ikervis and lower plugs still struggling

[Matt0029]

What would be the next treatment option for someone who's on ikervis has been for 6 months and lower plugs and is still struggling with dryness. Thanks for any advice.

[Meibum Ian]

What is known about your condition? Aqueous deficient? MGD? Obvious inflammation, etc?

[edmunder]

Yeah it depends on what the issues are. But probably an antibiotic, lipiflow or IPL.

Honestly if you have dryness i would be as agressive as you can with treatment. I wish i had known about this forum a year ago.

[hopeful_hiker]

I would suggest adding upper plugs. For instance,
farmgirl mentioned in her comments it made a difference for her whereas just the lower plugs did not do the trick. I would also recommend serum drops because they have healing properties and various nutrients similar to our tears. They do not’ increase tear production usually but they are good for improving TBUT and reducing ocular staining as well as promoting healthy nerve growth. If you have corneal neuropathy (abnormal nerve growth due to mechanical damage/inflammation/LASIK) then you could have “pain without stain” (symptoms worse than signs).

In addition, I know someone who benefited from TrueTear device. However, I have not seen many discussions about it here. This device is pretty new and expensive.

Even if you have normal TBUT, it would be good to get rid of blockage in the meibomian glands because the oils are important for lubrication, too.

Finally, do you know why do you have aqueous deficiency?

[quattroboy]

What would be the next treatment option for someone who's on ikervis has been for 6 months and lower plugs and is still struggling with dryness. Thanks for any advice.

Hi Matt0029 if I remember correctly you are in the UK like me and using the NHS?

If so the next steps are limited to current NHS protocols on dry eyes https://www.nhs.uk/conditions/dry-eyes/treatment/

So getting uppers plugs would be next, followed by getting your tear ducts cauterised.

Serum drops are next to impossible to get funding for on the NHS, my consultant briefly mentioned them when I ask about AMT and Pilocarpine (he dismissed both out of hand).

You could try scleral lenses, they are available on the NHS but maybe not for dry eye treatment.

Thinking beyond the NHS.

1. Private prescription for Xiidra need to import it or use an international pharmacy. I reckon 2 to 3 hundred quid per month.
2. AMT privately (mentioned above).
3. See if you can get Pilocarpine prescribed but check the side effects.
4. Stem cell injections. No idea how this works but there is some mention on the forum about them. Would be a visit to the states.


Have you tried diet changes? I really need to try and reduce my sugar intake but I'm a comfort eater with a very sweet tooth, sadly!

[Matt0029]

Thanks for all the help I am mainly aqueous deficient. Though my tear break up time has dropped now too. Yes I am in the UK. I think my dry eye was caused by lasek I was fine for 5 years after this though. Then it struck. Thanks I will look into corneal neuropathy. Another note is when I was on the steroid drops and ikervis at the same time was on steroids for about 2-3 month. My last month on this regime my eyes were perfect. They they have slowly gone back after dropping the steroid. Can any one offer any explanation to this?

[hopeful_hiker]

Can your doc test inflammation with inflammmadry? Dry eye clinics often have it, I would ask them. Steroids are for inflammation.

[deep_dry_eye]

Thanks for all the help I am mainly aqueous deficient. Though my tear break up time has dropped now too. Yes I am in the UK. I think my dry eye was caused by lasek I was fine for 5 years after this though. Then it struck. Thanks I will look into corneal neuropathy. Another note is when I was on the steroid drops and ikervis at the same time was on steroids for about 2-3 month. My last month on this regime my eyes were perfect. They they have slowly gone back after dropping the steroid. Can any one offer any explanation to this?

Since you are aqueous deficient and probable nerve damage caused by lasik, why dont you give AMT (Prokera) a try. Its really safe and simple, but it does cost money. My AMT insertion took like 5 mins, and only 3 days to absorb. My dr charged me 1.5k CAD per eye in Canada -- which is cheaper than Lasik, so why don't you give it a try.

[quattroboy]

Since you are aqueous deficient and probable nerve damage caused by lasik, why dont you give AMT (Prokera) a try. Its really safe and simple, but it does cost money. My AMT insertion took like 5 mins, and only 3 days to absorb. My dr charged me 1.5k CAD per eye in Canada -- which is cheaper than Lasik, so why don't you give it a try.

I agree the evidence suggests it very helpful in reducing the clinical effects of dry eye, including stabilising the tear film.

However my NHS doctor (consultant) didn't think it was a valid treatment. It simply isn't recognised as a dry eye treatment here in the UK.

I believe this chap does it. http://www.matheson-optometrists.com/

https://www.youtube.com/watch?v=Ttek1y-QdaQ

[Matt0029]

thanks for the replys I think inflammation is the main issue for me as when I was on the ikervis and steroids for a month or so my eyes felt perfect and my vision was a lot shaper. Want to try get back to that but I don't know how as I cant stay on steroids long term any ideas? Thanks.

[deep_dry_eye]

I agree the evidence suggests it very helpful in reducing the clinical effects of dry eye, including stabilising the tear film.

However my NHS doctor (consultant) didn't think it was a valid treatment. It simply isn't recognised as a dry eye treatment here in the UK.

I believe this chap does it. http://www.matheson-optometrists.com/

https://www.youtube.com/watch?v=Ttek1y-QdaQ

i dont know how it works in the uk, perhaps get another dr or fly to another country for a better dr. of course u gotta pay $$$ but its worth it for ur health

[hopeful_hiker]

Matt0029 have you tried Xiidra? You cannot use steroids long term due to the risk of glaucoma, etc. and damage from BAK preservatives. Xiidra and cyclosporine (Ikervis or Restasis) help reduce inflammation. Some people use them in conjunction because they are two different medications working through two different pathways. Another aspect of inflammation can come from the
eyelids/meibomian glands (e.g ocular rosacea) and bacteria. For this reason many use special eyelid scrubs or sprays. I use Avenova, for instance.
Finally, you could also have environmental allergies or sensitivities to eye drops.

[quattroboy]

Matt0029 How are you using the Ikervis? My understanding is it should be the last thing you place in your eyes before sleep, if you've use drops you must leave 15 minutes before inserting the Ikervis.

The Ikervis needs time to be absorbed into the eye. A lot of the science in these treatments is how to get the eye to absorb the treatment because the eye is very good at protecting itself from foreign substances.

[Matt0029]

thanks I would like to try Xdra but I don't think it's available in the uk yet. I see an NHS consultant but privately, I get my prescriptions Ikervis and Hylo forte prescribed through my GP. I don't have any damage on the surface of my cornea any more but my eyes have started to feel sore and painful again and vision getting worse, my tbut was 5 seconds right eye 4 seconds left eye last time saw my doc 1 month ago. My oil producing glands are pretty good so I have been told. I may go back soon as things seem to be getting worse. But I think my only options are cautery or upper plugs. Upper plugs have never been mentioned though I think some surgeons are against having no drainage in the eye? As said steroids and Ikervis sorted my eyes out. Ikervis on its own doesn't seem strong enough. I put it in at night as the last drop at night with no drops before hand for a good 30 minutes at least.. I press near my nose to block both ducts and close my eyes for 2mintutes.

[quattroboy]

I really think you should investigate AMT. It would help with the inflammation and the help stabilise the tear film, hopefully improving your TBUT which is very low.