DRY EYE - where we are now - II

[peter56]

Some links and some remarks -

http://www.ncbi.nlm.nih.gov/pubmed/23086372

If there are severe keratinisations at the lid margins, even a complete blink will hardly squeeze out any meibum!
The only successful treatment in order to stop and reverse such keratinisations of the ocular surface tissues
is topical retinoic-acid - tretinoin drops or ointment.
Dr Tseng and others are prescribing tretinoin since the early 80s to their patients.
Leiters does offer Retinoic- drops and ointments.

Many patients will recall, that oral retinoic-acid - accutane can cause severe damage to the meibomian gland cells.
So what will happen, if only small quantities of tretinoin will get into the glands, will that cause more damage
within the glands or will it heal the glands somewhat?

The Korb-Blackie team also have published an article in the Cornea, on the possible damage the warming-massages can cause to the Cornea.
They are claiming, that the warming of the cornea and the pressure of the warm compresses and the massages will frequently
deform - molt the cornea.
Since almost all ophthalmologists do recommend warming and massages of the lids as the key MGD Treatments, these "new" findings will
cause many discussions within the experts community.
Do These therapies really have such risks and pose a threat to the cornea?
If all MGD patients will ask for the Lipiflow instead of the older therapies, TearScience will become a goldmine.
So real risks and threats or more Lipiflow promotion.
I don`t wonna comment the efficacy of Lipiflow, many mild MGD patients will benefit from that treatment.

http://www.aao.org/isrs/resources/ou...nderforPrint=1

For me it is difficult to believe and to accept, that after very single Lipiflow 12 minutes session,
700USD - the disposable sets are being thrown into the garbage can!
Who does check, if really all ophthalmologists do so and not trying to clean the sets and to use them more than one time.
Is there a built-in counter in the Lipiflow computer.

Finally the Abstract on the goblet cells at the lid wipers -

http://www.ncbi.nlm.nih.gov/pubmed/22406942

[browneyesblu]

Hi Peter,

In the video you were kind enough to post for us awhile ago featuring Dr. Korb he does indeed warn that compress therapy may permanently change the shape of the cornea. He still prescribes it but monitors patients with corneal mapping at a minimum of every three months. Thank you for bringing this to our attention! This is certainly something to discuss with however is caring for our eyes. I'm not saying we should all panic and stop doing this therapy, it is likely one of the most effective treatments for clogged glands. But like everything else you can probably overdo it. And I for one am going to make sure I am being monitored.

Re Lipiflow if I ever have it I will watch to be sure the 'activator packages' are being unwrapped from a sterile container! Thanks again for making the point.

Goblet cells/lid wipers I am still in the process of absorbing that information--more later.

Regards,
Browneyesblu

[hankm9]

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[peter56]

Hi Hank,
thank you for the informations.
So it seems that TearScience has integreted some technical Features, preventing the repeated usage of the eye-sets.
But for me, it`s still difficult to accept throwing 700 dollars into the trash after only one treatment.

[peter56]

Meibomian gland probings


Hundreds of ophthalm world wide are performing now MG probings.
But there are no statistics available deside that of dr ******, the Inventor of the MGPs.
It is really strange, that they are performing probings for more than five years now, but beside the ****** study of 2010, there is only ONE other
study availabe from a doctor in NY on MGPs in ocular rosacea.

The main therapeutic objective of all MGD is to reopen the glands and to reactivate the glands secreting capabilities.
In the eyes - eyelids of patients suffering mild MGD, it may be sufficient to warm-up the lids and expressing the glands.
The warmness should melt - liquify sticky meibum and dissolve soft obstructions.

But in order re-open the glands in moderate to severe O-MGD, it takes the MG probings!
Since even a good MG expert will have problems identifying mild or severe obstructions, it will be necessary to perform probings in all eyelids of
moderate to severe MGD patients!
I don`t know, how and where to get all these probing ophthalmologists, but the few available statistics are very reliable on that issues.
Dr ****** does state, that he noticed the POP-noice in 41% of the probings. Even temperatures of up to 45°C at the lids - rear side will not
dissolve - remove such obstructions.
The MG probings are absolutely necessary for many moderate - MGD patients and for almost all severe MGD cases!
So dr ****** has made a great innovation by inventing the probings.

But I do have problems with the Long-term probings results that dr ******g and others are stating at their websites.
Many patients here in Europe are telling me, that they do have beneficial effects of the MGPs for 4 to 8 weeks only.
Not so many seem to have longer Lasting improvements.
Dr ****** and others do inject steroids into the MGs right after the probings. But I don`t know, if that makes a big difference regarding the long-time
results.
It may be important, that the patients do apply a Steroid ointment for up to 7 days after the MGP procedure.
That does Support the healing process of the small injuries the needles are causing.
Here most probing patients have to take the Azyther-drops for 3 days ahead of the probings and then 4-5 days after the surgery one more time for 3 days.

Surprisingly the patients here are getting no instructions for the post-probing treatments at home. Is that different in the USA?

We can only hope, that more teams will publish realistic post probing statistics and that they will improve the post-surgery therapies!

[bunnyrabbit123]

Dear Hank & Peter-
First, thanks to both of you for the all the great posts you provide. It occured to me (and I'm sure many others) why couldn't you take the set used on you home and re-use them for any subsequent treatment. When I go to the dentist, he doesn't toss the instruments used during my appt. Why can't these eye-sets be sterilised and reused? I want very much to try lipiflow but the cost is just stops me cold.
Hank, do you have any thoughts on why the benefits of your lipifow were so short lived?

[peter56]

Hi Bun,
in order to prevent infections and many possible law suites, here in our western countries they do have strict regulations.
Since the Lipiflow eye-sets are made from plastics, a sterilization in the autoclave or by gamma Radiation is not possible.
So all these devices and Tools that cannot be sterilized, should not be used a second time, even not for the same patient.
TearScience do make the eye-sets of plastics and not from metal materials and so they are disposables.

[bunnyrabbit123]

Hi Peter,
I'm sure you're right about this- since the eye-sets are plastic, I wonder what they actually cost to make? I can't believe it's anywhere near 700.00.

[browneyesblu]

Hi Peter and bunnyrabbit,

The plastic eyepieces, the part that contains the heating elements and the mechanical parts that push against the lids, and the leads that connect the whole thing to the computer are all one piece, so I guess it is rather expensive to manufacture. It would be smarter if they made it so the plastic eyecup detached and could be replaced so they wouldn't have to throw the whole thing out.

You are right Peter, Tearscience has a safety mechanism in the unit so that once used it will not work again. I know someone who had one eye done and was complaining because they can't use the same unit on the other eye, she can't afford to pay the full cost again.

Peter, in the Cornea article does it mention if Dr. Korb still prescribes warm compresses? It's probably more recent than the video. Does it say anything about monitoring with corneal mapping? The more I think about it the more I wonder if I should still be doing this.

Thanks,
Browneyesblu

[spmcc]

But in order re-open the glands in moderate to severe O-MGD, it takes the MG probings!

I've had probing with steroids (kenalog) injected into the glands with Dr. ******. I've also had two LipiFlow treatments (first at Herzig Eye in Toronto, ON; second at Central Eye in Richmond, BC).

One issue I have with ******'s probing is that he can't know if his probes are "popping" through fibrotic tissue. He is just guessing what the "pops" are. He could, just as easily, be sticking the probe through the wall/lining of the duct thus creating the pop. I can attest, as a patient, that you can hear and feel the pops in your head as he probes each gland. It's not fun. But he still does not know what is causing the pops.

In addition (and I think others have brought this up), *IF* there was some fibrotic blockage in the glands and you went for LipiFlow, I assume that LipiFlow would cause A LOT of problems. The treatment would be heating and massaging oil out of glands that are blocked. I would assume there would be swelling and perhaps infection and more harm after LipiFlow. I haven't heard of any harmful consequences except for Shanku who had a severe corneal abrasion afterwards. But nothing harmful to the lids that I know of.

So I'm not sure that I buy the fibrotic blockage idea. However, I do believe that there should be cleaning of the eyelid margins to make sure that debris/crud at the base of the lashes isn't blocking the outlet of the meibomian glands. Perhaps using a q-tip/cotton swab to "scrape" the area clean.

Finally, as for O-MGD (obstructive meibomian gland dysfunction), I have no oils coming out my glands. In the nasal region, the secretions are white worms. So, do I have O-MGD? How is this diagnosed? By no secretions?

[peter56]

Hi Browneyesblu,
according to the literature, the pressure and rubbing executed during the massages have higher risk of damaging the cornea than the
warm temperatures!

Here some references:

http://www.ncbi.nlm.nih.gov/pubmed/23665651

http://www.ncbi.nlm.nih.gov/pubmed/22309634

http://www.ncbi.nlm.nih.gov/pubmed/12446375 - Fulltext article

http://www.ncbi.nlm.nih.gov/pubmed/12695712

http://www.ncbi.nlm.nih.gov/pubmed/22668581

As well as These two fulltext articles,
the direct link doesn`t work, so please Google for:

optometry and visual science journal warm compress induced visual Degradation

optometry and visual science journal inner eyelid surface temperature as a function

[NotADryEye]

peter56

Dr. ******’s studies showed 38% of lids needed to be retreated at an average of one and one half years post probing. The reason for need to retreat at less than one year is unrecognized co-morbid disease which has an adverse effect on the MGs. The MGs are a barometer of the health of the ocular surface as well as systemic wellness. Once the MGs are opened with probing, they must be defended against these co-morbid diseases or they will ultimately re-occlude, thus becoming obstructed once again.

I am therefore not surprised that the probing patients in Europe are not having good long term results. It is likely, as I believe that everyone is looking for a magic bullet for treating MGD, that the co-morbidities are not being addressed. Perhaps this is why patients are sent home without instructions. Post-probing I was instructed to use one of the Theratears drops to help with any gritty sensation and to apply ice only if necessary. I did not need the drops or ice. And the day after the first probing Dr. ****** phoned me to see how I was doing. I told him it was a miracle as I was able to open my eyes and look at my family for the first time in 6 months.

I have been probed three times by Dr. ******. I can attest that reprobing was required due to co-morbidities incuding each of these: demodex mites, chalasis (which when symptomatic can be extremely painful and debilitating) bacterial infection, aqueous deficiency, Hashimoto's thyroiditis, etc. The second probe was performed about 8 months after the first. The third probe was performed about 9 months after the second.

Note that gritty is now thought to be multiple pops. Adding pop and gritty suggests that 67% of glands have periductal fibroses which constricts the ducts land leads to compromised meibum flow and obstruction with elevated intraductal pressure and ultimately atrophy of gland elements behind the obstruction or deeper in the gland. This is why there still may be some meibum at the opening of these glands that have obstruction deeper in gland. The meibum in these cases is from those acini close to the orifice, or in front of the blockage.

[NotADryEye]

One issue I have with ******'s probing is that he can't know if his probes are "popping" through fibrotic tissue. He is just guessing what the "pops" are. He could, just as easily, be sticking the probe through the wall/lining of the duct thus creating the pop.

The probe slides inside the duct like an arm in a sleeve. The probe can be visualized within the duct during the procedure. Note also that unpublished data from Mass Eye and Ear using confocal microscopy shows that with probing the periglandular fibrosis with congestion in o-mgd was relieved.

[peter56]

Hi,
thank you for your detailed reply!

So according to dr ****** the steroid injections and the MG expressions right after the probings should make the
differences regarding long term success.
I think it will be very difficult, keeper the glands open after the MG probings and after Lipiflow.

Indeed here in Europe I don`t know any MG probing ophthalm, that does inject steroids or does perform a careful expression of the re-opened Glands.
But the very small quantities of steroids will be squeezed out again by a few forceful blinks?

So the Team of dr Hardten does apply all nice expensive new gadgets, IPL to warm-up the glands before the probings,
then later on the Lipiflow too.

Do the ophthalm in North America really tell the patients what to do at home after the probings and the Lipiflow?
I have not read, that they do apply Azasite before and after the probings.
Only after the re-openings of the glands, very small quantities of Azythromycin can get into the gland orifices.

http://www.rheinmedical.com/hardten-...forceps-video/

http://www.refractiveeyecare.com/201...-gland-probes/

http://bmctoday.net/crstoday/2012/07...outflow-tract/

[spmcc]

As far as I know there have been no studies of probing on people without dry eye. In other words, the popping and grittiness may be found in "normal" people too.