Procedures are good for moderate-severe cases of dry eyes. Typically, these patients have seen some improvement with conservative medical therapy but are still symptomatic. We offer a wide range of treatments, as not all treatments work on all patients. Unfortunately, this can become a trial-and-error process until the proper combination for that individual is found. Dry eye is a chronic process and maintenance treatments with these procedures are expected in moderate-severe cases.
This may or may not be done in conjunction with a small superficial keratectomy, or removal of the superficial layer of the cornea. The amniotic membrane is the lining of the amniotic sac, the sac that envelopes the fetus in utero. This is harvested from pregnant women who are deemed healthy with no blood-borne diseases. This tissue is prepared and stretched tight over a large plastic ring. This is placed onto the patient’s eye. The membrane is opaque, so vision is limited for the next week. Additionally, the ring gives a nagging foreign-body sensation until it is removed the following week. The tissue has remarkable anti-inflammatory and pro-healing action and can be done as a quick outpatient procedure.
Patients can accumulate crusting on their eyelashes over time. This is typically caused by bacterial overgrowth—we all have bacteria that grow on our lashes. That is normal. But if there is too much growth or the balance between the different species of bacteria is thrown off, then the toxins secreted by the bacteria (especially Staphylococcus) can cause dry eye by that “lit match” theory we talked about earlier. When we start seeing a characteristic sheathing of the eyelashes, this is called biofilm. Eventually, mites called Demodex can start living off this biofilm. They typically come out at night, move around, mate and lay eggs. It sounds like some sort of horror movie, but keep in mind that mites are omnipresent; we see the percentage of this increase in patients as they age. The problem is these Demodex mites can secrete toxins and different patients have different levels of sensitivity to this. They can give patients chronic itching, especially at night, along with other dry eye symptoms. Recurrent styes and pterygia are common presentations.
BlephEx is essentially like a toothbrush with a medical grade sponge on the tip. The procedures requires nothing more than topical anesthetic eyedrops, though we do offer nitrous oxide for our most comfortable experience. Each eyelid is cleaned in succession for approximately 20 seconds for each lid. The feeling can be described as a strange, intense tickle with no recovery process. If Demodex is noted prior to the procedure, then a tea tree oil derivative is applied to the eyelids afterwards in order to kill the mites. This can cause some minor burning in the eyes for a few minutes afterwards, but no lasting discomfort.
We previously touched upon the nasolacrimal drainage system as normal part of the tear drainage process. This can be used to our advantage. Closing one of the two holes in a particular eye can keep the tears around the eye longer with each blink. Typically, we close the bottom eyelid puncta because gravity drags most of the tear flow downwards, so we get the biggest improvement in symptoms. It is usually tolerated very well, though patients could experience excessive tearing, a foreign body sensation, the plug falling out and very rarely, infection. This is best used once the inflammation in the eye has been calmed down, otherwise the dry eye symptoms could actually get worse! To that end, this does NOT stop the progression of dry eyes as there is no anti-inflammatory action. It only seeks to aid in symptom relief.
If plugs work but keep falling out, or if the plug head is causing a chronic foreign body sensation, then punctal cautery is an option. After receiving a small local anesthetic injection, cautery is used to permanently seal the puncta. Recovery is quick and painless.
If conservative therapy with omega-3 supplements and hot masks does not result in thin, free-flowing oil out of the meibomian glands, then Lipiflow can be an option. It works by applying heat to the back of all four eyelids simultaneously. It reaches a peak temperature of 108oF and holds that temperature for 12 minutes. Because the meibomian glands are anatomically closer to the back of the eyelid than the front, this is a more effective way to melt the oil glands since heat is not being unnecessary dispersed in transit. Unfortunately, no warm compress currently exists that would allow you to do this at home without possibly irritating your cornea or conjunctiva, so maintenance at home still consists of external hot masks/warm compresses. This process is painless and, frankly, most patients fall asleep because it is quite comfortable. The effect for this can vary but should probably be repeated annually. It works best in Stage 0 and 1 meibomian gland disease, as scarring in the meibomian glands would give a suboptimal result.
Intense Pulsed Light (IPL)
This is used as a dermatologic treatment for rosacea. This is a disorder of oil glands and can affect the skin and eyelids. IPL releases energy that is absorbed in pigmented tissues, including the red of blood vessels. In treating the skin of patients around the eyes, doctors noticed a funny thing. Patients were having improved dry eye symptoms as a beneficial “side effect!” Further insight into this reveals that it seems to decrease the inflammation associated with dry eyes. We are unsure of the mechanism exactly but it likely involves absorption of the light energy into the small blood vessels, the telangiectasias, of the eyelids. When these telangiectasias start to disappear, the inflammation likely goes down. This is a procedure that typically done for four consecutive months to build up momentum and then done as a maintenance procedure 6-12 months later, ideally just before the symptoms start coming back. Because the treatments spots can cause a momentary rubber-band snap feeling that can be uncomfortable, we offer nitric oxide and to make this a much more comfortable process
Meibomian Gland Probing (MGP)
The idea behind this treatment involves understanding the pathology of the individual meibomian glands. It is thought that inflammation contributes to thickening of the oil in the meibomian glands, as we previously discussed. However, inflammation may also contribute to tufts of new blood vessel growth, or neovascular membranes, that may start to slowly constrict the internal lumen of each gland, restricting flow, until it closes it outright. In this case, neither omega-3 supplements nor Lipiflow would work, as the loose oil would be trapped behind a neovascular membrane. We see this more often in Stage 2 and 3 MGD patients, though some Stage 1 patients benefit as well. Inflammatory conditions such as Sjogren’s Syndrome may be more likely to need this.
This procedure is more invasive and can be more uncomfortable, so we have patients use nitric oxide while we give a local anesthetic injection to the lower eyelids. Once numbness has been verified, a Maskin probe in used to go down 25-30 oil glands of the lower eyelids, one by one. In many cases, a small pop may be felt as the neovascular membranes are opened. After this done, the Lipiflow is found to be much more effective, provided there are still viable oil glands still present.
A novel concept involving the concept of biofeedback. Essentially a purchased device is used to insert into the nose. The two prongs at the tip create a small current which induces tearing by stimulating nerves. The tear composition is supposed to closer to our normal tears that we produce when blinking as opposed to the reflex tearing we get when our eyes are irritated. This device can be used many times a day for symptomatic relief. We no longer carry it, as there was a not a great demand for it, but the idea was radical in its approach to treating dry eye and deserves special mention.
Pterygia are signs of chronic ocular surface disease and are associated with Demodex in about 75% of our patients anecdotally. As these grow onto the cornea, they can cause disruptions in the tear film of the cornea, drying it out and exacerbating the dry eye process, creating a vicious cycle. Removal of these is done in the OR with anesthesia. Functional recovery is about a week with cosmesis taking up to a month.
Ocular Surface Reconstruction/Fornix Reconstruction
We discussed earlier about the fornix, the conjunctival pocket that helps provide a reservoir of fluid and how it can loosen in the setting of chronic inflammation. Since that problem is a mechanical one, it requires a mechanical solution. Treatment of this conjunctivochalasis is surgical and involves reforming the pocket with the aid of amniotic membrane. This is done in the OR with appropriate anesthesia for optimal comfort. Recovery can be up to one week from a functional standpoint and two weeks from a cosmetic standpoint.