BOSTON, Mass. (Ivanhoe Newswire) - Dry eye disease is caused
by a variety of things and standard treatment usually means medications, daily
eye drops, and ointments. Now there's a
new eye-opening option for sufferers and it only takes few minutes.
"I felt like I had a piece of glass in my eye," dry eye
patient, Diana Galson-Kooy, told Ivanhoe.
Diana Galson-Kooy has suffered with dry eye disease for
years.
"I've kind of gotten used to the pain," Galson-Kooy said.
It is caused by things like prolonged contact lens wear,
birth control, anti-histamines, and even staring a screen. vaporative dry eye affects the glands that
make tears.
"Her tears that she's making are leaving her eyes much
quicker than she should be," Dr. Ernest Kornmehl, MD, FACS, at Kornmehl Laser
Eye Associates told Ivanhoe.
Dr. Ernest Kornmehl
said, like Diana, the majority of his patients come in for dry eye treatments.
He is recommending this treatment for many.
"Perfect, you're doing wonderfully," Dr. Kornmehl said.
It is called LipiFLow.
"It takes 12 minutes and patients go to work immediately
after the procedure," Dr. Kornmehl explained.
Cups surround the eyelids.
They heat up and pulsate to melt blockages in her tear glands.
"It doesn't hurt. It
just is strange," Galson-Kooy said.
In FDA trials, 79 percent of LipiFlow patients showed
improvement. The doctor said those
improvements can last nine to 15 months.
Some LipiFlow patients, like Diana, will still need additional
treatments.
"They find themselves not taking the drops or ointments as
they were before," Dr. Kornmehl said.
"My eyes feel lubricated," Diana said after treatment.
It has brought some much needed tears to her eyes.
"It was unbelievable," Diana explained.
LipiFlow is FDA approved, but it is not covered by
insurance. The cost per eye can range
between $700 and $1,100.
RESEARCH SUMMARY
BACKGROUND: Dry eye syndrome is a common disorder of the tear
film. Dry eyes occur when tears are not able to provide enough moisture
for the eyes. For example, dry eyes will occur if the eyes are not
producing enough tears or if the tears are poor quality. Tears are a
mixture of water, fatty oils, and mucus. They help make the surface of
the eye clear and smooth while protecting against infection. For some dry
eyes can occur when there is an imbalance in the composition of tears.
Dry eyes can cause the eyes to sting and burn. Certain situations may cause you
to feel this pain of dry eyes, such as while riding a bike, or looking at a
computer screen for long periods of time. (Source: mayoclincic.com)
RISK FACTORS: Decreased tear production is a major cause of dry eye
syndrome. Certain factors may put you at risk. Factors include:
Being older than 50. Tear
production diminishes as you get older.
Being a postmenopausal woman. Lack of tears is more common in women, due
to hormonal changes.
Having a medical condition that reduces tear production. For example,
diabetes, lupus, scleroderma, rheumatoid arthritis, Sjogren's syndrome, vitamin
A deficiency, and thyroid disorders.
Having laser eye surgery.
Eyelid problems can also put you at
risk. Blinking spreads tears across the surface of the eye. If
there is an eyelid problem that makes it difficult to blink, tears may not be
spread across the eye adequately. Certain medications are also a risk
factor for dry eye disease; for example, drugs that are used for high blood
pressure, hormone replacement therapy, antidepressants, antihistamines, and
isotretinoin. (Source: mayoclincic.com)
TREATMENT: Dry eye syndrome goes beyond having irritated
eyes. It can cause frequent eye infections, scarring on the surface of
the eye resulting in vision loss, and decreased quality of life. For most
with mildly dry eyes, treatment includes over-the-counter eye drops. If
symptoms are more severe, treatment depends on what is causing it. If it
is caused by medication, then doctors will suggest switching medications.
Also, if there is an eyelid condition, then the doctor may refer you to an eye
surgeon to correct the problem. (Source: Mayoclinic.com)
NEW TECHNOLOGY: A revolutionary way to help treat dry eye syndrome is the
LipiFlow Thermal Pulsation System. It helps treat dry eyes by opening and
clearing blocked glands, which in turn will allow the eyes to resume the
natural production of oils (lipids) needed for the tear film. It's a fast
procedure that works by applying heat and light pressure to the inside of the
eye lid, allowing lipids to be released from the Meibomian glands. In a
clinical study, 79% of patients reported improved dry eyes within four weeks of
a single treatment. (Source: lipiflow.com)
INTERVIEW
Ernest W. Kornmehl, M.D., F.A.C.S.,
Medical Director at Kornmehl Laser Eye Associates talks about a new treatment
for dry eye.
Tell us what Diane is going through
right now?
Dr. Kornmehl: Diane is having a procedure called Lipiflow. She is
having it because she has evaporative dry eye. That means her tears that she's
making are leaving her eyes much quicker than they should be because the lipid
in her lids is abnormal. Diane has a chronic inflammation in her lids resulting
in thickening of the secretion. It should be a watery secretion and in her case
it's very thick. As a result the lipid layer which is the outer layer of the
tear film that prevents the water from evaporating is not working well and
therefore her tears are evaporating too readily.
How often do you see this?
Dr. Kornmehl: Every day, many, many times every day. Rosacea, a skin
condition that affects the glands in patient's lids, is common in people of
Northern European ancestry such as the Irish and English. These ethnic groups
populate much of New England. Many of these patients have meibomitis, often
associated with rosacea, which is inflammation of the lid margins.
What is the traditional treatment
for dry eye?
Dr. Kornmehl: For evaporative lid disease the standard treatment
would be warm compresses and sometimes we place them on medicine called
doxycycline which acts to thin the secretions of the lid margins. However when
the secretions become too thick they can't reach the boiling point to thin the
secretions so many patients are doing warm compresses and they're just not
effective. I personally don't recommend lid massage because I have seen too
many patients induce astigmatism, where the eye which is normally shaped
like a basketball becomes shaped like a football. Patients who rub their eye
can change the shape of their corneas over the long term.
So lipiflow is a newer treatment?
Dr. Kornmehl: Lipiflow is a new treatment and it's another important tool
in our armamentarium. The level of disease will determine whether or not a
patient will have Lipiflow alone or will also be placed on doxycycline. Many
patients with this lid problem also have aqueous tear deficiency which is
normally thought of as dry eye. Aqueous tear deficiency is only seen in about
thirty percent of patients where about seventy percent of patients have
evaporative dry eye. So many times both of these diseases have to be treated at
the same time. First they have to be diagnosed and then both have to be
treated.
So how effective has lipiflow been
for people with dry eye and maybe people with both?
Dr. Kornmehl: It's been very effective. How effective it is and how
much better patients will feel after the treatment will be determined by how
advanced their disease is. Patients who still have a good number of glands,
although they are not functioning very well will have a lot of relief following
the treatment. The secretions are very thick and these patients symptomatically
do best a month after treatment. But if patients come to us with very few
glands, the goal is not f symptomatic relief but maintainance of the glands
that they have to prevent the disease from getting to a dangerous level.
And that's once every nine to
fifteen months?
Dr. Kornmehl: Yes, patients should have lipiflow every nine to fifteen
months. The FDA studies showed that was the time period it remained
effective. And of course it will vary from patient to patient.
And is it best for mild to moderate
but maybe not severe?
Dr. Kornmehl: Well it's optimal if patients have mild or
moderate disease and that way they never get to the situation where they're
going to have advanced disease which is much more difficult to treat. Patients
are certainly going to symptomatically improve or feel a lot better if they
have mild or moderate disease. Patients with severe disease could feel better
as well but our goal in many of these patients is to maintain the glands they
have so they don't put themselves in further danger.
So for the majority does this mean
they don't have to take drops at all?
Dr. Kornmehl: For patients with mild or moderate disease that can be true
in many patients. Although I like to tell patients that the goal of this
treatment is to maintain their glandular function. Fortunately many of these
patients do feel much better. When you ask them patients realize that they're
not taking drops as frequently or not at all. Many patients on the other hand
receive other treatments as well to give them optimal results. So each patient
has to be looked at individually and followed closely. A thorough evaluation is
performed so we can tell a patient what their likely outcome will be, whether
it will be symptomatic improvement or simply to maintain function.
So were you excited when this first
came out, how excited are your patients?
Dr. Kornmehl: LipiFlow comes with a diagnostic tool called LipiView. The
technology is exciting because it allow us to actually see how thick, in a more
objective and quantitative way, the lipid layer is and correlate it with the
meibomium gland evaluator to see how many glands are functioning as well
as the viscosity of their secretion. This is important because it gave us
numbers which is helpful instead of making a qualitative judgement. Prior
to lipiflow I had many patients with toothpaste like secretions on warm
compresses. They were nor very effective because the secretions were so
thick that the warm compresses could not reach the boiling point necessary to
melt the thick secretions. they couldn't reach the boiling point to liquify the
secretions. So it wasn't really very effective except wasting the patient's
time and perhaps maybe just making them more comfortable with that hot pad on
their eye. Also what we find with warm compresses is that once patients feel
better they just stop doing them. Unfortunately, that's just human nature.
They'll stop doing it and then they will become symptomatic again and
unfortunately it then becomes a very helter skelter treatment modality at that
point. If patients would do warm compresses on a daily basis when their disease
is mild or moderate they would be more effective.
So who do you recommend LipiFlow to?
Dr. Kornmehl: The patients and I have a detailed discussion about the type of
dry eye that they have -- whether it's evaporative, whether it's simply tear
deficient or whether it's mixed. There are many patients with mixed disease.
How many glands they have and the viscosity of the secretions will determine
whether or not we recommend LipiFlow to them.
So that is what you would recommend
for the majority of patients?
Dr. Kornmehl: For patients with moderate to severe disease it's highly
recommended. In an optimal world where cost is not an issue patients with early
disease would also get the treatment. But there is a cost associated with it so
each patient has to judge with their doctors whether or not this would be best
for them at this time.
This is not covered by insurance and
comes right out of the patient's pocket?
Dr. Kornmehl: Exactly. In an ideal world everybody would get it.
What is the cost?
Dr. Kornmehl: The cost varies on whether or not LipiView is include in the
price.
Any side effects, any down sides?
Dr. Kornmehl: No we haven't had any side effects. The beauty of this
procedure is it's low risk benefit ratio. The treatment is outpatient, it takes
twelve minutes and patients go to work immediately after the procedure.
What are the results?
Dr. Kornmehl: What we notice is many patients feel well for the first
three days and notice a significant improvement then they return back to their
pre-lipiflow state. Then four to six weeks afterwards they notice
significant improvement that lasts anywhere from nine to fifteen months.
So if someone gets it and starts to
feel the same after the treatment in three days, they shouldn't freak out?
Dr. Kornmehl: No, and then there are some patients that take even longer.
We keep an eye on the patients and many times for the first month they're
maintaining the regiment that they were doing before the Lipiflow. What we
often see is that many patients with mild to moderate disease find themselves
not taking the drops or the ointments as they were before and no longer doing
their compresses. My feeling is they should continue to do the compresses and
just get in to a habit of it and think of it as ocular yoga. It probably
reduces their blood pressure as well but unfortunately most busy people don't
have the time to do that.
How long does it take?
Dr. Kornmehl: Well five to ten minutes but it's something that people just
don't do. Many patients say to me, doctor I'm just not going to do it. I'm too
busy traveling. I've got kids. Then they say I just want Lipiflow and that's
it. But unfortunately just like anything else, you'd like them to take a certain
number of drops a day but they're not going to do it, they're just too busy.
Anything else you want to add?
Dr. Kornmehl: Well we've been absolutely delighted with the results,
it's been a very important new tool in our armamentarium and its been proven
very effective in our hands as it was in the FDA trial. Patient selection is
extremely important and it's important that each patient be given an idea of
the likely benefits that they're going to have from the procedure. And that
would be determined by how extensive their disease is.
Will this become the new standard of
care for dry eyes?
Dr. Kornmehl: I think it will become the standard of care.
Is dry eye very common?
Dr. Kornmehl: Yes, dry eye is extremely common it's ubiquitous. Most
patients that come in to our office have dry eye. We do a lot of laser vision
correction in patients that have worn contact lenses for many years. The
contact lenses themselves induce dry eye over the long term by decreasing
corneal sensation resulting in decreased tear production. So patients are
getting dryer and dryer but they feel it less and less. In addition birth
control pills are also a common cause of dry eye in many women. Patients that
are on antihistamines have dry eye. Women as they move along in years become
dryer starting in their forties. So that's also very common. Patients that are
on hypertensives also have dry eye. Depending on what part of the country you
live in rosacea is a common disease that affects the meibomian glands resulting
in dry eye. So patients will come to me with either melbomian gland
dysfunction, aqueous tear deficient dry eye or both.
So a lot of things can cause dry
eye?
Dr. Kornmehl: Correct and patients are beginning to notice their dry eyes
much more now than they ever have because we're becoming a much more
electronically guided society. People are on computers much longer, if you have
children you probably noticed that instead of calling their friend and being on
the phone for an hour they'll be chatting on the computer for an hour.
So our own exposure?
Dr. Kornmehl: Our own exposure, yes. And patients always ask why they're
always dryer after watching TV or reading a book. It's because they don't blink
as much. And so when you go to a movie or read a book or watch TV your eyes
don't blink as much and you get greater evaporation. Particularly if you have
melbomian gland dysfunction. Therefore because warm compresses are often
tedious and patients aren't going to do them in many cases, I think it's safe
to say that lipiflow is becoming the standard of care for dry eye treatment and
for patients with melbomian gland disease.
So can you recommend any home
remedies?
Dr. Kornmehl: Well warm compresses are wonderful if you'll do them. But
unfortunately if you have advanced disease and the secretions are too thick
it's not going to reach the boiling point where the secretions will thin
and be effective.
Is that the only one -- warm
compresses?
Dr. Kornnehl: And doxycycline. Doxycycline for patients with meibomium
gland dysfunction is also effective. I find that with many of my patients we're
recommending doxycycline with lipiflow to see if there synergistic and more
effective than either one alone. And if patients think about blinking that will
also be a good thing.
How has lipiflow helped patients?
Dr. Kornnehl: When you do an FDA trial obviously you want to test
the modality so you can't have alternative therapies going on when you're doing
the treatment. With Lipiflow alone seventy nine percent of patients showed
improvement. Now in the real world we use other modalities as well so that
number is even higher and it's even more customized to the individual patient.
So we see wonderful things with Lipiflow in the future for doctors who are using
multi model treatments.
Is there a chance of it being
covered by insurance?
Dr. Kornnehl: Unfortunately with today's healthcare you could think
of it as a set amount of money. And for them to cover something else they would
have to take something else away. So coverage is not likely in the near future
Should medicare cover something like
this?
Dr. Kornnehl: Well I suspect something would have to be lifesaving or
immediately sight saving. And that's true in other areas of medicine as well.
The way healthcare is going patients are going to have to be more and more
responsible for paying for much of their care. And that's unfortunate
especially when we have a treatment that could improve the quality of their
life.
Are there other costs?
Dr. Kornmehl: Yes, tears and ointments are very expensive. You can
go and get a little bottle of tears for ten or fifteen dollars that doesn't
last very long. And many of our patients have to be on tears without
preservatives and that's even more expensive. There is a significant cost with
Lipiflow but if a patient is being treated for mild to moderate disease they
have to take tears and ointments less frequently and that's a cost savings. So
in the end it probably equals out.
Can all patients take Doxycycline?
Dr. Kornmehl: Doxycycline is effective for many patients unfortunately
many patients can't take it. It can cause gastritis and/or esophagitis which is
inflammation of the lining of your stomach or your throat. So you have to
be very careful. So when we give patients Doxycycline you have to tell them
they must take it with food and they have to be careful and aware of any sign
because they have to stop it immediately. It also can induce a rash in patients
when they're out in the sun. So it can be a dangerous drug if not used properly
and under supervision. It's an oral treatment and many patients have acid
reflux and are not candidates for doxycycline. For these patients Lipiflow has
been a God send.
And what does Doxycycline do?
Dr. Kornmehl: It thins the secretion in the lid margins. Many
patients cannot take Doxycycline. Pregnant women, woman that are that are
lactating or breast feeding can't take Doxycycline..
Twenty two million, where does that
number come from?
Dr. Kornmehl: Epidemiologic studies. I would suspect the number is much
higher than that.
Is dry eye something to pay
attention to?
Dr. Kornmehl: Contact lens induced dry eye is the most insidious form of
dry eye because their eyes are numb. Normally if your surface breaks down a
little bit your eye would say there's something wrong and maybe I'd better see
someone if it doesn't get better in a day or so. A patient with dry eye on the
other hand may have a cornea that has significantly reduced corneal sensation
and is numb. These patients have a greater likelihood of getting a corneal
ulcerh. Patients with all forms of dry eye who have break down of the corneal
surface may sense a low grade irritation but if they are one of the unlucky
ones they too are prone to a corneal infiltrate or an infection because it's
the surface cells that prevent these organisms from entering the eye. In
addition when the corneal surface is irregular you just don't see as well. And
many patients will notice if they blink a few times quickly they see better for
a second and then it gets worse again if it's not managed.
Do patients feel better after the
lipiflow?
Dr. Kornmehl: Yes but it may take 4 – 6 weeks. By stabilizing the tear
flow it's like you have a nice smooth mirror instead of having spots on the
mirror. It's like looking through spots on the mirror when you have surface
breakdown . But when your corneal is nice and clear it's like a beautiful
mirror where you get a great reflection and you see much clearer. And that's
why when we do laser vision correction it's imperative that one optimize their
dry eye prior to having surgery.
Do wearing contacts make you more
susceptible to dry eye?
Dr. Kornmehl: Yes. Years ago this wasn't understood but certainly it's been
understood for a number of years now. We find it very important to
educate general ophthalmologists and optometrists who are fitting many contact
lenses particularly in children. There is nothing wrong with contact lenses if
worn properly but children and adults should be advised to limit their wear
time. They should wear them to school and then if they're coming home and just
going to study they should take them out. If they're not doing anything on a
Saturday don't wear them. That way they can wear them safely for many,
many years. Don't overwear them and certainly never sleep in them. Sleeping in
lens really should never be done under any circumstances. Not only because you
are more likely to have dry eye from the long term lens wear but also because
you have a seven or eight times higher risk of ulceration if you sleep in your
lenses.
So contact lens were part of Diane's
issue?
Dr. Kornmehl: Yes, her mechanism for dry eye is multifactorial. She has
both aqueous deficient dry eye as well as meibomian gland dysfunction. So both
have to be managed.
FOR MORE INFORMATION, PLEASE
CONTACT:
Ernest Kornmehl, M.D., F.A.C.S.
Kornmehl Laser Eye Associates
(781) 237-3366
info@visionboston.com
