Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3 year retrospective study. Photomed Laser Surg. 2015;33(1):41-6. Craig et al. published the first prospective results of IPL use for the treatment of MGD. 35 In this double-masked, paired-eye, placebo-controlled study, 28 patients with mild to moderate MGD received three IPL treatment sessions to a randomly selected eye, while the other eye was assigned to serve as a sham-treated control. Treatment sessions were conducted at 1, 15, and 45 days from baseline and consisted of IPL treatment application to four periocular zones inferior to the eye. Lipid layer grade and noninvasive tear break-up time both improved significantly from baseline to day 45 in the treatment eye, but not in the control eye (both p<0.001). Subjective self-reported dry eye symptoms using the VAS also significantly improved in the treated eye but not in the control eye (p=0.015). Tear evaporation rate and meniscus height, however, were not significantly different in the treated eye compared to the control eye. 35 The Olympia study compared the safety and efficacy of TearCare with that of LipiFlow. The initial results indicated that TBUT and meibomian secretion scores saw similar improvements with both treatments, but 90% of patients in the TearCare cohort had a clinically significant decrease in Ocular Surface Disease Index (OSDI) score vs. 79% in the LipiFlow arm. TearCare participants also used 22% fewer lubricant drops post-treatment. 24 Vegunta S, Patel D, Shen JF. Combination therapy of intense pulsed light therapy and meibomian gland expression can improve dry eye symptoms and meibomian gland function in patients with refractory dry eye: a retrospective analysis. Cornea. 2016;35(3):318-22. But when your eyes feel dry and gritty every day — as a result of aging, underlying health conditions, certain prescription drugs or long hours staring at a computer screen— your doctor may suggest a stronger treatment. A traditional treatment involves placing tiny devices called punctal plugs into your tear ducts to keep your natural tears in your eye.

Bertino B, Blanchet-Réthoré S, Thibaut de Ménonville S, et al. Brimonidine displays anti-inflammatory properties in the skin through the modulation of the vascular barrier function. Exp Dermatol. 2018;27(12):1378-87.NuLids is a safe, natural and more effective alternative in the treatment of Dry Eye Disease. If too much pressure is applied during use, the self-regulating designs halts the movement. LipiFlow has an excellent safety profile, and a single treatment can more effectively improve the symptoms of MGD than a three-month daily course of oral doxycycline without the 40% risk of side effects that doxycycline carries. 21,22 The most common findings post-treatment are mild conjunctival injection and mild petechial conjunctival or skin hemorrhages, which tend to resolve within a few weeks of LipiFlow use. The Equinox (Marco) is an example of ocular LLLT. The procedure does not involve the use of gel and treats upper and lower lids simultaneously using direct and indirect photobiomodulation during the 15-minute application. The device uses LED lights to deliver focused wavelengths that target the mitochondria, stimulating production of the energy that powers the cell. 33 Connor CG, Narayanan S, Miller W. Reduction in inflammatory marker matrix metalloprotenaise-9 following lid debridement with BlephEx. Invest Ophthalmol Vis Sci. 2017;58:498.

Ophthalmology Management: For those who are unfamiliar, could you explain how the NuLids System works? I’ve tried everything on the market for 10 years and read about NuLids but I was skeptical once again that it would work. I would say if you have eyelid issues due to dry eye – RUN don’t walk to get this product!!! I’ve used it a week and it has been terrific! Nancy M, Nulids user Ikervis (CsA 0.1%, Santen) and CyclASol (CsA 0.1%, Novaliq) may be future cyclosporine options in the United States. Ikervis, available in Europe, is a once-daily preservative-free formulation. 12 It is a cationic emulsion containing CsA that leads to the long-lasting presence of CsA in the tear film and a higher bioavailability than the anionic CsA formulation of Restasis. 12,13 As a result, with only once-daily dosing, Ikervis is well tolerated and significantly improves symptoms and signs of patients with severe DED by six months. 12,14I can honestly say unequivocally, I’m very happy that I found this device Sandy’s DIY Health Advocacy iLux (Tearfilm Innovations; Carlsbad, California). The iLux is a handheld device that treats meibomian gland dysfunction with lightbased heat and compression, under direct visualization by the physician via a magnifying lens. The sterile, single-use, iLux Smart Tip has an inner pad that slips behind the eyelid being treated and an outer pad that’s pressed against the outer surface of the eyelid during heating and compression; the tip contains temperature sensors that maintain safe, therapeutic heat levels (between 104 and 108 F) during treatment. One-button control of heating and compression allows you to choose the location and duration of treatment. (iLux can treat both upper and lower eyelids.) IPL (Intense Pulsed Light). Intense pulsed light, or IPL, was originally developed for use in dermatology. Brief, powerful bursts of light at specific wavelengths (in this case, between 500 and 800 nm) cause changes in blood vessels near the surface of the skin, raise skin temperature and eliminate problematic flora on the skin and eyes, all of which may have a beneficial effect on meibomian gland dysfunction. (Many devices capable of producing this effect are on the market, but a popular one is the Quadra Q4 produced by DermaMed Solutions [Lenni, Pennsylvania].)

Xiao J, Adil MY, Olafsson J, et al. Diagnostic test efficacy of meibomian gland morphology and function. Sci Rep. 2019;9(1):17345. McDonald MB, Fumuso PW. Trehalose: A novel treatment for dry eye. Ocular Surgery News US Edition. July 10, 2018.Chhadva P, Goldhardt R, Galor A. Meibomian gland disease: the role of gland dysfunction in dry eye disease. Ophthalmology. 2017;124(11S):S20-6. Reducing dry eye symptoms and signs may be yet another application for Botox (botulinum toxin type-A, Allergan). While intraglandular injection of Botox is off-label, injection into the lacrimal gland and near the punctum can reduce lacrimal and tear drainage, respectively. 35 In a study of intractable DED patients, Botox injection into the medial part of the eyelid improved symptoms and signs and reduced tear cytokine levels. 36 In 2017, Syed and Sutula reported a new method of meibomian gland probing in which an operating microscope is used, von Grafe forceps are placed at the base of the tarsal plate and used to express meibum while a 2mm followed by a 4mm probe are used to break through obstructions and dilate the glands. 91.4% of treatments in their series of 70 eyelids resulted in symptomatic improvement, though more than half had relapse of symptoms during follow-up (range 1 to 64 weeks, mean 12.9 weeks). 55 Llamas-Moreno JF, Baiza-Durán LM, SaucedoRodríguez LR, Alaníz-De la O JF. Efficacy and safety of chondroitin sulfate/xanthan gum versus polyethylene glycol/propylene glycol/hydroxypropyl guar in patients with dry eye. Clin Ophthalmol 2013;7:995-9