EyeWorld Asia-Pacific June 2012 Issue

43 EWAP CORNEA June 2012 Close-up of a patient with evaporative dry eye showing a thickened and inflamed eyelid margin; lissamine green staining shows the anterior migration of the mucocutaneous junction and pooling within the contour irregularities A typical symptomatic evaporative dry eye patient with redness and developing irregular eyelid margin contour Dr. Carlson and a patient during the LipiFlow treatment Source (all): Alan N. Carlson, MD Non-pharmaceutical therapies for dry eye by Faith A. Hayden EyeWorld Staff Writer What to use when all else fails When pharma fails to relieve dry eye in the severest cases, patients still have options. Non- pharmaceutical treatments such as LipiFlow (TearScience, Morrisville, NC, USA), autologous serum tears, and intense pulsed light are therapies proven successful for evaporative dry eye caused by meibomian gland dysfunction. Could one of these alternatives be the answer your toughest patients are looking for? LipiFlow LipiFlow is a three-part thermal pulsation unit consisting of the LipiView Interferometer, which assesses a patient’s tear film; a Meibomian Gland Evaluator, which evaluates meibomian gland secretions; and the LipiFlow, a disposable, sterile, single-use biocompatible component made up of a lid warmer and eyecup. “The lid warmer generates heat directed onto both the upper and lower inner eyelid surfaces,” states company literature. “Behind the eyecup, an inflatable bladder pulses against the outer eyelids. The disposable fits under the eyelid, simultaneously delivering heat and pressure to both the upper and lower lids.” “The initial treatment delivery heats to 42.5 centigrade, which is about 108.5 Fahrenheit, and does so for 8 minutes,” explained Alan N. Carlson, MD , professor of ophthalmology, chief of corneal and refractive surgery, Duke Eye Center, Durham, NC, USA. “The initial 8 minutes delivers the thermal aspect of the treatment that liquefies the material hardened and obstructing the gland. The last 4 minutes of the 12-minute overall treatment is a pulsation that has a massaging or milking action on both the upper and lower lids that expresses the glandular material.” Some patients can benefit from one LipiFlow treatment up to 2 years, while others will need another treatment every 8-12 months. Because LipiFlow is not currently covered by insurance, some patients may need to space out treatments for economic reasons. “The cost of the equipment is [US]$100,000, and our cost for the disposable unit is [US]$700 per pair,” Dr. Carlson said. “It creates a substantial overhead.” Dr. Carlson charges patients US$1,500 per treatment and treats six to 10 patients a week. LipiFlow is not recommended for patients with an active ongoing infection, recurrent corneal erosion, or a thin filtering bleb. Side effects include a red, irritated eye for 12 hours after treatment. AST Autologous serum tears (AST) can be extremely effective in alleviating dry eye symptoms in some patients, but should be considered a last resort, said David Glasser, MD , Baltimore, Md., USA. “The idea of AST is that it contains vitamin A and several growth factors that promote corneal epithelial healing,” Dr. Glasser explained. “Those factors remain stable at refrigerator temperature for a couple of weeks and in the freezer for a couple of months. It’s not simple to make because you have to draw blood, centrifuge it, and get it from the blood collection into a sterile eyedropper bottle without contamination. Those steps aren’t that complicated, but they need to AUTOLOGOUS SERUM TEAR PREPARATION Blood collection and preparation Aseptic venipuncture to collect six tubes of patient’s blood Collect blood in no-additive, non-barrier tubes Tubes left upright to clot for 30-60 minutes Centrifuge tubes at 1,500 rpm for 15 minutes Autologous serum preparation in artificial tears* Perform following steps using aseptic technique (laminar flow hood ideal): Prepare aseptic workspace with 10% bleach or equivalent Remove tops from six artificial tear bottles (3 ml each) Remove tops from blood collection tubes Wash and don sterile gloves Gently draw off clear serum with sterile 3 ml syringe and needle (20-22 gauge) Inject serum through opening in dropper tip of artificial tear bottles Use separate tube of blood for each artificial tear bottle Use separate syringe and needle for each tube of blood (1 ml serum added to 3 ml of artificial tears will give a concentration of 25%) (2 ml serum added to 3 ml of artificial tears will give a concentration of 40%) Place drop of prepared serum on culture plate or transport medium for culture Replace caps and apply labels to bottles (name, date, contents, instructions) Patient instructions Instruct patient on drop techniques to avoid bottle contamination Bottles should be kept on ice for trip home Store unused bottles in freezer Store active bottle in refrigerator between applications Use one drop 6-10 times a day Discard active bottle after 1 week to reduce risk of contamination Epithelial defect closure typically occurs in 1-4 weeks *Modified from Shachar Tauber, MD (with thanks for sharing his technique) continued on page 44