Melissa Toyos, MD 

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,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by 

. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Growing up in Louisiana, I was once taken fishing for small sharks on the Gulf Coast. As I stood on the beach, holding my fishing rod, I remember experiencing the sudden revelation that if I succeeded in hooking a shark, the next step would be to reel it in to me. By my own efforts, I would go from being happy on the beach to being face to teeth with a dangerous shark.

Some doctors have similar feelings about dry eye disease. We now know the problem is very common, with a range of estimates that all point to the fact that many people with dry eye are sitting in our waiting rooms.

We have a lot of diagnostic options, so doctors can choose the approach they like best. But some doctors worry that once they reel in that dry eye diagnosis, they’ll be faced with a tough reality of treating it effectively. I felt the same way about opening a dry eye clinic, until I learned that positive results are possible with certain therapies.

When I started my practice, dry eye was an annoyance that many felt was just a moisture-level problem. With the confluence of dry eye’s effect on presbyopic lens performance, the exacerbating daily use of modern devices, and our recent understanding of inflammation as the root cause of dry eye, we have all become much more knowledgeable about the disease and its impact on the population.

Nevertheless, despite broad efforts by practitioners and high-visibility advertising campaigns with celebrities like Jennifer Aniston and Venus Williams, statistics still tell us that dry eye is dramatically underdiagnosed and undertreated. We need to change that.

Even dry eye experts find it impossible to agree on “the” test for dry eye. There is no clear-cut diagnostic test result. In my experience, tests do not quantify dry eye in a meaningful way, either. A number value might be the same or worse, but a patient feels better (or vice versa), leaving patients confused and frustrated. In my practice, we use screening questionnaires and testing primarily in FDA studies because they provide some objective data for an incredibly variable disease state.

Until there is a positive/negative dry eye equivalent to a pregnancy test, I’m going to continue to use the approach I find most effective: listen to my patients, ask questions, examine and push on lid margins to evaluate meibomian glands, and use compounded lissamine green stain to diagnose dry eye disease. My staff is trained to listen, get a careful history, and recognize the signs and symptoms of dry eye, even if patients aren’t complaining.

Before we opened a dry eye clinic in my practice, I wasn’t sure it was a good idea. Dry eye treatment was very individualized, and success could be incremental. This disease is widespread, underdiagnosed, and can be frustrating for both doctors and patients when they reach the end of traditional treatments without complete or even adequate resolution.

When I learned more about the work my husband, Dr. Rolando Toyos, was doing with intense pulsed light (IPL) therapy (Optima IPL, Lumenis), I got excited about the new clinic. A series of IPL treatments is the closest thing to a silver bullet that I have found, as it not only immediately reduces levels of cytokines and other inflammatory markers on the ocular surface, but also helps to improve the quality of secretions and the number of working glands over time.

IPL became a cornerstone of our new dry eye clinic. Other therapies include cyclosporine (Restasis, Allergan), lifitegrast (Xiidra, Shire), and, in select cases, loteprednol (Lotemax, Bausch + Lomb). We also offer platelet-rich plasma tears for dry eye, and we are the only U.S. distributor of a natural tear called Oculocin, composed of aloe vera (a humectant), naturally anti-inflammatory chamomile, and bee propolis, which provides the lipid component. We continue to explore cutting-edge research, including the effect of repository corticotropin injection (H.P. Acthar Gel, Mallinckrodt Pharmaceuticals) for severe dry eye. We’ve found that the advances treatment options available for dry eye today take the fear out of reeling in a diagnosis.

Dr. Toyos is a partner and research director at Toyos Clinic in Nashville, Tennessee.She is a consultant for Iridex; speaker and consultant for Valeant and Sun; researcher for Kala, Lumenis, Magellan, Novaliq, Opternative, and Sun; speaker, consultant and researcher for Shire, Mallinckrodt, and Mixto Lasering; and consultant and researcher for DigiSight.

Articles

Some doctors worry that once they make the initial dry eye diagnosis, they’ll be faced with the tough reality of treating it effectively. Luckily, positive results are possible with certain therapies.

Reeling in the shark: How to take the fear out of dry eye diagnosis and treatment

The holiday season bring lots of good cheer and also worsens dry eyes. Indoor heat lowers already low winter humidity levels and on top of that, patients are getting dressed up for events and parties where beauty-related dry eye problems abound.

Makeup is a major offender. Some patients with severe dry eye often find it virtually impossible to wear eye makeup. However, the majority of dry eye sufferers do try to glam up, and we can help them by making recommendations for products and treatments that can facilitate their holiday season and improve their resilience to the season’s challenges.

For many of my patients, makeup and beauty products are not optional. I try to minimize dry eye problems related to these products by telling them my recommendations for cosmetics and reminding them to always remove all makeup before bed, no matter how late they’re getting there.

Mascara – We’ve all seen mascara flecks in the tear film on slit lamp exams. There is no question that these products take their toll chemically, with a host of chemical ingredients. Mechanically, the flecks are uncomfortable and can be abrasive. “Thickening” and “lengthening” mascaras are particularly problematic because they incorporate fibers to create the desired effect, and the fibers can irritate the eyes.
		 

Eyeliner – Eyeliner can irritate the eye and contribute to dry eye simply because it is used on the eyelids. At the base of the lashes, it can harbor bacteria and be difficult to remove completely. Using eyeliner on the inside of the upper or lower eyelids can dramatically define the look of the eye, but it also can adversely affect the meibomian glands and tear film.

Eye shadow and powder – Any powdered makeup-eye shadow, face powder, bronzer, glitter, and so on-inevitably ends up in the eyes, causing problems that are similar to mascara flakes. People with dry eye may prefer to stick to cream-based products instead of powder.
		 

Lash growth products – Lash growth products containing prostaglandins are known to be pro-inflammatory-in fact, I reported on the first case of MGD associated with them. However, many of my patients consider these products mandatory, so I adjust with additions of high-quality fish oil, topical anti-inflammatories, and/or intense pulsed light (IPL) to reduce inflammation and reverse the damage.
		 

Eye makeup remover – Virtually all eye makeup removers contain detergents, which break up the tear film’s lipid layer. Currently, there are no great alternatives, but I steer my patients toward non-petroleum oil-based products.
		 

Eye cream – Patients with dry eye need to eliminate drying agents like retinoids, especially near the eye. I recommend creams without retinoids that instead contain peptides, which activate collagen-building fibroblasts. Hyaluronic acid is great to use in this delicate area too. (Yes, hyaluronic acid is good.) I try to minimize preservatives and fragrances in this delicate area.
		 

Eye whiteners – To make tired eyes look whiter, brighter and more radiant, I recommend brimonidine tartrate ophthalmic solution 0.025% (Lumify, Bausch + Lomb), an FDA-approved eye whitener. One drop works within minutes and lasts up to 8 hours.

In addition to educating patients about beauty products, I think the best defense is to make sure that they start the season with the healthiest eyes possible. I use IPL therapy (Optima IPL, Lumenis), which allows us to solve several issues simultaneously. IPL rejuvenates skin in the eye area, reduces ocular surface inflammation, closes off lid margin telengiectasias, improves meibomian gland function, and can even increase the number of working glands over time.

I also prescribe cyclosporine (Restasis, Allergan; Cequa, Sun Pharma) and lifitegrast (Xiidra, Shire), as well as loteprednol (Lotemax, Bausch & Lomb) for acute flares. I offer platelet-rich plasma tears made with an advanced centrifuge technology (Genius PRP, Reinvent Biologics) and a natural preservative-free tear product containing chamomile, aloe vera, and other natural anti-inflammatories. With dry eye disease under control-and, hopefully, with some beauty tips heeded-my patients can sail through the holidays with fresh, clear, healthy eyes.

Dr. Toyos is a partner and research director at Toyos Clinic in Nashville, Tennessee. She is a consultant for Iridex; speaker and consultant for Valeant and Sun; researcher for Kala, Lumenis, Magellan, Novaliq, Opternative, and Sun; speaker, consultant and researcher for Shire, Mallinckrodt, and Mixto Lasering; and consultant and researcher for DigiSight

The holiday season brings lots of good cheer and also worsens dry eyes-here's how your patients can effectively manage their symptoms. 

Help your patients embrace holiday glamour without worsening dry eye

Ophthalmologists have a great deal to offer facial aesthetics, and the addition of those patients can be very rewarding for both patients and physicians, says Melissa Toyos, MD.

Ocular aesthetics has long been considered not serious, scientific or important, compared to “real” ophthalmology. LASIK, contact lenses and presbyopic intraocular lenses serve both functional and aesthetic purposes, but services that are aesthetic alone can be dismissed.

The truth is, there is no more important feature in facial aesthetics than the eyes, and any aesthetic enhancements need to support the eyes’ healthy function.

Who but ophthalmologists have unique knowledge of the eyes, coupled with the fine motor skills to treat this delicate area that is so important to aesthetic outcomes? Ophthalmologists have been on the forefront of advancing aesthetic technologies for decades.

A husband-and-wife team of ophthalmologists first brought onabotulinumtoxinA (BOTOX Cosmetic, Allergan) to the public. The radiofrequency craze that is currently sweeping the aesthetics field was utilized in our experiments with conductive keratoplasty decades ago.

Ophthalmologists are also seeing the value of continuous wave lasers in retina and glaucoma-lasers that are only just beginning to penetrate the aesthetics field. We have a great deal to offer facial aesthetics, and the addition of those services can be very rewarding for both patients and physicians.

I first noticed this natural marriage between ophthalmology 20 years ago, when patients asked me if their cataract surgery had caused wrinkles around their eyes. Of course, they just couldn’t see the wrinkles before!

As a physician who these patients already viewed with trust and respect, it made sense for me to treat wrinkles in the eye area, and eventually to offer other facial aesthetic services. The patients overlap, and so do many techniques and technologies.

For example, the same laser we use to rejuvenate the trabecular meshwork in selective laser trabeculoplasty (SLT) is used to rejuvenate the skin and cheeks (Selecta II, Lumenis; MicroPulse, Iridex).

Today my practice offers many aesthetic services, including intense pulsed light (IPL) therapy (Optima IPL, Lumenis), treatment with a fractionated CO2 laser for facial resurfacing and tightening (Slim Evolution II with MiXto Pro, Lasering), invasive and noninvasive upper and lower lid blepharoplasty, hyaluronic acid fillers (Juvederm, Allergan; Restylane, Galderma), onabotulinumtoxinA, and deoxycholic acid (KYBELLA, Allergan) for fat under the chin.

We also offer custom skin care products, and I prescribe products like bimatoprost (Latisse, Allergan) for aesthetic purposes.

Recently, I treated a patient simultaneously for clinical problems and an aesthetic complaint.

Here in Nashville, we treat many of the Tennessee Titans cheerleaders. One of them came to me with dry eye complaints, as well as forehead pigmentation from sun exposure.

After her exam, I used IPL to treat her dry eye and the forehead pigmentation, as well as facial rosacea on the cheeks and chin. IPL improved her dry eye symptoms, and it rejuvenated her skin, reduced redness, and improved her comfort.

Colleagues in the aesthetics sphere recently pointed out to me that in our selfie culture, everyone is now in the public eye. Everyone is very aware of their appearance and wants to look their best. Combine that observation with the fact that our population is aging, and you see that the market for aesthetics is vast. It’s also woefully underserved.

Although many healthcare providers are getting into the aesthetic market, some of them unfortunately do not have our knowledge or experience. Patients are eager to learn more about their health and aesthetics from knowledgeable and reputable sources, but they don’ always find them.

Whom do you trust to perform blepharoplasty on your patients or inject fillers around their eyes-an ophthalmologist or someone in another specialty? For those cataract patients of mine with the “new” wrinkles around their eyes, I trusted myself to do it, and 20 years later, I still do.

Dr. Toyos is a consultant for Iridex; speaker and consultant for Valeant and Sun; researcher for Kala, Lumenis, Magellan, Novaliq, Opternative, and Sun; speaker, consultant and researcher for Shire, Mallinckrodt, and Mixto Lasering; and consultant and researcher for DigiSight.

The market for ocular aesthetics is vast, yet very much underserved in 2018

Author | Melissa Toyos, MD

Articles

Reeling in the shark: How to take the fear out of dry eye diagnosis and treatment

Help your patients embrace holiday glamour without worsening dry eye

The crossover between ophthalmology and aesthetics