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Brimonidine tartrate. More commonly known for its IOP-lowering effect, this also has anti-inflammatory properties. 20,21 Ocugen is working toward FDA approval of a twice-daily preservative-free drop of 0.2% brimonidine ophthalmic solution for the treatment of DED called Ocu310. It is a nanoparticle formulation of 0.2% brimonidine designed to increase the drug’s efficacy by prolonging retention time on the ocular surface. 22 Data from recent Phase III clinical trials is expected in the second half of 2019. 22 Unconventional Targets Cohn GS, Corbett D, Tenen A, et al. Randomized, controlled, double-masked, multicenter, pilot study evaluating safety and efficacy of intranasal neurostimulation for dry eye disease. Invest Ophthalmol Vis Sci. 2019;60(1):147-53.
Perhaps the most well known scleral lens used to treat ocular surface disease is the BostonSight® PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) lens (Boston Foundation for Sight, Needham, MA). The PROSE lens is custom designed using patient eye measurements so that the lens is not touching the apical or peripheral cornea but still maintaining minimal movement and optimizing fluid ventilation. An early retrospective review of 49 consecutive patients (76 eyes) with ocular surface disease treated with this lens found a 92% improvement in quality of life as a result of reduction in photophobia and pain. 53% of patients in this study achieved 2 or more Snellen lines of improvement in visual acuity. 67 Agranat et al. reported long-term follow-up data and found that 64% of patients using PROSE for ocular surface disease reported continued wear at five years. In patients with OSD and continued wear at give years, National Eye Institute Visual Function Questionnaire (NEI VFQ-25) scores increased initially and after five years of wear (mean increase +27.17 and +18.80, respectively). 68 A number of other retrospective studies have further demonstrated the ability of PROSE to significantly improve dry eye signs and symptoms in OSD, including various cases that result from Stevens Johnson Sydrome, chronic GVHD, and even neurotrophic keratopathy following skull base tumor resection. 69– 75 In a prospective, interventional case series of 38 patients with ocular surface disease, Stason et al. reported that PROSE significantly improved visual acuity and visual functioning, according to the NEI VFQ-25. 76 Currently, in-office MGD therapies are not fully covered by insurance, leaving patients with a large portion of the financial burden. Patient education regarding the benefits of in-office treatment in addition to home therapy is critical in establishing buy-in when it comes to cost and compliance. As practitioners, we must stay abreast of the latest technology and look to clinical data to determine which procedures to implement in our practices for the betterment of our patients’ lives.
Tauber J, Owen J, Bloomenstein M, et al. Comparison of the iLUX and the LipiFlow for the treatment of meibomian gland dysfunction and symptoms: a randomized clinical trial. Clin Ophthalmol. 2020;14:405-18. IPL (Intense Pulsed Light). Intense pulsed light, or IPL, was originally developed for use in dermatology. Brief, powerful bursts of light at specific wavelengths (in this case, between 500 and 800 nm) cause changes in blood vessels near the surface of the skin, raise skin temperature and eliminate problematic flora on the skin and eyes, all of which may have a beneficial effect on meibomian gland dysfunction. (Many devices capable of producing this effect are on the market, but a popular one is the Quadra Q4 produced by DermaMed Solutions [Lenni, Pennsylvania].) This means that you’re not having to buy as many eye drops, including over the counter or prescription drops. Does it work?
Accurately diagnosing obstructive MGD requires a combination of patient history, slit lamp exam and use of vital stains. While conducting your slit lamp exam, use your fingers or a cotton tip applicator to perform diagnostic expression of the central to nasal glands of the inferior lid. Press and hold for several seconds, noting the presence or absence of secretions and their quality. Borchman D. The optimum temperature for the heat therapy for meibomian gland dysfunction. Ocul Surf. 2019;17(2):360-4. Sabeti S, Kheirkhah A, Yin J, et al. Management of meibomian gland dysfunction: a review. Surv Ophthalmol. 2020;65(2):205-17.
In 2015, Toyos and colleagues published a retrospective review of 91 patients presenting with dry eye symptoms who were treated with IPL. They found that 93% of patients had improvement in symptoms and 87% improvement in TBUT over a median of four follow-up visits. Thirteen percent of patients reported adverse events, mostly related to localized redness and swelling, but there were no significant adverse events. 31 In addition, several other retrospective studies published have also indicated improvement in signs and symptoms of dry eye disease following IPL therapy. 33, 34
O ur understanding of the multifactorial nature of meibomian gland dysfunction (MGD) has evolved significantly since the early 1980s when the term “MGD” was first coined. 1 There is now a wealth of in-office interventions practitioners can implement in addition to at-home maintenance therapies. 2,3 Despite advancements in MGD treatment, however, these procedures are not fully covered by insurance and can pose a significant cost to the patient. By developing our comprehensive knowledge of MGD therapies, we as practitioners can more effectively identify which procedures will benefit the greatest number of patients, balance improvement in quality of life with cost and build patient loyalty within our practices. Exploring MGD Marco Advancing Eyecare. Equinox low level light therapy. marco.com/product/equinox/. Accessed March 2, 2021.While Lipiflow is a first-of-its-kind device to treat MGD-associated DED, several new treatment approaches are on the way that also hold promise for providing relief. However, one major limitation to the use of scleral lenses for dry eye disease is the lengthy and costly fitting process that may not be covered by insurance. In addition, there are currently only 12 eye care institutions that offer PROSE treatment, which can further limit accessibility to patients due to proximity or the cost of travel. In light of these limitations, the Boston Foundation for Sight launched a new scleral lens fitting system in January 2017 called BostonSight® SCLERAL. This web-based, data-driven fitting system allows patients to be fitted with far fewer modifications and by their regular, local eye care practitioner, thus providing a less costly and more convenient alternative to the PROSE system, though less customized. Li B, Fu H, Liu T, et al. Comparison of the therapeutic effect of Meibomian Thermal Pulsation LipiFlow on obstructive and hyposecretory meibomian gland dysfunction patients. Int Ophthalmol. 2020;40(12):3469-79. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II report executive summary. Ocul Sur. 2017;15(4):802-12. Dr. Akpek says she uses IPL on a regular basis. “I find that it’s very effective in severe dry-eye cases with significant disease,” she says. “It’s effective for both anterior and posterior blepharitis, particularly for treating Demodex mites, which are more common than most physicians think. However, IPL can be painful, it mostly treats the lower lid, and it cannot be used on darkly pigmented individuals.” For more information, visit dermamedsolutions.com/spa_equipment/ intense_pulsed_light/overview/.
O’Neil EC, Henderson M, Massaro-Giordano M, et al. Advances in dry eye disease treatment. Curr Opin Ophthalmol. 2019;30(3):166-78. Cyclosporine (CsA).The last decade has seen a tremendous growth in our understanding of the pathophysiology of DED, and treatment options have shifted from solely artificial tear supplementation to disrupting the underlying disease processes such as inflammation. 4 Many new and future dry eye drugs target the cycle of inflammation on the ocular surface that perpetuates this disease. 5
'Deep cleaning' devices for dry eyes
NuLids is a new at-home system that works by gently stimulating and rejuvenating the Meibomian glands and is an effective alternative treatment for dry eye disease. Whether you have dry eyes, blepharitis or Meibomian Gland Dysfunction, Nulids can be effective for you.
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