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Great options in dry eye treatment

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Dr Nicholas Young
BSc(Hons) BOptom PhD(Med)
GradCertOcTher
Dry Eye Centre, Heathmont VIC

Products
Oculus K5 Keratograph
Lipiflow Thermal Pulsation Treatment
Lipiview Interferometer

Suppliers
Designs For Vision
Device Technologies

At The Dry Eye Centre, we investigate and manage the complex problem of ocular surface disease. This is jointly due to several years of planning and increasing our extensive knowledge base, and practical experience desirable to work in this niche area.

As a husband-and-wife optometrist team, we made a significant financial investment in obtaining some of the best technology available for investigating and treating the condition. In the planning phase, we were mindful that most patients with dry eye spend an unnecessary amount of time and money on their eye care, often doctor-shopping for answers and commonly being misdiagnosed and misunderstood. We wanted to build a facility that took the time to validate our patients’ symptoms and provide them with an exceptional level of care. We understood that new technology would form an integral part of the business model.

Oculus K5 Keratograph

It has always puzzled me that traditional methods of diagnosing dry eye disease were limited to problematic invasive tests. These continue to dominate the literature as goal standards, not because they accurately reflect the condition of ocular surface, but because they are historically the best tests available. Some criticisms of classical tests include the interpretation and clinical significance of Schirmer-test-induced tearing, the effect of diagnostic dyes on ocular surface tension and chemistry, and the tear sampling techniques of osmolarity testing.

Non-invasive diagnostic metrics of dry eye are less well documented because they are novel, relatively expensive and not in abundant use. In deciding the diagnostic standards for our clinic, we wanted to be able to assess a patients’ ocular surface without disturbing it.

While this presented a challenge, in 2013 we became aware of the Oculus K5 Keratograph. This was the first device we knew of to offer an infra-red based, non-invasive dry eye diagnostic module. While there were devices on the market that performed one test or another, this device integrates a suite of tests. The K5 measures parameters such as tear meniscus height, non-invasive tear break-up time, tear lipid layer quality, tear flow rate, bulbar redness and infra-red meibography. Using grading scales, the K5 then characterises severity, enabling an uncomplicated interpretation of results.

As a keratograph, it provides all the benefits and features one would expect of such a device. Its capabilities for orthokeratology include an on-board fitting and lens selection library that is periodically updated by Oculus.

We have used the keratograph on many patients with the following observations:

  • It has become our primary device for assessing dry eye.
  • It complements our slitlamp observations, which follow non-invasive testing.
  • It has become an invaluable tool for explaining our observations to patients. Test results are available in graphical, data and image formats, which are convenient to display and easy for the patient to understand.
  • We still use diagnostic dyes to look at surface staining but this is done after the keratography.
E24 Figure 4 Oculus Keratograph
Oculus keratograph

Lipiview and Lipiflow

The meibomian glands, located in the eyelid tasrsal plate toward the anterior palebral conjunctival surface, lie parallel to each other and perpendicular to the lid margin. They produce a lipid (meibum) which is expelled onto the ocular surface on each blink through the distal gland orifice, promoting healthy tear exchange and preventing interblink aqueous tear evaporation. Meibomian gland pathology can be characterised in a number of ways, including by gland orifice congestion and keratinisation, limiting meibum flow, increasing aqueous tear evaporation and mechanical interference of the blinking mechanism itself. Left untreated, gland dilation, tortuosity and even complete failure and atrophy are likely.

Lipiview is a diagnostic device that uses interferometry to assess meibum quantity and quality. To some extent, I have found overlap between the lipid-measuring feature of the Oculus keratograph and Lipiview. However, Lipiview perhaps has the edge, as it produces a meibum score of lipid, whereas the keratograph is qualitative. Either way, patients in whom poor quantity and/or quality meibum can be identified may be suitable candidates for Lipiflow.

Lipiflow helps to restore meibomian gland function by evacuating the thickened oils and essentially allowing the glands to ‘breathe’. The device uses a disposable activator incorporating a heating element (directional lid warmer) and an inflatable air bladder (pump). The heater, which looks a little like a scleral contact lens, clears the cornea and lands on the conjunctiva. The pumps are positioned on the outside of the lid, effectively sandwiching the lids between the pumps and the heater. The activator is connected to the main device: a Windows-based dedicated PC with touch-control interface. The software consists of a patient demographic database module, an administration module and a treatment module.

During the 12-minute procedure, the device heats the glands to 42.5 degrees and then uses a compressive force of approximately 5 psi to express the warmed meibum from the gland orifices. The treatment module graphically displays the progress of the treatment, including temperature and pressure maintenance as well as other parameters.

Unlike steam-based procedures requiring manual gland expression, and unlike other experimental dry-eye devices, Lipiflow is an evidence-based and peer-reviewed treatment modality that has been designed from the ground up as a treatment for the most commonly presenting form of dry eye, evaporation.

The Oculus K5 is not necessarily predictive of a patient’s symptoms and neither is Lipiflow a cure. Both of these devices need to be used knowledgably. One of the traps for the eye-care professional is failing to understand that the signs and symptoms of dry eye are often discordant. This can lead to misunderstanding and regrettably, even dismissal of the patient’s concerns. When these devices are used proficiently with patience and dedication, the rewards are there.

We have been very pleased with our results using these devices and I am confident that the Dry Eye Centre, which is entirely dedicated to work in this area, could not have been structured as such without a commitment to these and other technologies we have introduced.

CASE STUDY

History

A 34-year-old female presents with a complaint of dry eye for the previous 18 months. She had acne treatment during her teenage years.

The symptoms are moderate severity dryness, grittiness, scratchiness, soreness and irritation. These conditions interfere with her working day and have prevented her from doing her job comfortably. The patient also mentions a mild burning sensation and occasional eye-watering, which she says is uncomfortable but tolerable.

She has been to several practitioners and tried most available lubricants without symptom relief.

E24 Figure 1

Figure 1. Case report. Oculus K5 infrared imaging reveals meibomian gland atrophy

Observations

Oculus K5 imaging

Tear meniscus height: approximately 0.25 mm (R & L).

Non-invasive break-up time: initial break 6.9 seconds and 5.0 seconds (R & L, respectively).

Average break 6.9 and 5.5 seconds (R & L, respectively).

Blinking pattern complete with no band keratopathy, corneas are clear of surface staining.

Meibography: approximately 25 per cent gland atrophy/distress (R & L).

Mild lid-wiper epitheliopathy (R & L).

Significant lid margin keratinisation, especially on the inferior lids.

Meibomian gland secretion score: fewer than six glands normally secreting (R & L).

Lipid layer thin with absent lipid prism (R & L).

E24 Figure 2 Abnormal Lipid E24 Figure 3 Normal Lipid
Figure 2. Case report. Oculus K5 imaging: abnormal lipid of patient shows no prism.

Figure 3. Case report. By comparison, the normal lipid is very prismatic (K5 imaging of a previous patient)

Diagnosis

Meibomian gland disease with marginal lid scarring, secondary to acne treatment with benzoyl peroxide.

Treatment: Pre-treatment lid preparation followed by Lipiflow.

Post Lipiflow, six week review: observations

Non-invasive break-up time: initial break 11.6 seconds and 8.6 seconds (R & L, respectively).

Average: break 14.2 and 13.7 seconds (R & L, respectively).

Meibomian gland secretion score (inferior lid): greater than six glands normally secreting (R & L).

Lipid layer thin, but lipid prism restored (R & L).

Note: patient’s unaided vision remained 6/6 in both eyes pre- and post-treatment.

Outcome

The patient’s symptoms are significantly reduced and she is able to continue working without discomfort. Windy conditions remain a problem outdoors but gasketed sunglasses have eliminated this. A home-based management plan has been introduced to help maintain treatment effect.

The plan includes gland-warming sessions, twice daily, using heat-controlled goggles, followed immediately by an eye lid detergent to remove tear debris while the gland is still warm. The patient is now free of lubricants. Review is set for three months.



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