Dry eye disease defined as a “multifactorial disease of the ocular surface needs a Holistic treatment approach!
If you’re frustrated by current dry eye patient management failure you should rather consider a Holistic approach. The importance of understanding and pro-actively addressing the underlying causes of MGD, lipid deficiency, and tear instability can improve patient outcomes dramatically especially when combined with advanced treatment approaches like LLLT Photo-modulation with expression.
Dry Eye Treatment
Slight Dry Eye MGDFX Treatment
Phase A List: Base line treatment protocol
- Dietary modifications: Increase water Intake, Gut Health and TG -Omega 3 (Form)
- Blepharitis/Demodex Lid Hygiene: Eyelid Debridment with Epstein Lid Debrider & Up MeiboFlo In office eyelid Debridement kit and Gel. (2 x weekly sessions)
- Hypochlorous Spray – Twice daily (significantly reduces bacterial load, deactivates bacterial inflammatory toxins and pro-inflammatory mediators)
- Meibomian gland Nutrition – Up MeiboFlo Eye serum: After care moisturizing and Nutrients-Organic Food state Amino acids with minerals & vitamins.
Dietary modifications: A,B,C
A)Increasing water intake is a simple recommendation with significant benefits for patients with DED.
B) Nutritional triglyceride formulation Omega-3 fatty acids are found as key foundational treatment. The current
ratio of 3:1 EPA to DHA is highly recommended.
Likewise, the meibomian glands require essential fatty acids (EFAs) as raw materials to produce the lipids that make up meibum. When reviewing Omega 3 as treatment for ocular inflammation there were some controversy results as seen with the Dream study. However, we have
found it to be significant and helpful and newer studies after cataract surgery has shown the benefits especially if a high EPA ration is used. Possibly the best option would be Nordic Naturals EPA-Xtra 2-3 capsules per day.
C) Gut Health research show that it contributes major inflammatory effects and should not be overlooked.
References:
1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575- 628.
Blepharitis/Demodex Lid Hygiene: Eyelid Debridment with Epstein Lid Debrider & Up MeiboFlo In office eyelid Debridement kit. (2 x weekly sessions)
Eyelid debridement (using a Epstein Debrider ( Round tip) – see technique in video below is crucial for removal of Biofilm and the Keratin like debris.
The Epstein Eyelid Debrider tool is a revolutionary device designed to enhance the efficiency and precision of eyelid debridement procedures. Developed with cutting-edge technology and expert craftsmanship, this device is meticulously engineered to deliver superior performance in the delicate process of removing debris and exfoliating the eyelids.
Up MeiboFlo™ Debridement in office procedure : The Up MeiboFlo™ Debridement Treatment Kit is designed specifically for in-office eyelid cleaning and debridement — a safe, gentle procedure that penetrates deeply to remove biofilm, dramatically reduces eyelid inflammation. The unique formulation assists in Blepharitis management, Stye treatment, De-capping of Meibomian glands and contact lens intolerance , to support healthier eyelid margins for improved Meibomian gland flow. It provides a comfortable experience while delivering noticeable clinical results.
Lissamine Green staining and Fluorescein helps to enhance the visibility of lid debris and Marx’s Line
Hypochlorous – Lid & Lash Spray
Hypochlorous spray targets the neglected lid margin & biofilm affecting tear film stability in MGD.
MGD is associated with alterations in the lid microbiome.
Decreased lipid production and meibum flow motivates the presence of bacteria and Demodex. The increased biofilm and bacterial toxins stimulate the snowball
cycle of inflammatory response.
This new generation hypochlorous is non-cytotoxic, it reduces bacterial population and inflammatory components.
Our Hypochlorous acid is produced through a proprietary method resulting in the purest forms of HOCL (stable -18 months). It is a gentle and effective oxidant that is naturally produced by our bodies’ white blood cells. It directly kills the bacteria on the lids and lashes.
Instruct patients to spray the HOCL onto the closed eye, with slight eye movements to spread and tissue wiping after 15 seconds. Patients could also spray HOCL
onto a cotton pad and wipe the eye. HOCL is also helpful to reduce skin inflammation in facial acne and rosacea, used twice daily; before the application of SM Derma Fusion nutritional Amino Acid multi vitamin cream.
Reference Papers of Baudouin is a must read:
1. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016;100(3):300-306.
2. Suzuki T. Inflamed Obstructive Meibomian Gland Dysfunction Causes Ocular Surface Inflammation. Invest Ophthalmol Vis Sci. 2018 Nov 1;59(14):DES94-DES101.
Meibomian gland Nutrition – Up MeiboFlo Eye serum, After care moisturizing and Nutrients-Organic Food state Amino acids linked minerals & vitamins
Let’s increase the level of Nutrition around the eye. Made of organic Food State nutrients this eye and face serum provides the essential Amino acids, minerals, vitamins and anti-oxidants to reduce eyelid inflammation and provide the amino acid support for protein Synthesis in the Meibomian glands.
The patient will love the cosmetic advantages and anti aging effects but more important the effect to eyelid health and functionality.
The exciting serum has been shown remarkable results with recent studies done for epithelial cell health on basement membrane level and underlining nerve cell health.
Further the Eye serum should be incorporated with Burn wounds and surgical wounds treatments , results show great Improved recovery time, reduced inflammation and significant less scarring with 3 times daily application.
During Medical procedures such as Eyelid surgery, Botox, Vital injections, micro needling or Chemo related skin laser, this nutritional eye serum is helpful with inflammatory management and improved healing time.
Dry Eye Treatment
Slight to Moderate Dry Eye MGDFX Treatment
Phase B: Add -on considerations to List
- In office Sessions ( 3-4x sessions: Lid debridements & Blephsteam or Redlight TX + Expression)
- Home Heat Mask and Blinking exercises
- Lagophthalmos & nocturnal exposure Drops – Lubricating drops (Optive Omega or Sustane Preservative free)
Focusing on a Holistic approach our recommended or go to choice artificial tear drop would be Optive OMEGA. Exciting results and positive patient feedback makes the drop a good first line choice to reduce friction and possibly aid with anti Inflammatory properties for Meibomian gland health.
Home Heat Mask and Blinking exercises
The Fresh eye Therapy Heat Mask with ThermaBeads™ will be most effective when used as part of the treatment plan.
Naturally hydrating for deep penetrating, moist heat therapy. The mask is Latex free & non-allergenic.The mask is user friendly and provide moist heat treatment. Patients are recommended to microwave for 20-26 seconds and to apply the mask for 10 min.
The home treatment aid to stabilize the lipid flow for improved gland function. The lid heating results should elevate the conjunctival temperatures from 36.2 to 37.1°C for the upper lid and from 36.7 to 38.3°C for the lower lid, and should be done at home 2x daily.
These results are consistent with previously published findings
Blinking exercises:
Blinking exercises can be extremely helpful to improve the normal gland secretion and more importantly improves the normal blinking patterns.
Patients have reported significant improvements when including this into the treatment protocols.
References:
All Warm Compresses Are Not Equally Efficacious.
Murakami DK, Blackie CA, Korb DR Optom Vis Sci. 2015 Sep; 92(9):e327-33.
In-Office Sessions: Eyelid Warming + Meibomian Gland Expression
A twice-weekly in-office eyelid warming session combined with manual meibomian gland expression is recommended, particularly for patients with mild to moderate dry eye.
Eyelid warming devices help heat the eyelids to approximately 40 °C, effectively melting the meibum and facilitating the clearance of gland obstructions. Manual expression of the meibomian glands should be performed within 30 seconds after the heating phase to maximize gland clearance.
Before initiating these in-office procedures, it is essential to address underlying eyelid inflammation, blepharitis, and Demodex infestation. Inflamed lid margins can cause significant discomfort during manual gland expression.
The Up-MeiboFlo Eyelid Cleansing Gel, used for lid debridement, has shown to be highly effective in calming inflammation and supporting healthy meibomian gland function.
Lagophthalmos & nocturnal
exposure
Lid Closure is important to restore the ocular surface after daily exposure.
Tear evaporation at night time will lead to discomfort and will demonstrate fluoresceinstained area along the lower third of the
cornea should the patient be seen early in the morning after.
Easy testing can help you confirm this frequent diagnosis of nocturnal lagophthalmos. There seem to be a huge link between patients with dry eye symptoms and lagophthalmos of 30% or greater.
Lagophthalmos testing:
During your questioning most patients will complain of dryness or pain upon awaking
While conducting your slit lamp exam you may reveal an incomplete blinking pattern. Be on the lookout for interpalpebral Conjunctival injection with possible staining using Lassamine green. Fluorescein corneal staining may become visible in patients with a reduced Bell’s phenomenon.
Dim the room and ask the patient to tilt their head slightly backwards or recline the chair, observing the lid closure using a penlight held below the lower lid margin. You should notice the exposed ocular surface after a minute with sometimes some top lid twitching.
In south Africa we have found using the comfortable Eyeseal 4.0 silicone mask with agel drop locks in moisture and works well with patients.
References:
Overlooked causes of dry eye .Arthur B. Epstein, OD, FAAO. Optometry Times Journal, Optometry Times September 2019, Volume 11, Issue 9
Dry Eye Treatment
Moderate To Severe Dry Eye MGDFX Phase C: Add -on considerations:
- Scleral lens and bandage lens options
- Amiotic Membrane placements
- RX Drops and assistance .(0ptimune (Cyclosporin) /Lotamax / Pred Mimims etc)