VIDEO: Nonpharmaceutical options in dry eye

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We mentioned earlier that we have a number of pharmacological agents available to us, which is thankfully tremendous, and we need those options. But we have nonpharmaceutical options, procedure-based options. For many years, we had ways to express the meibomian glands. I think we’ve minimized, again, meibomian gland dysfunction. Over 80%-plus of our patients who have ocular surface disease, at least in our practice and many of the data sets, have concomitant meibomian gland dysfunction. And what happens over time, once we lose those glands, we cannot bring them back, kind of like glaucoma. You can’t bring back those nerve fibers, and we can’t bring back those meibomian glands. So, the earlier we treat these glands, the better.

Now, pharmaceutical agents do help treat the symptoms a lot of times, like we talked about earlier. But we want to treat the glands, and what’s happening? Well, we have sometimes loss of the glands. We have epithelialization where the gland orifices, becomes smaller, as well as the oils and the composition of the meibum that we create are not as healthy over time, depending on other risk factors, as well as aging. So, you take all of those, and what happens? The gland stops functioning. It atrophies. And we have, again, those symptomology of decreased tear film breakup time and a lot of symptoms that we know of with ocular surface disease. And so, what we want to do is somehow re-excite those glands, reignite them, allow them to function better, but get rid of the blockage, that epithelialization that occurs over the surface of those glands. And so, there’s a number of different ways we’ve done it. Historically, we’ve had heating pads, Bruder masks, etc that can help, again, the heat can help thin out those oils, and then we can kind of do hot compresses and pressure to help open those glands up.

But we have other procedures now that can do that for us a little bit more predictably, a little bit more precisely. For instance, we’ve had for many years something called LipiFlow (Johnson & Johnson Vision), which is kind of ultrasound and heat that allows us to kind of help get those oils to thin out as well and allows us to express. We have also Mastrota paddles (OcuSoft) and other paddles that can allow us after the heat is applicated to open up those pores. We have something called TearCare (Sight Sciences), which are stickers that heat the glands. You put stickers on top and bottom for about 15 minutes. That allows us to, again, thin those oils out, and we manually express those glands. We have other things like iLux (Alcon) and BlephEx (Alcon). iLux also has heat and can express as well as find the glands that are not functioning. As well as BlephEx, which can help remove that epithelial, that thin kind of keratin layer that can cover those meibomian glands. We can probe, we can actually do physical probing, take a little wire and probe and open those glands, kind of get rid of that epithelial, that layer that blocks those orifices on the surface of the eye.

So we have a number of those products, and last time, I think I talked about intense pulsed light (IPL). IPL is something that I’ve gotten into recently, and I think it’s been around for a long time. I have good friends of mine out there who talk a lot about it, and I think it’s something that we don’t think about a lot. But I think it’s a great opportunity along with those expression type of procedures. Lumenis has their OptiLight that was approved a few years ago, and we have another company coming out called Lumibird that’s coming in the marketplace. And this idea is not just for rosacea patients, but anybody who has telangiectatic vessels on the margin, and there’s an inflammatory immediate response going on. And what happens by using the intense pulse light therapy just below the eyelid margin — we cover the eye to protect the eye — and it allows us to actually combat inflammatory cascade, and you see less hyperemia, less inflammation, and you see these glands sometimes function better significantly along with other treatment options, not one or the other, sometimes with a combination as well. So, IPL has been a significant benefit as well.

And we talked about other nonpharmaceutical type of procedures and technologies. Punctal plug delivery, we talked about punctal plugs helping out. And that Lacrifill, which is injection of viscoelastic into the lacrimal system through the lower punctum into the lacrimal system, the canaliculus as well as the superior. And that keeps the tears in the eye longer to aid in everything else that we’re doing as well. I think having these nonpharmaceutical procedures allows us to also take away some of the compliance issues but also address the underlying cause of inflammation of the glands on functioning better. So, drops do help a lot, but I think we also have opportunities to really help those glands function better and prevent them from dropping out and getting destroyed over time. So, the earlier we treat, the better we have chance of helping them and preventing it from getting worse.