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Good Afternoon everyone

Sorry it has been so long since we've posted anything.  We have been so busy opening up our new office in Ankeny, as well as seeing dry eye patients, that it has been some time since I added any new info.

 Here is some great info that I posted online in a few dry eye forums about post operative treatment!


 Post LipiFlow Treatment

1. Steroid use. We use Lotemax gel three times daily for two weeks. This mild steroid has long been used to lower ocular inflammation. It is quite mild, and rarely causes any increased intraocular pressure.

2. Fish oil - There has been recent research indicating that fish oil, specifically omega 3's, and the increased risk of prostate cancer. If the patient has prostate issues, we may not recommend Omega 3 treatment, but for everyone else, it's a no brainer. From lowering stress hormones, to improving good cholesterol to lowering bad cholesterol, Omega 3 is a great supplement to be on. I always say that since MGD is a oil issue, it makes sense to supplement with a healthy oil to promote a more regular meibum production in the body.

It is important to note that not all fish oils are created equal. First, you want a product that is Omega 3 and DHA, EPA only. You do NOT want Omega 6 or 9, which have been shown to INCREASE inflammation.

Also, there are two main ways fish oil is processed. There is the ethyl ester form, and the natural triglyceride form. The ethyl ester form is a more processed, less bio-available form that the body has a harder time absorbing, and actually degrades in the system to some nasty chemicals. Unfortunately, this is the form that most fish oils from Target, Walmart, Kroger, Costco, etc chain stores use. It's cheaper for them this way, and that's why you can buy 600 capsules for 10 dollars. You want to see the word "Triglyceride" on your bottle of fish oil. Many health food stores have this product. Two good examples are FortifEye and Nordic Naturals.

A simple way to test your fish oil is to use a stick pin to pop a hole in the capsule, and squeeze it in a Styrofoam cup. Leave it in the cup for ten minutes, and then take a look at the cup. If after ten minutes the cup has started to dissolve or be eaten away by the oil, you know you have a ethyl ester fish oil, or a lower quality fish oil. If it eats through Styrofoam, imaging what it's doing to your insides!

We recommend two capsules daily, with food, one in the morning and one in the evening. The goal is close to 3000mg of omega 3.

3. Warm compress - Once again, before the LipiFlow system, this was what we recommended most. The idea is to liquefy the oil in the glands to promote better oil release. However, this method has limited clinical effectively on its own. The glands themselves are deep within the lid in a structure called the tarsal plate, a thick collagen like tissue that protects the glands. In front of this tarsal plate are blood vessels that whisk away heat to protect the eye. Think of when you sweat. Your body recognizes that the body is hot, and to help regulate itself, it releases sweat to cool you down. Simple homeostasis. The eyelid is no different. Heat is recognized by the eye, and the blood vessels pump heat away from the lid. The method of warm compress is nowhere near the amount and placement of direct heat that is needed to tag thick clogged glands, and liquefy the oil. However, we have found that AFTER the LipiFlow procedure, when heat is directed to the BACK of the eyelid (right where the glands are), and that the glands have been purged of thick pasty oil, the use of the warm compress is much more beneficial at MAINTAINING a liquefied meibum. I continue to use the warm compress each morning, and my eyes feel GREAT after using it. We use the Bruder Mask, which contains little beads that heat up in the microwave and remain warm for 2-5 minutes, rather then a washcloth that stays warm for 10 seconds. The Bruder Mask is machine washable (cold water), and has worked very well for us. I know other people on the forum have used other masks, all of which I have heard good things.

4. Blinking exercises - When I first heard about blink exercises, I dismissed it. I thought it sounded ridiculous. The steroid, fish oil, and warm compress made sense, but I didn't think I wanted to discuss blinking with my patients. I didn't think it was going to be something the patient wanted to hear. "You need to blink more often". Of course, this is the quick answer, and leaves the patient wanting more. At least I wanted to hear more then just "blink more".

However, as time went on, and I started doing blinking exercises myself, and heard back from other patients following a good blinking regiment, I have come to believe that this is the most important part of having a good success with the LipiFlow system, ESPECIALLY IF YOU ARE A PARTIAL BLINKER.

A quick repeat from an earlier post about evaporative dry eye:

Our eyes feel dry because of decreased tears on our eyes, and the inflammation that results. There are decreased tears because these tears have evaporated. Tears have evaporated because there is a decreased lipid/oil component to the tears. There is a decreased oil component because the meibomian gland is not excreting oil. These glands are not working because the oil has solidified and become stuck under a fibrotic/collagen like tissue that grows over the orifice of these clogged glands. And what we are finding is the cause of this growth, rather then clean open glands in lid hygiene issues, are impartial blinks.

Full blinks cause a release of this oil. If you have the LipiFlow performed, but do not make a conscious change to improve your blinking habits, you may feel a little better from the procedure for a short while, but will then be right back where you started. I'm wondering if this is where many people have failed. Patients have the procedure, and make no changes. I think it boils down to we want immediate results, without doing anything different. It would be amazing if dry eye was simply cured by taking a tablet three times a day for a week, and living life the same way we had been. THIS IS NOT THE CASE WITH EVAPORATIVE DRY EYE.

What is a "blink exercise?" It's simply taking the time to stop and consciously think about your blinking. It takes 1.5 seconds to do it. Here is what I tell the patient:

"Take a second to stop whatever you are doing and think 'I'm going to close my eyes, and close them completely. I'm going to think about my eyelids shutting all the way and making contact. Stay this way for half a second, and then simply squeeze down for another half of a second, and open. That's one repetition. It's like lifting weights. Multiple reps."

"Now you need to find something that you do multiple times throughout the day, and link blinking exercises to these activities. Everytime you take a sip of water, or send an email, or walk from one room to the next, or turn the page of a book, and so on and so forth, you do a blinking exercise".

I've found that after doing them myself, my eye feels more moist, and I can often feel the tears on my eyes.

I had one patient back recently who said "Things have been going GREAT since the procedure!" While I've noted that almost all of my patients have returned 3 months post procedure doing better, this woman seemed very excited. So of course, I said "I'm glad that you are are doing better, and that you are so excited! Tell me, what have you been doing that you're so excited about the outcome?!?"

The patient reminded me that she works for Fed Ex. She drives a truck all day around town delivering mail and packages. We had talked about blinking exercises, as she was a partial blinker, and she had started doing three blinking exercises every time she came to red light while driving around town. Naturally, shes at a stop light many times throughout the day, and always does the blinking exercises.

NOTE: SHE HAS LINKED THE BLINKING EXERCISES TO SOMETHING SHE DOES MULTIPLE TIMES THROUGHOUT THE DAY. It made me realize even more how important this behavioral modification is to our schedules. If we don't think about improving our blinks, we are not going to be feel better. Our glands our going to clog again, and we are going to be right back where we started.

So, steroid use for two weeks, fish oil, warm compress, and blinking exercises are what I call the Big Four.

One last thing that we recently began recommending:

5. Manual lid debridement. Use one hand to pull the lid down and press in slightly so the lid margin becomes easily accessible. Looking in a mirror, take a Q-Tip, wet it slightly, and run it up and down along the lower lid, along the lid margin that makes contact with the eye. Do not use a cheap generic brand of Q-Tip. I know of some patients who have seen the professional grade cotton swabs we use in the office and purchase these online, as the cotton is of higher quality and doesn't dissolve on contact like some cheap brands. We have patients doing this once a week.

We now recommend these 5 things to all patients post operative LipiFlow. We have patients return in 3 months for a first follow up, and then again another 3 months for a second follow up.

A few extra things:

Some patients with ocular rosecia or other inflammed lid margin issues may already be on Doxy, or need to start a Doxy regiment, Azasite regiment, or something similar to address the inflammed glands.

As noted in an earlier post. It is thought that close to 30% of patients with evaporative dry eye also have an aqueous component. We often look at the patient 6 months post op LipiFlow to see if Restasis may be beneficial. Some patients are very happy, and we don't pursue Restasis at that point. Others who may not have tried Restasis in the past may be a better candidate now that the evaporative component has been addressed. The old battery of tested used for checking for aqueous deficiency are so variable that it's best to treat the MGD component if there is one, as it is so much easier to see and diagnose. I'll put in here that if the patient has the dry eye workup, and everything looks good from a evaporative dry eye component (no partial blinks, good gland structure, healthy oil secretion), we will most likely start with Restasis if the patient has not tried this option before doing the LipiFlow.

Noctural Lagophthalmus - I found about a year ago that I have this issue myself. My wife noticed on the few occasions that I fell asleep before her that my eyelids stay open a little when I'm asleep. I can be completely asleep, and she can see the whites of my eyes, and even the very bottom of my blue iris while asleep. This is obviously an issue, as all night long air is blowing across my eye if we have the overhead fan on, or the heater on, or the window open. I always recommend that if the patient lives with someone, and they don't mind being watched in their sleep, that they have someone check if this is going on. Chances are very high if you wake up with dry cracked eyes.

Alright, after reading all that, take the time to do some blinking exercises. Your eyes are probably pretty dry from looking at the screen so long! Take a break. I know I need one!!

TAKE HOME MESSAGE:

1. DRY EYE IS A CHRONIC ISSUE. Most people are on this forum because they are miserable, and they have been for a long time. We want an easy out. We want to take something for a week, and then be done with dry eye. IF THE BEHAVIOR MODIFICATION (linked blinking to daily tasks) DOES NOT OCCUR IN EVAPORATIVE DRY EYE, NO SIGNIFICANT CHANGE IS EXPECTED. I preach this to patients all day long, and I forget to do blinking exercises myself occasionally. In writing this tomb of a post, I've worked intently for over an hour, and hardly blinked. But as soon as I look away from the computer, I do my exercises. ALSO: It's important to note that if you only do your blinking exercises when your eyes are dry, you are always playing "catch-up". The evaporation has already occurred, and you're not making a change. The best thing to be doing is blinking exercises when your eyes are NOT dry (which for some of us is never, I realize).

Thanks for your time. 

Matthew Ward, OD