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Early on, Dr. Jaccoma got into dry eye disease way before it was well-known and discussed how it is today. Although there were minimal treatments at the time, he was on the forefront of dry eye treatment and continues to be today. For the past 10 years, he has been singularly focused on treating dry eye patients.
Dr. Jaccoma knew that there had to be a better way to treat dry eye disease, and he began incorporating nutritional supplements into his practice. These included flaxseed oil, fish oil, and omega-3s in general which helped hundreds of his patients find relief. He found that this was a much more effective way of treating dry eye disease than the artificial tears which were pushed on so many patients in the past. These oils were getting to the root of the problem, something so important when discussing dry eye disease. Since that time, he has continued to offer innovative treatment options for his patients.
When a patient comes into their office, Dr. Jaccoma uses a SPEED or OSDI questionnaire to gauge where the patient is in their dry eye journey. They make sure to take a complete history of the patient, including recording systemic conditions and medications the patient is taking.
After this, they run a series of tests to create three “baskets” for dry eye disease:
The aqueous portion of the tears, produced by the lacrimal gland, is like a firehose that works to take care of the lubrication of the eyes. However, this watery portion of the tears can become problematic when the eyes are dry. Often, patients will come in with watery eyes, and this is an indication that the aqueous portion is being overproduced to compensate for a tear film that is not working properly.
The eyelids have a big role in this because so many of us are using digital devices more often, and this can cause a decrease in blink rate. Without blinking, the tears cannot spread over the eyes properly and the oil glands in the eyelids begin to stop working. Stagnant oil becomes hardened and rancid, sitting there instead of working in the tear film. This causes inflammation, which contributes to the huge puzzle of dry eye disease.
The first test is a Schirmer test which gauges the amount of aqueous the eyes are producing. In those with aqueous deficiency, the score will come back less than 10 (and sometimes less than 6). These are the people who sometimes have autoimmune disease such as Sjogren’s syndrome. This also may mean they’re on a diuretic, drink too much coffee or alcohol, or they’re just not drinking enough water.
Treatment for this form of dry eye disease will often include increasing water intake, decreasing caffeine consumption, and addressing any underlying autoimmune contributors. Punctal plugs are often used in these patients, but they can be problematic because the natural tear flow of the eyes can become disrupted and unhealthy tears can become plugged up (think reusing dirty bathwater). Dr. Jaccoma usually avoids punctal plugs and opts for other, more effective treatments.
We look at tear breakup time (TBUT) for this basket. When we look at your cornea through our slit lamp microscope, we can use fluorescein to visualize the tear film. If you blink and your tear film dries up and shows dry spots in under 10 seconds, this is problematic and indicates oil dysfunction. Even if it’s less than 20 seconds, you might even have a problem if you work on a computer all day.
Tear osmolarity testing also allows us to look at how salty the tears are. If the tears are very salty, it means that this is an evaporative condition where the eyes are not producing enough oil.
The next thing that will be checked is the consistency of the meibum, or oil coming from the meibomian glands. Your doctor may push on your eyelids, attempting to coax some of the oil out of your glands. Is it toothpaste consistency? Or is it healthy extra virgin olive oil? We want to see extra virgin olive oil.
It’s important to also look at the tear meniscus, which shows if there are actually tears being kept on the eyes (vs. draining out). Dyes like fluorescein can also show us dry patches on the cornea or the conjunctiva. If the glands are likely the issue, photos will be taken of the glands to see how atrophied or plugged they really are.
This third bucket is for those with a combination of both aqueous deficiency and evaporative dry eye disease. Many patients have a combination because the vast majority of dry eye sufferers will present to their eye doctor with some form of blepharitis or MGD.
If a patient has a lot of inflammation, prescription eye drops may be warranted to decrease the inflammatory response. Intense Pulsed Light (IPL) can also be very beneficial in those who have lots of inflammation and especially in people who suffer from rosacea.
LipiFlow is often used to unblock the glands of people who have stagnation in their meibomian glands. This thermal pulsation device can help with MGD and stagnant oil. This is pretty great for many patients but will not solve aqueous tear deficiency. Also, it only gets as hot as 42.5 degrees Celsius and many of the stagnant oils need more than one treatment or higher temperature that hasn’t been studied. This is why Dr. Jaccoma began using radiofrequency treatment on many of his MGD patients.
When you have butter-like blockages in your meibomian glands, often more is needed than the heat and pressure that LipiFlow provides. Light can be beneficial in this case, which is what IPL does. However, it is not great at consistently melting the oil in some people. Radiofrequency addresses these issues, and it will also help with aging eyelids.
The radiofrequency device Dr. Jaccoma uses wakes up and repairs the skin cells that make collagen. These fibroblast cells become dormant in our 30s and our skin becomes thinner, crepier, and you end up looking older. By using radiofrequency, these cells can wake up again and get back to work. This leads to newer, healthier skin and decreases aging. Interestingly, the temperature used is also around 42.5 C (up to as high as 50 C, but care must be taken to prevent burning the skin).
Dr. Jaccoma did a study in a small number of patients using LipiFlow on one eye and radiofrequency treatment on the other. Findings showed that he got the same results as LipiFlow, but you can customize the radiofrequency treatment to be a bit hotter if needed. He also co-developed a shield that makes it easy to customize this temperature, protecting the eyes and providing a bit of back-pressure as well.
Just like LipiFlow, radiofrequency treatment will usually require more than one treatment to have optimal effects. This is because the cells need time to wake up again and sometimes the damage is great and needs time to be reversed.
When you visit Dr. Jaccoma in his office, he often combines it with IPL. After an IPL treatment, Dr. Jaccoma will use the device back and forth over the eyelids. This will feel hot to you, but this is required for the meibum to become liquid. He will do expression during this procedure to help remove the blockages in the glands and ensure the glands are open.
Radiofrequency treatment takes 10 minutes for all four eyelids, although a bit of extra time is required if you’re also having IPL done. It’s recommended to have a series of these treatments because inflammation is like a tree. There’s inflammation in the small twigs and branches near the surface of the skin, but there’s also extra inflammation stored in the trunk which is further down and more difficult to combat. If you don’t address this underlying inflammation, the surface inflammation will just come right back again.
It’s often recommended to return in 3-4 weeks for another treatment, as this is another opportunity to purge the glands again. When you first have your meibomian glands treated, they likely don’t know what to do because they haven’t worked in so long. But each time you go back in and have them treated, they begin to wake up more and more. In the meantime, you’ve knocked down inflammation and given them a better likelihood of working properly. Many patients will require multiple treatments, but each treatment is tailored specifically to each individual patient and their needs.
Each time the patient comes back, they take another questionnaire (SPEED or OSDI) that gauges how the patient feels. Even though a patient may not think they feel better, these surveys show that most often they do. Between treatments, it’s important to practice proper eyelid hygiene.
The severity of the disease coupled with how well the patient does in the time between treatments will dictate how often this treatment needs to be done. In addition, it’s important to address other factors that may be at play such as allergies, conjunctivochalasis, eyelid positioning, blinking, and other factors.
The FDA has cleared radiofrequency units for the treatment of aging factors, but they have not evaluated the device for dry eye and MGD. The treatment is considered “off-label” at this time. If you’d like to visit Dr. Jaccoma for this treatment or be set up with another doctor in your area who provides it, visit his website for Excellent Vision in Portsmouth, NH.
Dr. Edward H. Jaccoma is a Board Certified Ophthalmologist who has recently relocated to Connecticut after practicing in the Southern Maine area for 30 years. He specializes in General Ophthalmology, the medical and surgical management of dry eye-related disorders, as well as plastic surgeries of the eye and eyelid areas.
Dr. Jaccoma received his Medical degree from the University of Vermont where he graduated with a nomination to the Alpha Omega Alpha Honorary Society and his Bachelor of Science degree from Fairfield University.
He completed his internship in Internal Medicine at the Washington Hospital Center and his residency in Ophthalmology at the University of Virginia. He has also taught medical students and resident physicians at the University of New England College of Medicine, as well as serving as Medical Director of Medispas, delivering laser, injections, IPL, radiofrequency and surgical aesthetic care.
Additionally, Dr. Jaccoma will perform cosmetic eyelid procedures and will offer treatments for reducing the appearance of wrinkles and rejuvenating the skin. Dr. Jaccoma is a member of the American Academy of Ophthalmology and a Fellow of the American Medical Association.