DRY EYE - where we are now???

[peter56]

Hi everyone, to whome it may concern,
about ten days ago, I placed here the link to a video showing a lecture of Dr Donald Korb on dry eye - MGD etc.

http://www.dryeyephiladelphia.com/po...d-dysfunction/
and on Youtube:
http://www.youtube.com/watch?v=AYjBuWB7jrg -

Drs Korb and Blackie along with 2 teams from Japan are now the leading experts and trend setter on dry eye and MGD.

So I am very surprised and puzzled that not one member of this forum posted a comment or a question after watching this 90 min video.
It is clear, that US people do not believe very much what people outside the USA are saying, but that they do not react on
statements of their own leading experts is really strange!!
Here in Europe only people in the UK are able to understand such english lectures. Since I have no problems understanding
dr Korb`s lecturing, all english speaking patients should also be able understanding what he does say.

It is also clear, that newbies will have problems with all These issues, but even from the experienced old timers came no reactions
to that video.
Here now some remarks on the issues addressed in the video:

1. So the Insiders - ophthalmologists and optometrists do expect a successrate - improvement rate of the treatments of 10-20% only!

2. Debridement of the eye lid line! I have asked here some long time patients if they ever had such a debridement done, they did not know
what it is. I have searched this site for debridement of the lids, no results. So it seems that one of the most important early stage Treatment
is only being performed very rarely. So obviously the majority of ophthalm does not know this essential treatment or they don`t know to apply
the Golf-Club-Spud.
If they don`t know how to do debridement, they have to learn it without causing more damage to the lid margins than good.

3. According to Korb, Lipiflow will not be successful for the long term, if there is coming too much air to the ocular surface during the night.
So the success rate of Lipiflow should be higher, if the patients apply an ointment and a mask-badange for the night.

Are the Lipiflow patients being adviced to wear night protection and apply ointments after getting Lipiflow?

4. If the goblet cells-mucin at the lid wiper are so important to maintain a healthy ocular surface the quest is what can be done,
if the goblet cells are gone. The missing of that very small quantities of mucins can heve terrible consequences.
Transplanting a strip of nasal goblet cell containing mucous will get to big at the lid margins.
Maybe a customerized strip of labial glands from the mouth will solve these problems.

Beside sclerals, the labial minor salivary Gland transpl is currently the only way to help, if too many MG have been destroyed.
It seems the mucin - grease like liquid of the labial glands can replace - Substitute the missing mucins and lipids of the tear film at least
partially.

http://www.osnsupersite.com/view.aspx?rid=6529

http://www.articlesbase.com/medicine...s-5015033.html

Such labial - minor salivary lip glands transpl are now available in Spain, Germany, Brazil, Belgium, France, Argentina and
India. Now also a team from China has published the first positive results of the first 8 patients.

Finally dr Korb got a question on doxy and minoc etc. and his comment is that he never noticed a good therapeutic effects
of these drugs. Does that mean, that many many thousands of patients are suffering from the adverse effects of doxy etc.
without really proven benefical effects?

[peter56]

Here is a link to an article - pdf - on the issues of the Korb Video:

http://www.mcdonaldeye.com/documents...mosimFinal.pdf

New paradigm on dry eye

That is a site of a LASIK clinic!

I don`t know, if there is available a newer - 2013 Version of this article-presentation?

[BigNate]

Peter,

If I understand you correctly, you are making a very bold statement. This is irrelevant to the purpose of this forum, but several links that have been posted by American users have been links to studies done in Japan. Also, many American users take the advice of Dr. Tseng, who I cannot validate but would assume based on his accent is not American. Speaking for myself, I care mainly about what is going on in the US because it is US law that says which drugs I can/cannot take. If I was able to listen to Japanese and Korean doctors, I would be taking Diquafosol right now but it is not sold in my country at this point in time.

Thanks for posting your findings and summary of the 90 minute video. I myself watched the first 50 minutes of it about a week ago and felt the bias towards the benefits of Lipiflow kind of turned me off from the whole video.

[bakunin]

Here is a link to an article - pdf - on the issues of the Korb Video:

http://www.mcdonaldeye.com/documents...mosimFinal.pdf

New paradigm on dry eye

That is a site of a LASIK clinic!

I don`t know, if there is available a newer - 2013 Version of this article-presentation?

I read the file, but I didn't see any new paradigm.

Perhaps only the LWE new, that I never read before. But none new paradigm, none new explanations, none new treatments.

Anyway, salivary gland transplants is a "treatment' that I don't remember seeing a thread about it on this board. I know it is make in Brazil, and I read that the doctor that "invented" it is from the city I'm living now.

[peter56]

Hi all,
here is a link to one of the latest article - fulltext from some of the leading US experts and dr Bron from the UK.

http://www.aaojournal.org/article/S0...624-0/fulltext

[spmcc]

Hi Peter,

1) It will take me a couple weeks to watch a 90-minute video that requires me to focus (eyes and mind). I'll need some more time, please.

2) While I really like Korb and try to keep up on his research, I know some of his patients, and they aren't cured. So, Yes, he's great, but No, he's not that good.

3) For the last couple of years, I've become a little obsessed with goblet cells (after catching a cold and having my eyes feel so good). Since I've done all the *crazy* MG treatments (MG probing, LipiFlow twice, etc.), but I'm still not much improved, I'm beginning to believe that goblet cells (and mucin) are underappreciated. I'm looking forward to hearing what Korb says about goblet cells. Stay tuned...

4) I've seen dogs who had salivary gland transplants. From what I've seen, we're *definitely* not ready to do this to people (IMO).

Thanks for posting the video.

[BigNate]

spmcc,

If you are interested in goblet cells, you should look into Rebamipide and Diquafosol (if you aren't already). They are available in some parts of the world and are in phase III trials in other parts. They seem to both offer something no other drugs currently do, in that they are both defined as secretagogues, which I don't believe are currently offered.

[spmcc]

Hi Nate,

Yes, we're looking into Diquafosol. So far the only idea is to get tetrasodium salt compounded into eyedrops. However, I'm not a big fan of eyedrops in general. I currently use Muro 128 drops and that's it. I wear goggles 24/7/365, have all four puncta sealed, and on and on. Still, I try to avoid putting chemicals on my already sick and sore ocular surfaces. So far that's the best way I've found to "treat" my eyes.

Thanks for the thought though.

[peter56]

Hi SPMCC,
thank you for replying!

1. Obviously dr Korb is one of a very few ophthalm-optometrists that does perform a lid margin debridement for almost all of his patients.
It is terrible imaging, that there are many thousands of dry eye patients, living with these sharp edges at their lid margins that do rub over the
corneas-conjunctiva so many times a day, thereby causing most intensive mechanical irritations etc.
The english Google does not show any results for - lid margin debridement.
The german Google, no results and also no results in French and Spanish.
So obviously almost no ophthalm does know or perform such most important debridements.

2. We here were very alarmed after reading the study from dr Erich Knop and his wife Nadja - Charite-Berlin, on the goblet cells at the lid wiper:
Cornea - issue June 2012.
So these goblet cells at the lid margins do produce the mucin-water gel that makes it possible, that the lids are smoothly gliding up and down during the blinks.
It seems that in the eyes of most moderate to severe dry eye patients, these lid wiper goblet cells have been severely damged or destroyed completely.
The goblet cells do deliver the grease-like stuff - Muc5AC and other mucins for the gliding.
Also the Knop team discovered the functioning of the Lubricin on the ocular surface, as a component of the 6 layered tear film.

So in dry eyes we have missing or reduced mucins and lubricin in the conjunctiva, missing meibum and the most important missing mucins at the lid margins-wipers.

The goblet cells in the parpebral conjunctiva will come back if the inflammation and the dryness have gone.
If patients have Problems and pain even to open their eyes, then it is very likely that they do suffer from the rough lid wipers and the missing wiper mucins.

I don`t know any other Treatment options for such patients than sclerals or the labial-lip Glands transplantations.
Prof. Murube in Madrid has developed the big salivary gland as well as the labial-minor salivary gland transpl about 20 years ago.

Some people in Spain and Belgium that had the labial transpl are the only patients I do know, that were able stopping the scleral lens wearing after the surgery.
As you will know, wearing sclerals for more than 6-12 months, does mean for most patients no way back without sclerals.

3. As a patient living in the USA, did you ever try the Tseng Lipid ointment?
That is the ointment that has to be placed at the outer eyelid above the lashes. There is does melt slowly for 3-4 hours running thereby down onto the cornea.
The Lipid ointment does contain about 52% Mineral oil and other lipid substituting ingredients.

[littlemermaid]

Thank you, Peter, for posting very useful Dr Korb video (total 1:30:37). I listened to it in the kitchen like a radio and looked at his slides if interesting. Thank you, Dr Korb.

dr Korb is one of a very few ophthalm-optometrists that does perform a lid margin debridement for almost all of his patients.

Are we sure? He describes gentle debridement with a smooth instrument at 1:08 but only for people with mild dry eye without meibomian gland function. In the talk he describes different approaches for inflamed eyelids damaging the eye surface (lid wiper epitheliopathy), lubricants as first line treatment.

Dr Korb's sympathetic presentation is a training for docs new to this. Maybe not so much here for expert patients but that's a sign of what's available to us through this fab website. Also useful video on consulting Dr Korb and what he offers.

I liked his sympathy for neuropathic and post-lasik pain. New to me was: A goggle test for evaporative dry eye. The Line of Marks as a swollen ridge seen with lissamine green under the lower eyelid as an indicator of eyelid wiper epitheliopathy (around 1:03).

He says that in trials he didn't show meibomian gland reopening on oral and topical meds for infection and inflammation 'although maybe someone else can' [see PubMed and other videos here in Medical Literature].

Also see question at 1:27:50 'what are the roles of tetracyclines?' Peter, looks like Dr K is primarily interested in gland expression and physical changes in mgd - 'I am not an expert in that area', 'would think very hard before using them', something happened to his daughter after using it.

He didn't touch on prescription drops in development apart from artificial tears he's been involved in.

Useful video before considering Lipiflow. At 1:13:13, he shows blocked glands with meibomography and mentions one treatment would not be enough for that degree of blockage.

Cool 30-second test for lagophthalmos shown at 1:15:11. In dark, shine light down from upper lid fornix, whether can see line of light at eyelid join or not. Good description of how to use gel or mask for that. He describes how successful Lipiflow patients relapse with lagophthalmos.

Liked the slides of fibrosis in mgd and knowledge sharing that he acknowledged from Mass Eye and Ear ocular surface imaging, and teamwork in Boston.

Dr Korb makes an interesting point throughout on managing patient expectations. Honesty and integrity works best, I would think. For me, the problems always start when docs don't make clear what they know/treat and what they don't know/treat, so videos like this are very useful for patient information. He concludes 'Our primary goal is to reverse the [inflammation] cascade' (1:20:40).

wearing sclerals for more than 6-12 months, does mean for most patients no way back without sclerals

Peter, Is this what happens? Have you got refs?

[bunnyrabbit123]

I watched this video too and found it useful in that Korb seemed to be saying that in future dry eye would be treated the same way a dentist treats you, with regular appts.I think that regular careful debridement of lids and expression of the glands would be helpful. Thank you Peter for posting this.

[peter56]

Hi Littlemermaid,
thank you for replaying.

Scleral lens wearing:

Since the reduced blink frequence - Computer Vision Syndrome for example,
are causing chronical MGD, so what will happen in the eyes of scleral lens wearers?
My blink frequence while wearing soft lens is normal - very 4-5 sec.
While wearing sclerals I do blink one time in 2-3 minutes!
Some people wearing sclerals for up to 15 years now, do still have aqueous tears, but no more meibum.
Please refer also to my thread regarding the lid wipers!
The lid wipers - goblet cell Clusters are moving - rubbing on the dry hard plastic of the sclerals without
causing damage do the lid structures?


So at a certain point and time of the dry eye disease, the patients have to make this decision to wear
sclerals or trying to restore a better tear film.
Many people will be forced to wear sclerals, pain, Job, driving etc.
Only some of the patients, that got the labial gland transpl were able to discontinue the sclerals wearing.

[patrick]

good point!
brought this up a few years ago,because to my understanding wearing scleral lenses totally disrupts the mechanism of blinking,wetting and lubricating the cornea.
to my knowledge the corneal nerves are responsible for this action and whenever they're totally isolated from their environment it is only logical they stop sending signals to the brain all together. it seems to me that it is not unthinkable that in the course of time the whole system could shut down. and who knows if this is reversible or not?...
that doesn't mean i don't want to consider trying sclerals,because the thought of being almost completely symptom free is very tempting!..

patrick

[MartyM1985]

Some people wearing sclerals for up to 15 years now, do still have aqueous tears, but no more meibum.
So at a certain point and time of the dry eye disease, the patients have to make this decision to wear sclerals or trying to restore a better tear film.

Peter this is yet another instance of you insisting that wearing contact lenses and/or sclerals destroys the meibomian glands to a point of dysfunction, as well as other potential damage sclerals might cause. Besides the ONE study about contact lenses that has been cited on here numerous times, where is the research or data?

And where is the research or data regarding a decision of wearing sclerals vs. trying to restore better tear film? I doubt it is such a yes or no choice.

I have a hard time with your posts. You consistently post extreme black or white logic on wearing contact lenses and the damage it causes the eyes and MGD glands, and now you are extending that logic to scleral lenses.

Please, if you are going to post such conclusions, provide links to actual evidence or statements from an eye professional.

[spmcc]

Yes, we're looking into Diquafosol. So far the only idea is to get tetrasodium salt compounded into eyedrops.

I checked with Leiter's about compounding Diquafosol.

They wrote:

Unfortunately we have not been able to find a FDA approved supplier for this chemical. Thus we will not be able to compound this at this time.