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Dr. Sandra Cremers is leading the way in development of new dry eye treatments that have the potential to do more than simply cover the symptoms. In her current practice and research, she’s beginning to discover that using our own bodies may be the very best way to heal.
While working at Harvard, her main focus was angiogenesis research with Dr. Judah Folkman, looking at why rosacea patients have eye issues including neovascularization of the cornea. They found that patients that have rosacea may have an increased level of vascular endothelial growth factor (VEGF), which is known to increase the multiplication of blood vessels. This could translate into an increased risk for cancer, wet macular degeneration, or proliferative diabetic retinopathy in those with diabetes. This is fascinating research, and it has propelled her into her interest in those with dry eye disease.
After family members developed the condition, she began diving deeper into possible treatment modalities that would do more for patients than cover the problem. Now living in Rockville, MD, Dr. Cremers still does research on dry eye disease while seeing patients. Her knowledge of dry eye has expanded and she now performs platelet rich plasma (PRP) injections into the meibomian and lacrimal glands, a procedure that is quite new but an exciting development in the world of dry eye treatment.
There are three layers of the tear film, the meibum (oily) layer from the meibomian glands being arguably the most important. The aqueous layer which comes from the lacrimal gland is in the middle, and the innermost layer is the mucin layer which comes from the goblet cells of the conjunctiva.
The meibomian glands are actually able to be viewed at this time, using technology such as LipiView, where the goblet cells and lacrimal gland cannot yet be viewed with any device. When Dr. Cremers sees even one meibomian gland atrophied, she treats this as an urgency because it is very difficult to bring back the gland once it is gone. It is much easier to save it!
It’s very common now to see patients who have meibomian gland loss, most likely due to the increase in technology and screen time. Unfortunately, those with a vast loss of meibomian glands may be experiencing autoimmune disease, may have used Accutane, or it could be caused by too much screen time. This means that younger and younger patients are suffering.
When dealing with meibomian glands that are being lost, Dr. Cremers has a protocol she uses. The first and most important thing is to save the glands if possible. After that, removal of symptoms is explored.
1. Frequent blinking - just like you milk a cow to increase their milk supply, the more you blink the more oil you’ll produce. Screen time is a huge issue for this because we blink half as often when we’re in front of a screen, and this means the glands are not being milked like they should be.
a.) Warm compresses with massage - the heat will open the glands and massage will help remove the oil from the glands
b.) For rosacea, you’ll want to continue using warm compresses, but use a cold compress afterward
2. Thermal pulsation - LipiFlow is used in this step to keep the oil pumping and slow down the process of disappearing oil
3. IPL and probing - IPL works very well together with probing, applying the IPl to top and bottom lids. 6-8 sessions are usually needed for full relief. If there’s no oil coming out, probing will be done to remove any scarring.
a.) If someone is the unfortunate product of Accutane or an autoimmune condition that has caused incredible gland loss, LipiFlow, IPL, and probing can be very effective along with PRP treatments.
PRP stands for platelet rich plasma. Many of you may be aware of autologous serum, which is drawn from your own blood and centrifuged to make eye drops. It contains many of the molecules that are responsible for healing your body, making them potentially very beneficial for treating eye conditions. Platelets have a very intense amount of growth factors, interleukins and cytokines, which are responsible for healing you when you have a wound.
This is why PRP has been utilized in so many orthopedic procedures and it’s now making its way into the eye care world. If there are stem cells in the area, like there are in the meibomian glands, it makes sense that PRP would work in that area.
This is a treatment that’s usually reserved for those patients who have tried many things and failed to find relief. If a patient is not noticing improvement with autologous serum, different concentrations may be tried. 20% is the general starting point, but some patients will be prescribed 50% or even 100% autologous serum. If improvement isn’t noted within six months, PRP can be the next step in attempting to heal the ocular surface.
For the actual procedure, it is done after meibomian gland probing and expression of the entire oil column. The doctor will use a small cannula which will administer the PRP (100% fresh platelets) directly into the meibomian gland. No needles are involved. The thought is that if you can create a little space by probing and expressing, and there’s even one stem cell left within the gland, you can stimulate the gland to produce more oil.
The controversy with probing is the thought that there may be more scar tissue being created. This is something that we’ll need time to figure out, but in many doctors’ experience of doing probing for years, no worsening of scar tissue has been seen. The opposite may actually be true, that if you don’t have probing done the scar tissue will worsen.
Dr. Cremers also occasionally does PRP injections into the lacrimal gland, but right now this is reserved for those with Sjogren’s syndrome. Small studies on this have shown that Schirmer scores are improved in patients who suffer from Sjogren’s, and in doing all of these PRP and stem cell treatments researchers are really looking for a cure and not just a temporary fix.
While PRP treatment is not a guarantee, just like anything else, Dr. Cremers has seen immense success with this treatment. She notes a 90-95% success rate. Small studies are currently being published on her research, and there’s much more room for future research involving the comparison of probing alone vs. probing and PRP, as well as other studies.
Dr. Cremers has also used adipose derived stem cells as well as cord blood serum (using safe, embryonic stem cells). Although this is not a cure, the very best treatment may be the use of the patient’s own stem cells combined with their platelets and cord blood serum. Of course, stem cells can vary in quality based on many factors, including smoking history, poor diet and advanced age. The combination of stem cells, plasma, and cord blood serum is currently under an IRB Investigative Research Protocol.
The risk of this procedure is incredibly low, and Dr. Cremers hasn’t had a single complication so far. The largest risk is a potential stye (also a risk with LipiFlow), as well as the risk of infection and corneal abrasion.
There is some data to show that PRP treatments can help with regeneration of nerve tissue, goblet cells and the lacrimal gland. In Dr. Cremers’ research, they were able to show a regeneration of meibomian glands with PRP treatments by 25%.There’s always a subjective component to viewing the meibomian glands and measuring regeneration, so this is the importance of studying this over time.
If you’d like to learn more from Dr. Cremers you can visit her blog and use the search bar to find topics of interest. She also has a YouTube channel. If you’re interested in PRP treatment, you can find more information about her practice, Visionary Eye Doctors, on their website or call them at 301-896-0890. She does consultations for patients all over the world and can’t wait to help you improve your disease.
Dr. Sandra Lora Cremers is a board-certified ophthalmologist and a Fellow of the American College of Surgeons. She joined Harvard Medical School’s Department of Ophthalmology, the Massachusetts Eye and Ear Infirmary, in 2000. During this time, she worked with Dr. Judah Folkman on the angiogenesis basis of ocular rosacea, published surgical teaching tools, created the largest database of surgical outcomes for resident cataract surgery, was active in training residents and fellows and participated in the Lancaster Cataract Course and the Harvard Medical School’s Intensive Cataract Surgical Training Program.
During her tenure at Harvard Medical School’s Department of Ophthalmology at the Massachusetts Eye and Ear Infirmary as well as the DC area, Dr. Cremers performed thousands of surgeries, including state-of-the-art laser cataract surgery, such as the LenSx and CATALYS femtosecond laser, innovative intraocular lens implantations using the Symfony®, Symfony Toric®, ReSTOR®, TECNIS®, CRYSTALENS®, ReZoom®, Trulign®, Trulign Toric®, and toric IOLs LASIK and PRK refractive surgeries, glaucoma surgeries, such as iStent, Kahook Goniotomy, Cypass glaucoma surgeries, state-of-the-art no-stitch pterygium removal as well as advanced laser surgery for glaucoma, and complex reconstruction of the eye.
Dr. Cremers is also certified to perform Micro Invasive Glaucoma Surgery (MIGS) and Goniotomy Surgery for Glaucoma. In addition, Dr. Cremers is co-editor of Ophthalmic Surgical Procedures, 2nd edition and the upcoming 3rd edition with Thieme Publishing: the 2nd edition has been translated into three languages and is considered one of the best teaching textbooks for eye surgery.
Currently Dr. Cremers is conducting research into the connection between screen time and severe Meibomian gland loss in children, which she was the first to describe on her YouTube channel, as well as doing research to see how to cure Meibomian gland loss and dry eye disease with platelet rich plasma injections into the Meibomian and Lacrimal glands.
Patients from all over the world fly in to have a dry eye consultation and treatment with Dr. Cremers.