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Dr Korb's Diagnostics & Treatments incl: Osmolarity, MMP-9, Avenova, Tea Tree Oil

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  • Dr Korb's Diagnostics & Treatments incl: Osmolarity, MMP-9, Avenova, Tea Tree Oil

    I am always curious/interested in learning the latest strategies and right informaion from top experts from USA in diagnosing/treating MGD. These have helped me put my condition under control - mainly
    mastering compress (constant/wet heat, 43C), Pure HOCL (I've found), omega 3 + GLA
    although all doctors said no present of inflammation & almost none recommend omega 3.


    These opinion leaders employ
    Osmolarity, InflammaDry/MMP-9 & recommend pure HOCL, like Avenova (and tea tree oil, tto) etc. Now, I have found more info to support - so excited! I believe in

    objective testing & accurate diagnosis = results & stop progression, NOT trial & error.

    Here is data from Dr Korb company website http://www.korbassociates.com/eyecare-services/dry-eye
    I have also found his latest videos (2016 - published May 2018) & posted in another posting on Blephasteam (warm compress)
    in case someone wants to learn more. https://www.youtube.com/watch?v=vSShGZfxiFg&t=7s

    ---------------------------------------------
    DRY EYE DIAGNOSTICS

    Important tests for dry eye, which were developed through a partnership with Tearscience, Inc., include:
    • Meibography - Enables critical analysis of the structural integrity of the lipid producing glands of the lid.
    • Lipiview Ocular Surface Interferometer - Captures detailed digital images of the lipid content of the tears and quantifies the blinking reflex.
    • Meibomian Gland Evaluator - Measures the function of the glands during normal blinking.
    • Light Test - Diagnoses whether the lids are properly sealing to prevent exposure desiccation.
    • Evaporative Stress Test - Diagnoses whether improvement in symptoms occurs when evaporation of the tears is reduced.
    • Diagnostic Gland Expression - Examines the quality of the meibomian secretions and helps to establish a course of treatment.

    Other diagnostic tests include use of vital dyes, tear osmolarity testing (TearLab) and testing for inflammatory markers (Inflammadry), as well as testing for Sjogren's syndrome and conjunctival chalasis/CCH.

    DRY EYE INTERVENTIONS

    We offer state of the art treatments for dry eye including:
    • LipiFlow Thermal Pulsation System - Treats evaporative dry eye disease, using precisely controlled heat and gentle pressure applied to the eyelids, to unblock obstructed Meibomian glands during a 12 minute, in-office procedure. LipiFlow allows Meibomian glands to resume there natural production of lipid needed for a healthy tear film.
    • Lid Margin Debridement - Removes material from the lid margin, enabling secretions from the Meibomian glands to spread across the ocular surface.
    • Scleral Contact Lenses - Provide a fluid reservoir over the ocular surface which can promote healing of the ocular tissues and protect the surface of the eye from desiccation.
    • EyePrint Pro- is an optically clear prosthetic scleral cover shell designed to match the exact contours of the individual eye.
    • Custom Moisture Chamber Spectacles - Can provide relief from severe symptoms by enabling a high humidity micro-environment. These are also available in personalized prescriptions.
    • Eyelid Cleaning Service- Similar to a dental procedure, the lashes, lid margin, eyebrows and skin of the lids are thoroughly cleaned to control Demodex infestation and blepharitis.
    • Serum/amniotic fluid drops- for severe cases of dry eye these compounds contain growth factors which can promote ocular surface healing and normalization of corneal nerves.
    • Amniotic membrane bandage contact lenses- have been shown to promote healing of severely compromised ocular surfaces, including dry eye.




    These treatments are used in concert with more traditional methods of dry eye management including
    anti-inflammatory medications, lubricants, ointments and punctal occlusion therapy.

    DRY EYE PRODUCTS
    Donald Korb is the inventor of two commonly used dry eye products: Systane Balance™ and Soothe XP™

    Onyix™ sleeping mask http://www.cpap.com/productpage/eyeeco-onyix-eye-s...
    Panoptyx™ dry eye glasses http://www.7eye.com/home.php
    Lid cleansing products such as Tea Tree oil lid shampoos and Avenova™ cleanser http://avenova.com/
    Warm compress towels

    Learn more about dry eye with this intractive website https://www.oscb-berlin.org/

    (this link is provided in Dr Korb webstie - seems they work together??)
    Last edited by MGD1701; 30-Dec-2018, 08:43.

  • #2
    Treatment Options for MGD

    This is what I have prepared some weeks ago. Seems many doctors, even in USA, still do not know several (new) options/tests, I therefore decide to compile this, hopefully it can help you achieve more.

    Below is based on my daily learning/experiments & experience, in the last 2 years (since one & the only dr told me, 'Sorry, I can not help you,') from various American opinion leaders. Remember:
    only right order & combination can achieve (the best) results and save money/glands.

    --------------------------------

    Treatment Options

    BlephEx:
    in-office lid margin (debridement) & lashes cleaning to remove (years of) bacterial biofilms
    important is to find a skillful tech./doctor. more info:
    Dr James Rynerson, MG, https://www.youtube.com/watch?v=mm9uf4vCGyM&t=929s
    Dr Mile Brujic, Sept. 26. 2018 http://www.optometrytimes.com/dry-ey...drome/page/0/1

    Debridement (of the line of Marx & lid margin), invented by Dr Korb
    if capped glands present & to remove keratin from gland ducts/orifices - make lid margin smooth then tear spread evenly. Study shows this helps about 27%.

    Probing, if scar tissue present

    Manual expression (by doctors -- this is the cheapest)
    Prof. Clara Chan, Canada expressed for patients as most of her patient could not afford LipiFlow, IPL

    Mibo, IPL, *LipiFlow (only removes obstruction/blockage)
    Dr Korb mentioned in 2016 video that if one has no acini(?), LipiFlow works 0% so doctor should check this first.

    Some people complain LipiFlow does not help, but other issues are to blame (e.g. inflammation (demodex/bacteria), partial blinking, CCH/folds, medication, allergies, lids sealed issues etc).

    Dr Clifford L. Salinger cleaned lids first then LipiFlow then expressed glands
    ''Dr Periman: treats Clinical signs first, for example, if rosacea, IPL first

    Plugs
    help but make sure there is low/no inflammation

    *True Tear...*FDA approved, only available in USA at moment
    increase ALL layers production - works particularly effective for chronic pain
    trick is put it on the right place

    If Inflammation presents
    1) first BlephEx then LipiFlow
    Prof. Marguerite McDonald mentioned that many opinion leaders NOW employ such combination for a better result, kind of 1+1=2.
    BlepEx + LipiFlow = IPL, my own interpretations.

    2) IPL - particularly effective for people with rosacea/demodex/inflammation issue
    According to opinion leader, Professor Preeya Gupta (from USA)
    most successful for patients with
    advanced MGD, (mild to serve) evaporative DED
    Rosacea or Seborrheic Dermatitis
    Telangectasia lid margins
    a non-laser light source, suitable for almost any patient
    (Dr Toyos, 1st dr who applied IPL to treat dry eye, mentioned in one of his videos that there is NEW model which suits for (almost) all skin types, I recalled)

    --------------------------------
    However, better & still need to:

    Master warm compress (not easy - one American dr even says most people do it wrong. It took me 3 months to realize the tricks. A MGD expert, Dr Caroline Blackie and her team found that so-called Bundle Method, 45C (& re-heat every 2 min), proved to be the most effective. Many drs recommend: Burder/microwave or *Blephasteam/electronic (constant/wet heat of 42.5C) - People have Rosacea/inflammation, be careful with the temperature. In short, the best indication, in my view: should feel 1) oil flowing & 2) great aftwards. Bu it only works if the obsruction is removed.
    *Dr Korb also considers Blephasteam helps. More please read
    http://forum.dryeyezone.com/forum/dr...ueeze-lids-etc
    or watch Dr Korb's 4 videos (2016, published in 2018) I have found
    https://www.youtube.com/watch?v=mZyXyQi-5MQ&t=5s

    mibo heating pad - far infrared heat, usb

    Add omega 3 (+ GLA works more effective, that is why most doctors recommend HydroEye.
    Some recommend PRN, formulation of 3:1 re-esterified EPA and DHA only.

    perform Lid hygiene
    (with pure HOCL to control bacteria overgrow, like *Avenova, only availabe in USA,
    or Heyedrate (from USA but ship to UK etc??) but I have managed to find an alternative, **NatraSan, on the 3rd attempt - so you could try your luck too.) + healthy diet etc. The beauty of it: no resistance like antibiotics.
    **http://forum.dryeyezone.com/forum/dr...eyelid-hygiene
    (my post #9)

    I have discovered all these (compress, omega 3+ GLA, pure HOCL) by myself which help my eyes fit. If I had knew all these, I should be able to reach to this stage in about 2 months not 10.

    Artifical tear for MGD
    with Hyaluronic Acid/HA sometimes work better than oil-based for some people, especially advanced level, new research shows.
    Oil based: Retain MGD and Systance Balance, recommended by most doctors.
    ----------------------------------------------------
    LipiFlow vs warm compress
    LipiFlow
    1) constant heat can go inside the lids
    2) can massage ---- both of which warm compress can NOT achieve.
    Blephasteam has constant wet heat but the heat can not go inside the lids nor massage
    ----------------------------------------------

    Above are just some NEW/basic but important tools.

    PS
    Treatments normally involved 4 areas and should be treated at the same time & in a RIGHT order/combination for the best results

    1) obstruction: IPL, LipiFlow, Mibo, doxy etc.
    2) bacterial biofilm: BlephEx, debridement, pure HOCL spray like Avenova
    3) & 4) tear film stability & inflammation/allergy/demodex
    Last edited by MGD1701; 08-Jan-2019, 10:13.

    Comment


    • #3
      If you want my opinion...some of the tests are unimportant. MMP9, if you have lid disease, then you're going to have high MMP9. I think wjat the test told me was that restasis wasn't controlling my inflammation. So it's not a worthless test, but it's important in what context you use it. Osmolarity, again, I have dry eye and my osmolarity was under 300. Again, I guess it tells me my tears are "normal" saltiness. What you can extrapolate from that I'm not sure. Maybe it signifies that my main problem is not the lacrimal gland, it's just MGD.

      There are a couple on there there that aren't done very often. Testing lid closure I think is huge and rarely done.

      Nice write up.

      Comment


      • #4
        Now I finally understand why objective testings like MMP-9 and osmolarity are important/useful
        as they can rule out other issues which often overlap/mis-diagnosed,

        according to top experts/Professors Preeya Gupta & Chris Starr.
        These could be: allergic conjunctivitis, CCH, Floppy eyelids, SLK, AMBD etc. as
        NOT all tearing and foreign body sensation are dry eye, Dr Gupta means. More
        http://forum.dryeyezone.com/forum/dr...dr-mark-milner


        Dr Starr is regarded as an Osmolarity expert. He believes its accuracy/consistency and
        if something are wrong, there are reasons, perhaps fingerprints, make-up, eye drops etc.
        I also know most doctors in USA also use them to monitor if their treatment plans works.


        MMP-9
        Prof. Gupta added that this testing tells WHEN to initiate anti-inflamatory therapy
        (cortiosteroids, cyclosporine or lifitegrast/Xiidra etc.)
        I know some oponion leaders in USA still treat inflammation even MMP-9 is 'negative'
        as they consider it should not rely on ONE single testing.


        Tear Meniscus Height, TMH to measure tear volume to identify if Aqueous deficiency
        Prof. Gupta considers TMH is more objective (than schirmer).
        Can be detected by *slit lamp (as video below), OCT (Optical coherence, tomography) or Keratography 5M.

        Prof. Gupta considers 0.1mm is aqueous deficient (not sure if 0.2mm too??)
        Both of them mention osmolarity can NOT detect aqueous issue.


        *TFOS DEWS II Diagnostic Videos - Tear Volume (2018 Jan)
        https://www.youtube.com/watch?v=3a8JO45j9wI&t=30s

        phenol red thread - assess the amount of tear production over 15 seconds
        some doctors, incl Dr Clifford L. Salingerconsiders this is more accurate

        Some doctors say if Schirmer with serially abnormal results (below *≤5mm) over time are likely
        autoimmune diseases (sjogren, Lupus etc.)

        *Schirmer’s (I) without anesthesia (*≤5 mm at 5 min) is one of the indicators to classify as Sjogren per
        the American European Consensus Group, Table 5.1.

        I am so happy that I have finally collected all these info so I can identify my causes.
        Last edited by MGD1701; 05-Jan-2019, 08:21.

        Comment


        • #5
          Tear Meniscus Height, TMH to measure tear volume to identify if Aqueous deficiency

          I have been sick of doing schirmer, curious and searching for hard evidences and found out 1) & 2) below.
          I just did one again with anesthesia at a big hospital - first I declined saying it should be done at the end and presented all 9 results (from 0-30) in the past. But the junior dr insisted who had no clue about gland images when I showed míne so I explained what normal glands should look like. Later, the professor decided more tests should be performed. I waited for about 30 minues, I guess it was because I expressed my concerns several times that anesthesia would make results unrelaible. However, I think should wait for 2 hours - professor Starr mentioned similiar things (for the osmolarity test).

          I actually found a dr with Keratograph 5M to check
          TMH but she did not know how - seems many doctors do not know how so I have included the video. If doctors do not even realize schirmer is not objective and should be done at the end and without anesthesia - that is a very big problem.
          Last edited by MGD1701; 19-Sep-2018, 10:13.

          Comment


          • #6
            Originally posted by MGD1701 View Post
            Tear Meniscus Height, TMH to measure tear volume to identify if Aqueous deficiency

            I have been sick of doing schirmer, curious and searching for hard evidences and found out 1) & 2) below.
            I just did one again with anesthesia at a big hospital - first I declined saying it should be done at the end and presented all 9 results (from 0-30) in the past. But the junior dr insisted who had no clue about gland images when I showed míne so I explained what normal glands should look like. Later, the professor decided more tests should be performed. I waited for about 30 minues, I guess it was because I expressed my concerns several times that anesthesia would make results unrelaible. However, I think should wait for 2 hours - professor Starr mentioned similiar things (for the osmolarity test).

            I actually found a dr with Keratograph 5M to check
            TMH but she did not know how - seems many doctors do not know how so I have included the video. If doctors do not even realize schirmer is not objective and should be done at the end and without anesthesia - that is a very big problem.

            --------------------------------------
            Just added
            1) the video on TMH
            HOW?
            watch: TFOS DEWS II Diagnostic Videos - Tear Volume (2018 Jan)
            Clinical assessment of tear volume via lower tear meniscus height measurement .....
            https://www.youtube.com/watch?v=3a8JO45j9wI&t=61s

            2) Schirmer’s without anesthesia (≤5 mm at 5 min) is one of the indicators to classify as Sjogren per
            the American European Consensus Group, Table 5.1
            youre right the schirmer isn't accurate as far as my dr was concerned. He added 50 microliters of saline to my eye and washed it, then retrieved 4 vials of fluid to test for inflammatory markers. My schirmer was 2mm left eye and 3mm right eye. He said to me, you have tears, I added 50 microliters and got back much more. So he believes my schirmer will increase and that the initial results didn't match his findings.

            Comment


            • #7
              Schirmer
              Well, I am 200% sure I am right as I have collected sufficient evidences/experience.

              I did ask the professor at the end, ''Are you sure, schirmer would not affect all testings?''.
              'No', he answered patiently and explained why and did not appear unhappy.
              Well, I was still not 100% convinced so I searched for more evidences.
              I approached the producer of the testing machine I did - Bingo, I am right.

              I have been curious why almost all top opinion leaders in USA, including Dr Korb, do NOT employ schirmer (for some years but they did not mention their alternative) while all my doctors (including 3 big Uni. hospitals) still do it. Just until recently I found out HOW Drs Gupta and Toyos (1st dr employed IPL to treat MGD) measure - Tear Meniscus Height.

              I did about 10 times, half did incorrectly. The one early this year was the most funny - dr told me NO oil came out when she expressed 4 lids - which never happened before so I asked if schirmer/with anesthesia (they just did) was the reason. 'Possible', she answered and did not charge me money.
              Last edited by MGD1701; 12-Sep-2018, 13:30.

              Comment


              • #8
                Dr Toyos mentioned Tear Meniscus Height is more reliable (than schirmer) in one of his lectures/videos:
                1) he did schirmer for years and years but it did not give him any info
                2) with anesthesia will affect testing results and without anesthesia patients would tear so much which ruins schirmer test. ---- These are exactly what I have experienced.----

                Dr Korb briefly mentioned Schirmer in his 2016 videos/part 2, 21:00
                https://www.youtube.com/watch?v=mZyXyQi-5MQ&t=5s

                The problem is there are NO standards doctors could follow.
                Aqueous issue is related to (inflammation and) eventually will develop to Evaporative dry eye per TFOS 2017 report.
                Last edited by MGD1701; 08-Jan-2019, 10:17.

                Comment


                • #9
                  Just read this *article from Dr Laura Periman, dryeyemaster, Jul 25, 2018

                  ''the traditional measurements used (like OSDI and Schirmers) have limited sensitivity and specificity.
                  We are limited by the measuring sticks we currently have.
                  If we don’t get the results we expect, are we looking at a treatment that doesn’t work,
                  or are we just not using the right measuring stick?''


                  If doctors can not dectect such important aqueous deficiency issue accurately,
                  how can they treat us?? How can we stop progression?

                  Dr Periman measures Tear Meniscus Height.

                  *full text
                  http://www.ophthalmologytimes.com/nu...e-beyond-dream

                  PS - once I got schirmer 0, tested in a big Uni. hospital, which I only knew it after receipt of the report (4 months after the visit) and the doctor did not even prescribe me Ikervis nor recommend plugs. Another time in another place, I got 30, for the first time too.

                  Inflammation - MMP-9 test is more accurate as it can detect more things.
                  Last edited by MGD1701; 24-Sep-2018, 13:40.

                  Comment


                  • #10
                    found this is interesting:

                    ''Some traditional tests such as invasive TBUT and Schirmer test have been shown to have a low sensitivity and specificity and can be subject to error in interpretation; however, newer point-of-care diagnostics such as
                    tear osmolarity and matrix metalloprotease-9 (MMP-9) testing have been shown to have a high sensitivity and specificity in diagnosing ocular surface dysfunction.

                    Tear osmolarity ... performed before the instillation of eyedrops or other testing.
                    Patients were unable to have osmolarity testing if they had used artificial tears within 2 hours before testing.

                    Inflammadry test was administered before the instillation of eyedrops.

                    Result
                    ...The majority (44 [57.9%]) of the 76 patients who had abnormal MMP-9 levels were patients who had no previous ocular surface dysfunction. By contrast, there was also a small subset of patients who exhibited a normal osmolarity but had a positive MMP-9 (n = 28), suggesting the presence of non-dry-eye disease, ocular surface dysfunction, or dry-eye disease masquerader.

                    full text
                    https://www.jcrsjournal.org/article/...521-2/fulltext
                    Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation

                    By: Professors Preeya Gupta, MD & Chris Starr etc.
                    From Duke University Eye Center (Gupta, VanDusen), Department of Ophthalmology, Durham, North Carolina, and the Weill Cornell Medicine of Cornell University, Department of Ophthalmology (Drinkwater, Brissette, Starr), New York, New York, USA (2018?)

                    Comment


                    • #11
                      Found this useful.
                      https://www.ophthalmologymanagement....-eye-treatment

                      Comment


                      • #12
                        Just read this interesting/useful article,

                        Why osmolarity should be the top test for tear film evaluation

                        by Marc Bloomenstein, OD, FAAO Sep 26, 2018

                        in particular,
                        ''The Schirmer’s test, for example, is limited from the perspective that all it does is give us a volume of tears coming out of the eye with no information about the quality or property of those tears. Few doctors perform the test because it is not very predictive,...

                        For a patient with aqueous deficiency or an underlying systemic disease such as Sjögren’s syndrome, the Schirmer’s test could be beneficial to demonstrate the basal tear rate. However, we know that dry eye disease is multifactorial, so tear volume limits our ability to understand what is going on. Osmolarity is more definitive of the homeostatic nature of the tear and disease state.

                        Tear break-up time (TBUT) is somewhat informative, but it is not precise and lacks a strong predictive value. If I know that my patient’s tears are breaking up, I do not know the severity or underlying cause of the problem. Frankly, I can look at the meibomian glands and note the apparent lack of uniformity that is most likely occurring. In addition, although low TBUT implies a problem, patients with poor tear quality can have a high TBUT.

                        One of the best metrics for early dry eye disease is fluctuating vision, which is one of the first signs of a decrease or change in tear quality. I ask patients if their eyes get watery—can they see better if they blink? With the increased use of monitors, phones, and streaming videos, we see more and more symptoms at younger ages.

                        http://www.optometrytimes.com/dry-ey...ation/page/0/1
                        Last edited by MGD1701; 08-Jan-2019, 10:20.

                        Comment


                        • #13
                          Have added how Dr Neel Desai combines IPL with LipiFlow, on above #2 - which I find interesting.

                          Dr. Desi: When we combine IPL with LipiFlow –- IPL immediately after the first LipiFlow – patients typically notice a benefit after one or two treatments.
                          LipiFlow does such a good job of unclogging the glands, and then
                          the IPL works on the source of the inflammation and the clogged glands. Patients certainly need fewer maintenance treatments for both, spaced at greater intervals.

                          Comment


                          • #14
                            Found this useful - Do you all got such data?
                            what is ''Dynamic objective scatter index'' anyone knows?

                            ------------------------------------
                            ''Dry eye care must rely on objective methods to define structural and functional alterations of the lacrimal functional unit. We have the same approach in glaucoma with assessment of optic nerve structure and function. A consistent, disciplined use of metrics in dry eye care enables improved diagnostic accuracy and effective targeted therapy (See “Dry eye metrics,”). In addition, patient trust and cooperation with treatment recommendations are enhanced.''

                            Dry eye metrics


                            Useful dry eye metrics utilized at Bowden Eye & Associates include:
                            • SPEED score
                            • Tear film osmolarity
                            • MMP-9
                            • Meibomian gland count
                            • Meibomian gland score
                            • Dynamic objective scatter index
                            • Tear film lipid layer thickness
                            • Partial blink ratio
                            • Meibography grading
                            • Meibum grading and corneal staining pattern



                            https://www.ophthalmologymanagement....gy-integration
                            Oct. 1 2018

                            by
                            Frank W. Bowden III, MD, FACS,
                            is a cornea, refractive, glaucoma and cataract surgeon. He is a recognized dry eye expert. He is the medical director and founder of Bowden Eye & Associates. Dr. Bowden is also the president and medical director of Eye Surgery Center of North Florida. He is a founding partner of Dry Eye University and Dry Eye Access.

                            ---------------------

                            I recently learnt, from Dr Clifford L. Salinger preseation 2015, that positive predictive value for
                            osmolarity 87%
                            Tear Meniscus height 33%
                            staining 31%
                            Schirmer 31%...I actually think should be maybe 10%, 95% experts in USA do not use it for dry eye anyway

                            TBUT is only 25%
                            (I recall some drs, like Toyos and Prof. Starr consider non-invasive TBUT is more objective.
                            (They think TBUT by fluorescein dye irritating). My NI-TBUT are always almost double than TBUT.

                            (wonder why phenol red thread is not listed as he considers it is more accurate - for the tear volume)
                            Last edited by MGD1701; 22-Oct-2018, 12:20.

                            Comment


                            • #15
                              https://www.ncbi.nlm.nih.gov/m/pubmed/27438542/

                              based on on what I read of dynamic objective scatter index...it’s used to measure how light passes through the tear film post blink. It’s a way to discover early variance in the tear film in asymptomatic dry eye patients. So it may be able to predict dry eye before it becomes evident to the patient.

                              Comment

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