Advances in dry eye are coming at a furious pace, with new diagnostics and new therapeutic agents addressing a condition whose importance has recently been elevated because of its impact on vision and surgical outcomes.
Like many of my colleagues, I find the growing number of treatment options to be somewhat overwhelming and find myself a bit skeptical of new theories and treatments, particularly when costs are high and not covered by insurance.
Despite my natural skepticism, though, I’ve become quite impressed with the benefits of addressing biofilms as a cause of dry eye. Biofilms are extracellular debris that are created by bacteria and, in the case of blepharitis, accumulate on the lid margins and eyelashes, serving as a protective substrate upon which the bacteria can multiply. What follows the growing populations of bacteria is destructive inflammation in the familiar pattern that we call blepharitis.
Many believe dry eye starts with lid colonization by bacteria, creation of biofilms, then progression to meibomian destruction and eventually damage to aqueous-producing cells. Naturally, this isn’t the only path to development of dry eye. Other diseases such as Sjögren’s have their own mechanisms, but biofilms may represent a more important role than we have ever recognized.
With impressive success, our practice has adopted an approach to treating biofilms called microblepharoexfoliation using a device called BlephEx (BlephEx LLC). This treatment involves use of a rotary device and a soft sponge tip along with a gentle eyelid cleanser to remove biofilms from the lid margins and lashes much more thoroughly than any patient’s eyelid hygiene maneuver could. Using this approach now in dozens of patients for more than a year, we’ve seen significant relief among some otherwise recalcitrant cases. Similar success has been observed in other academic practices, and a formal clinical study is underway to rigorously test the benefits of this approach.
The BlephEx microblepharoexfoliation procedure takes a couple of minutes in the office and can be performed by a doctor or even a technician. To date, there is no third-party reimbursement or CPT code, and we charge about $250 for treatment to both eyes, which needs to be repeated once to twice a year, depending on disease severity.
In general, our patients have been receptive to this treatment and have found significant relief – sometimes immediately and within a few days in most cases. We have found the treatment to be very complementary to LipiFlow (TearScience), which, while more expensive, has also been quite successful in the subset of patients with significant meibomian gland disease.
Like many of my colleagues, I was quite skeptical of this unfamiliar approach to dry eye when I first heard about it from Dr. Jim Rynerson, who is the founder of BlephEx and chief proponent of the biofilm theory of dry eye. But patient feedback supersedes preconceived notions, and BlephEx is now a regular part of our treatment algorithm in our dry eye practice. It’s clear to me that biofilms deserve more discussion in the academic circles of dry eye and that this patient-satisfying therapy is here to stay.
Disclosure: Hovanesian reports he is on the medical advisory board of BlephEx and serves or has served as a consultant or medical advisory board member to Allergan, Auven, Shire and TearScience, all of which produce treatments for dry eye.