Neel R. Desai, MD

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 Welcome to “Eye Catching: Let's Chat,” 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 Neel R. Desai, MD. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Among the mechanical problems related to dry eye is conjunctivochalasis-the Tenon’s capsule condition in which long-term chronic inflammation and dry eye causes dissolution of normal Tenon’s fascia.

The conjunctiva becomes loose (not redundant), shortening the inferior fornix tear reservoir, where half the tear volume resides in healthy eyes. No amount of medication, supplements, or warm compresses will alleviate dry eye in the presence if this mechanical challenge.

I follow a two-pronged approach to the problem.

First, I surgically reconstruct the inferior fornix and tear reservoir.

Second, I start long-term therapy to control inflammation and dry eye disease. The result is relief from dry eye symptoms, including reduced inflammation that prevents conjunctivochalasis from reoccurring.

When we see patients who have had dry eye disease for many years, it is wise to consider mechanical deficiencies. They may have the biochemical etiology for dry eye disease, and this mechano-anatomical issue is a long-term consequence.

Diagnosis begins with a detailed history, including symptoms such as epiphora and foreign body sensation that is not relieved by artificial tears because the patient has no natural reservoir to retain them. In the slit lamp exam, I look at tear breakup patterns and staining on the lid margin architecture.

One of the most useful staining techniques for diagnosis is to drop a single drop of fluorescein and look for what I call a “morse code” meniscus because it looks incomplete, like a series of dashes and dots. When I see that, I know the patient has a mechanical problem that will render standard dry eye therapies ineffective.

Some doctors are hesitant to recommend surgery for conjunctivochalasis, but I find it very straightforward and readily accepted by patients with the symptoms of the condition. I explain to patients that the surgery is a minor procedure-a “mini facelift for the eye” that smoothes out wrinkles, removes loose areas, and restores normal anatomy so their eyes will feel better.

I also explain that the procedure works synergistically with patients’ at-home regimen, and I give them my dry eye handbook, which explains the reasons for each diagnostic test, as well as how testing and history tell us which treatment is best to target each patient’s type of dry eye.

The only way to treat conjunctivochalasis is to reconstruct the inferior fornix and restore the normal anatomy. Unfortunately, as a result of poor nomenclature, some surgeons choose repair procedures that exacerbate the problem. The term conjunctivochalasis falsely suggests that the patients have excess conjunctiva, so it is pinched and snipped or cauterized, inducing scarring and further contraction of an already foreshortened and poorly defined conjunctiva.

The goal of conjunctovochalasis surgery should instead be to provide for a regenerative and restorative procedure that:

Replaces the tenons fascia and provides a foundation for smooth, rapid, and healthy conjunctival re-epithelialization,

Restores the deep and well-defined anatomical definition of the inferior fornix or tear reservoir,

Prevents inflammation, fibrosis or conjunctival scarring, muscle restriction, and continued orbital fat prolapse, and

Provides for return to normal tear clearance, complete uninterrupted tear meniscus, patient comfort, and excellent cosmesis.

The active biological growth factors in cryopreserved amniotic membrane can be used to reform or replace diseased Tenon’s capsule. I remove diseased Tenon’s and conjunctiva and prolapsed orbital fat, and then I glue the amniotic membrane, which forms an effective platform for conjunctival growth.

The procedure takes about 10 to 15 minutes and is covered by insurance using codes for ocular surface reconstruction with multilayer graft, and conjunctivoplasty with extensive rearrangement of the conjunctiva and reconstruction of the cul-de-sac.

By smoothing out the conjunctiva and restoring the anatomy of the inferior fornix, we are able to use standard therapies for dry eye with greater beneficial effect, thus addressing both the anatomical and biochemical facets of the patient’s problem.

Follow-up Interventions and Continued Care

By the time patients present with conjunctivochalasis, they have experienced advanced dry eye disease for years. In addition to judging that surgery is the best treatment, I also like that a procedure covered by insurance offers a significant initial step toward healing and symptomatic relief.

Once my patients experience symptomatic improvement after surgery, I perform a combination of intense pulsed light therapy (IPL) (M22 OPT, Lumenis) to reduce inflammatory mediators from capillaries on the eyelids and around the eyes and thermal pulsation therapy (LipiFlow, Johnson & Johnson Vision) to clear the meibomian glands and help them function effectively again.

Thermal pulsation is a single treatment, although patients can be retreated a year later if needed. Patients typically have four IPL sessions two to four weeks apart, with maintenance treatment four to six months later and again after increasingly longer intervals (eventually reaching once per year).

I often prescribe cyclosporine (Restasis, Allergan) or lifitegrast (Xiidra, Shire), and patients continue re-esterified omega-3 fatty acid supplements (HydroEye, ScienceBased Health). I encourage patients to continue using hot compresses as well.

By continuing long-term care and therapy for dry eye, patients not only achieve the symptomatic relief they want, but also, in turn, prevent a return of conjunctivochalasis.

, is Director of Cornea, Cataract, and Refractive Services at The Eye Institute of West Florida, Medical Director of the Lions Eye Institute for Transplant Research, and President and CEO of Clarity Visionary Consulting. 

Dr. Desai is a consultant to Allergan, BioTissue, Lumenis, Johnson & Johnson Vision, and Shire.

Articles

Are you treating conjunctivochalasis effectively for dry eye relief?

: Welcome to “Eye Catching: Let's Chat,” 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 Alan B. Richards, MD. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Many older patients are told that their dry, red eyes are just a part of getting older, like aching knees or gray hair. It’s true-patients over 60 are far more likely to have dry eye than people under 30, but, like aching knees and gray hair, dry eye is treatable.

When these patients enter our practices, feeling uncomfortable and frustrated, unable to do the activities they love, and often repeatedly brushed off by other doctors, we need to convey that they’ve finally come to the right place. Though age is a factor in dry eye disease, it is certainly no reason to dismiss it.

In my practice, our words and actions convey our knowledge that dry eye disease is a real, well-understood, and objectively measured problem, and that we are a caring, experienced place to receive treatment.

The following strategies can help you convey those messages to patients of any age, but they are especially helpful for patients who have struggled over time with more advanced dry eye disease.

1. Offer the empathy and compassion they’ve missed

The average dry eye patient at my clinic has seen 3.2 other eye-care professionals in the past 3 years. Those doctors often dismissed the problem as common and “no big deal” or worse, treated patients like “they’re crazy” and it’s “all in their heads.”

They tell patients to use artificial tears and deal with it on their own, but these people are suffering, so they seek out someone else for the same complaints.

When patients find us, we want them to know that this is their last stop-they have found people who respect and understand what they are experiencing and know how to treat it. Conversations among doctors, patients, and staff are aimed at conveying compassion, empathy, and understanding about the effect of dry eye disease on people’s lives.

2. Take a history that informs both of you

Our process for taking a dry eye history conveys the same knowledge and compassion we demonstrate throughout the patient experience. To help us determine the type of dry eye and severity of the symptoms, we ask a series of yes-or-no questions such as, “Have you ever noticed your eyes are red? Are they sometimes dry and sandy or gritty? Does your vision start out fine, and then get blurry? Does it sometimes feel like there’s something in your eye? Do artificial tears last a few minutes, and then wear off?”
When patients who have been told that their symptoms are imagined or unimportant hear questions that validate those symptoms, they know that I understand the condition and the reasons behind it. This gives my patients a sense of confidence and reassurance that the diagnosis and treatment will actually offer results.

It’s a nice contrast for patients to finally feel they will be treated properly. The approach also works well for older patients because it is verbal, rather than written, and the yes-or-no answers are an easy and efficient manner by which we convey understanding while uncovering pertinent and diagnostically helpful symptoms.

3. Convey a clear, objective picture of dry eye disease 

For years, dry eye disease had the reputation in our profession of being murky and subjective, with no concrete definition or testing and few good ways to resolve patients’ complaints. That was then, and this is now. Dry eye is real, clearly defined, and measurable, and we can treat it effectively.

We need to convey that very plainly to patients. They don’t want to hear that their problem is very complicated, particularly in the case of older patients who may already be dealing with complex health problems.

I explain to patients that dry eye is a single inflammatory disease, with a spectrum of severity or longevity. This framework helps us to more easily understand the disease and target therapies to each patient. In my practice, we diagnose each patient’s disease state with a standardized approach to patient history, point-of-care testing, and dry eye examination.

4. Beyond diagnosis, use testing to educate and galvanize patients 

We continue to demonstrate our understanding of dry eye disease with a thorough testing and examination process, and we use the results to educate patients and ensure their buy-in for treatment.

Our standard battery of testing includes tear breakup time, corneal staining and testing for the MMP-9 inflammatory mediator (InflammaDry, Quidel). If the patient has meibomian gland dysfunction, we do meibography imaging of the glands (LipiScan, Johnson & Johnson Vision).

A thorough slit lamp examination and inspection of the meiboman glands and lid margins are key parts of the dry eye exam. As I talk to patients, I tell them how their MMP-9 numbers compare with normal eyes. I show them images of their blocked or missing meibomian glands alongside an image of healthy glands.

This evidence that their problem is real and measurable encourages their investment in the next step, which is to talk about treatment. A slit lamp photo of their staining pattern, blepharitis, or presence of conjunctivochalasis is often all that is needed to attain patient acceptance of treatment recommendations and better compliance.

By the time I discuss treatment options for dry eye, patients are already confident that I understand the problem. I’ve shown them the evidence. As a result, they are accepting and even enthusiastic about treatment.

Home care regimens are still part of the recommendation, but for patients with more advanced disease, I often recommend prescription medication and a synergistic combination of intense pulsed light therapy (IPL) (M22 OPT, Lumenis) and thermal pulsation therapy (LipiFlow, Johnson & Johnson Vision).

It’s important to take time to explain why this treatment approach might help them where other therapies have failed. I explain to my patients that cyclosporine (Restasis, Allergan) or lifitigrast (Xiidra, Shire) will help the eyes produce more tears with less inflammation, addressing they aqueous deficient component of dry eye.

IPL is a series of light-based treatments that address the inflammatory component of dry eye by treating the capillaries on the eyelids and eye area that promote inflammation, meibomian gland clogging, and pathological changes to the quality and characteristics of the meibum.

Thermal pulsation therapy is a heated massage that addresses the lipid layer of the tear film, thinning meibomian gland secretions and allowing for easier and more thorough expression.

Patients tend to be happy that we’re taking a different approach from previous doctors. In many cases, older patients have had dry eye disease for decades, and they are ready for some relief.

In addition to walking older patients through the process of diagnosis and treatment for dry eye, it helps to understand how their disease might differ from their younger counterparts.

There is a good chance that medications or underlying systemic conditions could be contributing to their dry eye. They could have a neurotrophic cornea or mechanical problems such as conjuctivalcholasis.

My older patients frequently have foreign body sensation and watery eyes. Visual symptoms are significant – some patients without visually significant cataracts think they need cataract surgery because of the effects of dry eye.

By being the doctor who finally understands and educates them about their disease, you can relieve their stress and frustration and give them the care they deserve.


Dr. Desai is the director of the Cornea, Cataract, and Refractive Services at The Eye Institute of West Florida, Medical Director of the Lions Eye Institute for Transplant Research, and President and CEO of Clarity Visionary Consulting.

Dr. Desai is a consultant to Lumenis, TearLab and Johnson & Johnson Vision.

Five strategic ways to care for older patients with advanced dry eye

” 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 

Preoperative treatment of ocular surface disease (OSD) is an asset that many cataract surgeons tend to undervalue. I often talk to peers who treat OSD as a nuisance problem that gets in the way of them proceeding with the ultimate goal of cataract surgery, but for those of us who are outcomes-driven and see that those outcomes help build the reputation and good will we need to grow our practices, treating OSD prior to surgery is an important goal in itself, not a speed bump on the road to surgery.


	If you think treating OSD before surgery is a burden, consider these numbers:

 up to 76.8% of patients presenting for cataract surgery had some form of OSD. At least 50% of them had severe enough OSD central to the visual axis that could negatively affect surgical outcomes if it were left untreated.

In my own practice, I treated patients with epithelial basement membrane dystrophy affecting pre-operative biometry with traditional dry eye therapies, superficial keratectomy, and placement of a cryopreserved amniotic membrane biologically active bandage (PROKERA, Bio-Tissue) for 5 days. After following this protocol, average Ks changed by at least 1D in 50% of patients and up to 2D in 19%. BCVA improved 1-2 lines. If we hadn’t treated the problem before surgery, inaccurate IOL powers would have led to refractive surprises after surgery.

As these studies help illustrate, by treating OSD, our practices accumulate better outcomes and happier patients, reduce costly postoperative chair time and enhancements, and get reimbursed for OSD treatment. It’s a win for patients, physicians, and our businesses.

Pre-Op Care for Mild, Moderate or Severe OSD


	The first step in this process is to get patients to understand the importance of treating OSD before surgery. I tell my patients, “I’d rather do this the right way than the fast way. If a surgeon were to neglect treating this and rush you to cataract surgery, you would have less-than-ideal results and not be as happy as you should be. We want to do this right the first time.” Based on the severity of OSD – mild, moderate or severe – I follow a protocol to get the best achievable outcome.

 – The vast majority of my cataract patients with OSD have the mild form. A below-normal TBUT and clinical signs might indicate mild blepharitis, MGD or SPK. The traditional course of therapy (artificial tears, hot compresses, lid cleansers and nutraceuticals) is usually enough to optimize the ocular surface. If the patient’s OSD involves MGD, rosacea or evaporative dry eye, I may use intense pulsed light (IPL) therapy (M22 Optima IPL, Lumenis) to reduce lid and eye area telangiectasia and break the vicious cycle of inflammation. I try to get in as many IPL treatments as I can before the cataract surgery (spaced 2 weeks apart), but I generally don’t hold up cataract surgery for the IPL series. If I am concerned about biometric accuracy due to OSD, I use PROKERA to normalize the surface rapidly for cataract planning.
		 

 – These patients have mild corneal staining and mild to moderate blepharitis, SPK or MGD. There may be topographic changes on the cornea, such as irregular islands, areas of dropout where data are absent, or inconsistency between biometry modalities. The RMS value is below .4 and does not seem to affect the central 6mm zone. In addition to traditional therapies, I generally start these patients on a steroid taper, as well as an immunomodulator such as cyclosporine (Restasis, Allergan) or lifitegrast (Xiidra, Shire). I consider IPL, as well as thermal pulsation therapy (LipiFlow, J&J Vision) for more rapid treatment of MGD prior to surgery. For patients with moderate keratitis (PEK or SPK), I consider placing PROKERA for 3-5 days without a superficial keratectomy in the more severe eye, and then treating the second eye.
		 

– Patients with severe OSD may have moderate to severe staining inside the 6mm visual axis zone, significant topographical irregularities, pronounced inconsistency between modalities of biometry, an RMS value greater than .4, Salzmann nodular degeneration, or recurrent erosion syndrome.

I follow the same treatments as mild and moderate OSD, while adding other appropriate therapies. For example, I may combine treatments, following thermal pulsation therapy with IPL. For some patients, I combine superficial keratectomy with PROKERA. Not only is the intensity of treatment higher for severe OSD, but it also requires more time for therapies to produce optimal results. Hence, it is important to impress upon patients the value-added benefit of this optimization process in terms of better, more accurate outcomes and greater breadth of choice in lens implant opportunities.


	Postoperative care for OSD begins before surgery, when we teach patients that the problem is chronic and requires long-term treatment. My patients have a long-term plan before surgery, which usually involves continuing traditional at-home therapies and prescription medications. If they have had thermal pulsation therapy and/or IPL, they will return for follow-up sessions, which usually taper to once per year. Patients understand that we have optimized their ocular surface, delivered the surgical outcomes they desired, and now we need to keep their ocular surface healthy and clear.

In our practice, we have seen that optimizing the ocular surface elevates patient satisfaction and word-of-mouth referrals. It also boosts our rates of refractive cataract surgery. Before treating OSD, we would offer refractive surgery to about 50% of cataract patients, but after treatment, that number rises to about 90%. Patients get better outcomes not only thanks to more accurate biometry, but also because they have expanded access to high-technology lenses and procedures. When our patients have better vision and our practice is growing, we cannot look at treating OSD as a nuisance – it is most definitely an opportunity.

is director of Cornea, Cataract, and Refractive Services at The Eye Institute of West Florida; medical director, Lions Eye Institute for Transplant Research; and president and CEO, Clarity Visionary Consulting. He is a consultant to Allergan, BioTissue, Lumenis, Johnson & Johnson Vision, and Shire.

1. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. 

The OSD opportunity: Hard facts and a protocol for cataract patients

: Welcome to “Eye Catching: Let's Chat,” 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 co-authored by 

The only way to treat dry eye effectively is with a 

. The problem is just so multifaceted, from its underlying causes and exacerbating factors to its sign and symptoms (or lack thereof), that there is no single “silver bullet” treatment.

In addition to standard therapies, we have begun pairing intense pulsed light (IPL) therapy using the Optimize Pulse Technology (OPT) of the Optima IPL system (Lumenis) with thermal pulsation therapy using LipiFlow (Johnson & Johnson Vision).

This one-two punch approach is logical: IPL treats inflammation, the underlying cause of dry eye disease. Thermal pulsation addresses meibomian gland dysfunction (MGD), a major component of dry eye pathology, by unclogging the glands and evacuating their abnormal content.

When we treat both the inflammatory source and the resulting clogged glands in patients with symptoms of both problems, we find that they experience long-term, definitive positive effects.

When patients have rosacea or visible symptoms of inflammation, such as telangiectasia, we treat dilated capillaries with IPL’s targeted wavelengths, causing them to involute. The result: leakage of inflammatory mediators is suppressed, interrupting the vicious cycle of inflammation and improving symptoms of dry eye.1

Recently, a few studies have directly demonstrated that IPL therapy reduces the inflammation.

In one study, tear sample levels of key inflammatory markers were dramatically reduced in eyes that were treated with IPL, compared with fellow eyes that were treated with sham.2

Another study using confocal microscopy showed that the density of inflammatory cells in the cornea significantly decreased after IPL.3

With IPL, we treat the entire malar region, from ear to ear, across the lower eyelids and bridge of the nose. This protocol allows us to address a large portion of blood supply to the lower lids as well as some of the upper lids (coming from the lateral part of the eyelid skin).

Treatment spans four sessions scheduled two to four weeks apart. Maintenance treatment starts at around six months and may spread to one treatment per year. Because IPL is used to treat facial rosacea as well, treatment of lower face telangiectasia can be combined with dry eye treatment.

The choice of IPL technology matters. At the Eye Institute of West Florida, when practitioners switched from a system that patients found to be hot and uncomfortable to the cooled head of the Optima IPL, the volume of patients who completed the series of initial and follow-up treatments grew from 80% to 95%.

In addition, the Optima IPL’s OPT feature ensures that the pulses of light are uniform and repeatable. Because the thickness of the skin is so thin close to the lower eyelids, ensuring that the light energy is delivered in a reliable manner is key to safety.

With a keen understanding of the pathophysiology of dry eye disease and the roles of ocular rosacea and MGD, we knew that IPL would work synergistically with thermal pulsation for many patients. MGD is perhaps the most significant contributor to evaporative dry eye (and a factor in aqueous deficient dry eye as well). It is caused by inflammation.

In the presence of chronic inflammation, the meibum’s composition changes to include more mono-unsaturated fats. Those fats have a higher melting point of close to 113 ï°F (45 ï°C)–warmer than body temperature (or the sustained heat of warm compresses). This “buttery” meibum does not melt into the tear film’s lipid layer as it should, and it clogs the glands.

Thermal pulsation therapy combines sustained heat and pressure to liquefy the meibum and clear the glands. Manually expressing glands is less effective, uncomfortable for patients and potentially scarring. Thermal pulsation is gentle and effective. After a single session, patients can experience improvement in signs and symptoms for nine months to one year.4 Anecdotally, we have seen the results last much longer.

When we determine that a patient will benefit from both treatments, we start with IPL, and then perform thermal pulsation within two weeks. We found that performing the first IPL and thermal pulsation on the same day is the most effective and convenient for our practice, but there are alternatives and other clinicians should use their own judgment to find what works best for them. IPL treatments continue at the normal two to four-week intervals until the series is done.

Based on our experience of more than 6,000 procedures of IPL alone, we have seen that the addition of thermal pulsation to IPL can reduce the total number of IPL sessions required before switching to a maintenance schedule (generally from four sessions to three).

In addition, patients after IPL and thermal pulsation reported to us that they notice symptomatic benefits after the first session, rather than after the second or third session as we see with IPL alone. The combination has stretched the IPL maintenance schedule as well.

With two safe and effective dry eye treatments at our disposal, it makes sense to treat signs and symptoms and the underlying inflammation simultaneously. Patients specifically referred to our dry eye clinics appreciate the results, but most patients are surgical candidates whose dry eye must be controlled before surgery and managed postoperatively. With a healthy ocular surface and tear film, we get accurate keratometry measurements and see better postoperative healing.


Steven J. Dell, MD, is medical director of Dell Laser Consultants in Austin, TX. He is a consultant Johnson & Johnson Vision, Bausch + Lomb, Presbyopia Therapies, Ocular Therapeutix, Optical Express, Tracey Technologies, Advanced Tear Diagnostics, and Lumenis.


Neel R. Desai, MD, is director of Cornea, Cataract, and Refractive Services at The Eye Institute of West Florida; medical director of the Lions Eye Institute for Transplant Research; and president and CEO, Clarity Visionary Consulting. He is a consultant to Allergan, BioTissue, Lumenis, Johnson & Johnson Vision and Shire.

References
1. Toyos R, McGill W, Briscoe D. Intense Pulsed Light Treatment for Dry Eye Disease Due to Meibomian Gland Dysfunction; A 3-Year Retrospective Study. Photomed Laser Surg. 2015;33:41–46.

2. Greiner JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Exp Ophthalmol. 2013; 41:524-530.

3. Liu R, Rong B, Tu P, et al. Analysis of Cytokine Levels in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction. Am J Ophthalmol. 2017;183:81-89.

4. Yin Y, Liu N, Gong L, Song N. Changes in the Meibomian Gland After Exposure to Intense Pulsed Light in Meibomian Gland Dysfunction (MGD) Patients. Curr Eye Res. 2018;43:308-313.

 is medical director of Dell Laser Consultants in Austin, TX. He is a consultant Johnson & Johnson Vision, Bausch + Lomb, Presbyopia Therapies, Ocular Therapeutix, Optical Express, Tracey Technologies, Advanced Tear Diagnostics, and Lumenis.

, is director of Cornea, Cataract, and Refractive Services at The Eye Institute of West Florida; medical director of the Lions Eye Institute for Transplant Research; and president and CEO, Clarity Visionary Consulting. He is a consultant to Allergan, BioTissue, Lumenis, Johnson & Johnson Vision and Shire.

1. Toyos R, McGill W, Briscoe D. Intense Pulsed Light Treatment for Dry Eye Disease Due to Meibomian Gland Dysfunction; A 3-Year Retrospective Study. 

2. Greiner JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. 

3. Liu R, Rong B, Tu P, et al. Analysis of Cytokine Levels in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction. 

4. Yin Y, Liu N, Gong L, Song N. Changes in the Meibomian Gland After Exposure to Intense Pulsed Light in Meibomian Gland Dysfunction (MGD) Patients. 

IPL + thermal pulsation: A thorough approach to dry eye

,” 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 Ophthalmology Times or UBM Medica.

When patients first visit my dry eye clinic, they have been seen by an average of 3.2 other eye-care practitioners in the past 3 years. Clearly, although we now know that dry eye affects millions of people, many of whom are in our practices, patients still are not getting the treatment they need.

For these weary patients, our dry eye clinic is the last stop, where they finally find the knowledge, understanding, diagnosis, and treatment they deserve. Intense pulsed light (IPL) therapy, an important and practice-differentiating component of treatment, has helped us provide long-term relief from signs and symptoms. That success has not only built the dry eye clinic’s reputation, but also turned dry eye disease into our practice’s largest gateway for new patients.

Although dry eye affects many people, we see a strong leading demographic in our clinic. These patients are typically women age 45 and older with higher-than-average education and income. Many are married with children and contribute to the care of a parent or in-law. They have very large social networks of friends and family.

These are the powerful demographics every business wants, but they tell us that’s not how they’ve been treated by the 3.2 other practitioners they saw before us.

Patients say they felt dismissed. They were told this is a normal part of aging. They were handed artificial tears or a treatment that didn’t work. When these patients find our practice, they get our interest, validation, and compassion. Their dry eye isn’t a nuisance; it’s a real disease with real treatments.

We perform a detailed, thoughtful, scientific workup. By taking the same approach we’d take for any other disease, we earn patients’ trust-a trust that’s solidified once they see the benefits of treatment.

IPL has been part of our dry eye toolbox for 10 years, and we’ve had technology (Optima IPL, Lumenis) for 3 years. This system delivers controlled amount of IPL energy in every pulse without energy spikes, making its results comfortable and repeatable.

We use this technology in combination with other treatments for many patients with moderate to severe dry eye (the stages of most patients who have long sought treatment) because it treats inflammation, the underlying cause of dry eye disease. We often use it along with thermal pulsation (LipiFlow, Johnson & Johnson Vision), which liquefies the meibum and clears glands affected by meibomian gland dysfunction (MGD), while Optima IPL breaks the vicious cycle of inflammation that causes MGD.

When we talk to patients about IPL, we explain that physicians using the technology for cosmetic treatment of rosacea discovered noted that treatment also improved patients’ dry eye signs and symptoms. We also explain that this IPL technology controls the energy of light delivered in each pulse to treat abnormal blood vessels without damaging the skin. Its constant energy levels and cooled tip mean the procedure has little discomfort or downtime.

It is also important to tell patients why the treatment works. Inflammation changes the character of the meibum, raising its melting point so it remains at toothpaste consistency at body temperature, clogging the meibomian glands. Thermal pulsation can unclog the glands, but IPL has a dual advantage in both helping unclog the glands and treat the inflammation that causes clogging.

We tell patients that they can expect a better tear film, greater comfort and less redness, as well as the added benefit of improved skin tone. We explain that we will be able to measure success objectively with improved ocular surface disease index (OSDI) score, tear breakup time (TBUT), and visibly better glands and meibum secretions.

Acceptance, satisfaction, long-term follow-up

The vast majority of our patients buy into IPL treatment. Once they understand that inflammation is the underlying cause, they see why prior treatments such as artificial tears, or even meibomian gland expression or thermal pulsation alone, did not deliver the results they wanted. The price point is accessible as well.

This IPL treatment is effective and comfortable, which is essential because our patients need to come back for the full series of four treatments, spaced 2 to 4 weeks. We have a very high rate of return.

Older IPL devices had a high initial pulse that was both uncomfortable and potentially damaging to the skin. The head got hotter with each pass, so physicians needed to lower the energy to less effective levels. The Optima IPL delivers fixed energy over 3 pulses, with a very predictable depth and wavelength, and the head is water-cooled for comfort.

Once patients start IPL treatment, they often see and feel dry eye symptoms improve quickly, and they enjoy the side benefits of improved skin tone and color. The satisfaction rate is very high.

After the four initial treatments, I see patients 4 to 6 months later, and then at increasing intervals until we’re doing IPL once per year. We schedule in advance or send reminders, but the patients themselves actually tend to drive the maintenance treatments.

Once they see and feel the effects of IPL, they ask for an appointment the moment symptoms begin to return. Optima IPL is supported by a lot of scientific evidence, but it speaks volumes that patients are calling us for additional out-of-pocket treatments months and years later.

In terms of return on investment, our Optima IPL probably paid for itself within 4–5 months. Beyond that basic metric, this treatment, which is safe and fast and fits easily into our clinic schedule, has helped us build our practice in several ways:

 – For every dry eye patient who enters our practice, those average 3.2 practitioners missed an opportunity. Our practice can seize that opportunity and deliver compassion, knowledge, and results. This level of service requires a multitude of treatment options and a protocol to best utilize them for great outcomes. IPL is a cornerstone because it treats the underlying cause of dry eye, and the aforementioned advantages of the Optima IPL make it an effective choice. 
 

– When we started doing IPL in 2008, we treated 4 or 5 patients every other week. Today, we do 15 to 20 procedures per week, with the Optima IPL helping increase both new patients and our return rate for the full course of treatment. We also perform IPL on a number of cataract patients to optimize the ocular surface for pre-op biometry and surgery in just 1 to 2 months.
 

 – Dry eye brings in so many patients, and once people know and trust us, they often use other services. The Optima IPL can directly help us generate revenue beyond dry eye treatment. Our oculoplastic partner uses the system to treat facial rosacea and vascular legions, as well as for skin rejuvenation and facial hair removal. The same patients get other aesthetic treatments such as injectables as well.
 

 – Treating dry eye compassionately and effectively isn’t the same as performing successful cataract surgery. These folks have seen other practitioners who failed them. Patients don’t simply recommend us-they sing our praises. As a result, dry eye has surpassed cataracts to become the largest gateway for new patients in our practice. Folks in that common dry eye demographic group, the women 45 and up with the wide circle of friends and family, know a lot of people who need cataract or LASIK surgery or want skin rejuvenation. From treating a single dry eye patient very well, our practice sees a ripple effect of exponential growth.

For weary patients, dry eye clinics are often the last stop. Here, they finally find the knowledge, understanding, diagnosis, and treatment they deserve. Intense pulsed light (IPL) therapy, an important and practice-differentiating component of treatment, has helped us provide long-term relief from signs and symptoms.