Goodbye to Dry Eye: The New 12 Minute Treatment--In-Depth Doctor Interview
Ernest W. Kornmehl, M.D., F.A.C.S., Medical Director at Kornmehl Laser Eye Associates talks about a new treatment for dry eye.
Tell us what Diane is going through right now?
Dr. Kornmehl: Diane is having a procedure called Lipiflow. She is having it because she has evaporative dry eye. That means her tears that she’s making are leaving her eyes much quicker than they should be because the lipid in her lids is abnormal. Diane has a chronic inflammation in her lids resulting in thickening of the secretion. It should be a watery secretion and in her case it’s very thick. As a result the lipid layer which is the outer layer of the tear film that prevents the water from evaporating is not working well and therefore her tears are evaporating too readily.
How often do you see this?
Dr. Kornmehl: Every day, many, many times every day. Rosacea, a skin condition that affects the glands in patient’s lids, is common in people of Northern European ancestry such as the Irish and English. These ethnic groups populate much of New England. Many of these patients have meibomitis, often associated with rosacea, which is inflammation of the lid margins.
What is the traditional treatment for dry eye?
Dr. Kornmehl: For evaporative lid disease the standard treatment would be warm compresses and sometimes we place them on medicine called doxycycline which acts to thin the secretions of the lid margins. However when the secretions become too thick they can’t reach the boiling point to thin the secretions so many patients are doing warm compresses and they’re just not effective. I personally don’t recommend lid massage because I have seen too many patients induce astigmatism, where the eye which is normally shaped like a basketball becomes shaped like a football. Patients who rub their eye can change the shape of their corneas over the long term.
So lipiflow is a newer treatment?
Dr. Kornmehl: Lipiflow is a new treatment and it’s another important tool in our armamentarium. The level of disease will determine whether or not a patient will have Lipiflow alone or will also be placed on doxycycline. Many patients with this lid problem also have aqueous tear deficiency which is normally thought of as dry eye. Aqueous tear deficiency is only seen in about thirty percent of patients where about seventy percent of patients have evaporative dry eye. So many times both of these diseases have to be treated at the same time. First they have to be diagnosed and then both have to be treated.
So how effective has lipiflow been for people with dry eye and maybe people with both?
Dr. Kornmehl: It’s been very effective. How effective it is and how much better patients will feel after the treatment will be determined by how advanced their disease is. Patients who still have a good number of glands, although they are not functioning very well will have a lot of relief following the treatment. The secretions are very thick and these patients symptomatically do best a month after treatment. But if patients come to us with very few glands, the goal is not f symptomatic relief but maintainance of the glands that they have to prevent the disease from getting to a dangerous level.
And that’s once every nine to fifteen months?
Dr. Kornmehl: Yes, patients should have lipiflow every nine to fifteen months. The FDA studies showed that was the time period it remained effective. And of course it will vary from patient to patient.
And is it best for mild to moderate but maybe not severe?
Dr. Kornmehl: Well it’s optimal if patients have mild or moderate disease and that way they never get to the situation where they’re going to have advanced disease which is much more difficult to treat. Patients are certainly going to symptomatically improve or feel a lot better if they have mild or moderate disease. Patients with severe disease could feel better as well but our goal in many of these patients is to maintain the glands they have so they don’t put themselves in further danger.
So for the majority does this mean they don’t have to take drops at all?
Dr. Kornmehl: For patients with mild or moderate disease that can be true in many patients. Although I like to tell patients that the goal of this treatment is to maintain their glandular function. Fortunately many of these patients do feel much better. When you ask them patients realize that they’re not taking drops as frequently or not at all. Many patients on the other hand receive other treatments as well to give them optimal results. So each patient has to be looked at individually and followed closely. A thorough evaluation is performed so we can tell a patient what their likely outcome will be, whether it will be symptomatic improvement or simply to maintain function.
So were you excited when this first came out, how excited are your patients?
Dr. Kornmehl: LipiFlow comes with a diagnostic tool called LipiView. The technology is exciting because it allow us to actually see how thick, in a more objective and quantitative way, the lipid layer is and correlate it with the meibomium gland evaluator to see how many glands are functioning as well as the viscosity of their secretion. This is important because it gave us numbers which is helpful instead of making a qualitative judgement. Prior to lipiflow I had many patients with toothpaste like secretions on warm compresses. They were nor very effective because the secretions were so thick that the warm compresses could not reach the boiling point necessary to melt the thick secretions. they couldn’t reach the boiling point to liquify the secretions. So it wasn’t really very effective except wasting the patient’s time and perhaps maybe just making them more comfortable with that hot pad on their eye. Also what we find with warm compresses is that once patients feel better they just stop doing them. Unfortunately, that’s just human nature. They’ll stop doing it and then they will become symptomatic again and unfortunately it then becomes a very helter skelter treatment modality at that point. If patients would do warm compresses on a daily basis when their disease is mild or moderate they would be more effective.
So who do you recommend LipiFlow to?
Dr. Kornmehl: The patients and I have a detailed discussion about the type of dry eye that they have -- whether it’s evaporative, whether it’s simply tear deficient or whether it’s mixed. There are many patients with mixed disease. How many glands they have and the viscosity of the secretions will determine whether or not we recommend LipiFlow to them.
So that is what you would recommend for the majority of patients?
Dr. Kornmehl: For patients with moderate to severe disease it’s highly recommended. In an optimal world where cost is not an issue patients with early disease would also get the treatment. But there is a cost associated with it so each patient has to judge with their doctors whether or not this would be best for them at this time.
This is not covered by insurance and comes right out of the patient’s pocket?
Dr. Kornmehl: Exactly. In an ideal world everybody would get it.
What is the cost?
Dr. Kornmehl: The cost varies on whether or not LipiView is include in the price.
Any side effects, any down sides?
Dr. Kornmehl: No we haven’t had any side effects. The beauty of this procedure is ot’s low risk benefit ratio. The treatment is outpatient, it takes twelve minutes and patients go to work immediately after the procedure.
What are the results?
Dr. Kornmehl: What we notice is many patients feel well for the first three days and notice a significant improvement then they return back to their pre-lipiflow state. Then four to six weeks afterwards they notice significant improvement that lasts anywhere from nine to fifteen months.
So if someone gets it and starts to feel the same after the treatment in three days, they shouldn’t freak out?
Dr. Kornmehl: No, and then there are some patients that take even longer. We keep an eye on the patients and many times for the first month they’re maintaining the regiment that they were doing before the Lipiflow. What we often see is that many patients with mild to moderate disease find themselves not taking the drops or the ointments as they were before and no longer doing their compresses. My feeling is they should continue to do the compresses and just get in to a habit of it and think of it as ocular yoga. It probably reduces their blood pressure as well but unfortunately most busy people don’t have the time to do that.
How long does it take?
Dr. Kornmehl: Well five to ten minutes but it’s something that people just don’t do. Many patients say to me, doctor I’m just not going to do it. I’m too busy traveling. I’ve got kids. Then they say I just want Lipiflow and that’s it. But unfortunately just like anything else, you’d like them to take a certain number of drops a day but they’re not going to do it, they’re just too busy.
Anything else you want to add?
Dr. Kornmehl: Well we’ve been absolutely delighted with the results, it’s been a very important new tool in our armamentarium and its been proven very effective in our hands as it was in the FDA trial. Patient selection is extremely important and it’s important that each patient be given an idea of the likely benefits that they’re going to have from the procedure. And that would be determined by how extensive their disease is.
Will this become the new standard of care for dry eyes?
Dr. Kornmehl: I think it will become the standard of care.
Is dry eye very common?
Dr. Kornmehl: Yes, dry eye is extremely common it’s ubiquitous. Most patients that come in to our office have dry eye. We do a lot of laser vision correction in patients that have worn contact lenses for many years. The contact lenses themselves induce dry eye over the long term by decreasing corneal sensation resulting in decreased tear production. So patients are getting dryer and dryer but they feel it less and less. In addition birth control pills are also a common cause of dry eye in many women. Patients that are on antihistamines have dry eye. Women as they move along in years become dryer starting in their forties. So that’s also very common. Patients that are on hypertensives also have dry eye. Depending on what part of the country you live in rosacea is a common disease that affects the meibomian glands resulting in dry eye. So patients will come to me with either melbomian gland dysfunction, aqueous tear deficient dry eye or both.
So a lot of things can cause dry eye?
Dr. Kornmehl: Correct and patients are beginning to notice their dry eyes much more now than they ever have because we’re becoming a much more electronically guided society. People are on computers much longer, if you have children you probably noticed that instead of calling their friend and being on the phone for an hour they’ll be chatting on the computer for an hour.
So our own exposure?
Dr. Kornmehl: Our own exposure, yes. And patients always ask why they’re always dryer after watching TV or reading a book. It’s because they don’t blink as much. And so when you go to a movie or read a book or watch TV your eyes don’t blink as much and you get greater evaporation. Particularly if you have melbomian gland dysfunction. Therefore because warm compresses are often tedious and patients aren’t going to do them in many cases, I think it’s safe to say that lipiflow is becoming the standard of care for dry eye treatment and for patients with melbomian gland disease.
So can you recommend any home remedies?
Dr. Kornmehl: Well warm compresses are wonderful if you’ll do them. But unfortunately if you have advanced disease and the secretions are too thick it’s not going to reach the boiling point where the secretions will thin and be effective.
Is that the only one -- warm compresses?
Dr. Kornnehl: And doxycycline. Doxycycline for patients with meibomium gland dysfunction is also effective. I find that with many of my patients we’re recommending doxycycline with lipiflow to see if there synergistic and more effective than either one alone. And if patients think about blinking that will also be a good thing.
How has lipiflow helped patients?
Dr. Kornnehl: When you do an FDA trial obviously you want to test the modality so you can’t have alternative therapies going on when you’re doing the treatment. With Lipiflow alone seventy nine percent of patients showed improvement. Now in the real world we use other modalities as well so that number is even higher and it’s even more customized to the individual patient. So we see wonderful things with Lipiflow in the future for doctors who are using multi model treatments.
Is there a chance of it being covered by insurance?
Dr. Kornnehl: Unfortunately with today’s healthcare you could think of it as a set amount of money. And for them to cover something else they would have to take something else away. So coverage is not likely in the near future
Should medicare cover something like this?
Dr. Kornnehl: Well I suspect something would have to be lifesaving or immediately sight saving. And that’s true in other areas of medicine as well. The way healthcare is going patients are going to have to be more and more responsible for paying for much of their care. And that’s unfortunate especially when we have a treatment that could improve the quality of their life.
Are there other costs?
Dr. Kornmehl: Yes, tears and ointments are very expensive. You can go and get a little bottle of tears for ten or fifteen dollars that doesn’t last very long. And many of our patients have to be on tears without preservatives and that’s even more expensive. There is a significant cost with Lipiflow but if a patient is being treated for mild to moderate disease they have to take tears and ointments less frequently and that’s a cost savings. So in the end it probably equals out.
Can all patients take Doxycycline?
Dr. Kornmehl: Doxycycline is effective for many patients unfortunately many patients can’t take it. It can cause gastritis and/or esophagitis which is inflammation of the lining of your stomach or your throat. So you have to be very careful. So when we give patients Doxycycline you have to tell them they must take it with food and they have to be careful and aware of any sign because they have to stop it immediately. It also can induce a rash in patients when they’re out in the sun. So it can be a dangerous drug if not used properly and under supervision. It’s an oral treatment and many patients have acid reflux and are not candidates for doxycycline. For these patients Lipiflow has been a God send.
And what does Doxycycline do?
Dr. Kornmehl: It thins the secretion in the lid margins. Many patientscannot take Doxycycline. Pregnant women, woman that are that are lactating or breast feeding can’t take Doxycycline..
Twenty two million, where does that number come from?
Dr. Kornmehl: Epidemiologic studies. I would suspect the number is much higher than that.
Is dry eye something to pay attention to?
Dr. Kornmehl: Contact lens induced dry eye is the most insidious form of dry eye because their eyes are numb. Normally if your surface breaks down a little bit your eye would say there’s something wrong and maybe I’d better see someone if it doesn’t get better in a day or so. A patient with dry eye on the other hand may have a cornea that has significantly reduced corneal sensation and is numb. These patients have a greater likelihood of getting a corneal ulcerh. Patients with all forms of dry eye who have break down of the corneal surface may sense a low grade irritation but if they are one of the unlucky ones they too are prone to a corneal infiltrate or an infection because it’s the surface cells that prevent these organisms from entering the eye. In addition when the corneal surface is irregular you just don’t see as well. And many patients will notice if they blink a few times quickly they see better for a second and then it gets worse again if it’s not managed.
Do patients feel better after the lipiflow?
Dr. Kornmehl: Yes but it may take 4 – 6 weeks. By stabilizing the tear flow it’s like you have a nice smooth mirror instead of having spots on the mirror. It’s like looking through spots on the mirror when you have surface breakdown . But when your corneal is nice and clear it’s like a beautiful mirror where you get a great reflection and you see much clearer. And that’s why when we do laser vision correction it’s imperative that one optimize their dry eye prior to having surgery.
Do wearing contacts make you more susceptible to dry eye?
Dr. Kornmehl: Yes. Years ago this wasn’t understood but certainly it’s been understood for a number of years now. We find it very important to educate general ophthalmologists and optometrists who are fitting many contact lenses particularly in children. There is nothing wrong with contact lenses if worn properly but children and adults should be advised to limit their wear time. They should wear them to school and then if they’re coming home and just going to study they should take them out. If they’re not doing anything on a Saturday don’t wear them. That way they can wear them safely for many, many years. Don’t overwear them and certainly never sleep in them. Sleeping in lens really should never be done under any circumstances. Not only because you are more likely to have dry eye from the long term lens wear but also because you have a seven or eight times higher risk of ulceration if you sleep in your lenses.
So contact lens were part of Diane’s issue?
Dr. Kornmehl: Yes, her mechanism for dry eye is multifactorial. She has both aqueous deficient dry eye as well as meibomian gland dysfunction. So both have to be managed.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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If you would like more information, please contact:
Ernest Kornmehl, M.D., F.A.C.S.
Kornmehl Laser Eye Associates
To read the full report, Goodbye to Dry Eye: The New 12 Minute Treatment, click here.