Making the case for targeted therapy for chronic dry eye
Where thermal pulsation treatment fits in today’s protocol.
By John Hovanesian, MD, FACS
Ophthalmologists often view dry eye as an less than satisfying part of practicing medicine because it is time-consuming to counsel patients, who often return unsatisfied with the treatment results. The first step in gaining satisfaction in the treatment of dry eye, for both our patients and ourselves, is to change one’s perspective and view dry eye not as a nuisance, but rather as an opportunity to help patients.
Embracing dry eye patients by identifying the specific cause and determining a targeted treatment option generally yields the best results. Research has shown that 86% of dry eye sufferers have a component of evaporative dry eye disease, also known as meibomian gland disease (MGD).1 Because evaporative dry eye is a long-standing disorder that has a complex physiology, conservative therapy often fails.
Patient undergoing thermal pulsation therapy with the activator placed on her eye.
In this article, I review the conventional management options, then discuss the use of thermal pulsation therapy as a new approach to treat chronic dry eye.
CONVENTIONAL MANAGEMENT OPTIONS
We ask patients to fill out a questionnaire that asks them to choose one of four grades that best describes the level of their symptoms: very much, somewhat, very little or not at all. Based on the patient’s responses and our examination findings, I recommend one of the following therapies.
Warm compresses are ideal for patients with MGD. We instruct patients to dampen a clean washcloth with warm tap water, or wrap it around a commercial “hot pack” (or two warm potatoes) to keep it warm — not hot. They should then gently rest the warm compress on their closed eyelids for 5 to 10 minutes, and repeat this routine at least four times a day. Although reasonably effective, this treatment can be time consuming, and patients rarely adhere to it for long.
Lubricant eye drops (artificial tears)
Most pharmacies offer over-the-counter “lubricant eyedrops.” We advise patients to try multiple brands to find out what works best. Preservative-free tears are least likely to cause toxicity or induce allergy, especially if patients use them more than four times a day.
We instruct the patient to apply one drop in each eye as often as necessary. If the patient wakes up at night or in the morning with a dry feeling, we instruct her or him to try using lubricant ointments or gels before bedtime. We advise against vasoconstrictors, except in rare cases.
Wraparound glasses help prevent tear evaporation and can help patients who spend a lot of time outdoors or in a car where ventilation causes drying of the eyes.
Flax Seed Oil
Taking 1,000 mg of flax seed oil one to three times daily can significantly improve dry eye symptoms, but the effect may take a month or longer. We caution patients on coumadin not to take flax seed oil without their primary-care physician’s permission because flax seed has inherent anticoagulant properties. Flax seed oil may also cause intestinal gas symptoms.
We instruct patients to humidify the room where they sleep. Changing the “weather” can help relieve discomfort from all types of dry eye.
For many cases, it is appropriate to apply a topical ointment to the lids at night. Bacitracin or erythromycin ointments are particularly useful. Azithromycin drops can have the added benefit of some anti-inflammatory properties because of its inhibition of matrix metalloproteinases (MMPs).
Punctal plugs help the eye retain more of its naturally produced tears. Among the added benefits of tear plugs for patients are no restrictions on driving, working or other activities after plug insertion, and most insurance plans cover plugs.
Cyclosporine ophthalmic emulsion (Restasis, Allergan, Irvine, Calif.) often reduces inflammation and promotes tear production. While its role in evaporative dry eye is less well understood than it is in aqueous deficiency, I offer it as an added tool for nearly every ocular surface disease patient.
THERMAL PULSATION THERAPY
How it works
A thermal pulsation system (LipiFlow, TearScience, Morrisville, N.C.) uses heat and gentle pulsatile pressure to unblock obstructed meibomian glands. In one study, 79% of patients reported improvement in overall dry eye symptoms — a relatively high rate of success for these challenging patients.1
Virtually any patient who shows evidence of evaporative dry eye is a candidate for thermal pulsation treatment. Because this treatment is an out-of-pocket cost for patients, I approach it with sensitivity. I offer less expensive therapies first, but also mention the availability of thermal pulsation therapy. Many patients with dry eye have seen other eye-care professionals and have tried other therapies to no avail, so they are often eager to try something new and innovative.
Caution is advised for recommending thermal pulsation therapy in patients with lid abnormalities, incomplete blink or aqueous deficiency that is the primary cause of symptoms. These patients may be less likely to experience significant relief.
That said, thermal pulsation therapy seems to be a “do-no-harm” procedure, and if all other treatments fail, it is simple, short and practically free of complications. It may be worth trying, as long as the patient understands the lower anticipated chance of success.
Any time a practice can provide a service that improves quality of life, everyone benefits. One of the most essential elements of success in your practice when introducing a new treatment is to communicate to staff what the treatment is, how it works and why you are enthusiastic about it. After all, your staff will, quite appropriately, echo that sentiment to patients.
Also consider talking to asymptomatic patients about treatment options for dry eye. Many who have given up hope and don’t complain of symptoms will benefit and will be grateful to the physician who offers them a treatment that works. We also encourage patients to write honest testimonials on Yelp.com, healthgrades.com and other websites for treatments that worked for them, which grows our reputation.
Ophthalmologists have the opportunity to make their practice a center of excellence for dry eye by offering patients targeted therapies and employing innovative techniques for the chronic disease. Putting patients’ needs first by improving their quality of life will yield more satisfaction for the physician and patient. OM
1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472-478.
About the Author
John A. Hovanesian, MD, is in private practice at Harvard Eye Associates in Laguna Hills, Calif., and is a clinical instructor at the Jules Stein Eye Institute, University of California, Los Angeles. His e-mail is email@example.com.