Dry eye disease (DED) is a common reason for patient visits, and its increasing prevalence underscores the need for effective solutions.
Left untreated, DED can significantly impact both quality of life and work productivity, necessitating thorough and intentional eyecare that surpasses the limitations of over-the-counter options.
In-office treatments such as intense pulsed light (IPL), radiofrequency (RF), Lipiflow, TearCare, iLux, BlephEx, and NuLids Pro offer targeted interventions to address meibomian gland dysfunction (MGD), a major cause of evaporative dry eye, in addition to other elements of DED as well.
Restoring proper meibomian gland function leads to improvements in tear film stability, ocular surface health, and overall dry eye symptoms.
Overview of dry eye disease
Characterized by a loss of tear film homeostasis, dry eye affects approximately 8.1% of the population in the United States.1,2 Its multifactorial nature poses challenges to accurate diagnosis and treatment.
Factors contributing to the development of DED include but are not limited to:1
- Advancing age
- Systemic conditions like Sjögren's syndrome
- Wearing contact lenses
- Using digital devices
- Exposure to environmental factors such as pollution and low humidity
- Taking certain medications like antihistamines, antidepressants, and isotretinoin
DED can be classified into two main categories: Aqueous-deficient dry eye (ADE) and evaporative dry eye (EDE), although it more commonly presents in a mixed form.1 ADE is characterized by reduced lacrimal gland secretion, while the more common form, EDE, is caused by abnormalities of the lipid layer of the tear film, typically due to MGD.2
What is meibomian gland dysfunction?
The most common form of MGD is obstructive in nature, as opposed to hypersecretory and hyposecretory types,3 and is characterized by chronic glandular inflammation, thickening of the meibum, obstruction of terminal ducts, and glandular atrophy.4
MGD is linked to an increase in tear evaporation, tear osmolarity, and levels of pro-inflammatory agents in tears as well as reduced lubrication.5 These factors collectively interfere with the stability of the tear film and disrupt the balance of the ocular surface.5
Available in-office procedures combat MGD by aiming to improve the function and structure of the meibomian glands with thermal pulsation techniques, gland evacuation, microblepharoexfoliation, intense pulsed light, and radiofrequency therapy to essentially enhance the quality of the lipid layer of the tear film.
Benefits of implementing DED in-office treatments
Effectively addressing the burden of dry eye symptoms has long presented challenges, as the traditional approach of home therapies offers limited short-term relief and relies heavily on patient compliance.
Conventional first-line treatments include over-the-counter preservative-free artificial tears, warm compresses, eyelid hygiene, and dietary supplementation with omega-3 fatty acids. Despite the foundational role of these home-based therapies in treating DED, not all patients experience sustained improvement, especially given the challenge of low compliance rates.
Research indicates that integrating home care with in-office procedures improves efficacy, thereby shifting the paradigm towards advocating home maintenance as adjunct therapy alongside doctor-delivered treatments.4
Establishing a dedicated dry eye clinic enables practitioners to provide advanced solutions that address the root cause of EDE, provide long-lasting relief to patients, and potentially reduce the burden of home care as well.
3 steps to implementing DED in-office treatments
1. Purchase proper diagnostic equipment
Starting your dry eye clinic may feel daunting when faced with the decision of selecting from the plethora of technologies available on the market. From my experience, acquiring a meibographer and a slit lamp imaging system are the bare essentials needed to kickstart a dry eye clinic and inspire a collaborative treatment approach with patients.
These technologies serve as essential diagnostic tools for dry eye evaluations as well as powerful visual aids for patients, helping them understand their condition and the necessity for treatment. By incorporating meibography, you can accurately assess meibomian gland structure, make treatment decisions based on the severity of the disease, set proper expectations, and monitor treatment progress over time.
These technologies help establish a baseline metric for future comparison, enabling clinicians to track progress and share measurable results with their patients.
DED diagnostic technologies in action
Here’s an overview of how I utilize these technologies in my practice.
Slit lamp
I capture slit lamp images and videos to:
- Document eyelid conditions such as blepharitis, Demodex, and ocular rosacea.
- Assess the condition of the eyelid margins with respect to the presence of:5,6
- Biofilm buildup
- Cosmetic makeup residue
- Eyelash follicle appearance
- Clogged meibomian gland orifices
- Signs of chronic disease such as changes in lid margin morphology (i.e. orifice plugging, vascularity, irregularity, and thickening, or anterior or posterior displacement of the mucocutaneous junction)
- Record meibomian gland expression (can be done with a cotton-tipped applicator) videos and evaluate the quality of expressed meibum. Secretions may be classified as clear, cloudy, granular, or inspissated (i.e., toothpaste consistency).7
- Capture baseline photos of damaged and desiccated cells on the ocular surface with vital dyes (sodium fluorescein and/or lissamine green) along with tear film instability.
- Record videos of incomplete blinks and/or incomplete lid closure.
Meibomian gland imaging
An eyecare provider (ECP) or trained technician can use devices such as the LipiView or LipiScan (TearScience), non-invasive infrared technology that quickly captures high-definition images for accurate visualization of meibomian gland anatomy.8
Meibomian gland imaging is necessary to:
- Grade the severity of meibomian gland atrophy, truncation, disorganization, and thickening to guide individualized treatment plans.
- Present a comparison of normal meibomian gland structure alongside the patient's own meibography image and help them identify glands that exhibit obvious changes in anatomical structure.
Patient education on DED
I’ve found that when it comes to patient education, pictures and videos speak much louder than words.
Therefore, I find it extremely helpful to:
- Review slit lamp footage and meibography with the patient, identify areas of concern, and utilize visual evidence to facilitate discussions about potential treatment options.
- This collaborative approach engages the patient and empowers them to play an active role in their treatment plan.
- It's important to emphasize that EDE caused by MGD is a chronic, progressive condition and may need ongoing intervention to fully address signs and symptoms before they become irreversible.8
- Patients should understand that addressing chronic inflammation requires collaboration between doctor and patient, often involving different treatment modalities and multiple sessions before symptomatic improvement is seen.
Co-creating a plan of action to treat DED
A collaborative approach to creating a comprehensive treatment plan begins by addressing specific aggravators of the patient’s condition.
Successful treatment may involve lifestyle modifications, including dietary adjustments, alterations to contact lens wear schedules, discontinuation of products like specific lash growth serums or false lash extensions, and other behavioral adjustments. Patient education is vital to promoting compliance with these modifications.
I employ three strategies to empower patients and enhance their role within their treatment:
- Build a customized eye hygiene regimen that is practical for the patient’s daily routine.
- This may include all or only some of the following: eyelid wipes, hypochlorous acid solution spray, warm compress eye masks, preservative-free artificial tears and lubricants, and moisture chamber goggles when appropriate.
- Consider all factors, such as the patient’s individual condition, out-of-pocket costs, and the number of office visits required, when selecting the appropriate in-office treatments and frequency.
- For instance, a patient diagnosed with Demodex blepharitis, ocular rosacea, and MGD may receive a recommendation for two to four sessions of microblepharoexfoliation, four initial sessions of IPL followed by manual gland expression, and one to two thermal heat and pulsation treatments within a 12-month plan.
- This proposed treatment regimen and number of sessions can then be adjusted to minimize out-of-pocket expenses while still aiming to achieve satisfactory results.
- By openly discussing available options and their associated benefits and drawbacks, patients can make informed decisions regarding treatment modalities.
- This collaborative approach ensures that the chosen treatment aligns with the patient's condition and preferences, ultimately optimizing their outcomes.
2. Understand available in-office DED treatments
In-office treatments for MGD employ various techniques, including thermal pulsation and meibomian gland evacuation, IPL, RF, and deep cleansing and exfoliation of the eyelids. Microblepharoexfoliation is beneficial for conditions like blepharitis, which often contribute to and coexist with MGD.9 IPL and RF may be employed independently or in combination to produce a synergistic effect.13
Considerations for choosing in-office devices for your clinic boil down to compatibility with existing clinic infrastructure and choosing treatments that can be integrated into the clinic's operations without significant logistical challenges.
For example, portable handheld devices may be easier to integrate into an office with limited space and limited technician support versus a larger device, which may take up more real estate and require more assistance.
Some treatments are completely automated, allowing ECPs to step out of the room and attend to other clinic duties while patients are undergoing treatments.
Evaluate the simplicity of setup and clinic workflow and factor in the upfront costs, ongoing maintenance expenses, necessary inventory (i.e., treatment tips, applicators, eyeshields, lubricants, etc.), and potential reimbursement rates associated with each treatment modality.
List of in-office DED treatment devices
LipiFlow (Johnson & Johnson Vision)
- Mechanism of Action: Vectored thermal pulsation applies targeted heat to the inner surface of the eyelids and rhythmic compressions to the outer surface of the eyelids.4
- Procedure Duration and Frequency: A one-time, 12-minute treatment session.
- Device Used: LipiFlow unit with disposable activators that are inserted into the eye after application of a topical anesthetic.
- Additional Considerations:
- The device is FDA-approved
- Dual mechanism of action
- Utilizes automated technology
- Requires application of a topical anesthetic
- May not be suitable for smaller lid apertures due to the activator size
- Large footprint, not easily mobile10
TearCare (Sight Sciences)
- Mechanism of Action: Open-eye wearable thermal energy utilizes targeted heat on the eyelids and is blink-assisted. The treatment is followed by a manual meibomian gland expression.4
- Procedure Duration and Frequency: A single, 15-minute session with the potential for retreatment as needed.
- Device Used: Portable TearCare console with two single-use, flexible SmartLid devices that adhere to the external surface of the eyelids.
- Additional Considerations:
- The device is FDA-approved
- Requires a manual evacuation of the glands following the procedure
- Utilizes automated technology
- Suitable for all lid aperture sizes
- Portable device
Lumenis Intense Pulsed Light
- Mechanism of Action: Pulses of light at specific wavelengths target abnormal blood vessels, reduce the level of pro-inflammatory mediators, increase mitochondrial activity, improve meibomian gland morphology and functionality, and photo-sanitize bacteria and Demodex.11
- Procedure Duration and Frequency: In total, four 10- to 15-minute sessions spaced out 2 to 4 weeks apart.
- Device Used: IPL system with specialized filters and eye protection.
- Additional Considerations:
- The device is FDA-approved
- Requires careful patient selection and consideration of contraindications
- Requires careful preparation, including cleansing the skin and applying ultrasound gel and protective eyewear
- Large footprint
Lumenis Radiofrequency
- Mechanism of Action: Utilizes electromagnetic waves in the radiofrequency range to generate and deliver controlled thermal energy to different skin layers to promote collagen production, liquify meibum secretions, and unclog the meibomian glands.13,14,15
- Procedure Duration and Frequency: In total, four 12-minute sessions spaced out 2 to 4 weeks apart.
- Device Used: Radiofrequency device with two handpieces.
- Additional Considerations:
- The device is FDA-cleared
- Requires application of conductive lotion
- Added benefit of skin rejuvenation and tightening15
- Can treat a wider range of skin types compared to IPL15
- Has synergistic effects on meibomian gland functionality when combined with IPL and manual expressions13,16
- Large footprint
Systane iLux (Alcon)
- Mechanism of Action: Simultaneously applies LED-derived heat and pressure to the eyelids. A disposable tip with the inner pad that makes contact with the inner surface and the outer pad applies pressure from the external side of the eyelid.4
- Procedure Duration and Frequency: Single 8- to 12-minute session with potential for retreatment as needed.
- Device Used: Handheld, battery-powered Systane iLux device with a disposable, single-use treatment tip. A built-in magnifier lens allows the clinician to view the gland orifices and manually adjust temperature and compression.
- Additional Considerations:
- The device is FDA-approved
- Suitable for all lid aperture sizes
- Limited to outer surface heat
- Device is portable
BlephEx
- Mechanism of Action: Utilizes a rotating micro-sponge to remove excess bacteria, biofilm, and bacterial toxins from the eyelashes and the eyelid margins.17
- Procedure Duration and Frequency: Typically completed in 6 to 8 minutes and performed every 4 to 6 months as needed.
- Device Used: BlephEx handheld device with a disposable rotating medical-grade micro-sponge.
- Additional Considerations:
- The device is FDA-approved
- Requires application of a topical anesthetic
- Requires practitioner to supply eye-safe cleansing liquid of choice or purchase BlephEx Lid Cleanser separately
- Device is portable
NuLids PRO (NuSight Medical)
- Mechanism of Action: Utilizes an oscillating silicone tip for mechanical debridement and stimulation of the eyelid margin to remove bacteria and desiccated skin, break up stagnant meibum, and enhance circulation.18,19
- Procedure Duration and Frequency: Usually completed in a few minutes with potential for retreatment as needed.
- Device Used: NuLids PRO handheld device with a disposable oscillating Soft Tip.
- Additional Considerations:
- The device is FDA-registered
- Does not require the use of a topical anesthetic20
- Can be used with a variety of gels
- Involves direct application onto the eyelid margins compared to the at-home version that uses an indirect method performed over closed eyelids
- The device is portable
3. Educate and empower staff on DED workflows
Educating and training staff is essential for ensuring optimal patient care from start to finish in a dry eye clinic. Allocating specific time for DED education allows all team members to cultivate an understanding of the fundamentals of DED and the diagnostic and therapeutic technology and products available in the clinic to address it. I recommend involving staff in training sessions led by company representatives to familiarize themselves with any new technology introduced to the clinic.
Technicians play a significant role in facilitating the workflow of a dry eye clinic. Their responsibilities may include performing diagnostic tests such as meibography, administering Standard Patient Evaluation of Eye Dryness (SPEED) questionnaires, preparing patients for dry eye treatments such as IPL, and tracking device and product inventory.
Staff members should also undergo training on scheduling patients effectively to allocate the appropriate amount of time for setup, treatment(s), and cleanup. It's invaluable to have dedicated staff in our office who spend additional time with patients reinforcing discussions from the exam room.
This includes reviewing home maintenance routines, demonstrating the proper use of warm compresses and lid hygiene products, and discussing proposed treatment plans (including device mechanisms of action, treatment duration, expected office visits, and associated out-of-pocket costs).12
Providing personalized attention allows patients to feel supported throughout the process. Additionally, extended interaction provides patients with an opportunity to express concerns.
Conclusion
By offering specialized services tailored to address the increasing prevalence of dry eye disease, ECPs can effectively meet the demands of a growing segment of the population affected by this condition.
Practices not only add value to their services but also generate additional revenue streams. By investing in the resources and expertise necessary to build and sustain a dry eye clinic, optometry practices can position themselves as leaders in providing comprehensive eyecare that addresses the complex needs of their patients.
