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We just had a great interview with Dr. Christopher Wolfe on how Lipiflow can help your blepharitis, dry eyes, and meibomian gland dysfunction. I will put some of the great talking points below, but tune in to the whole video for tons of great info on the treatment of blepharitis, MGD, and dry eye!
In general, it’s important to screen patients before they’re symptomatic. So many people will have symptoms that they would never attribute to these conditions, and it’s important to look under the hood. Screening for functioning of the meibomian glands and looking for the health of the oils coming from those glands gives us the sense of how severe the meibomian gland condition is. In his practice, warm compresses and eyelid scrubs are started on day one with most patients, unless there are no signs. After one month on this regimen, Dr. Wolfe begins looking deeper into the issue.
Eyelid hygiene is started early on because biofilm that builds up over time can begin to migrate back and affect the meibomian glands. Biofilm can be properly managed with a good eyelid hygiene regimen, and many people will find relief from this. Just like brushing and flossing your teeth, it’s an important daily step to preventing greater issues.
If the warm compresses haven’t done enough to clear the glands, we need to determine whether or not the issue is more of an oil issue (evaporative dry eye) or watery issue (aqueous deficient dry eye). InflammaDry is performed as well as tear film osmolarity and staining procedures to search for inflammation. If these things are positive, the underlying inflammation may be chronic or acute, and it’s up to doctors to figure out which it is.
When inflammation is present, it’s important to use anti-inflammatory medications such as omega-3 supplements, Restasis, Xiidra, Cequa, or low dose steroid eye drops in an attempt to bring the eyes back to their pre-inflammatory state. Most of the time, there is inflammation as well as an issue with the meibomian glands, but if there is inflammation only, then we know we’re dealing with a chronic inflammatory cycle.
The LipiFlow Thermal Pulsation System is a medical device proven to improve the function of the meibomian glands in those who suffer from meibomian gland dysfunction (MGD). The device consists of a computer console and single-use activators that are used directly on the eyelids.
When you're at your eye doctor's office, they may offer you this procedure if you have dry eyes and MGD. During the actual procedure, an anesthetic drop will be instilled in your eyes. The single-use activators are then placed on your eyelids, one side between your eyelids and your eyeball and the other side on the top of your lids (this ensures heating from both sides of the eyelid).
The activators have a corneal protector that vaults over the front of the eye, so it is completely protected from heat and pressure. The device is turned on and delivers heat and pulsation to the eyelids for approximately 12 minutes.
This system is great because not only is it heated (to 42.5 degrees Celsius, to be exact), but it also pulses in a peristaltic motion that works oil from the beginning of the glands to the terminal ends. Obstructed oil in the meibomian glands is able to be liquified and released onto the eyes, therefore working to prevent dry eyes.
LipiFlow is always considered if the patient has meibomian gland dysfunction as well as inflammation, or if their MGD has not improved withwarm compresses alone. It is important to note that this procedure is part of an entire dry eye protocol - LipiFlow will always do what it’s said to do, but it may not always work perfectly for everyone.
How do we know if LipiFlow will be successful? First, we have to look at the number of functioning glands. If there are less than 10 functioning glands in the lower eyelids and they have decent structure, LipiFlow will usually be effective based on gland function (the number of functioning glands was shown to improve in FDA studies on patients such as this). In addition to this, a dry eye questionnaire (SPEED) is important. These measure the patient’s symptoms as they see it, and are helpful to see how much improvement they’ve actually noticed after a procedure. Remember, your inflammation was not built in a day. It took years to overflow, so it’s going to take time to get this inflammation down.
Your eyes may become red and inflamed following the procedure, which is quite common. It is also common to experience burning, stinging, tearing, itching, and discharge. You may be given a steroid or comination steroid-antibiotic eye drop to use following the procedure, which will help with all of the above.
It is possible that the eyelids can become irritated and swollen due to the activators, yet this is less common, and you may experience blurred vision, which will go away on its own shortly after. There are side effects to any procedure you have done, and this should not stop you from trying out this treatment. Most people will never experience this and LipiFlow is a very safe procedure.
LipiFlow is FDA approved for the treatment of obstructive meibomian gland dysfunction. As MGD builds, the glands become obstructed by keratin-like plugs that need to be cleared out. Thus far, there aren’t any major studies that show that the glands elongate after LipiFlow (reversing atrophy). However, 51% of patients didn’t have to be retreated after four years of treatment with LipiFlow. Keeping inflammation down is key!
The safety and long-term effectiveness of LipiFlow has been proven in quite a few peer reviewed studies. They have shown that, after one treatment, over 85% of people saw sustained relief of their symptoms and improved meibomian gland secretions for up to 12 months, when compared to the usual warm compresses and eyelid hygiene used twice per day.
These studies are promising, but it does not mean that LipiFlow is the answer for everyone with dry eye disease. Many of those that have the procedure done find little relief, but this may be due to a few factors.
First of all, MGD may not be the main cause of their dry eyes. Yes, everyone has a little bit of MGD, but most dry eye is mixed. But if the reason for your dry eyes is hormonal or an issue with your lacrimal gland output, LipiFlow may give you minimal relief.
Another reason may be that you need more than one treatment. As stated earlier, there are many people who find relief after one treatment, yet there are quite a few patients who will need more treatments and will need ongoing treatments with LipiFlow to notice results. Everyone is different, and it comes down to finding out what works for you.
According to an article written by Dr. Jeremy Kieval, MD, the company Johnson & Johnson has significanly reduced the price of the activator tips to doctors, which makes the Lipiflow procedure not so expensive to the patient.
With this new activator price, doctors should be able to cut the price of the Lipiflow procedure in half. The cost to the patient should be more in line with the cost of a year's supply of prescription eye drops. This lower cost should also help doctors make the recommendation more readily to their patients. This in turn allows more patients to benefit from this procedure.
Historically, the cost was much greater. The applicators which attach to the eyelids are a single-use device, meaning they must be replaced with every single patient. In addition, it takes a lot of time for a practice to become experts in LipiFlow, and this takes a lot of manpower as well. If you’re looking at the cost of LipiFlow vs. the cost for chronic anti-inflammatory medication, it may be easier to justify the cost because it could be more cost effective than these prescription medications (depending on how much your prescription costs).
At this time, insurance isn’t covering LipiFlow and it may never be covered due to the way insurance companies work.
A recent retrospective, observational study has revealed that 70% of those patients treated with Lipiflow showed a reversal in their meibomian gland atrophy vs. those patients who had not undergone Lipiflow. In these patients where improvement was noted, small positive changes were seen in the glands. Researchers also found long term improvements in tear break up time, tear osmolarity, and corneal staining.
The researchers looked at the visible gland structure, or the amount of atrophy present in the patients studied, both before and after their treatments with Lipiflow. The Lipiview 2 was used to visualize the glands and, in an interesting and smart twist, Photoshop was used to assess the gland details down to the pixel level. The Meibum Scale, or the gold standard scale used to assess meibomian gland structure, changes by 25% increments so could not easily be used in this study because of the precise comparisons needed.
Despite a small treatment population, the results are very promising. For years, we have told patients that their atrophy was irreversible. This research provides us with hope that MGD can be overcome.
34:50 - Joy Marie - Ask for alternatives since the procedure is too expensive for most of us.
35:20 - Kon Bar - How effective is iLux compared to that?
35:50 - Karen Davis Mathews - Why does it take much longer to feel results vs MIBO? Lipiflow can take weeks/months where MIBO is days/weeks. Why does it cost so much more than MIBO?
37:05 - Traci Dudzic McCabe - Is it truly better than the regular lid expression treatment?
37:55 - Ali Ali - Is it better to get blephex before lipiflow or a debridement with a metal tool? Is it the same or is one better?
39:01 - Adam Richards - Would a treatment like Regener-Eyes be recommended before Lipiflow because it targets and reduces inflammation? Would that potentially create a better end result?
39:33 - Anu Chiarelli - Is there a benefit of choosing Lipiflow over IPL? If so, what is the benefit?
40:09 - Louise Budowski Cook - If it doesn’t work the first time should you keep trying? Can it eventually work even if no change after one time?
41:25 - Ellen Rocco - I had lipiflow about 5 years ago. Has the processes or prognosis improved?
41:53 - Sabrina Segarra - Will getting it done stretch out your lids?
42:15 - Tom Zachar - I have floppy lid syndrome. Am I a candidate for this? Will the procedure loosen my lids more?
43:19 - Marilyn Parver - Should it be used with a shield on the upper lid or is it safe to use on the upper lid?
43:57 - Joy Marie - Why do some of us develop blepharitis after Lipiflow?
45:01 - Adriana Iozzi Gonzalez - What are the lipiflow outcomes or experiences of patients with ocular rosacea and/or rosacea?
45:51 - Wanda Cation - I have shunt implants and tube shunts in both eyes, as well as lens replacement in both eyes. Would that disqualify me for lipiflow?
46:47 - Tracy Tulloh Galloway - Can progress be seen on the Lipiview machine?
47:49 - Tracy - What defines success for a patient who has undergone Lipiflow. What is the definition of a positive outcome?
He is a graduate of Oklahoma College of Optometry and, after completion of his training, won the Golden Retinoscope Award, the College of Optometry’s highest distinction for clinical excellence. In 2013 and 2015 he was awarded Young Optometrist of the Year for the Nebraska Optometric Association, and in 2016 he was awarded Optometrist of the Year for the Nebraska Optometric Association and the Young Optometrist of the Year for the American Optometric Association.
Dr. Wolfe has a passion for education. He is a co-founder of KMK Board Certification Review Services, a company specializing in preparing Doctors of Optometry to take the American Board of Optometry examination. He is also the founder of EyeCode Education, a company specializing in clinical and billing education. He is the co-author of the book: KMK Optometry Board Certification Review Manual and KMK Update and EyeCode: Billing and Coding. Dr. Wolfe is a fellow in the American Academy of Optometry and a Diplomate of the American Board of Optometry. He also has special interests in therapeutic scleral contact lenses to correct visual distortions in patients with corneal diseases. Dr. Wolfe is an avid runner and most of all, he enjoys spending time with his wife Jaime, daughters Ryan, Paityn, Camryn, Logan, Maisyn and sons Lincoln, Deacon and Benton.
Dr. Wolfe got into dry eye disease because of an interaction with a patient. At the time, he notes that we were trained that blepharitis would be obvious. But that’s not always the case! We have to be vigilant and look for those patients who don’t exhibit the outward signs, yet may have excruciating symptoms.
References:
https://www.ophthalmologytimes.com/article/exploring-reversibility-meibomian-gland-atrophy
https://www.ophthalmologytimes.com/lets-chat/3-questions-patients-always-ask-about-thermal-pulsation-therapy
https://www.jnj.com/innovation/lipiflow-thermal-pulsation-system-a-new-dry-eye-treatment
