Exploring the Management of Dry Eye - Episode 10

In-Office Procedures Used to Treat Dry Eye Disease

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Types of in-office procedures currently being used by ophthalmologists and optometrists to aid in the treatment of dry eye disease.

Cynthia Matossian, MD, FACS: Kelly, I’m going to come back to you. What types of in-office procedures do you offer? Then I’m going to open it up to you, Rahul and Milt.

Kelly K. Nichols, OD, MPH, PhD, FAAO: Cynthia, that’s your second sandwich reference. You’re making me hungry. There have been so many. As Milt mentioned, there have been so many new advances of things that we can have in practice. It can be really confusing because LipiFlow, TearCare, and iLux all are warning devices. They all function slightly different from one another. All have the same goal of clearing the meibomian glands. Also, as you mentioned, the sandwich of pairing that with manipulating the eye. There’s going to be some inflammation that, even in the short term, needs to be addressed. I like how you mentioned that, Cynthia. But then there are some other things, like cleaning up the eyelids, which may be more important in certain practices. We do that in our specialty dry eye clinic. We do not have IPL, or intensive pulse light, in our clinic. Maybe 1 of the other 2 could speak to that if you do, or radio frequency laser treatment. We’re more in the meibomian gland range with our treatments in clinic. I’ll turn it over to my fellow compatriots.

Cynthia Matossian, MD, FACS: I agree with you, Kelly. The ones you mentioned specifically address the viscosity and the impaction of the meibomian glands. There are, as you said, other options. Rahul, do you incorporate anything else?

Rahul S. Tonk, MD, MBA: You referred to intense pulse light. That’s a really nice treatment, and there are good data to support it across different categories of patients with MGD [meiobomian gland dysfunction]. In particular, I like that for my ocular rosacea and facial rosacea patients. Optimizing that with IPL ahead of a thermal pulsation treatment actually gives me more longevity. In fact, I had a patient just the other day who underwent both on the same day. Pandemic related, he didn’t want to come and ago. Had IPL and LipiFlow—very savvy patient, and now she gets a little more extension in terms of her next appointment. I do believe in IPL. We don’t do radio frequency treatment, although that’s interesting technology. I’m keeping my eye on that.

Also, on the obstructive component of it, we’re talking a lot about how to heat and warm the meibum and then express it mechanically. There’s a lot of technology that’s come about in that regard. From a procedural standpoint, I am a growing believer in meibomian gland probing, which Steve Maskin is popularizing. He has excellent data that, to his credit, he has put out in some good journals. It’s a little traumatic. You do need some good anesthetic. You need to have some sense as to what you’re doing. The probe will find the meibomian gland. It tends not to move into the wrong area, and you can get started with shorter probes for those of you listening who are interested in that. Then move away to higher probes. For a patient with severe obstruction who has, to some extent, some working glands, I will do probing first and program a thermal pulsation shortly thereafter. But there are a variety of other treatments that we can do. Procedure-based office treatments. We now have treatments for conjunctivochalasis. Great cautery rate, frequency ablation in the office or excision with AMT [amniotic membrane transplant] in the operating room. We have punctal occlusion, punctal cautery. We have microblepharoexfoliation, which is quite important, particularly for Demodex mites. I wanted to catch on the other side what Milton had mentioned about the comanagement and optimizing the ocular surface before cataract surgery. There’s this question, do we optimize that surface and then refer for cataract surgery, or do we send and then have the surgeon do that. Patients are much happier when all that has been worked on by the provider, who knows them best and optimizes that all and then they come, ready to go. Despite my best inclinations to get a surface optimized, when someone comes in hot for cataract surgery but has a poor surface, they’ll have to spend another few months optimizing that— the extent they’re dissatisfied. In a comanaged situation, we love when our optometrists take the bull by the horns on that.

Cynthia Matossian, MD, FACS: Excellent explanation. There are so many tools in our toolbox. Milt, what tools do you have in your toolbox?

Milton M. Hom, OD, FAAO: I’m not like Rahul. I don’t have a garage full of toys. We go with anti-inflammatory treatment, and then I do some basic mechanical therapy. If that doesn’t work, then we’ll add in manual expression behind the slit lamp. We have huge procedure of heating the lids and things like that. We go ahead and manually express the patient. As Rahul was talking about, a lot of times it’s Demodex. Demodex is a problem too. We’ll also do tea tree oil treatments in the practice and send them home with tea tree oil wipes.

Cynthia Matossian, MD, FACS: All these treatments are so complementary to one another because the Demodex patient we have to consider tea tree oil. There are other pharmaceuticals in the pipeline; we’ll get to that shortly. As all of you said so astutely, a lot of it is combining, mixing, and matching and finding that right balance. I use IPL, and I also use a lot of other heating and expressing devices of the meibomian glands. Like you, Rahul, I have found that they work in perfect synchrony with one another. I might do a LipiFlow, and 6 months later I’ll do an IPL and that will help extend the efficacy of the LipiFlow. And microblepharoexfoliation to remove that biofilm to open the orifices of the glands so more of the lipid can come out and coat the ocular surface is also really important. That can be done as an in-office procedure, or there are at-home treatment options. NuLids has a device, an electric toothbrush that you hold like an instrument, and it has an oscillating head that cleans between the lashes. Do any of you have experience with that instrument? It works. They buy it, and the head changes after each treatment. They put a proprietary viscous artificial tear or 1 that Newsight provides, then they go back and forth 30 seconds on each eyelid. It’s an at-home version of the microblepharoexfoliation, but it’s a milder, kinder version.

Milton M. Hom, OD, FAAO: I was going to ask Cynthia if she’s had success using that.

Cynthia Matossian, MD, FACS: My patients really like it. These are patients who have blepharitis. They have a lot of debris and collarets at the base of the lashes. Often there’s Demodex infestation. We’re using tea tree oil and this mechanical cleaning system.

Rahul S. Tonk, MD, MBA: I was just going to add to that. That’s a clever idea, and I want to get into it. Anything that can put more power in patients’ hands is critical. From the ophthalmologist and optometrist perspective, we were talking about demystifying dry eye and not making it so difficult to diagnose and care for. The same is true from the patient perspective. We have incredible products. Thanks to impressive industry collaboration and initiatives, patients can take care of their dry eye and do self-care better than ever. They’re very savvy. We just have to trust them and point them in the right direction.

Transcript edited for clarity.