What are the options for and barriers to in-office dry eye treatments?
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Options
When assessing a patient with dry eye, I try to determine the primary problem.
Many of these patients also have meibomian gland dysfunction and some have conjunctivochalasis, so oftentimes it can be multifactorial. At that first exam, it is nice to get a good picture of what is contributing to their symptoms.
There are a lot of tests on the market that can help, such as LipiView (Johnson & Johnson Vision) or other forms of meibography. There are tests for tear osmolarity, as well as MMP-9 testing such as InflammaDry (Quidel). However, talking with the patient and doing the exam are what I find to be most helpful.
We have several good options when it comes to in-office treatments for meibomian gland dysfunction. These eyes can be red and inflamed with a rapid tear breakup time, and in these cases patients frequently complain about burning as their primary symptom. A couple of in-office options for these patients include intense pulsed light therapy and LipiFlow (Johnson & Johnson Vision).
Conjunctivochalasis in my clinic is one of the more underrecognized contributors to dry eye symptoms. In these cases, there is redundant conjunctiva overriding the lid margin, resulting in a discontinuous tear film and leading to a complaint of foreign body sensation in patients. One option for these patients is conjunctival cautery, which can easily be done in the office. When you do this, you can see the conjunctiva shrink and watch as the tear film reestablishes itself along the lower lid. Patients can expect their eye to be sore in the first days of recovery, but it quickly improves, and once they heal, their foreign body sensation should be markedly improved.
For patients who have aqueous tear deficient dry eye and are not satisfied with artificial tears, we can offer punctal plugs. That can help make them less dependent on artificial tears throughout the day.
With dry eye patients, it is important that we advise them that this process is a marathon and not a sprint. At-home treatments will also be needed to help control their disease state.
Kristen Peterson, MD, is an ophthalmologist in Alabama.
Barriers
Over the years, we have had many effective in-office treatments. There are simpler ones, such as meibomian gland manual expression or removing the presumed biofilm on the surface of the lid with something such as BlephEx (Alcon).
We now have in-office thermal treatments that treat the meibomian glands either externally, such as TearCare (Sight Sciences), or inside the lid on the tarsal conjunctiva, such as iLux (Alcon) or LipiFlow (Johnson & Johnson Vision). The newest category is light therapy, either intense pulsed light (IPL) or low-level light therapy. Each of these reduces the inflammation in the glands themselves. Proponents of each feel strongly about their favorite; it seems as though both are effective.
We use almost all of these in our practice. I have been using LipiFlow for about 5 years and IPL for about 1.5 years. These treatments can be quite effective in the proper circumstance. The big issue is financial: None of them are covered by insurance. These therapies are all cash pay. While there have been efforts to have some of them covered by insurance, it has not amounted to true coverage. Insurance companies will arbitrarily declare that a treatment is covered, but the published fee fails to cover the costs associated with offering the service, not to mention the cost of amortizing the equipment itself.
The controversy with in-office treatment is no different from any other cash-pay service we offer. Are we comfortable discussing treatments that are not covered by insurance, especially if they are the only effective ones available? Doctors who wish to offer advanced care options need to answer this question in the affirmative.
Darrell E. White, MD, is a Healio/OSN Board Member.
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