Clinicians can look beyond eye drops for options to treat dry eye, blepharitis and meibomian gland dysfunction.
Several non-eye drop products, from cleaning kits to hot compresses, have recently been released for the treatment of ocular surface disease, and practitioners are finding success with these alternative therapies.
Steve Silberberg, OD, is using BlephEx, a handheld instrument for in-office treatment of blepharitis and dry eye caused by clogged meibomian glands, which he says minimizes the issue of patient compliance.
“The BlephEx treatment instrument is used to precisely and carefully spin a medical grade micro-sponge along the edge of the eyelids and lashes, removing scurf and debris and exfoliating your eyelids,” he told Primary Care Optometry News. “This also results in opening the clogged meibomian glands.
“The treatment considerably decreases the demand of time and expense on the patient’s part while providing instant relief,” Silberberg continued. “Some lid hygiene is recommended in tandem with this treatment. I present it as an option to every patient who is symptomatic or has obvious signs of these conditions. Often it can be done the same day in the office.”
BlephEx is safe for use on patients of any age, Silberberg told PCON, and is effective, painless and easy to use.
“The learning curve for using it is very quick,” he said. “The company also provides considerable supporting information, allowing a quick transition from novice to expert user. Although I typically use a small amount of topical anesthesia, I have performed it without any, with no adverse consequences.”
Silberberg recommends the treatment to both doctors and patients, who have given him positive feedback.
“This new, simple device and technique offers an inexpensive way to best take care of your patients,” he said. “They are grateful that our office is innovative and thank me for having the newest technology. I often get referrals from patients who have had the treatment done. Patients now call and request BlephEx.”
Silberberg noted that this procedure is not reimbursable by insurance at this time, but it is still relatively inexpensive for the patient. He also recommended that the device would be more effective if the tips came in multiple sizes, and that a kit including the recommended lid scrubs and anesthesia would increase efficiency.
Jack Schaeffer, OD, told PCON that the Bruder Eye Hydrating Compress and Stye Compress are effective and inexpensive ways to help patients with hordeola, meibomian gland dysfunction or other lid dysfunction.
“In the past, we had rudimentary regimens for treating, which would be some kind of hot compress that was difficult for us to explain and difficult for patients to follow,” he said. “And patients would be using a washcloth or rice in a sock.
“Bruder came in with a sophisticated treatment,” Schaeffer continued. “The compresses are convenient and come in a nice package. You put it in the microwave and heat it up, and the beads in the compress exude a wet heat.”
He also noted that the masks can be used both unilaterally and bilaterally.
In his practice, Schaeffer explained that patients with hordeola will use a compress for about 10 minutes in the office, but they have a separate protocol for meibomian gland dysfunction.
“When we book a patient for expression, we have them wear the mask in the office for 15 minutes and then we express the lids,” he said. “Afterwards, the patient takes the mask home and they use it for maintenance three or four times a week.”
The compresses get dirty, so Schaeffer recommends replacing them after no more than 6 months. He sells them in his practice.
Patients have been pleased with the compresses, according to Schaeffer, who is pleased with their safety and efficacy.
“The efficacy is phenomenal,” he said. “Now we have a true standardized way to apply heat to eyelids. It’s consistent and delivers a level of heat that’s effective in treating various issues.
“We think it’s very safe, because you’re not massaging the eyelids,” Schaeffer continued. “In our practice we’ve done topography pre-heat and 1 hour post-heat, and there was no significant change in the cornea.”
Schaeffer recommends the compresses to other doctors, with one note of caution.
“It’s important to keep a clean environment, and heating these masks in the office in a microwave that’s used for food is not good medical technique,” he explained. “I highly suggest buying a small microwave just for the compresses.”
Cliradex lid hygiene kit
The Cliradex Complete Advanced Lid Hygiene Kit (Bio-Tissue), which contains a gel as well as cleansing wipes, “represents a significant advantage over other commercially produced blepharitis kits as well as the ‘homemade’ versions involving diluted concentrations of raw tea tree oil,” according to Scott G. Hauswirth, OD, FAAO, a PCON Editorial Board member.
He noted that he uses it for in-office treatments of aggressive blepharitis, especially types involving Demodex mites.
“It contains the active ingredient in tea tree oil, 4-terpineol, in a topical cream,” Hauswirth explained. “There is a double-sided applicator included, as well as a box of Cliradex wipes.”
Hauswirth prefers using the Cliradex kit for multiple reasons, he told PCON.
Scott G. Hauswirth
“First, studies have shown that 4-terpineol is more effective with a faster kill rate than raw tea tree oil,” he said. “Second, the cream-like consistency of the product makes for safer application to the lids and lash base, so there is less likely a chance of over-application and resultant oil draining into the eye. Third, the thicker consistency means longer residence time on the surface with potentially greater potency against the offending organism.”
Patients are complaining less of discomfort and irritation after using the product, Hauswirth has found.
“From an integration standpoint, it is an easy adjustment to this kit from the product we were using prior,” he said. “I generally do two applications of the 4-terpineol cream at the visit, then give the patient a carton of Cliradex cleansing wipes to use at home on the eyelids.”
Hauswirth said the Cliradex wipes are sold in his optical, but that he uses the Cliradex kit as an in-office application.
Katherine Mastrota, MS, OD, FAAO, has found i-Lid Cleanser (NovaBay), a prescription solution, to be “an excellent adjunct to familiar commercially available and well established products.
“I-Lid Cleanser is a lid hygiene maintenance product,” she explained. “It is a bottled, liquid solution containing Neutrox, which is pure hypochlorous acid. Clinically, hypochlorous acid is generated in activated neutrophils and contributes to the destruction of bacteria. The solution is non-sensitizing and oxidizes quickly after application, so it is ideal for de-bulking microbial load and the associated biofilms from the eyelash base and lid margins.”
Mastrota told PCON that she has investigated the product on numerous types of patients, including those with dry eye complicated with meibomian gland dysfunction and blepharitis, those with atopic dermatitis, ocular rosacea or mild blepharoconjunctivitis as well as contact lens wearers.
For those in whom she also prescribes hot compress therapy, she suggests they use the i-Lid Cleanser first.
“It makes sense to me to de-bulk the lids both mechanically and therapeutically before a compress process,” Mastrota said.
“I generally show patients the spray-delivered product in the office, describe how to use it and send them with a prescription for their pharmacist to supply it,” she said. “I explain to them that although the product has a chlorine-like scent, it will not sting as they might expect.
Mastrota told PCON that NovaBay has early evidence that i-Lid Cleanser is acaracidal. From white paper studies, however, they have in vitro evidence that the hypochlorous acid solution has significant activity against a host of microbes, both gram-positive and gram-negative.
“It is presumed from these studies that iLid Cleanser would be efficacious against Bacillus oleronius, a Demodex-associated bacteria,” she said. “The bacillus may incite pathology as opposed to the mite.”
The only suggestion she has in terms of product improvement is the addition of an adjunct surfactant product.
“As i-Lid Cleanser contains only Neutrox and saline, it has no surfactant properties,” she said. “It will not remove most eye makeup, nor is it designed to do so. Akin to the dermatology and cosmetology practice of ‘cleaner and toner,’ i-Lid Cleanser, in my mind, is best used after makeup remover with a doctor-recommended surfactant product. Going forward, I would like to see a paired surfactant product as well as application pads added to i-Lid Cleanser.”– by Chelsea Frajerman
McMahon F, et al. Invest Ophthalmol Vis Sci.
2014; doi: 10.1167/iovs.14-15018. Accessed October 20, 2014.
For more information:
Scott G. Hauswirth, OD, FAAO,
is a Primary Care Optometry News
Editorial Board member. He is a member of the Minnesota Eye Consultants clinical staff, leads the optometric student externship program at Minnesota Eye Consultants and is adjunct faculty at the Southern California College of Optometry as well as the Illinois College of Optometry. He can be reached at firstname.lastname@example.org
Katherine Mastrota, MS, OD, FAAO,
is the center director of Omni Eye Surgery in New York. She can be reached at email@example.com
Jack Schaeffer, OD,
specializes in general optometry. He is the president and CEO of Schaeffer Eye Center, which has 16 locations in Alabama. He can be reached at firstname.lastname@example.org
Steve Silberberg, OD,
practices in New Jersey. He can be reached at email@example.com
Hauswirth is a consultant to Bio-Tissue. Mastrota is on the advisory boards of Bio-Tissue and NovaBay. Schaeffer has attended an advisory board meeting for Bruder. Silberberg is a consultant for Bausch + Lomb and CooperVision.