Mitchell Jackson, MD, Ophthalmologist and Founder and CEO of Jacksoneye talks about diagnosing Dry Eye and the TearCare treatment.
Talk to me about dry eye. How common is it in people?
Dr. Jackson: I have been in this field for 31 years and in private practice 28 years. Pretty much everyone you see has some form of dry eye. We see 50 to 70 patients a day and probably all of them have dry eye. Statistically it is about 350 million people globally, and 40 million people in the United States. Honestly, it is pretty much every patient. The severity of the dryness may vary from mild, moderate, severe, to different stages. Some people may be asymptomatic, and some may be more symptomatic. Some of the signs we see with dry eye don’t always correlate with the symptoms of dry eye so we may see really bad signs of dry eye on the exam but the patient may have very little symptoms and vice versa.
What are some signs of dry eye?
Dr. Jackson: Signs of dry eye would be seen in an eye exam and we see staining on the cornea. We put a flourescein dye in the cornea, and it looks like the Sahara Desert with little spots on the cornea. Everybody has a tear break up time (TBUT), where the longer it takes for the tear film to break up the less likely they have signs of dry eye. The typical TBUT is 15-20 seconds, and most patients with dry eye may go as low as 5 seconds or less. That is an example of the signs of dry eye. We do imaging of the oil glands and the most common form of dry eye disease is where you have obstructed oil glands or meibomian glands in the eyelids. They are in the lower and upper eyelids and they produce an oil layer to the tear film. Tear film has two components: a water or aqueous layer, which is full of electrolytes, enzymes, antibodies, and other components that protect the surface of the eye, plus an oil layer which holds the water layer on the tear film. So, if the oil glands are obstructed then the tear film evaporates instantly. With all of our advanced dry eye diagnostic testing we can determine if patients qualify for some of the newer treatments. Tearing is the most common symptom of dry eye. Patients often ask if I am tearing how can I have dry eye. Well what is happening is the accessory lacrimal glands are “burning out” and the emergency main lacrimal gland gets called into action as an emergency reserve, causing reflex tearing to compensate for the dryness. People can have a sensation of a foreign body or dryness however those are fewer common symptoms. Tearing, blurred or fluctuating vision are the most common symptoms of dry eye.
When dry eye happens, what are some treatments?
Dr. Jackson: When people come in there are two forms of dry eye. There is an evaporative type of dry eye which is related to the meibomian glands and there is an aqueous deficiency which is related to the lacrimal glands and the most common form is a mix of the two. Meibomian glands being a major problem by being obstructed or inflamed. So, you must always treat inflammation and/or obstruction of the oil glands and you try to increase tear production through many forms. A lot of the drops we use are palliative and they are over-the-counter lubrication drops or palliative options only. They give some relief, and some replace the water layer, some replace the oil layer, some replace both. You can use those but most patients when they come to see me have already tried two or three over the counter artificial tears and they are getting no relief. So, we put them on a prescription eye drop to reduce inflammation or try to increase tear production from the lateral glands. That still does not solve the most common form of dry eye which is the oil or meibomian gland obstruction or dysfunction. What we do is we recommend thermal treatments such as a TearCare treatment which is an outpatient lunchtime treatment while sitting in a relaxing chair. We put these strips on the lids and people can blink normal. It heats up the oil glands in an optimized temperature and then we express the glands and they become unobstructed and that gives almost immediate relief for patients because if they’re obstructed there’s no oil there to hold the tear film on. Patients see immediate relief of the obstruction with the oil gland treatment or thermal treatment such as TearCare than they would with a prescription drug which can take six weeks to three months to take effect.
Besides prescription drops are there other in office treatments besides the TearCare that people can use and how does that compare?
Dr. Jackson: Some people will get punctal plugs placed to block the tear ducts openings. Those are great for people who are aqueous deficient. It allows you to block the tear duct openings temporarily or permanently with little plugs. They allow the natural tears that you make, even if it is a little bit to stay on the eye longer. So, in short it helps keep the tear film on the eye longer. There are other treatments, and some are a little more claustrophobic for patients. They go on the eyeball, require a little more expertise, they are only localized, and can only treat certain gland regions. Some treat the vascularization of a rosacea problem of the oil glands. That is why I like that one because it fits any type of facial anatomy, eyelid anatomy of any type of patient, deep set eye, flat eye, tight eye, shallow eye, Frankenstein eyes. It does not matter. The device can go on and treat any type of person. It is not claustrophobic for those people who are afraid of coming near the eye. Patients can blink and it is extremely comfortable, and it actually serves a purpose by heating up the oil glands and eliminating the obstruction.
Are there any patients that it would not be a good option for?
Dr. Jackson: Anybody who will refuse to allow you to come near their eyes. Obviously, this device is patient friendly, but some patients may have some anatomy defects where you cannot use the device on the eyelids. Then you have oil glands. The imaging we do in the office part of our pre-evaluation will tell us if a patient has oil glands. Some patients, even kids, are born without oil glands and if they do not have oil glands, they are going to have to wait for something like stem cell therapy in the future to regenerate glands. So, you must have oil glands. Luckily, most patients come to me even though they are not healthy, but they do have glands that can be treated.
Tell me a little bit about the study that you guys did with this.
Dr. Jackson: The Olympia study was great. It was randomized multiple centers compared to warm compresses which we usually use. The Olympia trial was designed to demonstrate the safety and effectiveness of a single TearCare procedure compared to a single Lipiflow Thermal Pulsation System procedure in treating the signs and symptoms of dry eye disease. We have masks that we recommend patients use for their maintenance therapy. It showed that we helped their tear breakup time and symptoms and signs improved statistically compared to baseline. So, you had better tear breakup time, and less staining of the cornea. Patients felt better and they can function better afterwards. So, you help the symptoms there. We call their visual analog scale of the vast score and their eye dryness score. All those things improved symptomatic early in a clinical study fashion as well as their objective signs that we as a doctor looked at in their eye exam. So, it was great because this device, TearCare, showed that it helped post signs and symptoms of dry eye. A lot of the times I say symptoms and signs do not correlate. Sometimes patients will have worse signs, worse symptoms or better signs and better symptoms and this device will help both no matter what.
When a patient comes in and you are starting this procedure, walk me through what you do, what the patients must do.
Dr. Jackson: They have already come for proper evaluation or they might get the treatment at the same day’s evaluation. It is a sophisticated treatment, so they come in and they get a full gamut of diagnostic tests. We will do our lab exam where you put your chin in the machine and we look at the oil glands. We see if they are blocked. We will stain the cornea. See if they are staining or if there are any dry spots. We will see what their tear breakup time is and if it is even holding the tear film. Then we do imaging to see if they have oil glands. We will measure their osmolarity which is an electrolyte status of the tear film that tells us the state of dehydration of the tear film. So, we look at all those things in combination and it will tell us how severe their dry eyes from an objective scale. Symptomwise patients fill out a dry eye questionnaire when they come in. Some practices will use what is called the OSDI. Some will use the SPEED questionnaire but no matter the type of questionnaire it gives you in a quantitative fashion the severity of their symptoms. So, between the two symptoms and signs, we kind of know what their problem is, and where the problem is – is it inflammation? An obstruction? Or is it a lack of tear film? Or an eyelid defect? An anatomy defect? There are many things that contribute to dry eye. We also take a good history. Many things in the world will cause dry eye. For example, we treated a commercial airline pilot today. He is in an environment called the cockpit which is a “dry eye chamber”. There are medicines that cause dry eye. Most patients on blood pressure medicines, diuretics, and thyroid conditions. A lot of people have thyroid or other autoimmune diseases. If you are on your smartphone, laptop, iPad, iPod, or computer, all those near vision tests – our blink reflex goes down by at least seven-fold subconsciously. So, our tear breakup time is challenged even more when we are sitting all day doing these close tests. So, asking all the questions about certain medications, antihistamines people are taking for allergies, all these things can cause or exacerbate dry eye. A lot of patients have strikes against them before they even come in. They may be female, postmenopausal, and have no hormones to help the tear film. We look at all those things and I talk to a patient and say you have a lot of strikes against you already. Then we look at their eyes, we do the diagnostic testing, we look at their questionnaire and we put it all together and decide what the best treatment regimen is. Sometimes it is a prescription eye drop with a thermal treatment like TearCare.
If somebody does not have dry eye treated what could happen?
Dr. Jackson: A couple of things happen if you do not treat dry eye. If you do not treat it and they are having for example cataract surgery, they will not have an optimized visual outcome. You might fix the cataract, but they have a poor tear film and they paid for a premium lens to get rid of glasses, that may not work because their tear film’s not working. Also, oil glands will degrade or regenerate if you do not treat inflammation in the obstruction. They will just continue to go from mild to moderate to severe stage where they lose the glands completely. Then they become so symptomatic later that there are no treatments for them anymore. It is kind of like glaucoma where it is the silent killer that when it pressures up, you can go blind unless you are getting your eye pressure checked regularly to make sure don’t have glaucoma. Dry eye is a much more prevalent condition in the world and in the U.S. and it can really affect you in terms of your vision, your outcome from other procedures and your overall eye health and your quality of life can go way down. I have people who have perfect vision but they can only read a computer for one to two seconds before their vision blurs because their oil glands are so obstructed that the tear film doesn’t stay on the eye long enough.
How long does theTearCare procedure last?
Dr. Jackson: Patients come in for their TearCare procedure and we put a little numbing drop in the eye then we put the device on their eyelid. Then we express their glands right after and then they go home. They do not need a driver. They are back functioning the same way. Their eyes might be a little pink for a few minutes, but it is completely normal. We tell our patients that because dry eye is chronic and progressive, we must do repeat treatments even after an initial treatment. So, we see them back anywhere from six weeks to six months depending on the severity of their condition and if they need other treatments or not. But typically, with TearCare, they can go at least one year. Studies have not been done to test the durability of the effect, and the effects of TearCare are not permanent. However, re-treatment is easy and can be repeated as needed over time. So, some people need it more often depending on the severity but typically it is about a year. So, they can get away with one treatment per year.
What will the Tear Care do for somebody’s quality of life?
Dr. Jackson: For example, today we treated a commercial airline pilot. He flies to China pre- COVID on these 14 to 16-hour flights and he was miserable using lubrication drops all the time. We did one TearCare treatment a year ago and he said immediately he rarely had to use lubrication drops on a 14-hour flight. So, it significantly improved his quality of life for what he did as a commercial airline pilot. Me as a surgeon I am staring at a microscope and I am operating all day, not blinking as much. So that improves quality of life. Anybody who is doing a lot of computer work or up-close work you are blinking a lot less. So, if you are having degradation of your ability to work on a computer during the day just having a TearCare treatment can drastically improve the quality of what you do day to day.
Is it covered by insurance?
Dr. Jackson: Typically as of right now the answer is no however there may be insurance coverage in the near future. There are a few insurance policies that might have something currently but what we have discovered is the patient usually signs an Advance Beneficiary Notice form and they do pay out of pocket for. But it is very cost friendly and affordable for our patients. Most of our patients pay for it the day of the treatment, and we offer easy financing option if needed. It is not like buying a new car, a new house or anything big. This treatment is extremely critical, and we try to make it really price friendly so patients can have treatment the same day.
What is the typical cost?
Dr. Jackson: Typically, up to six hundred dollars, however pricing varies by practice and location, and insurance coverage of it is expected in the future.
Is it true that some eye surgeries can cause you to have dry eye?
Dr. Jackson: Some eye surgeries such as big retinal procedures they take down the conjunctiva of the white part of the eye and it causes a lot of trauma to the eye and that can damage structures in the eye. But typically, eye surgery does not cause permanent dry eye. Typically, it is the age process, hormones, certain medications, the environment, smartphones, close computer, eye patch, devices, and antihistamines. There are so many things that cause dry eye including genetic factors. Do we have glands? Are they obstructed? We have learned a lot over the last 31 years. So, in general when somebody has surgery on their eye, they are more aware of their eyes and they are paying attention to more things. So, it might be exacerbated short term, but you must take in all the other factors. For example, being in a cockpit for 14-hours a day is like being in a trial chamber which is like your eyes being in an oven. So, it depends. Every environment is different. People who live in Florida typically are not as symptomatic as those who live in the Midwest where in the middle of winter there is no humidity and it is 20-below. Our clinic becomes a dry eye clinic in January and February here. So, there are many different factors that can exacerbate or help the dry eye.
Have you noticed younger kids getting dry eye more often or has that always been the case?
Dr. Jackson: There is a study out of Duke that meibomian images show they have little to no oil glands. So, they are trying to determine if it is genetics or is it from everything we are doing now. When I grew up as a kid, I was playing baseball outside. I was not playing video games and all the stuff that kids do nowadays. So, it is a whole different environment, but we are probably exacerbating our own problems with what we do today. So, we are trying to learn, and it is becoming much more prevalent. A lot of it is that some of the things we are doing are exacerbating the condition, but we also have better technologies to diagnose it earlier and see what is happening. This might have been going on all along and you did not know.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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