Treatment of Dry Eye

After speaking with you, taking your history, examining your eyes, and performing appropriate, targeted diagnostic testing Dr. Muller will discuss your definitive diagnosis, or diagnoses, with you. She will then create a customized treatment plan specifically for you which is based upon your needs.

The first line of therapy is education, environmental and dietary modification, and other holistic recommendations.

Education:

Dr. Muller and her staff place a huge emphasis on education. They spend a lot of time explaining your diagnosis, treatment options, and what you can do to have the healthiest, most comfortable eyes and eyelids, and maintain your best vision, always.

Artificial Tears, Gels, Ointments and Lacriserts:

  • Preservative Free Artificial Tears: These products vary in their consistency, some are the consistency of water, while others are thicker, or more viscous. You should begin by using these drops proactively 4 to 8 times each day. These drops can be instilled in your eyes with your contact lenses in.
  • Preservative Free Gels: These products are more viscous, or thicker than drops, and therefore stay on the ocular surface longer. The drawback is that they can blur vision, but only slightly and only temporarily (i.e. for one to two minutes). If you are able to tolerate these during daytime hours they are very healthy for your eyes. You should use them proactively throughout the day. If you cannot tolerate minimally blurry vision during daytime hours, you can use them at other times. Gels are also great to use while flying, as the air in airplanes is extremely dry.
  • Lacriserts (Hydroxypropyl cellulose ophthalmic inserts): are a prescription “pellet” that you comfortably place in the space between your lower eyelid and your eye. This “pellet” slowly dissolves over many hours offering you continuous preservative free lubrication and moisturization. How to Use Lacriserts

Eyelid Hygiene:

  • Twice each day, in the morning and in the evening, you should apply warmth to your closed eyes for 20 minutes. Warmth is best applied using the Wizard Research Electric Heated Dry Eye Mask. Gel packs, heat masks (Optase, Bruder, other) which are heated in a microwave, and washcloths, are not as effective or convenient. This application of heat against your closed eyelids serves to loosen, or soften, the contents of your meibomian glands.
  • This application of warmth should be followed immediately by washing your eyelids, either at the sink or in the shower.  Washing your eyelids immediately following the application of heat willwash away the contents of your meibomian glands which you have loosened or softened, wash away bacteria that tends to gather at the base of your eyelashes and eyelids, and mechanically milk, or massage your glands to keep their contents flowing. This is best accomplished by closing your eyes and using gentle soap and water to “shampoo” your eyelashes/eyelids for a full minute (which is a very long time with your eyes closed). You can simply use your face soap or bar soap. If you strongly prefer to use a towelette, Optase is Dr. Muller's favorite.
  • In person, Dr. Muller and her staff will teach you how to perform "eyelid hygiene" optimally, including massaging the oil secreting glands in your eyelids (meibomian glands). Eyelid Hygiene

EYELID CLEANSING IS ANALOGOUS TO BRUSHING YOUR TEETH

Most of us know that brushing our teeth prevents the accumulation of plaque, and the development of cavities and gum disease. Another part of your daily hygiene should be taking the time to clean your eyelids and eyelashes. Cleaning your eyelids removes debris that can build up over time causing obstruction and loss of your meibomian glands, known as meibomian gland dysfunction (MGD). Prevention of MGD using early detection and intervention is essential to the long-term health and comfort of your eyes.

Anti-Inflammatory Treatments:

The underlying problem with dry eye is ongoing inflammation on the ocular surface. This ongoing inflammation causes long term damage to the surface of your eyes and to your tear producing glands, further reducing tear production over time if not properly treated.

  • Corticosteroids: Steroids can be used in the form of eye drops which are available in varying strengths. Steroids are also available in ointment form, usually used at bedtime. Throughout any treatment with steroids, Dr. Muller will monitor your eyes closely and carefully to make certain you don’t have any side effects or complications.
  • Topical Cyclosporine-A (Restasis and Cequa): treats dry eye by suppressing inflammation, increasing tear production and by protecting your lacrimal glands (tear glands) from being continuously damaged over time. Restasis.com
  • Xiidra (lifitegrast ophthalmic solution 5%): An FDA approved eye drop, taken twice daily, which improves both the signs and symptoms of dry eye. Xiidra.com
  • Nonsteroidal anti-inflammatory eye drops (NSAID)
  • Tacrolimus drops or ointment: have been shown to improve tear stability and the health of the ocular surface. Tacrolimus is also beneficial in the treatment of allergies which effect the eyes.
  • Tetracycline/Doxycycline: When prescribed in their full strength/dosages these medications function as antibiotics. When prescribed at lower dosages, this group of medications act as anti-inflammatory agents. Dr. Muller frequently uses these medications, in varying dosages, to treat dry eye, blepharitis, rosacea, meibomitis, styes (hordeola), chalazia, cellulitis, etc. They can be prescribed for days to weeks, or safely used (in lower dosages) for months.
  • Azasite (azithromycin ophthalmic solution): is an antibiotic eye drop that also has anti-inflammatory properties. It has been shown to be an effective treatment for both meibomian gland dysfunction and dry eye, relieving the symptoms of both, while enhancing the overall health of the eyes and eyelids.
  • Omega-3 fatty acids: Omega-3 fatty acids, ideally from both fish and flaxseed sources, are very healthy. Omega-3 fatty acids have a beneficial effect on dry eye due to their anti-inflammatory properties. They are also essential fatty acids that your eyes, eyelids and tear film need to function their best, be their healthiest and their most comfortable. Unfortunately, our body cannot produce them and most of us don’t get enough Omega-3s from our diet. Omega-3 fatty acids are an important part of any complete dry eye relief program; they also benefit the health of your joints and your heart. Omega 3 Fatty Acids
  • Dietary changes to reduce the inflammation in your body if you have food allergies, sensitivities or intolerances. Learn more here

Punctal Plugs, or Tear Augmenters:

  • Punctal Plugs are tiny (much smaller than a grain of rice), comfortable, biocompatible inserts that are easily placed in your tear ducts to block tear drainage from the surface of your eyes (i.e. a percentage of your tears are dammed up on your eyes instead of allowing them to run immediately off of your ocular surface). This passively increases the quantity of tears on your eyes, thereby increasing moisture and relieving dry eye. Dr. Muller places an anesthetic eye drop in your eye and then painlessly places a plug into the small openings in the nasal aspect of your eyelids. By performing this simple procedure your eyes immediately benefit from having more tears on the ocular surface, rendering your eyes more moist, more comfortable and healthier. Punctal plugs are readily reversible, and are available in many shapes, sizes and materials. Dr. Muller will educate you regarding which plugs she feels would most benefit you. There are certain circumstances in which Dr. Muller may offer a more permanent solution, namely partial cautery of your punctum (drainage ducts).

Tyrvaya* Nasal Spray:

  • Tyrvaya (varenicline solution) is a prescription nasal spray used to treat the signs and symptoms of dry eye.
  • Tyrvaya is pronounced "teer-vye-ah".
  • Tyrvaya is believed to work by activating the trigeminal parasympathetic pathway via the nose, resulting in increased tear production, i.e. by stimulating nerve endings in your nose, Tyrvaya triggers increased tear production.
  • Tyrvaya is to be used twice a day, approximately 12 hours apart.
  • The most common side effects of Tyrvaya can be sneezing, cough, throat and/or nose irritation.

*IT'S VERY IMPORTANT THAT YOU VIEW THIS VIDEO REGARDING HOW TO PROPERLY USE TYRVAYA:

Patient Resources | Tyrvaya® (varenicline solution) Nasal Spray (tyrvaya-pro.com)

Secretagogues:

  • Many people with dry eye also have dry mouth; especially those with collagen vascular, rheumatologic, or autoimmune conditions. Often people don't recognize how dry their mouths are until they're placed on a secretagogue. Cevimeline and Pilocarpine are medications taken orally to increase both tear and saliva production. They are FDA approved for the treatment of dry mouth. By increasing secretions elsewhere in the body, they also improve dryness of the eyes, skin, nose and vagina (treatment of these conditions is considered an off-label use of these medications).

Autologous Serum Eye Drops:

  • Autologous Serum Eye Drops: These are special eye drops which are custom made for you taking advantage of the natural growth factors, immunoglobulins, vitamins and other essential components present in your own blood. Dr. Muller will arrange for you to have your blood drawn (as if you were donating blood). Your blood will then be spun down using a centrifuge and the plasma rich liquid on the top will be made into eye drops for you. Autologous serum eye drops have been shown to decrease inflammation and scarring, promote healing and repair, enhance vision, and increase the health and comfort of the eyes.

Amniotic Membranes:

  • Amniotic membranes are therapeutic biologic corneal bandages (similar to contact lenses) used to enhance and facilitate healing for the treatment of dry eye and other ocular conditions. The corneal bandage lenses are composed of amniotic membrane (placental tissue). The natural therapeutic properties of these amniotic membranes help to reduce inflammation, pain and scarring, enhance comfort and vision, and promote and expedite healing. Dr. Muller gently and painlessly places the amniotic membrane on your eye in her office; you wear the amniotic corneal bandage for a couple of days. Amniotic membranes have received FDA clearance for wound healing and continue to significantly benefit Dr. Muller's dry eye patients. In-Office Use of Amniotic Membrane
  • New York Times Article Regarding the Medical Use of Placentas and Amniotic Membranes (October 8, 2024)

Manuka Honey – Optimel brand:

Manuka honey has both natural antibiotic and anti-inflammatory properties. Dr. Muller is always looking for natural ways to treat ocular inflammation (i.e., dry eye, meibomian gland dysfunction, blepharitis, ocular rosacea). Since these conditions are chronic Dr. Muller would rather lean on natural treatments rather than medications.

Dr. Muller recommends Manuka honey in two forms: drops and gel.

Manuka honey eye drops consist of 16.5% honey and contain a food preservative (Benzoic acid). We recommend our patients use these drops four times each day.

Manuka honey gel consists of 98% honey and are preservative free. We recommend our patients apply the gel to their eyelids one to two times each day.

Manuka honey products can sting or burn. The stinging/burning can last for seconds or minutes. This usually dissipates over time.

Muro-128 Eye Drops and Ophthalmic Ointment:

The surface of our eyes are covered with transparent skin known as epithelium. Muro works by strengthening this skin as well as by decreasing any swelling of the cornea (the clear dome on the front of the eye).

Compounded Ophthalmic Drops and Ointments:

Dr. Muller works closely with several compounding pharmacies to have medications which are not commercially available compounded. These compounded medications, both in the form of eye drops and ointments, can be extremely helpful in treating dry eye, blepharitis, meibomian gland dysfunction, ocular rosacea, etc.  Some examples of the medications we have compounded for our patients include:

  • Tacrolimus ophthalmic drops and ointment
  • Naltrexone tablets
  • N-acetylcysteine ophthalmic drops (see below)
  • Spironolactone ophthalmic drops
  • Insulin ophthalmic drops (see below)

We can also have preservative free versions of commercially available eye drops compounded for people who are sensitive or allergic to preservatives. Some examples include: Tobramycin, Timolol, Loteprednol, Dexamethasone, Erythromycin, Ketorolac, Cyclosporine, Ecothiophate, Pilocarpine, and Bimatoprost.

Compounded Insulin Eye Drops:

Topical insulin in the form of eye drops is an emerging area of research showing promise in treating dry eye disease, Meibomian gland dysfunction, ocular rosacea and blepharitis, collectively known as ocular surface diseases (OSD). These conditions involve inflammation, dryness, and damage to the cornea and conjunctiva (the ocular surface), lacrimal and Meibomian glands. Insulin has been found to have beneficial effects due to its anti-inflammatory and tissue-repairing properties, its ability to stimulate tear production and to improve corneal nerve function.

Insulin eye drops are believed to promote cell growth and repair of the surface of the eyes, the lacrimal glands and the Meibomian glands, and to accelerate corneal healing, especially in cases of persistent epithelial defects (PEDs) and neurotrophic keratitis (NK). Additional studies suggest topical insulin can help restore corneal nerve function, which is crucial to supporting the health of the cornea and ocular surface.

Compounded N-acetylcysteine eye drops 5%- 10% (NAC):

N-acetylcysteine is an acetylated derivative of the natural amino acid, l-cysteine. It can significantly improve patients’ symptoms by effectively treating dry eye, Meibomian gland dysfunction, blepharitis, and ocular rosacea because it has the following properties:

  • It’s a mucolytic and therefore improves tear film quality and stability by making the mucin layer of the tear film more uniform, healthier, and less viscous.
  • It’s an antioxidant thereby reducing the oxidative stress which damages the ocular surface in dry eye, Meibomian gland dysfunction, blepharitis and ocular rosacea.
  • It reduces inflammation of the ocular surface by modulating the inflammatory process, specifically by reducing the release of proinflammatory cytokines.

Dr. Muller can have N-acetylcysteine eye drops 5%- 10% compounded for you.

If, In Addition to Dry Eye, You Also Have Meibomian Gland Dysfunction (MGD), Blepharitis, or Ocular Rosacea They MUST Be Treated. Available Treatment Includes:  

  • Natural/Holistic treatment
  • Prescription Medications
  • Mechanical, Heat, and Light Therapies:
    • Blepharoexfoliation using a Golf Club Spud Debridement-Scaling procedure
    • Microblepharoexfoliation (MBE) using BlephEx
    • iLux
    • LipiFlow
    • TearCare
    • Probing of Meibomian glands
    • Exosome Therapy
    • Intense Pulsed Light (ILP) Therapy

Learn more about treating Meibomian gland dysfunction, blepharitis and ocular rosacea by clicking this link: MGD

Meibomian Gland Probing (MGP):

A safe, effective, restorative treatment.

Meibomian gland probing (MGP) is a safe and effective procedure for treating obstructive Meibomian gland dysfunction (OMGD). Obstructive Meibomian gland dysfunction can occur in people with blepharitis and ocular rosacea, in addition to people with Meibomian gland dysfunction (MGD). Meibomian gland probing should be considered when more conservative, first line treatments such as warmth, eyelid hygiene, medications, and in-office deep heat treatments haven’t been sufficiently effective, the patient continues to experience unwanted symptoms, and/or continues to suffer with recurrent infections of their eyelids (stye, hordeola, chalazia, cellulitis).

What is Obstructive Meibomian Gland Dysfunction (OMGD) and how does it differ from "Regular" or “Traditional” Meibomian Gland Dysfunction (MGD)?

In “traditional” Meibomian gland dysfunction (MGD), the Meibomian glands are clogged; in obstructive Meibomian gland dysfunction (OMGD), the Meibomian glands are mechanically obstructed or blocked.

There’s a distinct and very important difference between the clogged Meibomian glands seen in “traditional” Meibomian gland dysfunction (MGD) and the mechanically obstructed Meibomian glands seen in obstructive Meibomian gland dysfunction (OMGD).

In “traditional” Meibomian gland dysfunction (MGD) the oil inside the Meibomian glands, which in normal, healthy glands have the consistency of, and flows like, olive oil becomes viscous (with a thicker, firmer consistency like lard), clogging the glands, resulting in back pressure which stresses the glands causing the glands to shorten, atrophy, and ultimately be lost. These cases can typically be successfully managed with natural remedies, medications, and the application of heat at home coupled with proper lid hygiene, often followed by an in-office deep heat treatment known as a LipiFlow, iLux, or TearCare treatment. These deep heat treatments comfortably apply heat and pressure to liquify and express the solidified contents of the Meibomian glands, thus cleaning the Meibomian glands out. LipiFlow, iLux, and TearCare treatments are extremely effective at melting and cleaning out the contents of the glands, thereby allowing the Meibomian gland oils to flow freely again, unless there are also intraductal, or periductal, mechanical obstructions or blockages.

Obstructive Meibomian gland dysfunction (OMGD) is Meibomian gland dysfunction with either fixed, focal intraductal mechanical obstructions (cellular debris, granulation tissue, fibrosis) or periductal fibrosis, resulting in blockage of the Meibomian gland ducts or pathways. These blockages obstruct the flow of oils creating increased pressure behind the blockages. This pressure can result in lid tenderness and inflammation, gland shortening, atrophy and loss, recurrent eyelid infections (stye, hordeola, chalazia, cellulitis), and the classic symptoms of ocular irritation associated with dry eye, Meibomian gland dysfunction, blepharitis, and ocular rosacea.

Obstructions can occur at various points inside or outside the glands, allowing glands to be partially functional and secreting some oil, or entirely blocked. This is why some glands may produce a little oil, but still not be healthy.

Standard, first line medical treatment and in-office heat procedures used to clear clogged glands when treating patients with traditional Meibomian gland dysfunction (MGD) cannot provide sufficient relief for Meibomian glands with fixed mechanical obstructions found in patients with obstructive Meibomian gland dysfunction (OMGD). The obstructions must first be removed, cleared, or released for the patient to obtain relief from his/her symptoms, and to halt the progression of the condition. This is when Meibomian gland probing is medically appropriate, indicated, and invaluable.

If the Meibomian gland obstructions are not mechanically cleared the condition will progress. While symptoms can be episodic, the ongoing irritation, inflammation, and back pressure from the mechanical obstructions can result in cumulative, irreversible damage to the meibomian glands, the eyelids, and the surface of the eyes.

What Causes Obstructive Meibomian Gland Dysfunction?

The primary cause of obstructive Meibomian gland dysfunction is chronic inflammation (defined as months to years) of the eyes and eyelids.

Additional factors which contribute to the formation of Meibomian gland obstructions include:

-An accumulation, or buildup, of keratin (a protein) contributing to the narrowing or blocking of the Meibomian gland ducts

-Dead skin (epithelial) cells or debris can accumulate and block the glands

-Eye rubbing causing mechanical trauma and exacerbating inflammation; often secondary to environmental allergies causing itchiness

-Makeup in and around the eye: eyeliner, mascara, or other makeup’s residue and debris can block Meibomian glands, especially when applied directly to the waterline

-A reduced blink rate which can lead to a stagnation of the contents of the Meibomian glands, inflammation, and blockage. A reduced blink rate is often associated with heavy screen use (staring at screens results in a decreased blink rate), and/or contact lens wear (contact lens wearers often have a decreased frequency of blinking)

How is Obstructive Meibomian Gland Dysfunction Diagnosed?

The clinical diagnosis of obstructive Meibomian gland dysfunction (OMGD) should be considered when the standard, traditional, first line treatment modalities for Meibomian gland dysfunction have failed to provide sufficient relief of symptoms, the patient’s condition progressively worsens with continued loss of Meibomian glands as seen on meibography, or the patient continues to have recurrent infections of his/her eyelids (styes, hordeola, chalazia, cellulitis, etc.).

In this situation, Dr. Muller may suggest a diagnostic Meibomian gland probing to obtain additional information. During diagnostic Meibomian gland probing, Dr. Muller probes a few Meibomian glands to determine if mechanical obstructions are present. Such probing firmly establishes the diagnosis definitively determining the absence, or presence, of obstructive Meibomian gland dysfunction (OMGD).

How Does Meibomian Gland Probing Work/Help?

Meibomian gland probing (MGP) effectively treats obstructive Meibomian gland dysfunction (OMGD) by mechanically clearing the obstruction or blockage of each gland’s lumen or pathway, or by releasing the periductal cinching around the gland thus restoring the integrity and patency of the glands’ central ducts. This improves gland form and function, improves the flow of oil secretions, equilibrates intraductal pressure, and increases comfort.

Meibomian gland probing is followed immediately by a deep heat treatment (i.e. a LipiFlow) which clears the Meibomian glands allowing oil secretions to flow freely, stabilizing the tear film, thus relieving symptoms of ocular irritation and dryness.

NOTE: If the goal is to stimulate the repair of damaged Meibomian glands and the regeneration of missing Meibomian glands, this is the most advantageous or ideal time to apply Exosome therapy. Exosome therapy will likely be most effective at this time because the Meibomian glands have just been mechanically cleared, flushed out with a heat treatment, and thus are optimally accessible to the Exosomes. See below for further information regarding Exosome therapy.

How is Meibomian Gland Probing (MGP) Performed?

Meibomian gland probing (MGP) is a comfortable in-office procedure. The procedure is performed using a combination of topical anesthetic drops and surgical grade anesthetic gel applied directly to the eyelids, with or without medication by mouth, and nitrous oxide.

Once the eyelids are anesthetized, Dr. Muller gently exfoliates all four eyelids to uncap, or unclog, the Meibomian gland openings (orifices) located along the eyelid margins.

Next, an ultra-fine specially designed Meibomian gland probe is gently passed through the natural opening of each gland and into the Meibomian gland duct to mechanically unclog it. Dr. Muller delicately advances the probe when resistance is appreciated upon encountering an obstruction, painlessly alleviating it. The successful release of the obstruction both confirms the presence of obstructive Meibomian gland dysfunction (OMGD) and restores the patency of the gland duct.

There are approximately 30- 40 Meibomian glands per eyelid; each should be probed to obtain maximum relief of symptoms and protect against continued progression of Meibomian gland damage and loss.

Once Meibomian gland probing (MGP) has mechanically relieved the intraductal and periductal obstructions and re-established the patent outflow channels of the Meibomian glands, a deep heat treatment (i.e. LipiFlow) is performed to completely clean out, or evacuate, the Meibomian gland contents. Following the heat treatment Dr. Muller mechanically expresses any remaining contents from the Meibomian glands. Patients are then placed on a medical regimen which combines the use of various topical antibiotic and anti-inflammatory medications to optimize their results. Additionally, patients are instructed regarding an at home treatment regimen designed to maintain the benefits of their Meibomian gland probing (MGP) and reduce the likelihood of developing future Meibomian gland obstructions.

Meibomian gland probing (MGP) of all four eyelids takes about 30-40 minutes and is followed by a 12-minute-deep heat procedure (i.e. LipiFlow). Patients typically return to work immediately with no downtime.

Meibomian Gland Probing Outcomes:

Patients experience maximum symptomatic relief and protection against progression of disease, with longest lasting results, when they have undergone Meibomian gland probing (MGP) combined with a deep heat treatment, followed by compliance with the aforementioned at home treatment regimen/maintenance program.

It has been reported in the medical literature that 92% of patients experienced immediate relief of their symptoms and that all patients experienced relief by four weeks after probing.

The reported lasting relief of symptoms is thought to be due in part to the re-establishment of Meibomian gland orifices and central ducts after the removal of debris and obstructions. This improves gland function by allowing the Meibomian gland oils to flow freely again. There are also reports in the medical literature of Meibomian gland probing slowing further loss of glands, stimulating repair of damaged Meibomian glands, and the regeneration of missing or atrophied Meibomian glands. These results are even more dramatic when Exosome therapy is combined with Meibomian gland probing and a heat treatment.

How Frequently Do Meibomian Glands Need to be Probed?

The specific answer to the question regarding the frequency with which any given patient would benefit from repeat Meibomian gland probing is multifactorial and unique to each individual.

Inflammation is known to contribute to the formation and reformation of Meibomian gland obstructions. As a result, all sources of irritation and inflammation of the eyes and eyelids should be identified and properly treated to minimize the possibility of the glands becoming obstructed again.

If an individual has coexisting ocular surface issues such as dry eye, environmental allergies, ocular rosacea, blepharitis, Demodex, etc. contributing to the irritation and inflammation of his/her eyes and eyelids they need to be treated.

Other factors to consider include:

If the person has coexisting conditions, are the conditions multiple, mild, moderate, or severe?

How compliant is the person with regard to following Dr. Muller’s recommended at home treatment regimen/maintenance program?

Has the person remained comfortable and asymptomatic over time, or has he/she started to have symptoms again?

Is there evidence of progression of Meibomian gland dysfunction on objective diagnostic testing in the office, or has the progression of the condition been successfully halted?

Is there evidence of recurrent obstructive Meibomian gland dysfunction (OMGD)?

Both initial and maintenance probings are intended to mechanically open Meibomian gland orifices and ducts, remove obstructions, maintain patency of orifices and ducts, restore gland function, increase oil production (qualitatively and quantitatively), and stabilize the tear film, thus relieving symptoms of Meibomian gland dysfunction, blepharitis, ocular rosacea, and dry eye. In addition, the goal is to halt the progression of these conditions by stopping the progressive shortening, thinning and loss of glands, promoting repair and recovery of damaged glands, and potentially stimulating regeneration of missing Meibomian glands.

How Long has Meibomain Gland Probing Been Around for and is it Safe?

MGP has been around for over 15 years. Studies analyzing Meibomian gland probing (MGP) focusing on the procedure’s safety and efficacy have been conducted in the United States, Mexico, China, Russia, Cuba, Turkey, India, and Japan with peer reviewed articles having been published supporting the effectiveness of MGP for patients refractory to standard care as a first-line treatment for Meibomian gland dysfunction. In the studies reviewed, 94% of patients treated with MGP benefited from relief of their symptoms when compared with patients in the control groups.

No negative side effects or complications were reported.

Articles in the Medical Literature:

https://www.tandfonline.com/doi/abs/10.1080/09273948.2018.1522357?journalCode=ioii20

https://bjo.bmj.com/content/102/1/59

Exosome Therapy to Treat Dry Eye, Meibomian Gland Dysfunction, Blepharitis, Ocular Rosacea, and other Ocular Surface Diseases:

[See Below for Information Regarding the Use of Exosome Therapy to Repair Damaged Meibomian Glands and Regenerate Lost Meibomian Glands]

Exosome therapy uses a formulation of concentrated eye drops rich in exosomes harvested from umbilical cord stem cells. These drops are administered as an intensive one-day treatment (at home, work, etc.) to promote wound healing, potentiate repair of damaged tissue, stimulate regeneration of missing tissue, reduce inflammation, pain and discomfort, slow or halt the progression of disease, and enhance the overall health and comfort of the eyes and eyelids.

Exosome Therapy is:
-An extract derived from pluripotent embryonic stem cells with the ability to differentiate into any tissue type

-Biologically active; rich in growth factors, proteins, amino acids, lipids, mRNA, DNA, and anti-inflammatory cytokines

-Works by stimulating your body’s natural bio signaling to promote healing and repair of damaged tissue and regeneration of lost tissue

-Used after first line, conventional treatments haven’t provided sufficient relief

The potential benefits of using umbilical cord stem cell derived exosome therapy in the treatment of dry eye, Meibomian gland dysfunction, blepharitis and ocular rosacea (collectively known as ocular surface conditions) is both promising and exciting, particularly for patients who have not responded sufficiently to conventional treatment. Exosome therapy is intended to reduce inflammation, stimulate repair of damaged tissue and regeneration of lost tissue, improve Meibomian and lacrimal gland health and function, restore tear film stability, improve vision, and improve the health and comfort of the eyes and eyelids.

Articles from the medical literature regarding the use of stem cell derived exosomes for the treatment of ocular surface conditions:

Mesenchymal Stem Cell-Derived Exosomes in Ophthalmology: A Comprehensive Review - PMC (nih.gov)

Cell-free Stem Cell-Derived Extract Formulation for Regenerative Medicine Applications - PMC (nih.gov)

miR-204–containing exosomes ameliorate GVHD-associated dry eye disease - PMC (nih.gov)

Efficacy of Topical Mesenchymal Stem Cell Therapy in the Treatment of Experimental Dry Eye Syndrome Model - PMC (nih.gov)

Mesenchymal Stromal Cell–Based Therapy for Dry Eye: Current Status and Future Perspectives - PMC (nih.gov)

Repairing Damaged Meibomian Glands and Regenerating Missing or Lost Meibomian Glands by Combining Meibomian Gland Probing, LipiFlow and Exosome Therapy:

Thirty to thirty-five years ago when Dr. Muller was educated and trained the thinking and teaching was that once Meibomian glands were lost there was no way to regenerate them. However, that was long before the substantial expansion of our state of knowledge regarding dry eye, Meibomian gland dysfunction, blepharitis, and ocular rosacea which has taken place over the last few decades. Additionally, there has been significant growth and development in technology including Meibography providing the ability to image Meibomian glands, and a plethora of FDA approved medications and treatment modalities including, BlephEx, LipiFlow, TearCare, iLux, autologous serum, amniotic membranes, Meibomian gland probing, and Exosome therapy. Due to these advances, along with other cutting edge treatments we now have in our armamentarium, our patients are benefiting tremendously.

Amongst the most exciting developments in recent years has been the opportunity to effectively stimulate the repair of damaged Meibomian glands and the regeneration of missing Meibomian glands.  In this area we’ve had the greatest success with patients in whom we’ve combined Meibomian gland probing, LipiFlow and exosome therapy. These patients have benefited from improvement of their Meibomian glands in form (objectively and anatomically), function (enhanced oil production, both qualitatively and quantitatively, resulting in a more stable tear film), and have enjoyed significant improvement in their symptoms (subjectively). Below please find Meibomian gland images from several of our patients captured before and after treatment.

Some of the objective, anatomic improvements seen on Meibomian gland imaging are elongation of previously shortened glands, previously thin glands becoming wider, more robust and healthier, and regeneration of previously lost or missing glands.

Subjectively all patients reported significant improvement in their symptoms which, according to them, far surpassed the benefit they had experienced with prior medication and heat treatments without Meibomian gland probing and Exosome therapy.

The improvement these patients experienced was achieved by combining Meibomian gland probing and LipiFlow, with the application of exosomes derived from umbilical cord stem cells to reduce inflammation, stimulate repair of damaged tissue and regeneration of lost tissue, improve Meibomian gland health and function, restore tear film stability, enhance vision, and improve the overall health and comfort of the eyes and eyelids.

Meibomian Gland Images Taken Before and After Treatment Showing Repair of Damaged Meibomian Glands and Regeneration of Missing Meibomian Glands:

Repair of Meibomian Glands Left Lower Eyelid. Image on the left taken prior to treatment depicting damaged, shortened, thin Meibomian glands. Image on the right taken after treatment revealing healthier, more robust, wider, elongated Meibomian glands. Images of Meibomian gland repair and Meibomian gland regeneration. Regeneration of Meibomian Glands Left Upper Eyelid. Image on the left taken prior to treatment depicting missing, or lost, Meibomian glands. Image on the right taken after treatment revealing regeneration of Meibomian glands. Images showing Meibomian gland repair and Meibomian gland regeneration. Images showing Meibomian gland repair and Meibomian gland regeneration. Regeneration of Meibomian Glands Right Upper Eyelid. Image on the left taken prior to treatment depicting missing, or lost, Meibomian glands. Image on the right taken after treatment revealing regeneration of Meibomian glands. Images showing Meibomian gland repair and Meibomian gland regeneration. Repair of Meibomian Glands Left Lower Eyelid. Image on the left taken prior to treatment depicting damaged, shortened, thin Meibomian glands. Image on the right taken after treatment revealing healthier, more robust, wider, elongated Meibomian glands. Images showing Meibomian gland repair and Meibomian gland regeneration.

Intense Pulsed Light (IPL) Therapy:

While there are many IPL devices, there’s only one that's FDA approved specifically for the treatment of dry eye and Meibomian gland dysfunction. OptiLight by Lumenis was specifically designed to reach the delicate contours around the eyes. It uses patented state-of-the-art Optimal Pulse Technology (OPT) to deliver a safe, comfortable, effective in office treatment for dry eye, Meibomian gland dysfunction (MGD), blepharitis, styes (hordeola), chalazia, ocular rosacea and Demodex.

Intense Pulsed Light (IPL) therapy has been used in dermatology for decades demonstrating a long history of safety and efficacy. The first Intense Pulsed Light (IPL) device became available commercially in 1994 for use in the treatment of rosacea and acne. In 2015 Intense Pulsed Light (IPL) was used for the first time to treat dry eye and Meibomian gland dysfunction (MGD).

In combination with other treatments, Intense Pulsed Light (IPL) therapy can achieve long lasting relief of symptoms and slow, or stop, the progression of dry eye disease, Meibomian gland dysfunction (MGD), blepharitis, styes (hordeola), chalazia, ocular rosacea and Demodex.

How Does Intense Pulsed Light (IPL) Therapy Work?

Intense Pulsed Light (IPL) therapy successfully treats dry eye disease, Meibomian gland dysfunction (MGD), blepharitis, styes (hordeola), chalazia, and ocular rosacea by improving the health and functioning of damaged blood vessels in the area.

Inflammation is the underlying cause of dry eye (keratitis sicca) and a major component of Meibomian gland dysfunction. This inflammation harms blood vessels in the area causing them to dilate and rendering them hyperpermeable, or leaky, releasing plasma* into the surrounding tissue. The plasma released into the tissue contains pro-inflammatory mediators which fuel a vicious cycle of inflammation adversely affecting the health and comfort of the eyes and eyelids.

Intense Pulsed Light (IPL) utilizes light energy of specific wavelengths to precisely target the leaky, damaged, dilated blood vessels in the skin around the eyes rendering these vessels healthier. Inflammation in the area is dramatically reduced by stimulating constriction of dilated blood vessels and suppressing their leakage. IPL reduces inflammation by breaking the cycle of inflammation.

This reduction of inflammation allows for recovery of the Meibomian glands in both form and function, improves the quality of the tear film, enhances tear film stability, reduces evaporation of the tears from the surface of the eyes, and improves ocular lubrication, thus improving dry eye signs and symptoms. In addition to making patients much more comfortable, IPL therapy can also reduce reliance on medications. Lastly, Intense Pulsed Light (IPL) therapy stimulates collagen production in the skin which can improve the overall health and appearance of the eyelid area and surrounding tissues.

*The plasma which leaks from damaged blood vessels contains pro-inflammatory mediators including, but not limited to, vascular endothelial growth factor (VEGF), prostaglandin E2 (PGE2), and pro-inflammatory cytokines.

What To Expect on The Day of, and Following, Your Intense Pulsed Light (IPL) Treatment:

On the day of your treatment you can eat and drink normally.

Please do not wear any make-up on the day of your treatment. You can bring your makeup with you and apply it after your treatment.

Anesthetic eye drops will be placed in your eyes. Your eyes will then be covered with protective shields. This will be followed by the application of a thin layer of cooling gel to the area being treated (similar to the gel used for ultrasounds). Next, a handheld Intense Pulsed Light (IPL) device will be used to deliver gentle pulses of light.

A typical Intense Pulsed Light (IPL) treatment session for dry eye, Meibomian gland dysfunction (MGD), blepharitis, styes (hordeola), chalazia, and/or ocular rosacea lasts about 10-15 minutes.

Cold gel packs are then applied to the treated area.

There may be some redness, a warm sensation, and slight inflammation in the treated area which, if present, typically disappears in 1-72 hours.

There are no restrictions on activities following the treatment; patients can resume their normal activities as no downtime is required.

To ensure the best results you must protect your skin from the sun.  Following your IPL treatment it's essential to protect your skin from direct sun exposure for the first 72 hours and apply paraben-free sunscreen (SPF 30 or more) several times a day. Applying sunblock and moisturizer should be/become part of your daily routine.

Please follow the post-treatment regimen Drs. Malawer and Muller provide.

Treatment Schedule:

The treatment protocol needed to achieve optimal results includes 4 treatment sessions spaced 2-4 weeks apart. While some patients report improvement after 2 or 3 sessions, maximum improvement is achieved after 4 treatments.  Improvement in both the way you feel and look generally takes place gradually over weeks. The frequency of subsequent maintenance treatments varies from person to person, however, are generally performed every 6-12 months to ensure long-term benefits. Your custom treatment plan will be individualized and tailored to your personal needs.

Intense Pulsed Light (IPL) Therapy’s Safety Over Decades Has Been Established in the Treatment of:

Skin rejuvenation: Improving skin tone and texture. Reducing fine lines, wrinkles and signs of aging by stimulating collagen production thus giving skin a firmer, more voluminous, youthful appearance.

Ameliorating unwanted pigmentary changes, sunspots, age spots, and sun damage.

Rosacea and vascular lesions (spider veins, broken capillaries).

Enlarged pores by reducing pore size.

Treating acne by targeting the bacteria (p. acne) that causes breakouts and reducing inflammation.

Treating acne scars.

Prose and Scleral Contact Lenses:

Boston Sight Prose is a customized prosthetic device created for people with severe dry eye (and several other eye conditions). It is intended to replace, or support, impaired ocular surfaces with the goal of improving vision and comfort. It was FDA approved in 1994.

Scleral contact lenses are rigid gas permeable lenses which are both vaulted and have a larger diameter than standard contact lenses. People with dry eye can be helped by the special design of these lenses in the following ways:

  • The vaulting leaves a gap between the scleral contact lens and the cornea thereby protecting the cornea from having the contact lens touch it. The vaulting also creates a fluid reservoir that bathes the cornea.
  • The wider diameter of a scleral contact lens allows the scleral contact lens to touch the sclera (the white part of the eye) as opposed to mechanically touching the cornea, as standard contact lenses do. Scleral contact lenses must be custom fit. They are most often used to address corneal irregularities, astigmatism, and keratoconus. Scleral contact lenses can also provide symptomatic relief for people with severe dry eye.

Dr. Muller Also Recommends:

Dr. Muller recommends the use of a Nanodropper tip on your eyedrop bottles to reduce the eyedrop volume released each time you use your eyedrops. This reduces cost, waste, and the mess of excess drops running down your face.

https://nanodropper.com/

Additional Nanodropper Information:

Medication Compatible Nanodropper Tip Size
Miebo Size 14
Xdemvy Size 15
Alrex / Lotemax / Loteprednol Size 15
Olopatadine Size 15

Compatibility Spreadsheet: https://nanodropper.com/compatibility/

Link to order Size 15: https://nanodropper.myshopify.com/products/nanodropper-adaptor

Link to order Size 14: https://nanodropper.myshopify.com/products/nanodropper-adaptor-size-14

Humidifiers:

  • Using a humidifier when you’re traveling, on your desk at home or at work, and at your bedside is of great benefit. This is especially true if you travel to dry environments, high altitudes, in the fall and the winter when the ambient air is dry, and when the heat and air conditioning are on.

Hydration:

  • Staying well hydrated is extremely important. Drinking 7 to 8 eight ounce glasses of water each day, or drinking enough water until your urine is straw colored, is ideal.

Sleep and Hydrating Nighttime Masks:

  • Being well rested is imperative to your overall health and the health of your eyes. Getting 7 to 8 hours of sleep each night is recommended. Nighttime eye shields can protect your eyes while you sleep. These are especially helpful if you sleep with your eyes partially, or intermittently open, or if you sleep with a ceiling fan, a regular fan, near a vent, or with a C-pap machine. (Nighttime Dry Eye Relief)

Treating Other Eye Conditions:

  • It is extremely important to diagnose and properly treat all sources of inflammation and irritation of your eyes and eyelids. Other conditions that can exacerbate dry eye and make it much more difficult to treat include blepharitis, meibomian gland dysfunction, ocular rosacea, Demodex, environmental allergies, food allergies, sensitivities and intolerances, styes, chalazia, other.

Limiting Medications Which Exacerbate Dry Eye:

  • Minimizing, or completely eliminating, medications that exacerbate dry eye is extremely helpful.

Decreasing Contact Lens Wear:

  • The healthiest way to wear contact lenses is to simply wear them for going out socially, playing sports and exercising. Wearing eyeglasses to work is much healthier for your eyes since most people are sitting at a desk reading their computer screen(s) and/or documents the greater part of the day.

Good Looking Wrap Around Glasses/Sunglasses:

    • Wrap around glasses and sunglasses are a great way to decrease dry eye and allergy symptoms by protecting your eyes from environmental elements such as wind, UV, and allergens.  Now available in many styles and fits. They can be ordered with or without a prescription, and as clear, photochromic, polycarbonate or polarized lenses.
    • https://www.zienaeyewear.com/
    • https://7eye.com/