Chandra Mickles, OD, MSc, FAAO, FSLS, Associate Professor & Coordinator of Dry Eye Care Center at Nova Southeastern University talks about a new medication for Dry Eye.
Interview conducted by Ivanhoe Broadcast News in May 2018.
We’ve been hearing a lot more recently about dry eye but this is really a prevalent problem. How many people suffer from this?
Dr. Mickles: In the United States it’s around thirty million people that suffer from dry eyes. I would say one of the most common reasons why patients visit eye care professionals.
What is dry eye exactly?
Dr. Mickles: It is that there’s either a deficiency in the amount of tears or there’s poor quality tears that leads to evaporation of the tears quickly. Then the patient’s have dry eye. The surface becomes really, really dry and they feel like their eyes are dry or scratchy.
So the symptoms would be dryness?
Dr. Mickles: Dryness, scratchy eye, they feel like there’s something in their eye we call it foreign body sensation. Those are some of the common symptoms that patients report when they have dry eyes. They also report disturbances in their vision where their vision goes blurry and then comes back clear especially when they’re doing visually demanding tasks such as using the computer or their smart phone or reading.
Is this affecting more people at a younger age, are you seeing the spectrum in ages when it comes to dry eye?
Dr. Mickles: Normally we would see dry eye in patients that are forty or older however, I would say in the last couple of years anecdotally we’ve been seeing a growth in dry eye in younger patients even as young as elementary school. There’s been some work recently looking in to this and seeing what’s going on, why we’re seeing an increase in dry eye in children or in youth. Some people do think it might be the use of the digital devices. When you use a digital device there is this involuntary blink suppression that happens meaning that we stop blinking. When we don’t blink we’re not allowing the oil that comes out of our glands that produces an important component of our tears. We’ll go back to the glands.
Dr. Mickles: When patients are using a digital device or using a computer, their smart phone, there is an involuntary blink suppression that happens so we stop blinking. And blinking is important because it allows the tears to spread across the front surface of the eye. And also why blinking is important is because in our upper and lower eyelids we have these glands called meibomian glands and they produce the oil that prevents the tears from evaporating and when the patient blinks the oil comes out of the glands.
Is that a condition when the glands get clogged or what can happen?
Dr. Mickles: Yes. The glands when they become clogged we call that meibomian gland dysfunction. We don’t totally understand the cause of that but we do believe that there is bacteria that’s hanging around our eyelids and that’s where the meibomian glands sit. Those bacteria change the consistency of the oil that comes out of the glands so that oil instead of being liquefied is more like butter. If it’s like butter it can’t do its job of being liquefied and function to prevent the tears from evaporating.
So would that be considered a more severe case of dry eye, are there different levels of dry eye?
Dr. Mickles: Yes. Actually there’s two main types of dry eye. One is primarily caused by that meibomian gland dysfunction, the clogging of the meibomian glands. Seventy to eighty percent of patients that have dry eye they have that clogging in the meibomian glands. The other percent of patients they just don’t produce enough tears, the more watery part of the tears. That can be due to a myriad of things but often can be due to systemic disease that people might have and such they don’t produce enough tears.
So what can we do about dry eye and it’s I would imagine extremely uncomfortable and can prevent you from doing certain things. You can’t be on the computer so it might disrupt work, reading those kinds of things. So what can we do?
Dr. Mickles: For the most common type of dry eye which is caused by meibomian gland dysfunction the way we have treated that in the past is we would heat that clogged gland with a warm washcloth. We found that to be minimally effective due to poor retention of heat. Now we have Lipiflow that gets the glands to the appropriate melting point to really liquefy that butter I was talking about and change it to oil so it can prevent the evaporation of tears.
So Lipiflow is new technology and talk about how it works because we did see Robin having the treatment. So tell us how it works.
Dr. Mickles: The way it works is that it’s basically bringing that oil that’s more like butter consistency to the appropriate melting point so now it’s more oil like, more liquefied just like if you would heat butter on the stove. At the same time what’s important in treating that meibomian gland’s dysfunction it’s also expressing the gland. So you’re heating up the oil but you’re also expressing them. The way that is done with the Lipiflow it’s actually automated, actually pressing on the glands with a gentle pressure to express them.
So it’s doing both?
Dr. Mickles: Both at the same time. So that’s what’s really unique and innovative about the Lipiflow is that it is expressing the gland and heating it at the same time and doing both eyes at the same time. There’s no really other device right now that I know of that does that in this way.
Now you guys have done studies with the Lipiflow?
Dr. Mickles: I haven’t personally done studies with the Lipiflow but there are numerous studies on this device. Its FDA approved and recently there was a study showing that it prolonged contact lens wearing time for additional hours.
Say that again about contact lenses.
Dr. Mickles: The recent study that came out was that it showed that it prolonged the contact lens wear. The contact lens wearers sometimes they can’t wear their lenses as long as they would like to. It has shown to improve the wear time, a comfortable wearing time with the contact lens. It also was shown to be more effective than using antibiotics. So antibiotics is another way that we treat meibomian gland dysfunction. We believe one of the causes of the meibomian gland dysfunction is bacteria hanging around the eyelid. So we do use antibiotics and just one use of this Lipiflow device was shown to be better than using antibiotics.
You had mentioned the whole thing takes how long?
Dr. Mickles: The whole procedure takes twelve minutes. It’s short and the studies show that it lasts at least twelve months. So you do it one time and the treatment efficacy can last twelve months which is amazing.
Without extra use of say drops or anything like that?
Dr. Mickles: It is still recommended to do your maintenance what we call lid hygiene at home – just to keep the lid under control and keep the bacteria from being around the eyelids. It’s kind of like I think of it similarly to you need your teeth cleaning every six months right but you’ve still got to brush your teeth every day so the same idea.
And lid maintenance at home would be what, what would you do?
Dr. Mickles: I was telling you about the warm compress we’ll still recommend patients do the warm compresses at home with the washcloth or they can do it with a mask, there’s some masks out there that actually retain the heat better than the washcloth. They can also scrub their lashes what we call lid scrub to get rid of the bacteria hanging around their lashes.
Would every dry eye patient be a good candidate for Lipiflow or does it depend?
Dr. Mickles: It does depend because there are two main types of dry eye some patients will have both but they need to have meibomian dysfunction to be treated with the Lipiflow. We need to see some signs of that they have meibomian dysfunction because if they do not then we’re not really treating their type of dry eye with Lipiflow.
It lasts twelve months I know some people want to do it more.
Dr. Mickles: They don’t need to because it’s massage, patients just love the massage aspect of it so yes.
I know it’s in limited use right now correct?
Dr. Mickles: Yes.
It’s only in certain centers around the country?
Dr. Mickles: Yes. So it’s only certain centers, actually in South Florida it’s really only four centers.
So as of now this is not covered by insurance.
Dr. Mickles: Right, as of now it’s not covered by insurance.
How much does it cost?
- Mickles: So at Nova we charge nine hundred and then it can go as high as fifteen hundred I’ve heard.
But that’s a treatment. Obviously for patients like Robin it’s worth it.
Dr. Mickles: Yes. Dry eye when it’s severe it can be debilitating for sure. I’ve had patients that have come in they can’t even open their eyes. They can’t function, they can’t work so for those patients they don’t mind paying nine hundred dollars at all. If you think about all the other things we pay for our purse and phone and your eyes are the most important thing right? So you want to make sure that you’re able to have those eyes to continue to function every day.
And that’s critically important because she was also saying if you don’t get the treatment or you don’t keep up with the management what can happen, you can dry out the corneas.
Dr. Mickles: You can dry out your corneas but what is the problem? If you don’t get treated the glands eventually will die or atrophy and I can show you some images of what I mean, what that means. But the point is that it would be too late and then we can’t even use any treatments to help the patient because they don’t have any glands for us to work with then.
You could lose your vision eventually, would it mean losing your vision or it would just mean living with that chronic—-
Dr, Mickles: Really bad chronic dry eye and really severe chronic dry eye it can affect the vision. So the quality of vision, not that they’ll go blind but the quality is so poor that they can’t see well enough to work or do their daily activities the way they would like to.
So your advice is if someone sees this report and they think they have dry eyes go get checked out and see what your treatment can be?
Dr. Mickles: Right. If they think they have dry eye I would advise them to come in so we could do a thorough evaluation and determine the type of dry eye they have and then recommend the appropriate treatment for them. So for each of my patients they get a customized treatment plan because every patient is different. As I said before, approximately eighty percent of patients do have this type of dry eye the meibomian dysfunction. So a lot of them need some type of treatment probably this Lipiflow to help them.
And Lipiflow can be very effective.
Dr. Mickles: Yes, it can be very effective. Time and time again just with my patients and also from the studies it’s proven that it works.
If people want to learn more what’s your web site? Send it to me. Can Lipiflow cure dry eye?
Dr. Mickles: No, no. so dry eye once you have it is a chronic condition just like having diabetes in a sense, you always have got to keep it under control. So you always have it but we keep it under control. The great thing about Lipiflow or any treatment is that we’ll get it to a point where they may not have to use so many artificial tears or use so much treatment at home. But you’re still going to have to do some sort of maintenance care. We just use an analogy of the dentist is that you know we still have to brush our teeth every day right, but are we going to have six month cleaning, maybe not every three months, some people need three months but we still need some sort of maintenance.
So it has to be managed just that you need to stay on top of it?
Dr. Mickles: Yes, you need to stay on top of it.
And if Lipiflow is right for you it could be that once a year and then you manage at home the drops and so forth?
Dr. Mickles: Right, they may cut back, like some of my patients say they can cut back on the drops with the Lipiflow but may want maintenance of you know cleaning their eyelids and things like that. What can be an inconvenience to patients using drops all day and some patients have really severe with use of artificial tears every two hours. I mean can you imagine working and putting your drops in every two hours. So you do something like this we can cut it back to maybe twice a day using artificial tears.
If you don’t treat dry eye the worst case scenario is you could dry out the glands?
Dr. Mickles: Yes, the glands could actually what we call atrophy or basically die yes. And then your dry eye by the time you have severe symptoms it’ll be too late because we can no longer treat the gland because there’s no glands to treat any longer.
Does it damage the cornea?
Dr. Mickles: Yes. So dry eye in itself does damage the cornea, is that reversible? Yes that’s reversible though where the glands themselves to our knowledge today because we’re doing a lot of research on that, they do not come back. Once they’re gone they don’t come back. But the cornea itself if we treat it enough aggressively the damage that occurred it can be healed basically yes.
END OF INTERVIEW
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