Hi guys,need suggestions.Lipiflow? xiidra work on blepharitis? or need add restasis?

[hyzlt7980]

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Hi, everyone

I was diagnosed MGD and blepharitis.

I am on Xiidra, warm compress, systane eye lid wipe, 2700mg omega-3, blinking exercise.

Now, if I do not use computer or cell phone, I have no symptom. If I work, every 40 minutes I take a short break, then I can work the whole afternoon. So dry eye is not a big trouble for me now.

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But I want to cure it. I want to wear contact lenses.

1. I have question about Xiidra. I start Xiidra just a week ago. The doctor said xiidra works faster than restasis. So She prescribed xiidra to me. But the post I read here they also suggested use xiidra with restasis to treat inflammation. So can xiidra treat inflammation alone or I need to ask for restasis and use them together?
2. Second question is about lipiflow. I have visited serveral doctor, including a very professional doctor. He checked the photo of my Meibomain gland and he said that the blockage is not serious. The main problem is the inflammation and partial blinking. He suggest me to take restasis(but I took xiidra instead, do not ask me why. The doctor cannot prescribe drug to me for some reason) and do blink exercise. He said I do not need to do lipiflow.But the second doctor I visited strongly recommend me to do lipiflow and said my inflammation is not serious. so should I do lipiflow or not. I did lipiview, the lipiview show my average LLT is 72 and 88. All above 60nm(below 60 you are considered not normal)

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I upload the picture(may be not clear, doctor said I did not lose any gland and not too much blockage).

So anybody who has the experience can give me a suggestion. Should I continue the regime or should I do lipiflow?

Also, I hear IPL is a good option. does it work better than lipiflow? how does it work?

Sorry to ask so many question. But I really need some suggestion.

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Update (Aug 1st, 2018):
It is so great to receive so many reply. Thank you, guys.
Here is my latest condition:

Xiidra appears to be working very well. But the side effect is also very annoying. miId headache, mild dizzy, mild eye discomfort after applying gentle pressure on eye. I will contact with the doc to see should I continue or not.

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Update Aug, 10th

Side effects of xiidra is now gone. Having been using it for 3 weeks and it help a little bit.

However, recently, after I did warm compress and blink exercise. Some white and transparent come out of my eye lid and attached to my eye lash. The substance is a little bit sticky. Anyone know what it is ?

[edmunder]

Well you are ahead of the curve. You are getting treatment before its bad.

Im not sure what to do. If its inflamed you should do IPL. if you can get IPL locally you dhould start and fo it monthly for a while. 6 months.

I dont know if you will be able to wear contacts again. Good luck.

[Guest]

First off, sad to say, you cannot cure this. You can however manage it and make things better. But it will progress as you age.

that said, I would not use any drugs right now. I would start with hot compress, make sure you do it correctly, there are a lot of people in here who can help with that. Get a hypochlorous acid spray and clean your lids after every compress, 2x a day. Use preservative feee artificial tears as needed. Start there. Avoid drugs until it's necessary.

If you really want to go the extra mile, get autologous serum. It is never bad to use serum imho. Best eye drop you can buy.

Also, avoid activity that bothers the eyes. I limit my computer use now...I have to. If I don't, I end up with burning eyes.

You really want to avoid inflammation. That's the point of the artificial tears and compress/lid wipes. To keep things lubricatex and clean so you keep inflammation down. Good luck.

[deep_dry_eye]

First off, sad to say, you cannot cure this. You can however manage it and make things better. But it will progress as you age.

that said, I would not use any drugs right now. I would start with hot compress, make sure you do it correctly, there are a lot of people in here who can help with that. Get a hypochlorous acid spray and clean your lids after every compress, 2x a day. Use preservative feee artificial tears as needed. Start there. Avoid drugs until it's necessary.

If you really want to go the extra mile, get autologous serum. It is never bad to use serum imho. Best eye drop you can buy.

Also, avoid activity that bothers the eyes. I limit my computer use now...I have to. If I don't, I end up with burning eyes.

You really want to avoid inflammation. That's the point of the artificial tears and compress/lid wipes. To keep things lubricatex and clean so you keep inflammation down. Good luck.

i respectfully disagree. i think u should continue on xiidra to get your inflammation under control.

imo, xiidra is a really good drug in controlling and reducing inflammation.

[deep_dry_eye]

lipiflow is low risk, and will probably help. it just costs money.

restasis and xiidra both reduce inflammation, im personally on both at the same time. xiidra is a new and good drug, and more responsive than restasis

[Guest]

lipiflow is low risk, and will probably help. it just costs money.

restasis and xiidra both reduce inflammation, im personally on both at the same time. xiidra is a new and good drug, and more responsive than restasis

They do they exact same thing in different ways. They both block T cell mediated inflammation. Restasis stops new T cell formation, that's why it takes a long time to work. Because the existing T cells need to die off before you notice an effect. Xiidra destroys T cells that are currently active. So it works much faster because there's no lag time.

So I will respectfully disagree with you. This person said, dry eye is not a problem for me. So that says to me, he's doing pretty good. If he's doing pretty good, I suggest he stays away from immunosuppressive drugs. They are extremely dangerous and should be respected in my humble opinion. No disrespect, but steroids, xiidra and restasis are for level two dry eye sufferers, people for whome the traditional treatments failed. So I think he should fail with those treatments first, then consider a dry eye drug.

[deep_dry_eye]

They do they exact same thing in different ways. They both block T cell mediated inflammation. Restasis stops new T cell formation, that's why it takes a long time to work. Because the existing T cells need to die off before you notice an effect. Xiidra destroys T cells that are currently active. So it works much faster because there's no lag time.

So I will respectfully disagree with you. This person said, dry eye is not a problem for me. So that says to me, he's doing pretty good. If he's doing pretty good, I suggest he stays away from immunosuppressive drugs. They are extremely dangerous and should be respected in my humble opinion. No disrespect, but steroids, xiidra and restasis are for level two dry eye sufferers, people for whome the traditional treatments failed. So I think he should fail with those treatments first, then consider a dry eye drug.

I respectfully disagree as well. Cyclosporine and lifitegrast are theorized to do what you mentioned above, but the exact mechanism of action is unknown. Cyclosporine is theorized to downregulate T-cell production; while lifitegrast binds to T-cells. However, I am -very- confident that lifitegrast does something more than binding to T-cells. I am actually working with some doctors on a new drug study on lifitegrast, and we have potentially some very exciting research to publish in the near future. Additionally, there are patients that respond to 1 drug but not to other, and there are patients that only respond when on both drugs, and some patients don't respond to any drugs. Our understanding of the disease is quite limited still.

Steriods are of a different class of drugs, steriods can be potentially dangerous long term because they can cause IOP increase. Ophthalmic cyclosporine and lifitegrast do not have such side effects, and are deemed quite safe for long term usage.

The rationality behind attacking the disease aggressively w/ immunosuppressant drugs early is to immediately control and reduce inflammation, such that the disease does not progress further, but hopefully reverse itself.

Of course, these are just opinions. Some medical doctors agree w/ you, some agree w/ me. Some doctors are much more conservative in treatment, some doctors are much more aggressive in treatment. It remains an unanswered question, at least in the published literature, on which way is more effective.

It is up to the reader, or patient, to do their due diligence and trust their own judgements, and perhaps their doctor's as well.

[Guest]

I respectfully disagree as well. Cyclosporine and lifitegrast are theorized to do what you mentioned above, but the exact mechanism of action is unknown. Cyclosporine is theorized to downregulate T-cell production; while lifitegrast binds to T-cells. However, I am -very- confident that lifitegrast does something more than binding to T-cells. I am actually working with some doctors on a new drug study on lifitegrast, and we have potentially some very exciting research to publish in the near future. Additionally, there are patients that respond to 1 drug but not to other, and there are patients that only respond when on both drugs, and some patients don't respond to any drugs. Our understanding of the disease is quite limited still.

Steriods are of a different class of drugs, steriods can be potentially dangerous long term because they can cause IOP increase. Ophthalmic cyclosporine and lifitegrast do not have such side effects, and are deemed quite safe for long term usage.

The rationality behind attacking the disease aggressively w/ immunosuppressant drugs early is to immediately control and reduce inflammation, such that the disease does not progress further, but hopefully reverse itself.

Of course, these are just opinions. Some medical doctors agree w/ you, some agree w/ me. Some doctors are much more conservative in treatment, some doctors are much more aggressive in treatment. It remains an unanswered question, at least in the published literature, on which way is more effective.

It is up to the reader, or patient, to do their due diligence and trust their own judgements, and perhaps their doctor's as well.

You have to take the patient into account. I think you should be aggressive as possible.i haven't seen his eyelids or anything that's going on. So I'm using his "sensation" of dry eye and it's impact on his life to determine how aggressivevto be. He said he's fine, Its not bothering him, he just wants to prevent progression. Well then, without a diagnosis, why would he take any anti-inflammatory drug steroid or not? Giving him restasis and xiidra, when you said the mechanism of action is unknown, and we don't know what's causing his inflammation if he even had any, is not aggressive...it's like throwing a bunch of stuff at the wall and hoping it will stick. I agree with you, the complete mechanism of action isn't known...which is scary in a sense. Especially with xiidra because it's so new. All of these drugs have side effects that havevto be taken into account.

now if he said, guys I'm dying over here, I'd say yeah, get a diagnosis, start on a steroid and taper into restasis/xiidra and see if it helps. But if the guy can keep the glands clean and not need drugs for the next 20 years that's clearly a better situation for his long term health.

[deep_dry_eye]

You have to take the patient into account. I think you should be aggressive as possible.i haven't seen his eyelids or anything that's going on. So I'm using his "sensation" of dry eye and it's impact on his life to determine how aggressivevto be. He said he's fine, Its not bothering him, he just wants to prevent progression. Well then, without a diagnosis, why would he take any anti-inflammatory drug steroid or not? Giving him restasis and xiidra, when you said the mechanism of action is unknown, and we don't know what's causing his inflammation if he even had any, is not aggressive...it's like throwing a bunch of stuff at the wall and hoping it will stick. I agree with you, the complete mechanism of action isn't known...which is scary in a sense. Especially with xiidra because it's so new. All of these drugs have side effects that havevto be taken into account.

now if he said, guys I'm dying over here, I'd say yeah, get a diagnosis, start on a steroid and taper into restasis/xiidra and see if it helps. But if the guy can keep the glands clean and not need drugs for the next 20 years that's clearly a better situation for his long term health.

Most drugs, even antibiotics, we don't know the -exact- mechanism of action, yet we usually deem them quite safe. In many life and physical sciences, while we might not understand the underlying mechanics, we can observe the effects and probability distribution of effects. For example, we still have no idea how gravity works, yet we have a very high confidence that gravity will cause an apple to react a certain way when dropped from a tree.

Similarly, we have no idea the mechanism of action of autologous serum or AMT, however we also deem these to be low risk and potentially helpful towards the patient.

And yes, its true, sometimes in medicine its just throwing a bunch at the wall and hope it sticks. That's literally how many drugs are discovered. Its through an evolutionary process where we just throw a bunch of random molecules at a petridish and hope it sticks. In fact, if you read the literature on Xiidra, it was originally designed to do something else, but then it turned out to work well w/ dry eyes. A lot of our recent science and medical advances are via such random walks.

The rationality to not wait till his/her symptoms get worse is once again to control and reduce the inflammation early on. One theory is that if the patient symptoms get paid, it may be too late. I am on the side of the fence of the opinion is that we should treat this disease early and aggressively. One example is glaucoma and diabetic retinopathy, if you detect and treat it early, you have a pretty good patient outcome rate, however if you wait till symptoms manifest, you're pretty much guaranteed to go blind. Other examples are various types of cancers, if you are able to detect and treat them early, you have good patient outcomes. However, unfortunately, many cancers are detected or treated too late and are irriversible.

I respect your opinion, and I am not saying I am right or wrong. I am however providing my opinion to the reader/patient and they can do their own due diligence.

[Guest]

Most drugs, even antibiotics, we don't know the -exact- mechanism of action, yet we usually deem them quite safe. In many life and physical sciences, while we might not understand the underlying mechanics, we can observe the effects and probability distribution of effects. For example, we still have no idea how gravity works, yet we have a very high confidence that gravity will cause an apple to react a certain way when dropped from a tree.

Similarly, we have no idea the mechanism of action of autologous serum or AMT, however we also deem these to be low risk and potentially helpful towards the patient.

And yes, its true, sometimes in medicine its just throwing a bunch at the wall and hope it sticks. That's literally how many drugs are discovered. Its through an evolutionary process where we just throw a bunch of random molecules at a petridish and hope it sticks. In fact, if you read the literature on Xiidra, it was originally designed to do something else, but then it turned out to work well w/ dry eyes. A lot of our recent science and medical advances are via such random walks.

The rationality to not wait till his/her symptoms get worse is once again to control and reduce the inflammation early on. One theory is that if the patient symptoms get paid, it may be too late. I am on the side of the fence of the opinion is that we should treat this disease early and aggressively. One example is glaucoma and diabetic retinopathy, if you detect and treat it early, you have a pretty good patient outcome rate, however if you wait till symptoms manifest, you're pretty much guaranteed to go blind. Other examples are various types of cancers, if you are able to detect and treat them early, you have good patient outcomes. However, unfortunately, many cancers are detected or treated too late and are irriversible.

I respect your opinion, and I am not saying I am right or wrong. I am however providing my opinion to the reader/patient and they can do their own due diligence.

Again, you're comparing gravity, which is a phenomenon that we can recreate 100% of the time...to a drug that passed helping only 15% of the patients (restasis).

Your anologies don't stand because they're not equal. Knowing the mechanism of action is less important in regards to safety as actual human use. So a drug like doxy that's been used for YEARS vs xiidra that's maybe a decade old...again, no comparison. We have way more data.

the mechanism of action again, is irrelevant in the sense that, you need years of data and use to determine if something is safe. So I err on the side of caution and just assume it's dangerous. I'm not using a dangerous drug for no reason. It's literally that simple. You're willing to dump the drugs in hoping for relief and I refuse to take something that's not helping me. That's what it boils down to.

[Lweaver]

Hi there! I have pretty bad MGD with gland drop out. I use Xiidra and have been since 2016. I think it helps with inflammation control but it hasn’t made much of a difference in symptoms. I used a steroid a while back which helped the most for a while, but I’m terrified to use again since it raised my eye pressure. Plus you can’t stay on it a long time. I plan to have Lipiflow done.

[deep_dry_eye]

The response rate of Xiidra is estimated to be closer to 80% than 15%. Additionally, despite the published 15% of Restasis, the dry eye drs I've talked to have a much higher clinical response rate when given to the suh-population of patients who have been identified to have inflammation problems. I was originally skeptical on Restasis since I thought it was for aqueous dry eyes only, but I was later convinced otherwise.

Actually, we can't recreate gravity 100% of the time. There are many quantum scenarios where classical physics don't deterministically apply.

Agreed, more data is always good. However, Xiidra does have a very well published safety profile. Lifitegrast has really good pharmacology. There is very low systemic absorption (i.e., localized) and no evidence of any toxicity in the drug. IMO, it is far better than any steriod-class drugs which can cause IOP increases and other much more adverse side-effects.

Doxy / azithromycin are safe drugs from a pharmacology perspective as well. In fact, I'm a heavy believer of topical azithromycin for the treatment of MGD. However, antibiotics have their own risks as well, since you can develop antibiotic resistance and can't be used long term. IMO, for long term usage, Xiidra/Restasis are definitely the safer drugs.

I don't think its fair to call Xiidra a "dangerous drug". It's a safe drug. What you can argue is that the confidence interval or p-value of the drug is not very small (smaller is better). i.e., compared to antibiotics. I'm quite confident if you talk to most dry eye specialists, they will agree that Xiidra is a relatively safe drug to use long term. There has been no evidence supporting otherwise.

At the end of the day, it's risk assessment. You take a walk out of your house is a risk. Taking drugs is a risk, not taking drugs is also a risk. IMO, the risks of not controlling the inflammation outweigh the risks of Xiidra.

[Hokucat]

hyzlt7980 , I’m not a doctor, but looking at your gland images, it looks like some of your glands are short (starting to atrophy), and you have some gland loss in the inner corners, mostly in the two lower pictures. I would get this confirmed from another doctor, given your current one says you have no gland loss. If you do have some short or loss glands, and/or given it’s already been confirmed you have blocked glands, LipiFlow may be a good first procedural treatment for your MGD. IPL is good too, but not as readily available. Some people have gotten results doing both when just LipiFlow alone didn’t work.

As mentioned above, likely you will not be able to wear regular contacts again. However, you might be able to wear scleral lenses, which have been increasingly used to manage dry eye symptoms. The lenses are dome-shaped so they are filled with saline to protect the corneas, and the lens edges lay on the sclera/white part of the eye. Not everyone can tolerate sclerals, but it could be worth a consult to see if you can, and if it provides comfort. I wear mines 12 hours a day, and it helps with daily functioning and comfort.

http://www.bostonsight.org/PROSE/PRO...y-Eye-Syndrome

[hyzlt7980]

Hi there! I have pretty bad MGD with gland drop out. I use Xiidra and have been since 2016. I think it helps with inflammation control but it hasn’t made much of a difference in symptoms. I used a steroid a while back which helped the most for a while, but I’m terrified to use again since it raised my eye pressure. Plus you can’t stay on it a long time. I plan to have Lipiflow done.

omg. I have used xiidra for almost 2 week. It helps a lot for me. I do not need to rub my eye and rarely use eye drops. However, I got some headache which is not serious but annoying. I also have some symptom like high eye pressure. I have not consulted this with doctor. That is so sad to have side effect otherwise xiidra can make me live normally

[hyzlt7980]

Well you are ahead of the curve. You are getting treatment before its bad.

Im not sure what to do. If its inflamed you should do IPL. if you can get IPL locally you dhould start and fo it monthly for a while. 6 months.

I dont know if you will be able to wear contacts again. Good luck.

Well. sadly in a small city, no IPL offered. xiidra works great but with some annoying side effect. I think I will do lipiflow and swich to restasis