Dry Eye Coach

Dr. Doug Devries discusses how intense pulse light fits into his clinical practice. Find out about patient selection, presentation and treatment protocols.

Whitney Hauser: Hi, I’m Dr. Whitney Hauser with Dry Eye Coach podcast and we welcome today Dr. Tal Raviv, Founder and Medical Director of the Eye Center of New York. Welcome, doctor.

Tal Raviv: Thanks for having me. I’m a fan of your podcast.

Whitney Hauser: Oh, very good. Very good. Thanks so much. We really enjoy doing them and we rely on experts like yourself to provide us some content and clarity on a lot of interesting issues in dry eye disease. Today we’re going to be talking about dry eye treatment pre and post cataract surgery. And this, I know, is impactful for our patients and for our practices both in optometry and ophthalmology. So we’re just gonna kind of get the ball rolling here in a few minutes with some questions, but is there anything just sort of off the top of your head that comes to mind about pre and postop for eye disease that listeners need to consider?

Tal Raviv: I think we’ll get into the conversation, but certainly the fact that we have a whole podcast on this just highlights the importance of it and we’ll get into why that is, and it’s an issue that I talk about every day. In fact, my last patient today was someone who was post op with dry eye, and we got into this conversation. The more we speak with them before, the better prepared we are to speak with them after.

Whitney Hauser: Right, right. I think we’ve all heard that before. You know, it’s your fault if it happens afterwards. Otherwise, if you’ve diagnosed on the front end, you know, it’s really something that the doctor and patient really try to conquer together.

Tal Raviv: Exactly.

Whitney Hauser: To kind of set the foundation, in the Trattler’s Landmark PHACO study that was published a few years ago, we found that about three quarters of patients presenting for cataract surgery had ocular surface disease and at least half have ocular surface problems that alter the results of biometry or could otherwise negatively affect surgical outcomes. So, like you said, there’s such an impact to the patient in terms of the numbers and in terms of their ultimate outcome with the surgery. I guess the first question really to kind of get things going is, those numbers are very large. So let’s talk about what they mean. What is the impact or what could dry eye have on the outcomes of cataract surgery if it went untreated?

Tal Raviv: Well, I think that study, the PHACO study, was really a great paper in documenting what many of us already know, but actually documenting even worse than what we thought. He found up to 78 percent, and, you know, I think Dr. Gupta had a study that found up to 80 percent of patients coming in for cataract surgery, had some signs and symptoms of dry eye disease. Now, how does it affect us? It impacts cataract surgeons in three ways. Not the surgeons, but patients and then their conversations with their surgeons, that is. Number one, as you mentioned, is getting poor biometry or keratometry which is a key part of our calculations. Keratometry is exquisitely sensitive to dryness and if we don’t pay attention to that, the studies have shown – Alice Epitropoulus has great study showing as well – that with high osmolarity, we’re likely to have an error in our biometry. So that’s a very specific, long lasting effect on those patients — they end up with a refractive error that we don’t desire. Number two is that dry eye signs, such as punctate kerotopathy and corneal staining also have a negative effect on the visual quality, so if we place an advanced technology lens, such as a presbyopic IOL in the patient and they revert back to their worn out cornea that’s dry, they’re going to have poor visual outcome. They won’t see far

Whitney Hauser, OD, says that doctors don’t need to invest in expensive technologies to start diagnosing and treating patients with dry eye symptoms. As doctors become more familiar with it and assess their community’s need, they can scale up.

At the Dry Eye Coach Podcast, we recently sat down with pioneering expert Neel R. Desai, MD, to discuss his views on dry eye’s present and future. Dr. Desai is the Director of Cornea, Cataract, and Refractive Surgery at the Eye Institute of West Florida, Founder and Director of the Dry Eye Center of Excellence, and Medical Director of Alliance Eye Bank and Institute for Transplant Research.

Listen to the full conversation with Dr. Desai, previewed here in an excerpt about combining LipiFlow and intense pulsed light (IPL) therapy, an approach that Dr. Desai has studied in depth.

Dr. Hauser: You mentioned that you treat dry eye aggressively, with a focus on its underlying causes. If that includes IPL, a lot of practitioners wonder if you the treatment area includes facial telangiectasias as well as the eye area.

Dr. Desai: My treatment zone for IPL (M22 Optima IPL, Lumenis) is from lateral campus to lateral campus, including the bridge of the nose. Based on the education we do, we have a very high level of patient acceptance for IPL. And it works. We see very few non-responders who are too far-gone in terms of gland atrophy.

While I’m treating the eye area, I also treat telangiectasias in the cheeks and chin. Patients love it. After treatment, they notice that not only are their dry eye symptoms getting better, but their skin looks rejuvenated as well. It’s a value-added service.

Dr. Hauser: Do you combine IPL with additional treatments or is it a standalone?

Dr. Desai: It’s a patient-to-patient decision. We’ve developed an internal protocol for a combination of LipiFlow (Johnson & Johnson Vision) and IPL based on the response I’ve observed from this approach. The typical protocol for IPL alone is four treatments, 2 to 4 weeks apart, followed by maintenance treatments at 4 months, gradually increasing in duration to once per year. Patients usually begin to notice results after the third or fourth treatment.

When we combine IPL with LipiFlow – IPL immediately after the first LipiFlow – patients typically notice a benefit after one or two treatments. LipiFlow does such a good job of unclogging the glands, and then the IPL works on the source of the inflammation and the clogged glands. Patients certainly need fewer maintenance treatments for both, spaced at greater intervals.

Dr. Hauser: I couldn’t agree with you more. I think a lot of our colleagues are either in the obstruction camp or the inflammation camp, and they don’t necessarily combine those two processes together. In reality, they’re very intermingled. I think you’ve hit the nail on the head. If you can evacuate the gland and sort of hit the reset button with LipiFlow, and then you go forward with IPL, you’re addressing both.

Dr. Desai: I have patients call months ahead of their scheduled maintenance treatment to schedule their appointments for IPL or LipiFlow, which is also typically repeated once per year. That tells me everything I need to know about efficacy and

At the Dry Eye Coach Podcast, we recently sat down with pioneering expert Neel R. Desai, MD, to discuss his views on dry eye’s present and future. Dr. Desai is the Director of Cornea, Cataract, and Refractive Surgery at the Eye Institute of West Florida, Founder and Director of the Dry Eye Center of Excellence, and Medical Director of Alliance Eye Bank and Institute for Transplant Research.

Listen to the full conversation with Dr. Desai, previewed here in an excerpt about combining LipiFlow and intense pulsed light (IPL) therapy, an approach that Dr. Desai has studied in depth.

Dr. Hauser: You mentioned that you treat dry eye aggressively, with a focus on its underlying causes. If that includes IPL, a lot of practitioners wonder if you the treatment area includes facial telangiectasias as well as the eye area.

Dr. Desai: My treatment zone for IPL (M22 Optima IPL, Lumenis) is from lateral campus to lateral campus, including the bridge of the nose. Based on the education we do, we have a very high level of patient acceptance for IPL. And it works. We see very few non-responders who are too far-gone in terms of gland atrophy.

While I’m treating the eye area, I also treat telangiectasias in the cheeks and chin. Patients love it. After treatment, they notice that not only are their dry eye symptoms getting better, but their skin looks rejuvenated as well. It’s a value-added service.

Dr. Hauser: Do you combine IPL with additional treatments or is it a standalone?

Dr. Desai: It’s a patient-to-patient decision. We’ve developed an internal protocol for a combination of LipiFlow (Johnson & Johnson Vision) and IPL based on the response I’ve observed from this approach. The typical protocol for IPL alone is four treatments, 2 to 4 weeks apart, followed by maintenance treatments at 4 months, gradually increasing in duration to once per year. Patients usually begin to notice results after the third or fourth treatment.

When we combine IPL with LipiFlow – IPL immediately after the first LipiFlow – patients typically notice a benefit after one or two treatments. LipiFlow does such a good job of unclogging the glands, and then the IPL works on the source of the inflammation and the clogged glands. Patients certainly need fewer maintenance treatments for both, spaced at greater intervals.

Dr. Hauser: I couldn’t agree with you more. I think a lot of our colleagues are either in the obstruction camp or the inflammation camp, and they don’t necessarily combine those two processes together. In reality, they’re very intermingled. I think you’ve hit the nail on the head. If you can evacuate the gland and sort of hit the reset button with LipiFlow, and then you go forward with IPL, you’re addressing both.

Dr. Desai: I have patients call months ahead of their scheduled maintenance treatment to schedule their appointments for IPL or LipiFlow, which is also typically repeated once per year. That tells me everything I need to know about efficacy and value. When patients are paying out of pocket, and they’re doing so voluntarily and early, I know that they see it working. The results are worth every penny that it costs them out of pocket.

She discusses where ocular surface disease has been historically and where it’s headed in the future. Listen as this dedicated clinician and researcher talks about her passion for dry eye and why you should share her enthusiasm.