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Part One: Our Dry Eye Clinic Evaporative Dry Eye Education and Evaluation

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  • Part One: Our Dry Eye Clinic Evaporative Dry Eye Education and Evaluation

    Good Day Everyone

    I've recently been posting about my practices experience with Evaporative Dry Eye/Meibomain gland dysfunction and use of the LipiFlow system, and I have received multiple questions.

    I'm going to post two large posts that should provide most answers as to our experience with the system, the patient experience at our dry eye evaluation, and some education on expectations, outcomes, results, and post operative treatment. So grab a hot drink, and get ready to read

    A brief history: I have been battling dry eye on a personal level for over eight years. It was around my sophomore year of college that I began to notice waking up in the morning with dry, red, eyes. I didn't think too much of it at the time, and thought using one of the over the counter "get the red out" drops would fix the problem, and started using those 4-5 times a day (not a good idea). My eyes soon became even MORE red. After stopping this drop, things got a little better, but every evening around 6:00 pm, my eyes would have a pinkish/red color, and every morning when I woke up, it felt as if someone had rubbed sandpaper across my eyes.

    Over the last few years, I had tried almost every pharmaceutical, natural, or home remedy dry eye treatment I could find online.

    Below is a list of what I had tried
    -Artificial Tears Drops (often 10-12 x day with no relief)
    -Lubricating Gels at bedtime
    -Steroid drops
    -Warm compress with a hot washcloth and the rice-in-the-sock method
    -Lid scrubs
    -Fish Oil (3000 mg of triglyceride form)
    -Castor Oil (this is part of the liquid vehicle in Restasis. Just leaves a sticky mess)
    -Moisture Goggles
    -Taping lids shut while sleeping
    -Punctal Plugs
    -And multiple other things that I am not going to list here, because of how ridiculous they were, and I'm embarrassed to admit I even tried them.

    None of these provided much relief. My eyes still felt and looked horrible after 6:00 PM. I tried not to look people in the eye too long when speaking with them, because I knew they would notice the redness. I was unable to wear contacts any longer then three hours, because they began to feel like hard plastic in my eyes.

    I had the LipiFlow procedure performed on my eyes for the first time in June of 2013. I had to travel to another state. The procedure was done quickly without much information, without expectations discussed, and zero explanation on post op treatment.

    While I didn't have the best experience with the doctor, I did not some improvement in my dry eye symptoms over the next few months. I still had an issue with contact lens wear, and I still used regular artificial tears.

    A few of the other doctors in my practice had the procedure done themselves, and everyone experienced some sort of benefit. More on why I say "some sort of benefit" later...

    With everyone feeling a little better, we decided to do a little more research, and found that places like Mayo Clinic in Arizona, OMNI center in Colorado, and a few other ophthalmology practices across the USA had been doing well. We talked with lots of doctors, as well as a few patients, and decided to invest in the technology.

    That's a very quick history on how we got started with the technology

    Now on to the discussion the should provide some good feedback to dry eye patients, so you can experience what a patient interested in the LipiFlow system SHOULD go through before having the procedure done.

    Before you have the procedure done, you need to know what the LipiFlow and LipiView do.

    Every other Tuesday night for the past six months, my practice has invited our patients with dry eye into the clinic for snacks, wine, and a one hour PowerPoint presentation on the different types of dry eye, how the LipiFlow system works, and the research behind it.

    I'm going to try to write out the key points of my one hour oral seminar.


    I know there is a lot of info on this Forum about this already, but it's always good to repeat.

    Current research indicates that up to 80% of patient with dry eye have an evaporative component. These patients tears evaporate more quickly, leaving the eye dry and irritated, and can lead to over production and burnout of the lacrimal gland, which produces the watery part of the tears. I say close to 1/10 patients with dry eyes do well with artificial tears and restasis. So it makes sense that so many people who use these products still have dry eye.
    Of that 80%, close to 40% have a combination of both evaporative dry eye and aqueous deficient. These people may feel a little better with artificial tears or Restasis, but the evaportative component is not being addresses, thus they still suffer. (Nichols KK, Foulks GN, Bron, AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Investigative Ophthalmology & Visual Science. 2011)

    The cause of evaporative dry eye is important to understand. Our eyes feel dry because, due to decreased tears on our eyes, and the inflammation that results. There are decreased tears because these tears have evaporated. Tears have evaporated because there is a decreased lipid/oil component to the tears. There is a decreased oil component because the meibomian gland is not excreting oil. These glands are not working because the oil has solidified and become stuck under a fibrotic/collagen like tissue that grows over the orifice of these clogged glands. And what we are finding is the cause of this growth, rather then clean open glands in lid hygiene issues, and impartial blinks (more on impartial blinks later)

    It was also thought that dry eye increased with age. It used to be thought that an older patient would have more dry eye, while a younger patient would not. However, I believe that Computer Vision Syndrome is a real thing and a real problem. We blink 60% less while using electronic devices. Most working people go to work and they are on a computer all day long, under florescent lights, with a bright computer screen shining at them. We drink coffee or energy drinks with caffeine, which are diuretics, decreased water in the system.


    So the purpose of the dry eye evaluation is to see what type of dry eye the patient has, and if the patient will be a good candidate for the p

    The LipiView system is used to analyze the tear film of the patient. The patient looks into the instrument and blinks normally for about 30 seconds. The system then analyzes the tear film, the quality of oils on the eye, the duration of oils on the eye, and partial blinks.

    Tear film - the tears should look like oil or gasoline on water. With each blink, colors such as gold, copper, maroon and blue are easily seen using the LipiFlow system on a non dry eye patient. A large 48 inch HDTV on the wall allows the patient to watch their oils spread across the eye with each blink. White, grey, and black colors (lack of above colors) indicate a poor tear film, or poor oil in the tears.

    Duration and quality of tears - the technology scores the patient on a scale of 0-100, 100 being the best score, as to the quality of oils. The number of times that a patient blinks during the test can provide info as well. If the patient blinks 15 times in 30 seconds, often that indicates some evaporative issues, as the patient needs to blink often to try and spread tears.

    Partial Blinks - I have found this to be by far the most interesting and helpful evaluation for the patient to understand why they may have dry eye issues. It is known from a physiological standpoint that in order for the glands to secrete oil, the eyelids need to blink, and make contact. This 0.3 psi of pressure between the lids results in a small amount of oil to be expressed from the glands, resulting in oil release onto the eye. This oil then is pulled back up and over the eye in a lid-wiper motion, similar to a windshield wiper on a car, and the oil/tear combination is spread across the surface of the eye. If the blink is a partial blink, then there is no contact between the lids, and no oil is expressed. When I sat for the LipiView for the first time, I had 15 blinks in a 30 second period, and 15 of them were partial. In my personal experience, I'm finding close to 9/10 patients who have an evaluation are significant partial blinkers, meaning more then 50% of their blinks are partial, and roughly 25% of those who come in for a dry eye evaluation are 100% partial blinkers (again, I myself am in this group). Again, it is often this chronic partial blink that results in oil hardening and blocking the gland, as the oil has nowhere to go if it's not being secreted. Over time, this oil is re-asorbed by the body to be used for other metabolic purposes. In the process of re-asorbing this oil, the gland also dies/atrophies. It's similar to if you break your arm and you are in a cast. When you cut that cast off in however many weaks, the arm is often smaller and weaker for awhile, as the body was not using it. Of course, a cast is on only for a few weeks to months, whereas if the patient has been a partial blinker for years, the glands have slowly started to die away due to not being used.


    After the LipiView is performed, the patient is then taken into an exam room, and sits in front of the slit lamp to have the glands themselves expressed and evaluated.

    Gland expression - There are roughly 25-30 meibomian glands on the bottom of each eyelid. When pressure is applied to the lower lid with either a finger or a cotton swab, oil should be observed exiting the meibomian glands. We evaluate how many of the 25-30 glands are expressing, and the quality of the oil expressed. Meibum expression should look like olive oil as it is expressed. It should be liquidy, and create a greasy look across the lid margin as it is expressed. As meibomain gland disfunction progresses, this oil changes in consistency. It first often becomes cloudy, so that it's not a nice yellow olive oil color, but a cloudy murky color. Some glands can even look like pimples, where a little pressure causes an eruption, and a pus-like consistancy to then run down the lid. As further progression of gland blockage occurs, it can become what we call inspissated, or "toothpaste" like. If you imagine squeezing a tube of toothpaste from the bottom up, you get a long string that comes out, and then lays on the lid margin. It is not liquidy, so it doesn't dissolve into the tears to provide anti-evaporative properties. It simply lays on the lid margin, hard and compact, and does little good for the patient.

    Gland evaluation - We then examine the glands themselves. The 25-30 glands on the bottom lid can easily be evaluated by using a simply device in the office called a transilluminator, which is essentially like a little flashlight. Many doctors use this light, and have you follow it with your eyes while keeping your head still to check eye motility/muscle function. The glands should extend the entire length of the eyelid, and they should be straight and uniform. As atrophy occurs, they become shorter, and can become twisted. I've often seen engorged glands, due to the oil backing up, and essentially expanding the gland like a tire with too much air pressure. There is nowhere for the oil to go, and the gland dilates.

    We evaluate the lower lid glands in three sections: temporal, central, and nasal. We also evaluate what percent of the glands have atrophied: 0-25%, 25-50%, 50-75%, or >75%. It is very important to note that my education with patient, expectations, outcomes, and everything else at this point can change greatly depending on what percent of gland structure is left. If the patient is a partial blinker, with poor oil secretion, scoring low on the LipiView with multiple dry eye complaints, but has only 0-25% atrophy, then I'm much more optimistic about the outcome of the procedure. If the patient is more then 50% atrophy, the discuss is very different.

    Atrophy of 0-50% - As stated above, I'm often more optimistic for this patient. The glands may be blocked, but if we can remove this blockage with the LipiFlow system, and the patient can make some good post-operative changes (we'll get to this), then I am expecting this patient to notice some relief. Symptoms should improve, such as less grittiness, less watering, less use of artificial tear and possibly increased contact lens wear. This has been what patients have been telling me at their first 3 months follow up. The gland structure that remains should be able to provide oil to the patient after the removal of blocked glands.

    Atrophy of 50-100% - Our discussion changes greatly here. At this point, I tell the patient that the purpose of the procedure is not so much to improve symptoms as it is to try and prevent further gland loss. There is the chance that the patient will not feel any better. The goal is so that they do not feel worse. The patient needs to understand this before they leave. I feel there may be many patients out there with significant atrophy who were told that the procedure would make things better, when the little gland structure they have left really makes that difficult to achieve. I have seen a few of these patients. Some of these patients I have had to turn away, as the procedure would be a waste of their time, as too little gland structure remains. I'm interested in how many people out there should have been informed of this, but the doctor did not do so and treated anyway. In the last six months I have had two patients past 75% atrophy, who after all education still elected to do the procedure. They had tried everything else, and they understood that most likely they would not feel any better. One gentleman had driven four and half hours to get to our clinic, and said he was willing to try anything. At three month follow up, he noted no improvement. At six month follow up, he noted small improvement. A female patient at 75% atrophy has returned twice for follow up, and still has no improvement. However, both patients had been educated and were well aware of their situation, so both patients noted they were still happy they attempted the procedure. I can't stress enough here that education is key, and that the doctor should be spending enough time with the patient to discuss the likely outcomes based on all the info found during the dry eye evaluation.

    Actually LipiFlow treatment, and post-operative treatment will be discussed in Part Two.

    Thanks for reading


  • #2
    Could low Tear Breakup Times also having contributing factors of poor epithelial cells, incomplete coverage of epithelial cells by mucin, low aqueous production?