Dry Eye Management

For many dry eye patients, inflammatory conditions such as ocular rosacea and meibomian gland dysfunction, are the underlying cause of long-standing dryness and discomfort. Inflammation in the skin affecting the meibomian glands leads to poor oil quality and flow, exacerbating evaporative dry eye. While medication regimens can manage symptoms, they do not treat the root cause of the inflammation. For patients looking for alternative options to their inflammatory skin and eyelid conditions, Seema Eye Care Centre is proud to offer Lumenis OptimaTM IPL.

IPL, or Intense Pulsed Light Therapy, has been cleared for treatment by the FDA in over 20 different skin indications. It works by delivering light pulses that penetrate the skin, heating abnormal blood vessels below the surface to heal inflammation of the skin and eyelids. The process is performed with maximal safety and comfort and is fully customizable to the patient’s skin type and condition. Each treatment is performed in approximately 15 minutes, and results can be seen in as little as 1-2 treatments, although your doctor will recommend likely 3-4 sessions for initial treatment of inflammation, followed by a maintenance treatment every 6-12 months.

During treatment, patients report feeling a warm sensation, however, IPL should not feel uncomfortable. Your doctor usually follows up IPL with meibomian gland expression to increase good oil flow and aid in the healing process. You will also be advised to avoid direct sun exposure for several days after treatment and to apply SPF.

While IPL is relatively new to the world of ophthalmology, it has been used by dermatologists for over 20 years to treat various inflammatory skin disorders¹. However, initial ophthalmological studies show a significant improvement in the dry eye following IPL treatments, both clinically from a medical perspective, and symptomatically from patients’ perspectives².

For more information on IPL treatment, please contact Seema Eye Care Centre.

1. Goldberg DJ. Current Trends in Intense Pulsed Light. Clin Aesthet Dermatol. 2012; 5(6):45-53.
2. Vora GK, Gupta PK. Intense Pulsed Light Therapy for the Treatment of Evaporative Dry Eye Disease. Curr Opin Ophthalmol. 2015; 26(4): 314-8.

LipiFlow

The LipiFlow^TM thermal pulsation treatment, approved by the FDA, is a non-invasive option for patients who suffer from evaporative dry eye. The eye is treated with a topical anesthesia drop, and a disposable eyepiece shaped to avoid contact with your cornea is inserted under your lower and upper lids. Once in place, the patient simply relaxes and allows the thermal pulsation unit to warm the meibomian glands, and gently massage the glands to expel the oils, thereby opening and preserving the meibomian glands.

The result is the lipids (oils) can better flow into the tear film, to maintain a healthy level of lubrication on the surface of the eye. With just one treatment, you may experience sustained relief, and studies have shown that LipiFlow^TM helps to significantly reduce dry eye symptoms and improve tear film quality on the surface of the eye¹. Your doctor will inform you if LipiFlow^TM is the correct treatment for your dry eye symptoms.

Prior to LipiFlow^TM, several tests will be carried out to assess the quality of the oils from your meibomian glands, how well your glands are functioning and how blocked they may be, and how well you are blinking. Ask your doctor for more information and to find out if you are a candidate for this evaporative dry eye treatment.

1. Lane SS et al. A New System, the LipiFlow, for the Treatment of Meibomian Gland Dysfunction. Cornea. 2012; 31(4): 396-404.

Restasis

Restasis (Cyclosporine 0.05%), is a prescription medication used to treat patients with the aqueous deficient form of dry eye. Restasis is a preservative-free ophthalmic solution, used twice a day. It works by increasing the natural process of tear production. Unlike artificial tears that simply lubricate the eyes temporarily, Restasis aids the eyes in increasing the natural lubrication process.

Results may not be seen immediately, and your doctor will advise you that you will need to try Restasis for at least 3 months prior to notice an improvement in dry eye symptoms.

Xiidra (Coming Soon!)

Xiidra (Lifitegrast 5%) is a new, preservative-free ophthalmic solution to treat dry eye signs and symptoms. It works by targeting inflammation caused by immune system responses. Like Restasis, Xiidra is dispensed as a “minim” or single-use container and is applied twice a day (usually morning and bedtime).

Approved for use in the United States, Xiidra is currently going through the approval process here in Canada. Ask your ophthalmologist for more information about Xiidra, and check back with our website for more updates on the approval status for Xiidra.

Ikervis

Ikervis (Cyclosporine 1%) is a new, preservative-free ophthalmic solution for the treatment of inflammation caused by dry eyes. A new solution formulation allows for a higher concentration of Cyclosporine with a new model of drug delivery, resulting in enhanced absorption of the drop, meaning you only need to use Ikervis once per day!

Punctal Plugs

Tears produced by lacrimal glands eventually drain to the puncta, small ducts in the upper and lower inside corners of each eye, then into the nose. This is why your nose runs when you cry! In some cases, dry eye symptoms may be due to the fact that tears are draining too quickly. Your doctor can insert small plugs that help to maintain your tears on the surface of the eye, essentially creating a reservoir of tears to keep the eyes lubricated. These plugs are completely reversible, nearly invisible to the human eye, and inert, meaning your body will not react to them. Some plugs are even naturally dissolving over time.

For patients who like the effect of punctal plugs, but may encounter issues such as plugs often falling out, the option of punctal cautery is a surgical, permanent option to close the puncta. With punctal cautery, your surgeon will anesthetize the lids, then use a very small probe to cauterize and scar the puncta, causing them to permanently close. To prevent excessive tearing, usually, only one punctum per eye is cauterized.

Moisture Goggles

Moisture goggles are a great option to maintain a better level of humidity for the eyes, especially for patients in Southern Alberta, where the environment is very dry and increases susceptibility to evaporative dry eye disease. The moisture goggles’ soft seal creates a moisture chamber around each eye, decreasing exposure to environmental dry eye conditions. This can allow for more comfort when performing tasks such as computer work, reading, cycling, running, or driving.

Omega 3 Fatty Acids

Studies have shown that incorporating Omega 3’s through both diet and supplementation is an effective strategy to decrease dry eye symptoms^1,2. Omega 3 fatty acids work by improving the quality of the oil layer in the tear film and decreasing inflammation. There are various forms of nutraceutical products available including dry eye vitamins, Omega 3 supplements, fish oils, and flaxseed oils. Regularly incorporating these into your daily diet is beneficial for your eyes as well as your whole body!

1. Biljana M et al. The Relationship Between Dietary n-3 and n-6 Fatty Acids and Clinically Diagnosed Dry Eye Syndrome in Women. Am J ClinNutr. 2005; 82(4):887-93.
2. Creuzot C et al. Improvement of Dry Eye Symptoms with Polyunsaturated Fatty Acids. J Fr Ophthalmol. 2006; 29(8): 868-73.

Blinking is very task-dependant. In a world where we are constantly staring at screens, our blink rate tends to decrease, and the meibomian glands are unable to properly deliver the necessary oils to maintain a healthy tear film on the surface of the eyes. The staff at Seema Eye Care Centre can discuss exercises and strategies with you to increase your blink rate and quality of blinks!

Scleral Contact Lenses

While it may seem counter-productive to some patients to use a contact lens as a dry eye therapy, since contact lens wear can often exacerbate dry eye symptoms, scleral contact lenses can be used specifically for this purpose. Scleral lenses vault over the cornea and rest on the sclera or the white of the eye. The result is that the vaulted pocket over the cornea is filled with tears, providing a space that holds the tears in and prevents easy evaporation. A proper scleral contact lens fit is important. Your ophthalmologist will work closely with your optometrist to ensure scleral lenses are a safe treatment option.

Meibomian glands are small glands that sit on the margins of the top and bottom eyelids. In healthy eyes, 40 glands are located on each of the top lids, and 30 sit on each of the lower lids. The force of a full blink causes oil to be expressed from these glands and then spread across the surface of the eyes. This aids in lubrication and maintaining a healthy amount of tears in the eyes. Over time, however, oil can become thicker, and glands can become clogged. Eventually, severely clogged glands can be lost completely, decreasing the amount of oil delivered to the surface of the eye. This process of gland loss is due to several factors, including the aging process, inflammatory conditions such as rosacea or meibomian gland dysfunction, and poor habits such as incomplete blinks while doing focused work.

To maintain as many functional glands as possible, meibomian gland expression can be performed, in which your doctor will use a tool to apply a certain amount of pressure to the lids in order to express thicker oils that may be building up within the lids. By opening these glands, and practicing full blinks, the amount of oil delivered to the surface of the eyes can be increased, relieving evaporative dry eye symptoms.

Your doctor may recommend coupling meibomian gland probing with IPL treatment to treat the root causes of inflammatory skin and eyelid conditions.

BlephEx

For patients experiencing inflammatory dry eye with red, irritated, itchy, or scaly eyelids, BlephEx can be used to remove excess bacteria and debris built up on the lids, which can aid in decreasing dry eye symptoms. During BlephEx, a cleaning solution is mixed with a small amount of tea tree oil, which is known for its antiseptic, antimicrobial, and antifungal properties. A small soft cleaning tool is then used to apply the tea tree oil cleaning solution for a deeper cleansing to remove debris and bacteria, such as Demodex, from the lid margins. Your doctor will determine if this treatment is right for you.

For patients who have severe Meibomian Gland Disease and are resistant to any of the above treatments discussed, Intraductalmeibomian gland probing is a procedure that has been clinically proven to be successful in improving patient symptoms and findings^2-5. Using modified masking probes, the meibomian gland orifices are probed and then the expression of the gland is performed to allow patency for the gland to develop. This procedure is done after ample anesthetic is applied to the surfaces of the meibomian glands to ensure it is painless. A steroid/antibiotic drop is then given post-treatment for one week. Because it is an invasive procedure, we typically reserve this procedure for only severe cases of meibomian gland disease.

1. Syed ZA, Sutula FC. Dynamic Intraductal Meibomian Probing: A Modified Approach to the Treatment of Obstructive Meibomian Gland Dysfunction. OphthalPlast Reconstr Surg. 2017 Feb 17
2. Sik Sarman Z, Cucen B, Yuksel N, Cengiz A, Caglar Y. Effectiveness of Intraductal Meibomian Gland Probing for Obstructive Meibomian Gland Dysfunction. Cornea. 2016 Jun;35(6):721-4
3. Ma X, Lu Y. Efficacy of Intraductal Meibomian Gland Probing on Tear Function in Patients With Obstructive Meibomian Gland Dysfunction. Cornea. 2016
   Jun;35(6):725-30
4. Nakayama N, Kawashima M, Kaido M, Arita R, Tsubota K. Analysis of Meibum Before and After Intraductal Meibomian Gland Probing in Eyes With Obstructive Meibomian Gland Dysfunction. Cornea. 2015 Oct;34(10):1206-8