Jennifer Rayner
BAppSc (Optom) GradCertOcTher
Alleve Eye Clinic, St Peters SA
Equipment
OCULUS Keratograph 5M
Eye Light IPL/OPE and Light
Modulation unit
My Mask
Supplier
Designs For Vision
Jennifer Rayner explores the benefits of a dry eye treatment regimen that combines the use of the Eye Light IPL/OPE and Light Modulation unit.
Ms P, a 31-year-old woman of Indian heritage presented at the Alleve Eye Clinic with burning, gritty, dry and red eyes following corneal cross linking and topography-guided PTK treatment for kerataconus in 2015. She experienced recurrent corneal erosion syndrome and had PTK to correct it but suffered corneal scarring of the left eye post treatment. A disposable soft contact lens was worn in the left eye for comfort and correction of vision. Ms P used artificial tear supplementation up to a dozen times a day and would experience so much dryness that she would not be able to insert the contact lens with comfort or ease. Daily lens replacement increased the irritation of the left eye so she changed to a monthly disposable lens as extended wear.
She was diagnosed with polycycstic ovaries nine years prior to the consultation which resulted in hair thinning; she was on oral spironolactone for this, but ceased it after suffering dry mouth and fatigue as side effects. Her last hormone tests, three years prior, showed elevated testosterone levels and low oestrogen levels. She was under the care of a dermatologist for her hair thinning and dermatitis.
On initial examination, her visual acuity was R -0.25/-0.50×130 (6/6), L -4.25/-1.75×120 (6/6). There was no anterior blepharitis, lid margin telangiectasia or corneal staining but mild bilateral conjunctival staining, often indicative of dry eye. Meibography using infra-red imaging showed very early meibomian gland (MG) drop out (Figures 2A-D).
Schirmer testing was good at R 13, L 28 mm over five minutes (using topical anaesthesia) but the meibomian glands yielded little meibum despite in-room Blephasteam and firm lid expression. She had a full and complete but frequent blink rate. A diagnosis of evaporative dry eye (EDE) from meibomian gland dysfunction (MGD) was made.
As per my typical regime, she commenced warm lid compresses using the DERM mask daily for 10 minutes, Optimel manuka honey gel 98% to the lower lids and oral omega 3 supplementation. While she persisted in doing warm compresses at home, she would have to take out the lens to apply the heat at night and then would need to rinse the lens in the morning as it became irritated overnight.
I reviewed her several times over five months with very little progress to improve the quality of her meibum. Her MGs remained difficult to express; she was still symptomatic and using eyedrops frequently. We discussed the use of oral doxycycline but she had irritable bowel syndrome, and with lack of obvious ocular surface inflammation, she was reluctant to proceed down this pathway. At this stage our clinic had the use of the EyeLight IPL and red photo-modulation mask and I suggested to her that we trial this. She returned the following week for her first IPL and photomodulation session (Table 1).
The Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) Definition and Classification committee updated the definition of dry eye disease (DED) to recognise the multifactorial nature of dry eye as a disease of the ocular surface where loss of homeostasis of the tear film is the central pathophysiological concept. Aqueous deficient dry eye (ADDE) and evaporative dry eye (EDE) exist as a continuum and elements of each are considered in diagnosis and management. Tear film instability, hyperosmolarity, inflammation and damage along with neurosensory abnormalities are recognised as aetiological triggers of the vicious circle. Evidence suggests that the majority of DED is evaporative in nature.¹
Obstructed, poor functioning or atrophied meibomian glands can lead to lipid layer disruption of the tear film and subsequent evaporation – and 86 per cent of dry eye sufferers demonstrate meibomian gland dysfunction.² Prevalence rates can range from seven to 33 per cent and risk factors include: use of computers and devices, medications, refractive surgery, auto-immune disease, sex hormones and contact lens wear.³ Despite numerous interventions, Ms P’s meibum remained inspissated and she was subsequently symptomatic.
Diagnosis of dry eye disease includes both signs and symptoms and can be differentiated from other ocular surface diseases by using the clinical decision algorithm recommended by the TFOS subcommittee.1 Therefore it is important to perform a myriad of tests to determine where the DED falls on the spectrum between ADDE and EDE and the severity in order to devise an appropriate treatment plan.
Clinic protocols vary. I follow the DEWS II recommendation of triaging questions, risk factor analysis (medications, contact-lens wear and so on) and the performance of diagnostic tests such as tear break up time, osmolarity and ocular surface staining scores. Further sub-testing can be then undertaken for ADDE (Schirmer or phenol red thread testing) or EDE– ease of MG expression, meibography and lipid layer analysis.¹ I find the OCULUS Keratograph 5M (Figure 1) to be an excellent diagnostic tool that provides many of these tests to help diagnose DED and its severity, as well as being an excellent education tool for patient understanding and compliance.
The question remained why Ms P’s functional MGs remained inspissated.
Spironolactone can help block androgen receptors at the site of the hair follicle to help thinning hair. Reduced production of androgens can slow down the progression of hair loss caused by androgenic alopecia and can also encourage hair to regrow.⁴ Ms P had reported having high levels of testosterone prior to starting the medication—this potential drop in androgen levels may have been a contributor to her MGD (androgen deficiency is associated with the development of both ADDE and EDE) whereas the roles of oestrogen and progesterone in DED is less understood⁵ but she was symptomatic prior to starting the medication.
Prolonged contact lens wear is well known to be a cause of DED³ and as corneal cross linking is not known to normalise altered nerve morphology from kerataconus,⁶ these two factors may also contribute to ongoing discomfort and contribute to the inflammatory cycle.
A trial of four IPL sessions, two weeks apart using the Eye-Light IPL/OPE followed by a 15 minute light modulation session using red LED lights was undertaken. Looking at Table 1, there were no changes in meibum secretions or symptoms until the third session. By the last session, the oil had softened significantly, she had decreased her frequency of drop use and was a lot less symptomatic and decreased bulbar redness was noted. Four weeks later she continued to improve and was hardly using any drops at all—an outcome expected from the cumulative improvement with IPL over time.⁷ When I reviewed her recently, her use of drops had increased slightly, but we put that down to her probably requiring a further IPL session for maintenance and we have scheduled another session in a month’s time.
IPL has been shown to be an effective tool in the management of MGD.⁸ In the case of patients affected with MGD, destruction of abnormal erythematous blood vessels reduces a key reservoir of inflammatory mediators, thus removing a major source of inflammation from the eyelids and meibomian glands. MGD is associated with inflammatory skin conditions that occur near the lid margins such as Rosacea⁹ and may also be used to control surface bacteria and demodex mites.¹⁰ Ms P had been experiencing an increase in her dermatitis and there was a question from her dermatologist of a possible underlying, as yet undiagnosed, auto immune disease. IPL has been shown to decrease the levels of inflammatory markers in the tear film over a 12-week period.¹¹ As well, IPL has been found to improve the microstructure of the MG.¹²
The decrease of inflammatory markers may have improved meibum quality and it is possible actual MG function was improved. Certainly, despite the decrease in non-invasive break-up time (NIBUT) noted in her right eye (possibly due to less MG) her symptoms decreased, her ease of meibum expression increased and ocular redness decreased.
What remains of interest is the incorporation of light modulation (LM) with the sessions. It has been found that different compositions of ester in various meibum secretions can cause changes in the melting point of the meibum leading to MG obstruction.¹³
There has also been a positive hyper-thermal effect with the safe and effective application of near-infra red LED device to the eyelids in non-inflamed obstructive MGD-improving symptoms, decreasing orifice obstruction scores and improving tear evaporation times. Further to this, LM has been shown to be a safe method to decrease inflammation and increase healing properties (such as increasing fibroblasts and increased synthesis of collagen, particularly of the skin.¹⁴ Given that it has been shown to decrease inflammatory markers on the skin and decrease erythema, it is a possibility that LM is another tool to manage the inflammatory process of DED in the lid and surround surfaces as well as the lid margins.¹⁵
The Eye-Light IPL/OPE is proving to be a very useful tool in my dry eye tool box to manage obstructive MGD particularly—as presented in the case here—in the absence of inflammatory vascular conditions such as facial rosacea. Of particular interest is the additional use of the light modulation mask. As well as providing thermal heating to the upper lids (where IPL is not treating) for ease of MG expression, its use to decrease surface inflammation, and potentially treat surface bacteria and Demodex mites is very exciting. For those already in possession of an IPL unit, the My Mask is available as red LED light modulation device and a perfect addition to an IPL unit. A separate device, it can be used in conjunction with IPL or as a stand-alone treatment, and can be performed by ancillary staff in a separate room.
Dr Jennifer Rayner is principle consulting optometrist and co-owner of Alleve Dry Eye Clinic in St Peters, South Australia. The clinic is dedicated solely to the diagnosis, treatment and management of dry eye.
Dr Aaron Lech
OD, FAAO
ClearVue Eye Care
Roseville CA USA
Shifting demographics demand well-equipped professionals.
Let me start by assuring you that I do not consider myself a guru or a health care demographic soothe-sayer. I put my pants on one leg at a time. Like most everyone else in the eye care industry, my successes are the product of three things: a supporting team of work colleagues; a commitment to innovation; and vendor support for diagnostic solutions, data management and utilisation.
Still, as I look at the eye care market in the US and Australia, I can say with a certain level of guru-like confidence: I am compelled to believe that the future of optometry is quite bright.
As practitioners of optometry in Australia, you have been blessed with two significant studies, which, when combined with current demographic changes, reveal the amazing opportunities for optometrists nationwide.
In 2005, The Eye Health in Australia study1 was published, setting out a background regarding the epidemiology of eye disease and injury in Australia. Based on data from the WHO (World Health Organization) and the IAPB (International Agency for the Prevention of Blindness), the study made clear that the optometric community needs to pay attention to the impact of population ageing.
The projected need for care
Analysis of the study data, including the number of patients that required active management of disease in 2002 and the projected need for care by 2032, indicates that over six million Australians will require medical eye care services. This doesn’t even include the surveillance of additional disease suspects and the treatment of uncorrected refractive error.
Further review of changing population demographics by 2032 reveal that Australia will see a population shift among individuals over 55 years of age to the tune of 4.5 million people. This leaves a total of 8.9 million people requiring much closer surveillance. The shift represents a change in the ratio of patients likely to need eye care services from 1 in 5 to 1 in 3 (roughly 33 per cent of the population). When combined with the fact that an estimated 9.7 million Australians had at least one sight problem in 2002, greater than 50 per cent of the projected population will need some form of optometry service.
The second study, Optometric Supply and Demand in Australia: 2011–2036,2 published in Clinical and Experimental Optometry, set out to answer the question that troubles many optometrists: ‘are there too many of us?’ According to the conclusions of this study, there is a coming surplus of 1,200 optometrists given current demand for Medicare services (except in Queensland, Tasmania and the Northern Territory).
However, the study seemed to overlook a few key items. First, its assumptions were based on Medicare service demand only (which we all acknowledge is a moving target and is not the only reason patients seek our care). Second, ageing and disease demographic analysis was given minimal attention.
In fact, if you combine the findings of the optometric workforce supply study with the current trends in ophthalmology training programs and the projected epidemiology demands, a significant opportunity seems to be at the doorstep of Australian optometrists.
Table 1. Over six million Australians will require active management of eye conditions by 2032
When we note the ophthalmology workforce changes and projected graduation rates for the collective eye care profession, the ratios of providers-to-patients is quite favourable. In the ‘Workforce Study’ an assumed ratio of 18 optometrists to 100,000 members of the population was projected. Adjusting for static ophthalmology supply and increasing population growth, ratios could likely be closer to two ophthalmologists to 100,000 and 14 optometrists to 100,000. Essentially, we have a tsunami of baby boomers affecting both patients and providers.
If these modest adjustments are accurate and the ageing population exerts the pressure on services similar to countries such as the US, the future is indeed bright. For optometry, these ratios indicate that an average of 3,500 patients will require care by each optometrist in Australia (7,100 x 50 per cent = approximately 3,500).
With this type of demand, optometrists must prepare by investing in the systems, equipment and education necessary to take our place in this new millennium of opportunity.
As I say, I am not a guru or a health care demographic soothe-sayer, but I am compelled to believe that the future of optometry is quite bright.
Founder of ClearVue Eye Care in Roseville, California, Aaron Lech is a recognised innovator in the optometry field, and has pioneered diagnostic practice strategies over the past 15 years. In 2017, as a guest of ZEISS Australia, Dr Lech conducted a six-city tour of Australia and New Zealand to discuss how optometrists can improve efficiencies in a rapidly changing market.
References
1. Commonwealth of Australia. Eye Health in Australia; a background paper to the National Framework for Action to Promote Eye Health and Prevent Avoidable Blindness and Vision Loss [Internet]. Canberra: Department of Health; 2005 [cited 2018 Apr 17] Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/1A5409787D800F2CA257C73007F12F3/$File/cov.pdf
2. Healy E, Kiely PM, Arunachalam D. Optometric supply and demand in Australia: 2011-2036 Clin Exp Optom 2015; 98: 273-82
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