With the incidence of dry eye disease (DED) ranging between 5% and 34% of patients over 50 years old,¹ dry eye patients can comprise a large part of most ophthalmology practices. Additionally, there is evidence that both the annual prevalence and incidence of the condition is in

creasing amongst multiple age groups.² According to the TFOS DEWS II global dry eye definition, “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play etiological roles.”³

Since DED is one of the top two reasons for unhappiness after a cataract surgery with a presbyopic IOL⁴ and more than 80% of patients presenting for cataract surgery actually have dry eye,⁵ it has become even more important for ophthalmologists to adequately manage dry eye. While we are fortunate now to have an ever-expanding list of FDA-approved medicines for dry eye, treatment can be complex and require multiple modalities. Luckily, we have a growing number of in-office treatments to help our patients as well.

In this article, I will describe current available techniques for the treatment of dry eye in the office.

BLEPHEX

While it is easy to focus on the aqueous deficiency in dry eye, we must remember that 86% of dry eye is evaporative in nature⁶ and can be linked to the eyelid margin. In a study of more than 1,148 patients with ocular discomfort or irritation, 36% were diagnosed with blepharitis.⁷

It is important to look closely at the lid margin on each patient and to identify scurf or collarettes, a classic sign of anterior blepharitis. Also, we need to observe signs of posterior blepharitis, which include red, thickened lid margins and conjunctival hyperemia.

The BlephEx treatment, also known as microblepharoexfoliation, was created by Jim Rynerson, MD. It allows the clinician to safely and painlessly clean the eyelid and remove blepharitis.

The Blephex device utilizes a soft, medical-grade micro-sponge that quickly rotates along the lid margin to remove scurf, collarettes and bacteria that accumulate and ultimately worsen the ocular surface. The procedure takes about 6-8 minutes, and patients can resume their normal activities immediately afterwards. In my personal practice, patients experience symptomatic relief from the typical burning, itching and stinging sensation that I had previously diagnosed simply as dry eye. Usually the symptomatic relief is quick and occurs within days of the treatment.

I have been recommending patients to have the procedure done 1-2 times per year, but I still closely monitor them at each visit and let them know that treatments can be repeated sooner than that if needed. I also place patients on an at-home lid hygiene routine, including hypochlorous acid spray, such as Avenova (NovaBay Pharmaceuticals) or Acuicyn (Sonoma Pharmaceuticals), in order to maintain a healthy eyelid environment.

As it is also a cost-effective treatment, I am comfortable offering Blephex to my patients as a first-line therapy. I am confident that they will experience a relief in symptoms with very little risk or downside to the procedure.

LIPIFLOW

The next three treatments specifically focus on treatment of the meibomian glands, which are critical in the pathophysiology of evaporative DED. By applying heat and compression to the glands, the goal is to improve meibomian gland function and improve dry eye symptoms.

LipiFlow (Johnson & Johnson Vision) is a treatment for meibomian gland disease (MGD) that utilizes automated thermal pulsation technology. It consists of a single in-office treatment for 12 minutes that simultaneously warms and applies a gentle peristaltic pressure to the meibomian glands of both upper and lower lids bilaterally. It requires the placement of a topical anesthetic drop in order to place the activators, which encompass both the inner and outer lid.

LipiFlow has a long history, as it has been on the market for more than 10 years and more than 400,000 treatments have been performed worldwide. A study by Blackie et al showed a three-fold improvement in meibomian gland function that was sustained over a 12-month period.⁸ In one study, a single LipiFlow treatment prior to cataract surgery improved mean postoperative dry eye symptoms, based on improved patient scores on the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) dry eye questionnaires.⁹

TEARCARE

TearCare (Sight Sciences) applies heat to the external eyelids in order to warm the meibum in the meibomian glands. Unlike LipiFlow, the device remains external to the lids during the process and allows the patient to blink and maintain an open eye position during the 15-minute thermal lid warming process. A consistent temperature of 45° C is provided by the SmartLid and SmartHub technology.

After the warming portion of the procedure is complete, the SmartLid device is removed and the clinician begins the meibomian gland clearance with the proprietary clearance forceps provided. These forceps allow the clinician to apply a customized amount of pressure to treat each gland and simultaneously view the treatment.

The Olympia clinical trial data for TearCare showed a statistically significant improvement in both tear break-up time (TBUT), meibomian gland secretion score (MGSS) and also a statistically significant decrease in OSDI.¹⁰

ILUX

iLux (Alcon) is a handheld device that simultaneous allows the clinician to warm and compress the meibomian glands while observing the glands through the magnifier of the single-use, disposable Smart Tip patient interface. The device uses infrared light energy to warm the glands quickly and efficiently and allows manual adjustment of gland compression based upon clinical judgment.

A clinical trial studying iLux found it achieved a statistically significant improvement in TBUT and MGSS and a statistically significant decrease in OSDI.¹¹

PROKERA

Prokera (Biotissue) is a cryopreserved amniotic membrane (CAM) that can be used in multiple corneal conditions. Some evidence indicates that CAM can be used to help improve patients with moderate and severe DED by helping to promote surface hydration and protection due to the bandage-like effect of the CAM sitting on the ocular surface for days.

It appears that the CAM itself helps reduce corneal inflammation,¹² and a study by John et al showed that CAM may help restore corneal nerves in those with DED.¹³ In addition, the DREAM study by McDonald et al looked at 97 eyes with severe dry eye refractory to maximum medical treatment. These patients had been diagnosed with Stage 2-4 DED, as defined by the Report of the International Dry Eye Workshop (DEWS), and treatments that had previously been tried included artificial tears, steroids, cyclosporine-A, antibiotics, serum drops, punctal plugs and non-steroidal anti-inflammatory drops.

After placement of Prokera Slim, 88% of patients showed an improvement in the ocular surface and symptoms of dry eye as well as a statistically significant reduction in the DEWS score.¹⁴

The placement of an amniotic membrane in the office is straightforward, and the procedure is well tolerated. Often, a partial tape tarsorrhaphy is recommended, and I always inform the patient that they may have some discomfort from the device; however I have found that patients overall tolerate both the procedure and device very well. I like having this as an option for my severe DED patients, especially those who are in extreme discomfort and have been refractory to other treatments. In addition, the procedure is often covered by medical insurance, which can be helpful for our patients.

PUNCTAL PLUGS

An article on in-office dry eye treatments would not be complete without mentioning punctal plugs. Punctal plug insertion is a quick procedure that can easily be performed at the slit lamp with minimal risk and minimal discomfort. They are usually covered by insurance and can provide a benefit to patients with dry eye not relived by ocular surface lubrication. They can also be helpful when managing postoperative dry eye symptoms from cataract or refractive surgery.

An AAO ophthalmic technology assessment reviewed the published literature evaluating the safety and efficacy of punctal plugs used in the lacrimal drainage system and found that punctal plugs “resulted in ≥ 50% of improvement in symptoms, improvement in ocular-surface health, reduction in artificial tear use and improved contact lens comfort in patients with dry eye.”¹⁵

The assessment found that the plugs were well tolerated and serious complications were infrequent, with the most common being plug loss (40%). Other complications included epiphora (9%) and irritation requiring plug removal (10%). Canaliculitis was the most common problem found in intracanalicular plugs.

Interestingly, there are no Level 1 studies describing the safety or efficacy of punctal plugs, but they remain an important tool for our dry eye patients.

CONCLUSION

In-office treatments for the management of DED have expanded our current options to help our patients manage this multi-factorial disease. It’s important to be aware of current and emerging treatments in order to provide a comprehensive treatment plan that targets all different etiologies of DED.

Whether managing routine dry eye office visits or pre- and postoperative surgical care, DED is an ever present and frequent co-morbidity, and effective management will greatly increase both your and your patients’ satisfaction. OM

REFERENCES

1. Dana R, Bradley J, Guerin A, et al. Estimated prevalence and incidence of dry eye disease based on coding analysis of a large, all-age United States health care system. Am J Ophthalmol. 2019;202:47-54.
2. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye Workshop. Ocul Surf. 2007;5:93-107. [No authors listed]
3. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15;276-283.
4. Gibbons A, Ali TK, Warren DP, Donaldson KE. Causes and correction of dissatisfaction of after implantation of presbyopia correcting intraocular lenses. Clin Ophthalmol. 2016;10:1965-1970
5. Trattler W, Majmudar P, Donnenfeld E, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) Study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
6. Wu H, Lin Z, Yang F, et al. Meibomian gland dysfunction correlates to the tear film instability and ocular discomfort in patients with pterygium. Sci Rep. 2017;7:45115.
7. Venturino G, Bricola G, Bagnis A, Traverso CE. Chronic blepharitis: Treatment patterns and prevalence. Invest Ophthalmol Vis Sci. 2003;44:774.
8. Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol. 2016;10:1385-1396.
9. ClinicalTrials.gov . Pilot study for treatment of meibomian gland 9. dysfunction (MGD) prior to cataract surgery. https://clinicaltrials.gov/show/NCT1808560 . Accessed Feb. 8, 2021.
10. Loh J, Trattler W, Dhamdhere K, Bloomenstein M, Hovanesian J, Jackson M, Saenz B; A novel, targeted open eye thermal therapy and meibomian gland clearance in treatment of dry eye: A randomized control trial (OLYMPIA). Paper presented at the Virtual American Society of Cataract and Refractive Surgery Annual Meeting; May 16, 2020.
11. Hardten DR, Schanzlin JD, Dishler JG, et al. Comparison of a handheld infrared heating and compression device for treatment of meibomian gland dysfunction to a thermal pulsation device. Presented at the Annual Meeting of the American Society of Cataract and Refractive Surgery (ASCRS); April 13–17, 2018
12. Cheng AM, Zhao D, Chen R, et al. Accelerated restoration of ocular surface health in dry eye disease by self-retained cryopreserved amniotic membrane. Ocul Surf. 2016;14:56–63.
13. John T, Tighe S, Sheha H, et al. Corneal nerve regeneration after self-retained cryopreserved amniotic membrane in dry eye disease. J Ophthalmol. 2017;2017:6404918
14. McDonald MB, Sheha H, Tighe S, et al. Treatment Outcomes in the DRy Eye Amniotic Membrane (DREAM) Study. Clin Ophthalmol. 2018;12:677-681.
15. Marcet M, Shtein R, Bradley E et al. Safety and efficacy of lacrimal drainage system plugs for dry eye syndrome: A report by the American Academy of Ophthalmology. Ophthalmology. 2015;122:1681-1687.

About the Author

Jennifer Loh, MD, is founder and medical director of Loh Ophthalmology Associates, located in Miami, and serves on the board for Eye Physicians of Florida. Dr. Loh is also a clinical faculty member for the newly accredited ACGME Larkin Hospital Ophthalmology Residency program.

Disclosures: Dr. Loh is a consultant, speaker and has received research funding from Sight Sciences. She is also a consultant for NovaBay and Johnson & Johnson Vision.