on the skin’s tolerance to the IPL.

B. Meibomian Gland Probing: A microscopic cannula is inserted into every meibomian gland. Works very well to open up scarred meibomian glands. 
It is not FDA and very uncomfortable. 
I have many posts on this blog with more information on MG probing. 

4. FDA-FLAGGED Procedures: MiBo Thermoflo (MiBo Medical Group) uses sustained thermoelectric heat delivered via a handheld probe, through the lid, to the meibomian glands. Heat at a temperature of 108 degrees is emitted from the probe, and a technician massages the patients’ lids to generate better meibum flow. I did not mind using this & it felt plesant on my eyelids. However, the FDA sent the company a warning letter: https://www.raps.org/news-and-articles/news-articles/2018/12/fda-flags-lack-of-design-controls-at-mibo-medical

4. To Treat Demodex and Clean up the Biofilm of the Eyelid:

A. Tea Tree Oil Scrubs
B. Avenova, Acucyin, HypoClor
C. BlephEx or BlephScrub which is a microblepharoexfoliation using a rotary soft brush or cuetip to remove the Demodex mites and other non-pathogenic/dangerous bacteria that increase the neutrophils, histones, and other inflammatory factors on the eye’s surface. The procedure only takes minutes in the office and can be performed by an optometrist or a technician. It is a complement to LipiFlow, which has been shown successful in the patients with significant MGD.
Blackie CA, et al. Clin Ophthalmol. 2016;doi:10.2147/OPTH.S109663.
Craig JP, et al. Invest Ophthalmol Vis Sci. 2015;doi:10.1167/iovs.14-15764.
Finis D, et al. Ocular Surface. 2014;doi:10.1016/j.jtos.2013.12.001.
Greiner JV. Eye Contact Lens. 2016; doi:10.1097/ICL.0000000000000166.
Gupta PK, et al. Can J Ophthalmol. 2016;doi:10.1016/j.jcjo.2016.01.005.
Nelson JD, et al. Ocular Surface. 2017;doi.org/10.1016/j.jtos.2017.05.005.
Satjawatcharaphong P, et al. Optom Vis Sci. 2015;doi:10.1097/OPX.0000000000000670.
Toyos R, et al. Photomed Laser Surg. 2015;doi:10.1089/pho.2014.3819.
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