Blog
More on the “pipeline” & notice about some recalled drops, too.
First the good: “Global health care company Grifols has announced that the US Food and Drug Administration (FDA) has cleared the company’s Investigational New Drug (IND) application to initiate a phase 2 trial to assess its immunoglobulin (IG) drops (GRF312 ophthalmic solution) for the treatment of dry eye disease (DED).1 The drop has the potential to become the first-ever ocular surface indication for an IG, according to a news release.”
From https://www.optometrytimes.com/view/us-fda-clears-grifols-investigational-new-drug-application-for-immunoglobulin-drops-for-the-treatment-of-ded?ekey=RUtJRDoxMzc2NUY0My0zNkZDLTQ3MTAtQkM5Ny02NUMwQjkxNEYzNzk%3D&utm_campaign=emailname&utm_medium=email&_hsenc=p2ANqtz--W10iWBq4V7dpx4RuXUoNWCBcc8dlnPiFPwDNthnKXSU13up41XQYAf-zXxikJaTSKF8IRD9d9jfmTwllLnsIeu1KqQw&_hsmi=362995484&utm_source=hs
So what does this mean? Many of you suffering with autoimmune-related diseases are aware that Immunoglobulins (also known as antibodies, they are the basis for our immune response to body-invading “enemies,”) are complex proteins made by our body’s white blood cells known as plasma cells. Invaders such as bacteria and viruses along with certain cancers, have unique proteins called antigens, that become known to these plasma cells and trigger them to make the immunoglobulins. In certain autoimmune diseases such as rheumatoid arthritis, some cells produce a chemical known as TNF-alpha (Tumor Necrosis Factor). This is one of a group of chemicals made by the body termed cytokines, which in the case of TNF-alpha, can bind to other cells and trigger an immune response leading to inflammation. Immunoglobulins targeted to TNF-alpha can neutralize or “block” it and prevent this inflammation.
Many of my patients with severe forms of inflammation - especially when autoimmune related, have ended up on so-called iVIG - or intravenous immunoglobulin therapy. This has been sight saving in many cases and life saving, in some. The idea of applying immunoglobulins directly to the surface of the eye seems a small but significant leap towards helping those with autoimmune surface problems.
It is also true that our immune system is a bit like a finely tuned race car’s engine, in the sense that minor things can get it running roughly, and take away its ability to effectively keep us out of trouble with germs and cancers. Immunoglobulins can help put this engine “back in tune.” At this stage, I’m not sure what kind of antibodies and which pathways will be targeted by this new eye drop, but I’m excited to see pharma companies begin to use this novel technology to help dry eye sufferers.
Topical Immunotherapy is not totally new to ocular surface treatments, as Interferon (a natural chemical produced in the body to help fight viral infections and cancer-producing mutations by signaling the immune system to attack these “intruders”) has been used for many years to treat ocular surface squamous neoplasias (OSSN are cancerous growths on the surface and commonly affecting the cornea). Because many (if not all) sufferers of dry eye disease have an inflammation-related component, the is great potential for this new group of medications! Phase two is a significant, necessary step towards possible FDA clearance for prescriptive use - and further testing will be necessary before it becomes commercially available.
MORE GOOD and EVEN MORE PROMISING news - is the recent FDA approval for a new dry eye medication, acoltremon ophthalmic solution 0.003%, which should hit the pharmacies as “Tryptyr,” soon!
”Alcon announced that the FDA has approved acoltremon ophthalmic solution 0.003%, a first-in-class transient receptor potential melastatin 8 (TRPM8) receptor agonist, for the treatment of the signs and symptoms of dry eye disease (DED). The drop, previously known as AR-15512, will be sold under the name Tryptyr. The neuromodulator stimulates corneal sensory nerves to increase natural tear production rapidly following instillation.1” This triggers the corneal nerves that sense cooling from menthol and sense a signal to the tear producing glands and cells responsible for making the tears I call the “sprinkler system” - the best water, salt, protein and oil form of tears that I call the “salad dressing.” It seems that this would be similar to the tears produced by neurostimulation from products like the old “TrueTear”, the newer iTear and nasal spray in the form of Tyrvaya. Since it has yet to be available in pharmacies, and is still in the early “rolling out” phase, I can’t comment on more specifics than to say that Japan has had menthol-type, artificial tear products available for some time and menthol can be found in some current over the counter tear drops - so by targeting the exact mechanism by which menthol works, it seems likely this will be a significant step forward. (Above quote and following quote excerpted from the link below article): “The approval is supported by 2 phase 3 clinical trials, COMET-2 and COMET-3, that evaluated more than 930 patients with a history of DED.3 In the trials, 4 times more Tryptyr patients experienced at least a 10-mm increase in natural tear production at day 14 when compared to vehicle. COMET-2 saw 42.6% vs 8.2% of patients with at least a 10-mm increase, and COMET-3 saw 53.2% vs 14.4% (both P < .0001). Additionally, it was noted that Tryptyr demonstrated a statistically significant natural tear production as early as day 1. Acoltremon was well tolerated in the studies, and no serious ocular adverse events were reported.”
from: https://www.optometrytimes.com/view/fda-approves-alcon-s-tryptyr-ar-15512-for-signs-and-symptoms-of-dry-eye-disease?ekey=RUtJRDoxMzc2NUY0My0zNkZDLTQ3MTAtQkM5Ny02NUMwQjkxNEYzNzk%3D&utm_campaign=emailname&utm_medium=email&_hsenc=p2ANqtz-_mTaVg9x1wV-ZRbNGFInsS9QC9SsB0S9K4Wp5pgXHpK7mb9HbZl750rN_uLXgBCkNpT4EUoVKVqmgl367EqTmJpZewIQ&_hsmi=364094868&utm_source=hs
NOW SOME BAD NEWS:
“BRS Analytical Services, LLC, has initiated a voluntary recall at the consumer level of five different ophthalmic products due to potential quality concerns. The move was made by its distributor AvKARE.
First thing’s first: Which products are these?
In its recall notice, BRS identified the following:
AvKARE Artificial Tears Ophthalmic Solution
AvKARE Carboxymethylcellulose Sodium Ophthalmic Gel 1%
AvKARE Carboxymethylcellulose Sodium Ophthalmic Solution
AvKARE Lubricant Eye Drops Solution
AvKARE Polyvinyl Alcohol Ophthalmic Solution
In total: This reportedly accounts for nearly 75,000 individual products distributed across the U.S., though specific stores or states were not identified. See here for expiration dates.
What does ‘consumer level’ mean?
This type of recall is considered the most extensive, as it entails the removal of all products from all points in the supply chain—from the manufacturer to, most importantly, consumers.
And what led to its initiation?
Per AvKARE, the move was made due to “manufacturing cGMP (Current Good Manufacturing Practice) deviations” uncovered during a recent FDA audit. More details on that here.
And what’s the concern in this recall situation?
Keep in mind: The concerns identified in this case were done so by the FDA itself. While AvKARE noted that the current “health hazard to [users] is unknown,” these cGMP deviations could potentially “lead to products of unacceptable quality.”
As such: “It is not possible to rule out patient risks resulting from these products,” the distributor stated.
Speaking of risks … any reports of adverse events?
So far? No, AvKARE did not address any specific instances.
And if I need to report an adverse event?
Submit a form online via the FDA’s MedWatch Adverse Event Reporting program or by mail/fax.
What should I do if I have some of these products in my inventory?
The supplier asks consumers and eyecare providers to immediately discontinue use and remove from active inventory. For these customers, AvKARE is requesting they complete a Quantity to Return section and a customer information page, accessible here.”
From: https://emails.eyesoneyecare.com/more-eye-drop-recall?ecid=ACsprvtk0uapl0jZQE-1VEV_EG-noC8D4bONg1Nm5-_Exo2dHoq06FRYILHm6uYzJilHMkH6FFyL&utm_campaign=%5Bglance-marketing%5D%20weekly%20ophthalmology%20newsletter&utm_medium=email&_hsenc=p2ANqtz-9Lljcj4EBnsWflVQdAXCxckL4v4quMNrGm_wmbd4QVVh2nHccg52ou7Qlh9sOu0JDTZ0_Zb-ZMDibF-EkjWxgXuID4Pg&_hsmi=361655586&utm_content=361655586&utm_source=hs_email
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
What is the best approach for a dry eye sufferer approaching an operation under general anesthesia?
Thanks to a patient of mine who is soon approaching a very substantial set of abdominal surgeries, I reviewed and can now share a severe dry eye patient’s protocol for eye care when undergoing significant surgical procedures (particularly if unrelated to the eyes).
In preparation for the upcoming surgery:
- Have a thorough dry eye exam by an experienced dry eye specialist (preferably one you’ve had a good experience with and who knows your conditions). If you routinely require “maintenance” treatments (IPL, RF, BlephEx, ZEST or other lid hygiene treatments, etc…) then such care may be advised in preparation of the upcoming surgery to help with any related extra stresses from the surgery and recovery. Pulses of topical steroids or punctal plugging treatments are sometimes employed for those with anticipated extra levels of inflammation and/or dryness.
- If using Autologous Serum Tears (ASTs) or Platelet Rich Plasma Drops (PRP), get enough put aside for several weeks of use every up to 2 hours. If obtained frozen, then keep frozen and arrange for transport to the hospital in a frozen state. (Many commercial freezer packages exist for this purpose and your tears may commonly arrive this way).
- If using prescription or over the counter drops or ointments, nasal sprays or other renewable eyecare related prescriptions and products, obtain enough for several weeks use.
- If possible, meet with the anesthesia team prior to the surgery and advise them of your eye issues (and any other medical issues). Review all your medications including any and all supplements and eye-related prescriptions.
- If possible, meet with your surgical team and review the same information as the anesthesia team got.
- If using Omega Oil supplements, check with these teams as to when to best stop and then restart them, as they can have mild blood thinning side effects/benefits (a benefit if you want thinner blood for better circulation, but a negative side effect if the surgery could involve extensive bleeding).
- If you have a history of uveitis (iritis) or any herpetic eye diseases (HSV, HZV), then get extra advice on use of antiviral and anti-inflammatory medications, immunomodulators, etc, from your eye specialist prescribing those medications. (Many will require higher doses during their recovery from surgeries due to the extra stress on their immune system, but over-aggressive anti-inflammatory medications taken orally may also slow recovery/healing from surgery – so this complex balance is usually a question for the prescribing physicians and the surgical team).
- If you are on Biologics for your inflammation, or autoimmune disease, you might coordinate with your Rheumatologist and Surgeon so that (if possible) the Surgery will take place so that the biologic (if dosed periodically) dose is strategically planned prior to Surgery, so that when the date for the Surgery occurs, the effect of the biologic is at - or is approaching - it’s anticipated highest level of effect.
For hospital staff involved in your dry eye care:
- During the actual surgery and as long as you may be on assisted ventilation or be kept in an unconscious state, extra eye protection is warranted. Most anesthesiologists are aware of the risk to overexposure of eyes if they are inadvertently allowed to stay open during active general anesthesia and will commonly use tape to close the eyes completely. This is of a higher risk in patients with active ocular surface disease and worth reiterating to the anesthesia staff and those directly involved with your after care in the ICU and for general postoperative care.
- If you are sensitive to tape, or if you commonly use an eye sealing mask or special tape at home, check with the staff if you can have them use the same care while in the hospital. Anti-evaporative glasses have special seals around them and may prove useful during the recovery phase when you are interested in using your eyes for reading, texting, watching TV but are still having post-op difficulty keeping eyes from drying out. (They are also helpful for routine non-postoperative use).
- Most patients will benefit from use of an occlusive ointment in their eyes while undergoing their anesthesia/surgery. This also can be useful when sleeping/resting postoperatively and if you have a preferred ointment, see if they will let you bring it to the hospital for them to apply it for you. Common over the counter ointments include Retaine, Hylo and Systane brands. Prescription ointments like Lotemax (a steroid for those with active inflammation) and some with antibiotics (erythromycin) and steroids (Tobradex, Maxitrol, and a number of generic equivalents).
- Staying well hydrated is important to post-op dry eye recovery (as well as all aspects in healing and dry eye life). Please ask how soon you can begin drinking water and in what quantity after your surgery. When you can’t drink, ask that they pay special attention to running enough iv fluids to keep you well hydrated. They may wish to monitor your input and output so your task is to be faithful to recording the amount you take in and the amount you pee out (they have measuring devices for both measurements).
- If you wear contact lenses, it is likely you won’t be able to wear them until you are more fully recovered and should have appropriate spectacles to wear in place of the contacts. Swelling of the conjunctiva (the clear membrane on the surface of the white of the eyes) is fairly common in the immediate post-op timeline and may persist for some time afterwards, so contact lenses that fit well before, might not until this settles down. If you wear scleral contacts for dry eye, once you are fully conscious and able to take care of insertion and removal, it may be prudent to resume, but ask the team how soon they will let you resume them to be sure.
- Once you are out of the OR, the task of daily eye care needs to resume. Your lid hygiene continues to be important and you should review with the nursing staff In advance, what you routinely do (i.e. Hypochlorous Acid spray over lids and lashes twice daily, Zocuwipes or other approved lid wipes to clean lids, lashes and face at least once daily vs a botanical oil-based skin and face cleaner like Stone Crop Gel twice daily). If warm moist compresses are a routine part of your care, check to see how soon that might be available (and do you “lid crunches” after 3-4 minutes of moist heat to help express those lid oils).
- If you use ASTs or PRP, that can start after your exit from the OR and can be administered by the nursing staff until you are able to do it yourself. If you routinely rely on artificial tears, then use only preservative free versions and they may also be administered (preferably chilled) every hour as needed. Keeping them on ice at your bedside is a convenient way to keep up with a every 1-2 hour treatment for the first few days and then weaned to your comfort level once you are back in control, thereafter.
- If despite all the above and best laid plans, there appears to be extra dryness or damage, then an in-hospital consult may be required from an on-call eye doctor. Though they may not necessarily be a dry eye expert, they should be capable of diagnosing and treating abrasions, erosions, flare ups of HSV, HZV infections, inflammations and other potentially sight threatening issues. Don’t be afraid to advocate for yourself!
- Once you are sufficiently recovered and sent home, it should be fairly easy to resume your “normal” care. If normal doesn’t seem to suit your post-op needs, reach out to your dry eye specialist for additional recommendations.
Once recovered, it is appropriate to check in with your dry eye specialist to let them know how you made out and if you are experiencing any additional dry eye or vision problems. Follow up can be adjusted according to these conversations.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
More on “Serum Tears”
I don’t usually post entire publications in my blogging - preferring to provide a non-MD-friendly “Cliff Notes” version with links and references - but while this breakdown of Serum Tears for dry eye and ocular surface disease treatment is focused on educating generalist eye doctors, it is “readable” for most non-MGs and provides such a great overview that I couldn’t help myself from cribbing the full article (with a few of my annotations inserted as a double-parenthesis). I’ve posted on Serum Tears in a number of earlier posts for those who like to find my personal touches relating to specific indications - easily linked here: https://www.eyethera.com/search?q=serum%20tears&f_collectionId=5f1772c75adebf1951219a32
“Published in Ocular Surface
Everything You Need to Know about Autologous Serum Eye Drops
This is editorially independent content supported by advertising from Vital Tears
Apr 17, 2024
14 min read
8.7K views
Review essential information that eyecare professionals need to know about using autologous serum eye drops to manage ocular surface disease (OSD).
Autologous serum eye drops—sometimes called serum tears—are drops made from a patient’s own blood. First described in 1984 by Fox et al. as a treatment for keratoconjunctivitis sicca and then reintroduced and popularized by Tsubota et al. in 1999 as a treatment for epithelial disorders associated with Sjögren’s syndrome-related dry eye, serum tears have been used in the treatment of ocular surface disease for over 30 years.1-2
Overview of autologous serum eye drops
Blood serum has a similar pH and osmolarity to natural human tears, but includes a higher concentration of the following:
Epidermal growth factor (EGF) - ((helps promote healing and health of the “skin-like” surface of the cornea or clear window of the eye))
Vitamin A
TGF-β
Fibronectin
Cytokines
Lysozyme
Nerve growth factor (NGF) - ((as dryness, many medicated non-dry-eye related drops, contact lens wear, eye surgeries and a host of infection and immune-driven diseases all cause damage to corneal nerves and as these herves are critical to producing healthy tears and maintaining a healthy surface for the eye, this is a key feature of serume tears in most cases. A higher level of this can be found in Oxervate - where I’ve posted on this before: https://www.eyethera.com/blog/whats-new-in-2024-lets-focus-on-the-nerves?rq=oxervate ))
Note: Serum also has a much lower concentration of surface immunoglobulin A (SIgA).3-4
With a similar or higher concentration of growth factors, serum tears are believed to address the lack of epitheliotrophic elements in dysfunctional tears (which contribute to epithelial defects) while promoting wound healing as well as lubrication of the ocular surface.1-4
Specifically, nerve growth factor—which aids in the regeneration of corneal nerves—is present in higher concentrations in serum than in natural tears, and has been shown to support symptom relief and nerve regeneration in patients suffering from neuropathic corneal pain.5,8-9
Producing autologous serum drops
To create autologous serum eye drops, blood must first be collected from the patient and screened for bloodborne pathogens, which might render it incompatible for processing. After the sample is confirmed as suitable, it is permitted to clot for a period of 30 to 120 minutes, then centrifuged for 5 to 15 minutes at 1500 to 3000g until the serum is separated.3-4
The serum is then diluted to 20 to 100% ((dilution of 20% is a standard “starting dose” for many to try, but may increase to 100% - as pure serum with no saline to dilute it - for those with the greatest degrees of surface disease and the poorest of their own tears)) with a saline solution or other diluent and then dispensed to the patient with instructions for storage and application. All processing must be completed in a sterile environment in order to prevent contamination, as the solution is generally devoid of preservatives. For this reason, serum tears must be maintained in a frozen (or at minimum refrigerated) state for a period of no longer than 3 months.
As Geerling et al. noted in a 2004 paper proposing a standard operating procedure (SOP) for the production of autologous serum drops, these ranges in the production process tend to be quite wide compared to other manufacturing processes since there is no existing SOP for the production of autologous serum drops.3
Clinical evidence for autologous serum drops
Several systematic reviews of the literature have identified case-control and cohort studies as well as case series and case reports directed toward the efficacy and safety of serum tears.6,10-12
Geerling et al. found in their review of the literature that serum tears showed efficacy in treating severe dry eye and superior limbal keratoconjunctivitis, with 20 to 100% efficacy for symptomatic relief, 39 to 61% efficacy for reduction of fluorescein staining, and 33 to 68% for improvement in rose bengal positive epitheliopathy. ((I describe the different types of surface staining - where Lissamine Green is analogous to Rose Bengal - and their significance, here: https://www.eyethera.com/blog/more-on-staining-the-surface-of-a-dry-eye-and-what-it-means?rq=lissamine )) Additionally, there is some evidence for the use of serum tears in the treatment of recurrent corneal erosion syndrome and persistent epithelial defects, and as an adjunct treatment for ocular surface reconstruction.3
The 2020 Ophthalmic Technology Assessment for the American Academy of Ophthalmology (AAO) found that out of 13 studies, all noted improvement in at least one sign.6 Similarly, other recent systematic reviews have found that serum tears have few adverse effects and perform similarly to artificial tears in practice, although Pan et al. noted that there was inconsistent evidence of improvement after more than 2 weeks of use.10-12
As a blood product, serum tears are not regulated by the US Food and Drug Administration (FDA), but individual states may have separate regulations that could affect production.6
Who is the right candidate for autologous serum drops?
The primary indications for the use of autologous serum tears include:3-4,6
Moderate to severe dry eye disease, often recalcitrant to other treatments
Diffuse superficial punctate keratitis with severe inflammation
Persistent non-healing epithelial defects
Non-infectious corneal ulceration (e.g., neurotrophic keratitis, chemical injury, etc.)
Drug or preservative toxicity that prohibits the use of artificial tears or other commercially available therapies
While patients with severe dry eye are traditionally the primary candidates, serum tears can be used for patients with a wide spectrum of dry eye, from those who have failed conventional treatments like artificial tears, topical immunomodulators, lid hygiene, or neuroactive nasal sprays.
Similarly, patients with autoimmune-related ocular surface disease, such as those with Sjögren’s syndrome, rheumatoid arthritis, or those undergoing chemotherapy or treatments with biologic agents and have developed corneal disease as a result of those treatments, are prime candidates for serum tears.2,7
Another group of patients who often benefit from serum tears are those with neurotrophic keratitis, graft versus host disease, limbal stem cell deficiency, and patients with neuropathic corneal pain.5,8-9
Finally, perioperative cataract or corneal surgery patients may benefit from serum tears, particularly in those individuals who have undergone laser-assisted in situ keratomileusis (LASIK)/photorefractive keratectomy (PRK) or corneal crosslinking with non-healing epithelium.13
Contraindications for autologous serum eye drops
There are no documented contraindications for the use of autologous serum. Clinicians may need to consider not using serum tears in patients with poor tolerance of blood draws, poor venous access, or low blood counts.14 For example, in patients with hematologic conditions, clinicians should work with the patient's hematologist/oncologist to help decide if blood draws for serum tears can be performed.
Some settings that prepare serum tears follow blood-donor guidelines that disqualify certain patients from supplying their own blood for serum tears; however, all settings preparing serum tears should practice universal precautions when drawing and processing blood and serum.
When is the right time to initiate treatment?
The 2017 Tear Film & Ocular Surface Dry Eye Workshop II (TFOS DEWS II) report categorizes autologous serum drops as a third-line treatment, to be used when first- and second-line therapies fail.15
However, as dry eye treatment and management turn towards an “interventional” approach, many practitioners are bringing in therapies that were historically considered as “last resorts” much earlier in the treatment protocol.16
In certain cases, a practitioner might consider including serum tears as a first-line treatment rather than waiting for other therapies to fail, particularly when treating a patient with neurotrophic keratitis or keratitis in the setting of autoimmune conditions for whom serum may be especially effective.
Proper dosing of autologous serum tears
The most common concentration of serum tears found in the literature is 20%,3 but concentrations can range from 20 to 100%. However, much depends on the clinician's preference; some like to start at 20% QID or more, while others prefer to start at 40% QID or more and then adjust based on the individual patient’s response. A common dosing schedule is four times per day,4 but some will go as high as eight.3
How to access autologous serum drops
In the last 5 years, it has become much easier to access serum drops than it was a decade or more ago. Prior to 2015 or so, the major barrier to utilizing serum tears in dry eye treatment and management was one of simple access.
Serum drops can be prepared by blood banks, eye banks, or any appropriately equipped laboratory (e.g., with a centrifuge and the other necessary equipment) with sterile work areas, such as compounding pharmacies.
But for some patients, the hassle of finding one of these facilities made serum tears a less than appealing option. Exacerbating the problem, many community-based compounding pharmacies do not delve into the area of ophthalmic preparations.
The company Vital Tears is another option, providing services for ordering, producing, billing, and shipping serum tears in various concentrations. While serum tears are rarely covered by insurance—although some plans will reimburse if patients submit a claim—the service offers serum tears in three- and six-month supplies with costs averaging $130 per month. However, the amount of time the supply will last depends on the concentration and dosing of the prescription.
Scheduling follow-ups and when to expect results
As with any dry eye treatment protocol, the efficacy of serum tears for a particular patient’s condition can be assessed on a regular follow-up schedule. For some, this means following up at 3 months, while others may prefer to have patients come in earlier.
On follow-up, the primary things to look for are decreased inflammation, conjunctival injection, corneal staining, and punctate staining—the full dry eye workup. Additionally, we’d like to see improvements in visual acuity and the response to a validated dry eye questionnaire (e.g., Ocular Surface Disease Index [OSDI], Standard Patient Evaluation for Eye Dryness [SPEED], or Dry Eye Questionnaire 5 [DEQ-5]).
Some patients may stay on serum tears for the long term, especially if they were initially prescribed due to autoimmune conditions or neuropathic pain. Patients who were prescribed serum tears for dry eye flares or as a post-operative dry eye regimen may find that they can taper off the serum tears once they have reached a successful outcome.
Case reports on autologous serum eye drops
Case report 1
Patient presentation
From Dr. Venkateswaran: A 70-year-old male presents with blurred vision and pain, saying, “I just can’t open my eyes.” Patient history revealed metastatic cholangiocarcinoma treated with multiple chemotherapeutic agents, including cisplatin, gemcitabine, durvalumab, and tepotinib.
The patient had previously tried:
Punctal plugs
Topical steroid drops and ointment
RESTASIS (cyclosporine ophthalmic emulsion 0.05%) TID
Regener-Eyes TID
Tears Q1 to 2H
The patient had felt improved when using PO prednisone for cancer.
Ophthalmic examination
Best-corrected visual acuity (BCVA)
20/25-2 OD
20/30-1 OS
Telangiectatic lids
Rapid tear breakup time (TBUT) and keratopathy
Treatment plan
We initiated treatment with serum tears 40% 6x/day OU, as well as the following:
Tyrvaya (varenicline solution nasal spray) BID
XIIDRA (lifitegrast ophthalmic solution 5%) BID OU
The patient was advised to continue the Lotemax (loteprednol etabonate) ophthalmic ointment QHS OU, use the serum tears frequently, and start warm compresses.
Follow-up
Follow-up occurred at 2 months, and the patient showed significant symptomatic improvement. BCVA was stable, and the patient said that he felt the serum tears had made a big difference.
Case report 2
Patient presentation
From Dr. Dang: A 40-year-old Asian female presented with severe dry eye with a history of filaments OS. Her past medical history included systemic lupus erythematosus, and her ocular history included the aforementioned filamentary keratitis, neurotrophic keratitis, and ongoing keratoconjunctivitis sicca.
She had undergone the following procedures and treatments:
Lipiflow
IPL series
XIIDRA
Regener-Eyes
Oxervate (cenegermin-bkbj ophthalmic solution) x 8 weeks
Alrex (loteprednol etabonate ophthalmic suspension) 0.2%
Her current medications included:
Hydroxychloroquine 200mg BID
Tyrvaya BID
20% autologous serum QID OU
Ophthalmic examination
Figures 1 and 2 highlight slit lamp images OS before autologous serum (top) and OS with filament before autologous serum (bottom).
Figures 1 and 2: Courtesy of Vin Dang, OD, FAAO.
Treatment plan
We increased the concentration of her serum tears from 20% to 50% for an improved surface.
Follow up
Figure 3 demonstrates a slit lamp image OS after initiating autologous serum treatment.
Figure 3: Courtesy of Vin Dang, OD, FAAO.
Patient communication
Because serum tears are rarely covered by insurance, some patients may be unsure about the benefits versus the cost of the treatment. Patients also require being informed of the experimental nature of this treatment along with the FDA approval and insurance status in order to receive informed consent to the treatment.
The conversation in this case might go something like this:
“Ocular surface disease is chronic, and there’s no magic bullet. What we’re looking for right now is something that can help you have more good days than bad ones, and I think that, in your case, this treatment is worth trying. It’s made from your own blood, so it’s designed to mimic what is present in your own natural tears.
I’d like you to try your best to use it daily. Since it’s made out of your blood, the FDA can’t approve it, so insurance won’t cover it—but think of it as an investment in your eyes. If you try it for a few months and don’t feel like it’s working, we’ll try something else—but give it a shot and we’ll see how it goes.”
Conclusion
Accessing serum tears is no longer the barrier to entry that it used to be a few decades ago—for patients or practitioners.
With few adverse effects or contraindications, serum tears are a useful tool for eyecare practitioners seeking to offer customized dry eye treatment and management.”
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Smoking and Vaping and the eye
From an Eyes on EyeCare publication (link above and contents below) we learned more on vaping effects - and how they can be worse than plain cigarettes on uveitis - a form of inflammation inside the eye. My sense is that anything that flares inflammation is bad - not just for inside the eye but on the outside too (and likely everywhere else inside the body). Cigarettes have been found to make inflammation related to thyroid eye disease much worse (See my earlier posts on “TED” or Thyroid Eye DIsease: https://www.eyethera.com/blog/8lemgnwt0bqqd15fmqr9ljrkdfe420?rq=TED and https://www.eyethera.com/blog/revisiting-thyroid-eye-disease-another-look-at-ted?rq=TED and vaping has often been touted as a “better alternative” to cigarettes - yet many studies continue to dispute that.
From Eyes on EyeCare:
“Are e-cigs bad for my eyes?
A study recently published in Ophthalmology evaluated the association between electronic cigarette (e-cig) use and the development of uveitis.
Give me some background.
E-cigs are devices that produce a heated aerosol from nicotine-containing e-liquid.
Notably: A previous study found that the sputum from e-cig users contained increased levels of oxidative stress-related proteins that were implicated in the development of uveitis.
Now talk about the study.
In this retrospective study, investigators recruited 419,325 e-cig users and 419,325 non-users with a similar racial distribution to compare the prevalence of uveitis development. E-cig users were excluded if they had a previous history of smoking traditional cigarettes or comorbid conditions that may influence the risk of uveitis.
Primary outcome measure: The incidence of new-onset uveitis.
Findings?
E-cig users were associated with an increased risk for uveitis compared to non-users. Additionally: The risk for uveitis development continued throughout the 4-year follow-up period, suggesting that the effect of e-cig use on uveitis risk was both short- and long-term.
Traditional cigarette use was also linked with an increased risk of uveitis, but significantly less than e-cigs.
Further: Patients with a history of both traditional and e-cigs had a higher risk of uveitis than those who only used traditional cigarettes.
Limitations?
These included:
A lack of information on the duration and quantity of cigarette exposure
Researchers could not isolate the effect of secondhand exposure to vaping or traditional cigarettes
The retrospective design meant the direct causation between e-cig use and uveitis could not be definitively established
Take home.
These findings suggest an increased risk for uveitis in e-cig users compared to non-users. The study authors recommended that clinicians caring for patients with a history of e-cig use should be aware of the potentially increased risk of new-onset uveitis.”
A very good blog summary (not my own) of the general effects of vaping can be found here: https://www.doughertylaservision.com/vision-blog/short-term-and-long-term-side-effects-of-vaping-on-your-eyes/
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
A few updates on prior topics…
Having had more time with some newer products and a recent update on further delays on an expected new product, I can provide some “new updates.” As of today, I have updated my posts on Xdemvy and Demodex treatments https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease?rq=xdemvy My Lacrifill and punctal plugging treatments https://www.eyethera.com/blog/news-updates?rq=lacrifill and can say a few words about Reproxalap. My initial post on this novel, “steroid-like” anti-inflammatory (working upstream in a way that can have near immediate effectiveness without the apparent risk of elevated eye pressure or accelerating cataracts) is found here: https://www.eyethera.com/blog/are-there-any-new-eye-drops-for-dry-eye?rq=Reproxalap
Unfortunately the FDA did not find enough evidence of efficacy in the latest round of FDA-application-related studies: https://ir.aldeyra.com/news-releases/news-release-details/aldeyra-therapeutics-receives-complete-response-letter-us-food-0 It is possible that it will pass muster later this year, as at least some of the FDA’s reservations were based on preliminary study results where more data should be available later this year. In an eye doctor publication “Ocular Surgery News,” Dr. White summed things up well (as he so often does) - and since I share his “fanboy” cheering for Repraxolap, I will post his comments here: “Sad tidings arrived in my inbox early this morning. Once again, reproxalap has come up short with its FDA filing for approval.
All the right people are saying all the right things as we read in CEO Todd Brady’s comments and as we are hearing from the halls of AbbVie: Aldeyra will carry on with the studies it launched in response to last fall’s FDA response, and AbbVie is still “all in.” According to Mr. Brady, a second field trial and another dry eye chamber study will report topline results in the upcoming second quarter.
So, what does it all mean? I have made no secret of my fanboy status for reproxalap. The mechanism of action — inhibiting the reactive aldehyde species that sit at the tippy top of the entire inflammatory cascade pyramid — makes a ton of sense to me. Regulating ocular surface inflammation with a single drop, as if you had your hand on a rheostat, is a highly attractive proposition. I have been not-so-silently cheering for this drug for several years.
Unfortunately, the choice of so-called “chamber” studies, heretofore untested as routes to FDA approval, has proven to be an obstacle. A field trial readout last fall met its endpoints.
Hopefully, both trials still open will do so as well. Will two positive field trials be enough? Will it matter how the dry eye chamber trial turns out if the field trial is positive? It is time for Aldeyra and AbbVie to start spreading glad tidings of a new and wonderful treatment option.
Fanboys and girls alike are out here with fingers and toes crossed.
Darrell E. White, MD
A friend and colleague - (as well as the inventor of the Zocuwipes and Zocugel products I find so helpful) - Peter Pham, MD, pointed out from a chemical perspective, reproxalap faces some basic chemistry issues. Highly simplifying and paraphrasing him, the natural environment of the surface of the eye is a chemical hotbed of activity with lots of chemical competition for this upstream inhibitor of inflammation to fight against. He notes: “This would help to explain why it took a second dose an hr or so after the first before any significant effects showed up.” My sense is that when working with a new, novel approach to a complex problem like dry eye disease, that there will likely be a good place for reproxalap in the future, but we have a bit more to learn about the best way to use it (and perhaps for which group of patients it will be most beneficial). Keep your fingers (& toes) crossed (like me).
Pain Part 4 - less mainstream options - LDN and acupuncture
LDN from Johnson Compounding: https://naturalcompounder.com/compounding/low-dose-naltrexone/
LDN aka Low Dose Naltrexone has received some attention from the medical community, as it can help provide relief from chronic pain while reducing inflammation - and has been gaining popularity in Sjogren’s Syndrome treatment. From a review article de Carvalho JF, Skare T. Low-Dose Naltrexone in Rheumatological Diseases. Mediterr J Rheumatol. 2023 Mar 31;34(1):1-6. doi: 10.31138/mjr.34.1.1. PMID: 37223594; PMCID: PMC10201089.
In their introduction, they write:
“Low dose naltrexone (LDN) has been proposed as a new form of analgesic and anti-inflammatory treatment for several chronic pain conditions.1 This compound is functionally and structurally similar to the opioid antagonist naloxone, but with longer half-life and better oral bioavailability, and it is usually prescribed for treatment of opioid addiction.2 The typical dosage of naltrexone used for treatment of opioid addiction ranges from 50 to 100mg/day1; LDN refers to a dosage of 1–6 mg/day.2 At such low levels, naltrexone exhibits paradoxical anti-inflammatory and analgesic properties. The analgesic effect of LDN results from the blockage of mu- and delta-opioid receptors and to a lesser extent kappa-opioid receptors in the central nervous system leading to a feedback-mediated increase of these receptors and improving the endorphin system.1,3,4 The anti-inflammatory effects are due to blockage of the toll like receptor 4 (TLR-4) in the microglia cells, at central nervous system.5 These microglia cells, when chronically stimulated produce several pro-inflammatory cytokines, substance P, nitric oxide, and excitatory amino acids that are associated to the so-called sickness behaviour: cognitive impairment, mood and sleep disorders, fatigue, pain amplification and malaise, a group of symptoms similar to those found in patients with fibromyalgia (FM).1
LDN has been used as an alternative for treatment of several rheumatologic conditions such as FM, dermatomyositis and Sjögren’s syndrome.6–19” I should note that endorphins are our body’s own “opioids” which are capable of blocking pain and allowing our body’s to endure what some might term “superhuman” levels of exertion during exercise.
Since advanced dry eye conditions can result in chronic pain (including Sjogren’s Syndrome), I’ve begun to prescribe this medication for some and have been variably impressed by results. In this study compiling data from a broad base of published studies and case reports (which still resulted in small numbers of reported patient experiences), side effects ranged from mild gastrointestinal (abdominal pain, diarrhea) and minor insomnia and vivid dreams, to no side effects and results were at least equal to placebo (which can still be a significant positive). I should note that the side effects were reported in treatment of fibromyalgia patients and not for the Sjogren’s or other rheumatological treatments, so it isn’t clear if this shows a difference relatable to the spectrum of diseases or to the reporting.
Since inflammation is a common component of many diseases - including dry eye, it makes sense that any treatment resulting in less inflammation is likely to help. Unfortunately, LDN is not yet available through common pharmacies and as of this posting, must be ordered through “compounding pharmacies.” As such, it has yet to be covered by most health insurance companies and the compounding varies by the pharmacy producing it. One company I’ve used has a useful webpage on LDN and their compounding here: https://naturalcompounder.com/compounding/low-dose-naltrexone/ Because it can complicate treatment for those who might need opioids for greater levels of pain control and can trigger release of our body’s own forms of opioids, it is generally best to work alongside primary care physicians and may at times even require the expertise of pain specialists - so this form of treatment is still somewhat controversial and probably not appropriate for every dry eye sufferer.
While LDN is fairly “new age",” and can be “complicated,” acupuncture is definitely “old age” and perhaps less complicated. To assure that acupuncture has a place in relieving pain outside of Far Eastern Medicine, it is worth noting that it has found its way into military applications that include battlefield injuries: https://jts.health.mil/assets/docs/education/Battlefield_Acupuncture_Handbook.pdf
In a text covering the history of acupuncture A. White, E. Ernst, A brief history of acupuncture, Rheumatology, Volume 43, Issue 5, May 2004, Pages 662–663, https://doi.org/10.1093/rheumatology/keg005 an excerpt states:
“Acupuncture is generally held to have originated in China, being first mentioned in documents dating from a few hundred years leading up to the Common Era. Sharpened stones and bones that date from about 6000 bce have been interpreted as instruments for acupuncture treatment [1, 2], but they may simply have been used as surgical instruments for drawing blood or lancing abscesses [3]. Documents discovered in the Ma-Wang-Dui tomb in China, which was sealed in 198 bce, contain no reference to acupuncture as such [3], but do refer to a system of meridians, albeit very different from the model that was accepted later [4]. Speculation surrounds the tattoo marks seen on the ‘Ice Man’ who died in about 3300 bce and whose body was revealed when an Alpine glacier melted [5]. These tattoos might indicate that a form of stimulatory treatment similar to acupuncture developed quite independently of China.
The first document that unequivocally described an organized system of diagnosis and treatment which is recognized as acupuncture is The Yellow Emperor’s Classic of Internal Medicine, dating from about 100 bce. The information is presented in the form of questions by the Emperor and learned replies from his minister, Chhi-Po [6]. The text is likely to be a compilation of traditions handed down over centuries [7], presented in terms of the prevailing Taoist philosophy, and is still cited in support of particular therapeutic techniques [8]. The concepts of channels (meridians or conduits [3]) in which the Qi (vital energy or life force) flowed are well established by this time, though the precise anatomical locations of acupuncture points developed later [9]”
Focusing on the use in treating eye pain, an excellent review: Eye acupuncture for pain conditions: a scoping review of clinical studies - can be found here: https://pmc.ncbi.nlm.nih.gov/articles/PMC7989101/ While this does not look specifically at dry eyes and related eye pain, it does cover migraine and trigeminal nerve pain - which are common dry eye issues. These China-based studies found good efficacy with few side effects (with a few reports of fainting, dizziness, chest and abdominal discomfort). A dry eye specific report: “(This was) a prospective, randomized, double-blinded, sham-acupuncture-controlled study” can be found here: https://pmc.ncbi.nlm.nih.gov/articles/PMC6497118/#S0002 The conclusion of the article was: “Both true and sham acupuncture improved OSDI (a common means of scoring dry eye-related symptoms) at 1 week after treatment, however, the improvement in OSDI was significantly greater in the true treatment groups than the sham group at 6 months after acupuncture. True acupuncture treatment improved many subjective assessments of dry eye symptoms, however, other common indicators used to objectively assess dry eye (tear flow, corneal staining, TBUT) remained unchanged. While there were trends towards improvement in the sham acupuncture group, this did not reach statistical significant during the study period. This suggests a true treatment effect of acupuncture rather than a placebo effect. Acupuncture can, therefore, be an effective adjunct to routine clinical treatment of dry eye.”
While I have limited experience with either LDN or acupuncture for dry eye pain relief in my patient population, I remain open to novel treatments with a scientifically studied degree of safety and efficacy. Further research seems warranted and it is also worth noting that other integrative medicine and pharmacological approaches to pain continue to be researched and appear to show promise. I will be quick to share as I learn more!
To find more of my posts about all things dry eye-related, feel free to use the search bar in this blog section.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Pain PART 3
An important and relatively obvious point about pain is that the “condition” of the brain will greatly affect how and to what degree pain is perceived. Some things about brain health are hard to control (genetics, aging, traumatic injuries, etc), while others can be modified (nutrition, inflammation, sleep, circulation) by diet, exercise and lifestyle.
One issue that is critical and seems less intuitive, is how we clear “debris” from our brains. This pathway to a healthy brain occurs by sleeping, as well as by how we sleep. Specifically, it has been found that 8 hours of sleep (or at least eyes-closed resting) is hugely helpful, but also sleeping on one’s side is better than sleeping on the stomach or the back. This is because the “sewer system” of the brain (called the glymphatic system) is most active in our sleep and most efficient when we are on our side.
A second pathway for keeping our brain (and bodies) healthy, is exercise. Our bodies were “built” for physical work and most of us probably “work” our bodies at only a fraction of their capacity for physical work during an average day. Zone 2 Cardio is a fancy name for exercising at 60-70% of “flat out” capacity. This is a level where casual conversation should not sound breathless but be “hard enough” to prevent us from casually singing and should be sustainable for longer periods of time. Since age, weight and general physical “shape” all play a key role in determining what that kind of exercise should look like, I recommend consulting your primary care physician and reading a good article by the Mayo Clinic you can find here: https://mcpress.mayoclinic.org/nutrition-fitness/zone-2-cardio-what-is-it-and-why-is-it-trending-online/
Avoidance of chronic stress (not always an easy task!) is another way to ease the brain and help corral pain. This could include meditation, working with professionals to help with emotional and psychiatric issues, surrounding yourself with supportive friends and family and getting the rest and exercise that help break cycles of stress. Daily walking for as little as 10 minutes can help reduce stress and improve circulation. Exposure to sunlight can help the body produce Vitamin D and appears to bolster the immune system while improving the function of mitochondria (the “furnaces” that produce energy in our cells), boosting cellular function and metabolism. In a more recent podcast, Dr. Huberman explores these relationships with a fellow doctor who specializes in Pulmonary medicine, Dr. Roger Seheult. https://www.hubermanlab.com/episode/how-to-enhance-your-immune-system-dr-roger-seheult
Dr. Huberman also notes that trust can play a critical role in healing and reducing pain. This trust can take the form of religion, or be based on trust in others around us to help and support us. C. S. Lewis has expounded on this aspect of pain control in his work (published in 1940!) titled “The Problem of Pain".” In an excellent book review, “The Book Nook” provides these insights:
“What makes Lewis's treatment of Pain in this book remarkable is his refusal to offer simplistic platitudes. He confronts the problem of pain with intellectual rigor, philosophical depth, and emotional honesty. He doesn't claim to resolve all questions but provides a framework for thinking about suffering that offers hope without denying its profound difficulty.
The book is particularly powerful because Lewis speaks from personal experience. He wasn't writing as someone immune to suffering, but as someone who had wrestled deeply with pain, loss, and doubt. This gives his philosophical and theological reflections a raw authenticity that resonates with readers.
Here are the key insights:
1. The Nature of Free Will
Lewis argues that genuine love requires free will. If humans were programmed to always do good or were prevented from making harmful choices, we would essentially be robots, not beings capable of true love or moral choice. Pain, in this context, is a consequence of free will - the ability to make choices that can harm ourselves or others. This freedom means suffering is not a design flaw, but a necessary condition for meaningful existence.
2. Pain as a Developmental Tool
Contrary to viewing suffering as purely destructive, Lewis sees pain as a critical mechanism for spiritual and personal growth. Just as physical pain alerts us to bodily harm, spiritual and emotional pain can alert us to deeper psychological or moral issues. Pain disrupts our comfortable illusions, forces us to confront our limitations, and potentially redirects us toward personal transformation.
3. Suffering as Divine Pedagogy
Lewis suggests that God uses suffering as a form of education. Comfort and constant pleasure can make humans complacent and self-centered. Pain, by contrast, can break down our ego, strip away our self-sufficiency, and create openness to deeper spiritual realities. It's not that God delights in our suffering, but that suffering can be a profound teacher.
4. The Theological Perspective of Redemptive Suffering
Drawing on Christian theology, Lewis explores the idea that suffering is not meaningless but can be redemptive. Just as Christ's suffering was understood as transformative and ultimately salvific, human suffering can have profound meaning beyond its immediate experience. This doesn't minimize pain but offers a framework for understanding it.
5. The Limits of Human Understanding
Lewis is careful to acknowledge that while these philosophical perspectives offer some insight, they don't provide complete answers. The problem of pain remains, at some level, a mystery. He argues for intellectual humility - recognizing that our human perspective is limited and that complete understanding may be beyond our current capacities.
Ultimately, "The Problem of Pain" doesn't eliminate suffering but offers a perspective that can transform how we interpret and respond to it. It suggests that pain, while real and often terrible, need not be the final word - that meaning, growth, and even hope can emerge from our most challenging experiences.
BOOK: https://amzn.to/3DOS4hJ “
While much has been learned about pain since the time this book was written, it is clear that at a theological and practical level, there is still a lot of truth to his philosophy. There are also suppliers of this book other than The Book Nook’s link to Amazon and it may be available at your local library.
More on Pain- and ways to control it.
Though the focus of my practice – and therefore, these posts – is on the eyes, much of what this blog series will capture, can often be generalized to other parts of the body and other “kinds” of pain. Dr. Huberman remains a key source of this information and my earlier post on pain references his excellent podcasts on this subject. I also draw from my years of practice and basic foundational teachings to “round out” and complement the referenced podcasts. Because each patient is different and the pain they bear is an amalgam of their perceptions and beliefs, this post is meant to give foundational information that may or may not be relative to any given patient and their disease state – so working with a good dry eye doctor (and possibly a good pain specialist) is important.
As I discussed in the last post, pain and inflammation are related (and necessary) – but particularly regarding the eye, control of inflammation is often essential in avoiding scarring and inflammation-related damage that can compromise the function of the eye. Anti-inflammation is at the heart of many dry eye related therapies, as chronic inflammation is bad and dry eye disease is typically chronic in nature. As to which comes first – the inflammation or the dryness – appears to vary, but the result is a “vicious cycle” that perpetuates both the inflammation and the dryness as one feeds off the other. I’ve posted substantially on these topics, but for clarity’s sake, I’ll provide a thumbnail version as this helps lead a conversation about control.
A key concept in understanding dry eye, is understanding the many basic facets that can provoke it. Probably the most common cause I see appears to relate to lifestyle. Staring at screens (as these posts can incite – sorry, but it can affect me while writing them, too), causes the “Ocular Heart Attack” I’ve posted on before. Suffice it to say, keeping eyes open is an open invite to evaporation – and the longer one stares, the more likely the oil layer will separate, and the water will begin to leave, as it moves off into the drier air. These “dry spots” uncover the nerves in the clear window (cornea) and the cooling induced by evaporation together with the stimulation of these now “raw” nerves, will trigger reflex tearing (the “firehose” of salty water) and a blink. “Top down” control from the brain may reign in the strength and completeness of that blink in an effort “not to miss anything” – so weak, irregular blinking (like a weak, irregular heartbeat) causes poor replacement of the “Sprinkler system salad dressing” and the salt-watery “Emergency backup tear” begins to dilute the wholesome “salad dressing” tear – provoking inflammatory damage of that delicate surface layer.
Add to that, the oil glands in the lids are becoming dormant – in part from the poor nutrition common to the modern “American” diet, and in part from the lack of exercise provided by the big, strong blinks experienced when outside actively “hunting and gathering,” as our great ancestors did – (because we generally spend too much time indoors staring at these screens) – and one can begin to see how “fixing” this problem may include nutritional support, active exercise and “retraining” our minds by developing better “blink habits.” Without enough “good oil” in the tear’s “salad dressing” recipie, evaporation will happen faster and the damage from that will lead to higher levels of inflammation and then more dryness.
A second continuation of inflammation can then ensue as the dormant oil glands go on to house increasingly rancid, nasty oils as germs begin to set up housekeeping along the lid margins and amongst the openings to the glands, lashes and skin margins where good cleaning can be a challenge. Germs feasting on these oily products commonly contain lipases – enzymes that break the oils down into digestible “bites” and whose initial byproducts contain soaps (seen as little white “bubbles” along the lid margins) and then subsequent byproducts of their digestion (endo and exotoxins) are a strong bugle call to the body’s defense system – also known as inflammation! Soaps cut through the remaining oils – so evaporation becomes even more excessive – and these germs incite a riot from the body’s defenses, adding to the redness and then dryness.
For dry eye-specific pain, this brings us to the commonsense approach of eating a healthy diet rich in essential Omega oils, drinking more water (and less of the things that dry us out, like caffeine and alcohol), spending more time outside in unpolluted “nature,” where we can exercise our lids with better blinking and then good lid hygiene (all of these covered in earlier posts). What is significant and perhaps under-appreciated, is that good, full-body exercise (anything from vigorous walking, to jogging, running, biking, etc) has added benefits in handling pain. Huberman advocates zone 2 cardio exercise 3-5 times per week (assuming this exercise is not aggravating an injury and doesn’t go against their doctor’s advice), along with getting 8-hours of sleep (or resting) per night. Additionally, he points to the “glymphatic system” as the “washing through” process of clearing debris out between the ends of neurons (the brain’s “wires”) which helps restore healthy brain function, and he notes work discovering that sleeping on one’s side (so not the back or belly) also helps in the efficiency of this “sewer system” of the brain.
Perhaps more intuitive, he points to research showing that person’s “in love” – especially in longer or stronger relationships, have higher tolerances to pain. The “high” from loving emotions, like the rush from adrenaline, each contribute to the ability to withstand severe levels of personal harm, which would cause higher levels of pain – yet are “less perceived” under these circumstances. We all hear stories of a loved one’s comforting presence relieving pain better than strong medications – or wartime injuries where the soldiers carry on – sometimes for extended periods, with Herculean levels of activity after grave injuries – and may not appreciate the degree or extent of those injuries while performing those duties. Mystics and Monks who lean into religion or go into trance-like states may similarly endure severe pain while in those states. Our bodies appear to be “programmable” – likely a mix of the neural plasticity referred to in my earlier post, as well as the body’s chemistry - surging hormones and specific chemicals or “neural transmitters,” which alter our perceptions and energize us in times of severe pain and related stress. My next post will spend more time investigating what some of these responses can be and how we may modify them to better suite our personal perceptions of pain.
Eye Pain – what it can mean and what you can do to control or moderate it.
Designed by Freepik”www.freepik.com
The perception of pain is a critical function of the nervous system. Children born without the ability to perceive pain tend not to live very long – not just because they can inadvertently inflict terrible injuries on themselves, but because the recognition of pain appears to be the necessary stimulus towards healing those injuries.
For those of you unfamiliar with Dr. Andrew Huberman, he is (unlike me) a neurobiologist and (much like me) an ophthalmologist, who I’ve drawn information from for this blog. I can point you towards his excellent podcast lectures with a link to one specific to this topic, here: https://www.hubermanlab.com/episode/essentials-control-pain-heal-faster-with-your-brain
I’ve posted several times on corneal pain and the role it can play in inflammation. A few posts key to this context can be found here: https://www.eyethera.com/blog/why-do-my-eyes-hurt-even-though-my-eye-doctor-says-they-look-fine and here: https://www.eyethera.com/blog/whats-new-in-2024-lets-focus-on-the-nerves?rq=pain
The point raised by Dr. Huberman that I think is vital to our understanding, is that inflammation is necessary to a healthy life – and therefore a good thing. What is also true, is that unbridled, continuous inflammation is not a good thing – and in the context of dry eye disease, it can be an undercurrent of the root causes of dry eye. Interfering with inflammation in the immediate, healing phase of an injury can dampen the pain response and if carefully applied – while it may draw out the time required to heal - it can also lead to a better result. This is especially true when it comes to many forms of eye surgery.
Glaucoma, cataract, corneal and retinal surgeries all trigger inflammation (and pain). Allowing the healing to occur as quickly as the body can drive it will often result in scarring and can undo the benefits of that surgery - or even result in severe complications (including chronic pain). I’ve already posted a substantial amount of information on inflammation (see: https://www.eyethera.com/search?q=inflammation&f_collectionId=5f1772c75adebf1951219a32 ) – but in the context of healing, we eye surgeons commonly prescribe strong steroids with slow tapering doses to keep a lid on inflammation and slow the healing to a rate consistent with our objectives for the surgery. When it comes to controlling inflammation associated with dry eyes, the same holds true. Our goal is to reduce inflammation and thereby reduce pain, without totally neutralizing the inflammation or the pain associated with this healing (so healing can be effective and complete)..
So, if inflammation is necessary for healing, then pain is a necessary part of that healing. And what is pain, other than a sensation? Well, pain typically begins with stimulation of nerve endings but ultimately is registered, interpreted and acted on, by the brain. Dr. Huberman points to the “top down” aspects of pain, when he uses illustrations such as the case of a construction worker who fell onto a 14-inch nail that skewered his boot. The worker was in such exquisite pain, that he couldn’t move his foot in any tiny direction and had to be carried by coworkers to an emergency clinic. After carefully cutting his boot away, it was determined that the nail had missed injuring his foot by passing between his toes. The perception that it had caused injury caused this severe pain. The “top” – or brain – was “causing” the pain from “down” (in this case, the foot).
Dr. Huberman goes on to relate the work on phantom pain, where an absent arm or leg may continue to cause debilitating pain. A brilliant scientist (Vilayanur Ramachandran: Professor of Psychology, University of California San Diego) constructed a box with mirrors which would allow a patient to put his or her remaining arm or leg in and then view it as if it were the missing appendage. Patients who had been in exquisite pain were often able to manipulate the “missing” arm or leg in the box and imagine it as “normal.” In less than a day, what had been unbearable pain for months or years was reduced to imperceptible – through “altered perception.” This ability of the brain to change how it functions, has been termed “neural plasticity.” Because this can happen from “top down,” it suggests that much of the pain we experience can be modified to become less disabling, by tapping into this ability for neural plasticity. My next post will be more about this!
An updated Index for 2024 - and a promise for more to come. Happy Holidays to you and yours!
An Updated Index Present.
Wrapping up 2024, I look forward to 2025 and the newer drugs, technologies and information/education coming in the New Year.
Dry eye disease is real, is often disabling, extremely prevalent and most of all, treatable. Sometimes it takes a village and almost always, it requires specialized help to get to, and ultimately deal with the many root causes. Too often we are led to “Band Aid” drops and treatments that can temporarily mask symptoms even as the disease progresses - leading to a bigger problem to eventually fix. Worse, some of these “Band Aids” can actually accelerate the progression they are otherwise covering up. Early detection and early intervention is currently the best answer and I hope my blogging points more sufferers to a better understanding and to better outcomes.
Winter is Coming. 10/21/24
A New Energy Option. 10/13/24
More Dry Eye News: And How Do I Know If I Have Dry Eye Disease?. 10/6/24
More on Unapproved and Possibly Dangerous Eye Drops. 09/29/24
A Patient's Plea for Help and What YOU Can Do to Help Them. 09/22/24
Study on Dry Eye Disease in Patients. 09/15/24
Rosacea Take Away "Pearls". 09/08/24
Rosacea and Dry Eyes Part 10. 08/04/24
Rosacea and Dry Eyes Part 9. 07/21/24
Rosacea and Dry Eyes Part 8. 07/07/24
Rosacea and Dry Eyes Part 7: The Mental Aspects of Rosacea. 06/30/24
Rosacea and Dry Eyes Part 6, The Tetracyclines. 06/16/24
Rosacea and Dry Eyes Part 5: How Did Rosacea Happen to Me? 06/09/24
Rosacea and Dry Eyes Part 4: Why Doctors Get Involved 05/27/24
Rosacea and Dry Eyes Part 3: Commonly Associated Skin Conditions. 05/19/24
Rosacea and Dry Eyes Part 2: How Common Is It? 05/12/24.
Rosacea and Dry Eyes, A Common Pairing that Needs Recognition Part 1. 04/29/24
News Update. 04/21/24
Making Tears Part 8. 04/14/24
Making Tears Part 7. 04/07/24
Making Tears Part 6. 03/31/24
Making Tears Part 5. 03/24/24
Making Tears Part 4. 03/10/24
Making Tears Part 3. 03/03/24
Making Tears Part 2. 02/25/24
Making Tears Part 1. 02/11/24
Where Do Tears Come From? 02/04/24
Why Rub Your Eye? 01/28/24
What's Up When the Sprinkler System "Dries Up"? 01/21/24More on Staining the Surface of a Dry Eye and What It Means
More for 2024. 01/14/24
What's New in 2024? Let's Focus on the Nerves! 01/Even Dry Eye Specialists Get the Blues. 07/24
Why Do My Eyes Feel Tired All the Time? 01/01/24
Happy Holidays and Getting to Know Dr. J. 12/25/23
More about CCH. 12/17/23
Eyedrops and Glaucoma. 12/10/23
Why Do My Eyes Hurt?... 12/03/23
Even Dry Eye Specialists Get the Blues. 11/26/23
Revisiting Thyroid Eye Disease (TED). 11/19/23
Testing Part 8. 11/12/23
What Do Dry Eye Tests Mean? 11/06/23
What Do Dry Eye Tests Mean Part 6. 10/29/23
What Do Dry Eye Tests Mean Part 5 10/22/23
More on Staining the Surface of a Dry Eye and What It Means Part 4. 10/15/23
What Do Dry Eye Tests Mean Part 3. 10/08/23
What Do Dry Eye Tests Mean Part 2. 10/01/23
What Do Dry Eye Tests Mean? 09/24/23
Is It Safe to Buy an Eye Drop? 09/17/23
Can (CCH) Conjunctivochalasis (or anything to do with poor health) get better without surgery? 09/10/23
More Infectious Eye Drops and an FDA Warning. 08/27/23
How Early in Life Can We Get Dry Eye Disease? 08/20/23
Castor Oil Shouldn't Be Rubbed in the Eyes. 08/13/23
Introduction To Dry Eye Disease. 12/29/21 to Present
Prior Index to Dry Eye Posts 7/23/23 https://www.eyethera.com/blog/index-of-blog-posts?rq=index
Winter is coming! How this can require extra “adjustments” when you have dry eye disease.
Apart from the Internet streaming services we default to and may binge on (like the HBO GOT series this title riffs on), many of us (at least in the Northern Latitudes) will spend even more time inside, staring at screens and/or books to pass the winter months - and dry eye patients often ask what they can do to mitigate their misery during this season.
A close colleague of mine (who I just met in person after collaborating for years) Dr. Laura Periman recently posted to a FB group of dry eye sufferers, this golden nugget: “Cold air doesn’t hold as much water as warm air. Radiant heat instead of forced air heat may help. Also, Ziena (moisture chamber) glasses or onion goggles.” To further riff off this information, an obvious but often overlooked addition, is to add a humidifier to moisten the air and avoid sitting near sources of moving air (like fans).
I also posted to the same question, “in my experience, the amount of attention and reflected light from the average digital screen can be more detrimental to blinking and evaporation than a printed book with "adequate" lighting (super bright lighting can also reflect strongly off a printed page and will depend on the quality of the paper as to how "reflective' it is). There are screen lighting options that can reduce the digital glare, as well as some glass coatings for your glasses.”
Such eyeglass coatings can include:
Anti-reflective coating – this is particularly helpful as this can reduce glare (so sometimes referred to as “anti-glare”) by reflecting unnecessary light rays that would otherwise be further scattered by a dry eye’s surface, making it harder to see clearly. Since light accelerates evaporation (I use the analogy of rain clouds dropping their water on the ground. If the clouds shield that ground moisture from the sun, the ground stays wet – but part the clouds and shine the sun and the water rapidly disappears (evaporates).
Anti-fog coating – when coming in from the cold, dry air, glasses will tend to fog up inside a warmer, moister area like your well-humidified home, store or office. Anti-fog coatings can come in many forms including those you can apply from towelettes or via sprays.
Blue light filtering coating – I covered this in some depth in an earlier blog post, here: https://www.eyethera.com/blog/do-blue-blocking-glasses-help-with-dry-eyes?rq=blue%20light
UV protective coating – UV comes in 3 forms, UVA, UVB and UVC. Unless you are a welder, you probably don’t need to worry about UVC (the most damaging of UV light) as it is fully absorbed by the Ozone layer in our atmosphere. But UVA and UVB are not sufficiently impeded by the Ozone layer and can be detrimental to our eyes (and skin). Wearing UV coating protection can be helpful to our eyes (and wearing sun blocking agents helpful to our skin).
Scratch-resistant coating – If, like me, you can be “hard on glasses” then such coatings over plastic lenses can save the cost of more frequent replacement (or wearing scratched up glasses that can blur our vision and add to unnecessary eye strain).
Use of contact lenses can also be more challenging since a decent tear layer is most often needed for a proper fit and good tolerance of wearing them. I covered more about contact lenses – and their care, here: https://www.eyethera.com/blog/z9r2sgjxe1iyza1k6535laildtqilm?rq=contact%20lens and here: https://www.eyethera.com/blog/6g9blza7q7q9zmhychmq509nsad9a4 - so if you are nearsighted enough to read comfortably without your glasses or contacts – or can wear reading glasses instead of contact lenses, then that may be a better option (at least in dry, winter weather).
As always, I recommend consulting a good dry eye expert/specialist to help determine what is best for you and your eyes.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.
A New Energy option - Plasma Pens and Dry Eye Disease!
What is Jett Plasma therapy, and would it help dry eyes?
Jett Plasma Medical (or JPM) is a direct current-mediated medical device that uses the “4th state of matter” to provide highly targeted treatment of skin and mucous membranes. Developed in Europe and now used by some practices around the world, I am excited to announce being chosen as the first practitioner in the USA to acquire this novel device. While I’ve had it “under my wing” since May of 2024, it has taken approximately 5 months for me to feel comfortable with the device and its uses as they apply to a number of my dry eye patients. Currently, treating dry eye disease is recognized as an “off label” use as it has not been evaluated for this purpose by the FDA yet in this country.
Plasma is recognized as the 4th state of matter, since there are solids, liquids, gases and then plasma. Using Radio Frequency energy, it is possible to create a plasma (in simple terms, an electrically charged ion cloud) from the gases in our atmosphere. These “ion clouds” contain electrons, which can flow into and out of the ion cloud, with predictable precision. I should note that there have been many machines marketed as plasma energy devices in the USA, which have been available for some years (and largely used in the aesthetic side of medicine). Combining certain gases and alternating currents can provide much higher levels of plasma energy, but in my research, the Jett Plasma Pen with its direct current technology is uniquely suited to treatment around delicate eye and eyelid areas with its unidirectional energy flow.
In several of my posts, I’ve detailed how “ion channels” are gateways into and out of cells responsible for making tears (among every other cellular function in our bodies). Electrons from the plasma can spin off and create more of these ion channels in an event called “electroporation.” These tiny “pores” are then gateways allowing passage of the ion “tokens” to activate various cellular functions. In low power delivery, this can have the ability to “recharge” the cells, reinvigorating them. Laboratories have used this technology for years to alter the states of cell cultures to tweak them into revealing cellular secrets and to change them in ways that can benefit humanity. When the power is intensified, it can reliably take out weak and dead cells or be used in a more surgical way to penetrate, cut, cauterize and behave like a precision scalpel. Medications like steroids may be in a better position to enter tissues when applied during a treatment. Activating the mucin-producing goblet cells, plasma helps them deliver their mucous during a treatment!
Add to the repertoire of this plasma energy, the electrical stimulation of muscles and nerves. Electricity is the common activator throughout our bodies and this plasma application can equally stimulate them. Patients report a feeling like a “TENS” unit (an electrical device used to stimulate nerves and muscles to reduce pain). This can also create a “tingling” sensation around dental fillings and metal implants. Like other RF devices, we don’t apply this energy to patients with pacemakers or other implanted electrical devices that cannot be safely turned off during a treatment. A benefit of activating muscles in the lid is that this can facilitate the emptying of the Meibomian Glands – as well as encouraging and strengthening those muscles. In a common aesthetic application, this muscle strengthening adds some natural “filling” of the tissues, which can add “air into the balloon” that is our face. Stimulating the skin, while strengthening (and “bulking up”) the underlying muscles - can result in smoother, younger-looking skin and facial features.
In my clinical practice, this has augmented the abilities I have to treat my dry eye patients. Specifically, some lid margins develop “capping” over the openings to the oil producing Meibomian Glands, and this technology has helped me to sequentially “scour” this capped material (waxes, skin cells, keratin, bacteria and the like). By removing this biologic “varnish” from the surface, it allows freer access to these oil glands and their oily products (meibum). Secondly, by applying this energy over the conjunctival membrane overlying these glands, I’ve witnessed the plasma’s capacity to breakdown and breakup the heavier “concrete-like” products inside those that have more advanced clogging of this type. My tools have so far been limited to using mechanical cleaning and scrubbing devices (ZEST and BlephEx), heat (RF, Lipiflow and the like), light (IPL) and probes (of Dr. Maskin’s design). I’ve had to “scrape” the lid margins to reduce the “varnish” and apply substantial pressure to move some of these “concrete-like” products from the glands.
In a series of prior posts, I detailed the apparent source of the more “pasty” meibum as coming from the interaction of germs with the normal human oils within these glands. These “germs” can include the decaying bodies of Demodex (the tiny mites that frequent our lids – more of my posts deal with that ugly issue) – who may feed on even smaller bacteria (as well as dead skin cells and our oils). In researching Dr. Maskin’s work (and others), scar tissue can also contribute to clogging, as well as the tiny “keratin granules” that can also form in our oil glands. Keratin is the stuff of hair and nails, so it is no surprise that such material can also be a significant source of an oil gland’s clogging. Remarkably, the plasma appears to break this all down into a more liquid form and allows me the clinical ability to move this stuff out of these highly clogged glands when nothing else appears to do the trick.
So, is Plasma the “Holy Grail” of dry eye (and perhaps all of medicine)? I wish it was that simple. I find that each of my tools has their own clinical (and often unique) usefulness. Much as the Plasma can be used to kill germs and “clean” lids, I still find a ZEST-modified BlephEx to be a quicker, simpler and in some cases, likely more efficacious tool for general lid cleaning. In some cases, I would recommend using that as a “starting tool” and then add the Plasma treatment on top of that, since it can then sequentially scour more persistent “varnish-like” capping material when needed. Plasma (in this iteration) doesn’t significantly raise the temperature of the tissue the way we can with other modalities (like my off-label use of the many Radio Frequency tools available today). Once oils turn to wax, any reliable heating device can offer a general purging of the waxy oils in a quick, noninvasive, in-office procedure. IPL, while poor at heating clogging waxy oils, is great at closing off abnormal, inflammation-carrying blood vessels – something that appears unique to this light therapy. IPL and some Low Level Light Therapies, also have been heralded for uniquely activating the cells that make tears (a term called “photo-biomodulation”). This appears to activate the cellular furnaces (called mitochondria) which can add energy to the cellular function. Plasma can also affect cells in a “electro-ionic-biomodulatory” way, thanks to the ion channel effects – so I would postulate that the two forms of therapy may be “synergistic,” where each can augment cell functions in their own unique and additive way.
Where RF and Plasma overlap, is in their abilities to perform delicate surgical tasks. Plasma Pens have been recognized for plicating conjunctivochalasis – abbreviated CCH (typically with tiny “spot weld-like” cauterization points). Each point will heal with tiny scars, binding the “CCH” or loose membrane, back to the white (sclera) of the eye wall. Another overlap is in the ability to turn wayward lids in the direction that better suites normal lid function (see my posts on the eyelid innie and outtie). Some doctors in Europe have been using Plasma for a less invasive form of blepharoplasty (again using the small point-like cautery function to tighten the skin without actually cutting it). Having a new tool is exciting and exploring the range of what it can do is still a work in progress – made easier and safer thanks to colleagues in Canada (Drs. Friedman and Salsberg in Toronto), as well as many in the EU and the COMPEX team that developed and are now marketing this tool in the Czech Republic). For more information, see this link: https://www.ophthalmologytimes.com/view/nonablative-treatment-offers-safety-efficacy-and-multiple-applications-for-the-cornea
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.
More Dry Eye News (& how do I know if I have dry eye disease?)
While I’ve covered some of this before, I had a dry eye sufferer recently ask me if they had MGD - knowing that they had Conjunctivochalasis (CCH) from another doctor. My answer was like this:
“While testing with fancy equipment is helpful, most doctors can tell by observing how quickly the tears evaporate during their slit lamp exam and then by pressing over the oil glands during the same exam. One less specific but generally helpful way for you to test at home, is to set a stopwatch for 20 seconds and then blink. Start the watch at the moment of your blink and time how your eyes feel over those 20 seconds without blinking. If you comfortably can last the full 20 seconds and your vision doesn’t change, then there’s less chance you have MGD. (My very first post touched on this test here: https://www.eyethera.com/blog/rn9p8ouyjzjhyfpkvrysxjx28no0q8?rq=blink%20test ) In my experience, most people with CCH also have MGD, but every case is different.”
Recently a new “dry eye hack” has come on the study scene that can help address this rapid evaporation - a so called “TRPM8 agonist” that is being studied as an eyelid wipe that can trigger the “Sprinkler System” to create a fuller tear production. “Transient receptor potential melastatin 8” or TRPM8 to those in the know, opens the “ion channels” I described in my posting about how tears are made (I describe ions as “tokens that open gates” in this blog: https://www.eyethera.com/blog/making-tears-part-2?rq=ion where the gates are the so called ion channels). Key to this discussion is how various ions that pass through certain gates can trigger tear production at higher rates. TRPM8 is the gate triggered by the cooling common to evaporation - so a NORMAL response to evaporation, is to make more tears. Since eyes with MGD have accelerated evaporation (because the lack of oil exposes the water of a tear to air - which leads to early and extensive evaporation), one of the common complaints I hear from my MGD patients, is how their eyes “puddle up” when they expose their eyes to cold, dry air.
In a normal eye (without dry eye disease), the healthy tear produced by evaporation would have enough oil floating on top, so as to “seal in” the moisture under that oil and allow a healthy patient the opportunity (should they be so inclined) to continue skiing down the slopes without leaving a trail of salty tears in their wake. Adding a chemical to the lid’s margins - that causes the ion channels to trigger tearing - would create the same effect that the skier encounters (without the skies and without the cold dry air of the slopes). I think this could be a good adjunctive treatment for dry eye patients, but that it would work best if that tear can contain enough “good oil” to act as the natural “shield” that protects this tear from rapid evaporation. Otherwise it seems likely it will spool up the “Reflex Tearing” of the “Firehose.” This means more salty tears that will also rapidly evaporate and potentially leave a patient looking like they are actively crying (when they don’t mean to).
I discussed “Neurostimulation” in an earlier post https://www.eyethera.com/blog/what-is-neurostimulation-for-dry-eye-treatment-and-do-i-need-it?rq=fire%20hose and see the TRPM8 stimulators as a somewhat related version of this. If the oil glands are overly “clogged” then any stimulation of the tear production is liable to produce salty tears that will go on to evaporate and leave more salts behind. Another of my posts goes into more detail about why you don’t want “overly salty tears” here: https://www.eyethera.com/blog/overly-salty-tears?rq=fire%20hose Ultimately, it is crucial to protect, support and encourage your oil glands to do their best. If they work well, then many of the other technologies to stimulate good tear production will help you make good tears!
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.
More on unapproved and possibly dangerous eye drops.
Among others - see below
FDA warns consumers of contaminated copycat eye drops
https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-contaminated-copycat-eye-drops?fbclid=IwAR085_VOsxm-9x0CtykAzUJF2Fb4Rn2nQzBFAd7HYsdwc6EBKu31z9hy_jI_aem_AfyHpReFyoRIaWRypfQKaucUi2WHDOhHkA7HxmLNfxqe1dwwFHXGJmlWgjMWkFb2a-A
“The (US)FDA is warning consumers not to purchase or use South Moon, Rebright or FivFivGo eye drops because of the potential risk of eye infection.
These are copycat eye drop products that consumers can easily mistake for Bausch + Lomb’s Lumify brand eye drops, an over-the-counter product approved for redness relief.”
While most of you know my stance on the “eye whitening” eye drops like Lumify (as well as some Visine, Clear Eyes and others advertising to “get the red out”) -
I posted on this topic here: https://www.eyethera.com/blog/can-i-use-eye-whiteners-like-visine-or-lumify-when-my-eyes-get-red?rq=lumify
They go on to say “South Moon, Rebright and FivFivGo eye drops are unapproved drugs and should not be available for sale in the U.S. They claim to treat eye conditions such as glaucoma, which is treated with prescription drugs or surgery.
Patients who have signs or symptoms of an eye infection should talk to their health care provider or seek medical care immediately. FDA recommends consumers properly discard these products.”
Of particular concern, is how close the packaging was made to copy the Bausch and Lomb Lumify product:
“Comparison of authentic Lumify with copycat products
The South Moon, Rebright and FivFivGo photos are examples of the images that appear on various websites. Some of these copycat products may be falsely labeled with “Bausch + Lomb” at the top of the packaging. The actual products may look different.”
Of potentially equal or greater concern (with Halloween around the corner) is this statement by the American Academy of Ophthalmology (AAO): “What Ophthalmologists Want You to Know About Eye Color-Changing Drops
What NOT to do for Halloween (or any other time of the year)!
“The American Academy of Ophthalmology says popular products making the rounds on social media are unproven, unregulated, and potentially dangerous
SAN FRANCISCO, Calif. — The American Academy of Ophthalmology is sounding the alarm on over-the-counter eye drops advertised as eye color-changing solutions. These products are not FDA approved, have not been tested for safety or efficacy, and could potentially damage the eyes.
“Consumers seeing these products on TikTok or elsewhere online need to know that they are not FDA approved,” said JoAnn A. Giaconi, MD, clinical spokesperson for the American Academy of Ophthalmology. “The ads show dramatic before-and-after shots and vague information on how the drops actually work to change eye color. But here’s the reality, there’s no evidence that they do anything at all, and no evidence that they’re safe.”
Because the products are not FDA approved, they have not undergone rigorous safety and efficacy testing, and it’s unclear if Current Good Manufacturing Practice regulations were followed during production. Unregulated manufacturing facility conditions can lead to contaminated products that can cause dangerous eye infections.
Potential safety risks of using unregulated eye drops include:
Inflammation
Infection
Light sensitivity
Increased eye pressure or glaucoma
Permanent vision loss
Manufacturers claim that the drops include an ingredient that adjusts natural levels of melanin in the iris, the colored part of the eye. But there is no evidence that the formula can target the iris pigment. And if the drops did destroy the pigmented cells in the iris, it could potentially harm the eye, causing light sensitivity, eye inflammation, and eventually vision loss. It’s also unclear how other parts of the eye that rely on melanin to function properly, such as the retina, would react to this ingredient.
“Social media and the internet are full of potentially dangerous eye health claims. Bottomline, the Academy advises the public to never put anything in the eye that isn’t made to go in the eye,” Dr. Giaconi said. “You’re putting yourself at risk for painful eye conditions or even blindness.”
The safest way to change eye color is with colored contact lenses, but only if the lenses are prescribed, dispensed, and fitted by a qualified eye health professional.
For more information about eye health and how to protect your eyes, visit the Academy’s EyeSmart website.”
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.
A patient’s plea for help - and what YOU can do to help them…
If you’re reading my posts, then chances are better than even that you have some degree of dry eye disease, in which case, then you, like many of my patients, will question if treatments can return you to a state of “normalcy.”
The short answer is yes - because I also have dry eye disease with Rosacea and primary Meibomian Gland Dysfunction and have been able to function well for the last 12 years knowing that I have this problem and treating it accordingly. I’ve offered treatments for nearly 40 years of my dry eye care practice but have been practicing this degree of interventional dry eye care for only 12 years at this level - and find a range of patient problems that require a range of treatments to fix these problems, as well as a range of improvement, depending on the patient, the range of the problem, and the degree of treatment.
I have an ask for you - that you find the FaceBook online Dry Eye Support Group (assuming you use FB/Meta) and then post there - if you feel that treatments have allowed you to return to a state of “normalcy” (where you might sometimes forget to do some of your dry eye “homework” because you feel good enough that your eyes are again being taken “for granted”). These dry eye sufferers generally have yet to feel that “normal” and are still looking for validation that some of these therapies can actually work for them.
Generally speaking, the earlier you catch the disease and the more aggressively it’s treated, the easier it is to turn it around,. Caught and treated early, it becomes easier to achieve a degree of normalcy. Maintaining this normalcy, in my experience, often requires a fairly structured program of “homework“. For most, this consists of getting enough oral omega 3, 6 and 9 oils (and digesting them), as well as regular strong, blinking patterns with occasional hot compresses for those with the waxy obstructive version of this problem (or Meibomian Gland Probing, for those with the tougher, scar tissue obstructions). It is also critical to address inflammation through diet and lifestyle as well as sometimes requiring medication as well as sometimes IPL or other therapies. Lid Hygiene is always important and I look at this a bit like I look at the dental issues that we suffer. Those who take care of their lids will have better function and longer lasting glands.
Many ask about the regular use of artificial tears when they are suffering with dryness. Eyes need moisture and using artificial tears when you can’t make your own is a good thing to do. However, I’ll differ with the American Academy of Ophthalmology (who recommend use of preserved artificial tears up to every 2 hours), in that I only recommend preservative free artificial tears if you’re going to use them at all. This is because any preservative is a toxin and applying toxins to your eye on a regular basis is only going to contribute to more problems making tears - as you hurt these tiny glands trying to make your tears, with those toxins. The biggest concern that I have is, if your only treatment is artificial tears, then you are applying a Band-Aid to a deeper problem that in essence “Kicks the can down the road” without solving the problem that’s causing the problem. I’ve posted on this before, here: https://www.eyethera.com/blog/why-cant-i-just-use-some-tear-drops-or-ointments-instead-of-all-this-work?rq=artificial%20tears
I advise that you should seek the advice of a good dry eye doctor who can best diagnose what’s causing your problem and help you to fix it. Working with the good dry specialist is your best recourse!
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Study looks at the correlation of humidity, temperature, and air pollutants on dry eye disease patients
https://www.ophthalmologytimes.com/view/study-looks-at-the-correlation-of-humidity-temperature-and-air-pollutants-on-dry-eye-disease-patients
While this study only included 53 patients, they did find statistical significance in common parameters associated with air pollution. No great surprise that polluted air will aggravate dry eye disease!! But it does elevate concern that we need to take steps to ensure we live in clear, clean air. Our eyes are covered in our body’s living cells - and as such, this delicate, important, advance-life-form is truly the “canary in the mine.” For those unfamiliar with this analogy, coal miners digging many hundreds of feet below the surface of the earth, could encounter pockets of toxic or flammable gases that could be odorless to human noses. Miners would carry canaries with them, as these delicate birds would succumb to these gases before they would otherwise be toxic to a human. When the canary looked sick (or went belly up), then the miners knew it was time to get out of the mine. As a physician, scientist and fellow human with kids and grandkids to worry about, I hope we can control the human footprint we are pressing into the backbone of our world before we succumb to the toxins we are fast-creating.
Rosacea takeaway “Pearls”
After 10 posts on Rosacea, it occured to me (after a much needed summer vacation), that I could wrap this up with some general suggestions I often share with my Rosacea patients. While much of this mirrors my take on dry eye treatments in general, I do have more specific, Rosacea-related “Pearls” I can share.
If the Meibomian Glands (MGs) are clogged with waxy oils, it remains critical to clear them. A “heated massage” from a dry eye specialist using appropriate equipment is often necessary - and there are many effective options for this, depending on the “melting point” of the clogging. Milder clogs (of a buttery consistency) will usually respond to most modalities and can sometimes be cleared through “homework” using a heat mask (like a Bruder) and “lid crunches.” I coax patients to apply the heated Bruder mask for 3-4 minutes, while meditating or listening to a favorite song (most last this long). After the 3-4 minutes of continuous moist heat, the more buttery secretions can become more liquid - but as soon as the heat is removed, the oils will firm back up. Using the retained heat, while leaving the mask in place, a conscious, firm (but not grimacing) upper and lower eyelid “squeeze” will compress the glands and squeeze out the liquid oils. Counting to 3 to compress and then to 3, to relax the lids, we repeat this exercise about 20 times (which takes about 1 minute). At the conclusion, you remove the mask and hope to sense looking through a “greasy tear",” which is slightly blurry, but an accomplishment in terms of turing over the thick, old oils - and making room for newer, fresher oils.If the nature of the patient is to produce thicker oils, then a routine use of this heated expression several times a week can result in consistent, better flow. It also helps strengthen the lid muscles (so even unconscious blinking can become stronger blinking) and it may help intensify “muscle memory” - so that those unconscious blinks become actively stronger blinks throughout the day.
If MGs are able to produce thin, clear oil on exam, then a heated expression is less helpful and can become counter productive. This is because the greatest purpose of heat is to thin oil and dilate the pores that are the mouth of these glands. But if the oil can flow easily, then heat is not only unnecessary, it can dilate the blood vessels distributing the proteins and chemicals that produce inflammation - thereby increasing redness, swelling and damage to tear-producing cells. When clogged MGs are unclogged through treatments, this is usually a fair tradeoff against the inflammation from dilating blood vessels - as poor or absent oils will aide evaporation and increase inflammation. I liken these thin, clear, but inflammatory oils produced by rosacea-affected MGs as being more like “kerosene” than being the better “extra-virgin vegetable (& fish) oils” our eyes would prefer. When I treat eye patients with Rosacea, I will commonly use a deep eyelid-cleaning tool (BlephEx and/or ZEST), IPL and a heated expression (with off-label Radio Frequency). Following the heat of IPL with a little more heat and massage will help unclog any waxy oils, but also can help “purge” any inflammatory oils - making way for better, newer oils to be produced.
Once Rosacea-related oils are flowing, the trick is to keep them flowing and containing the “good oils” rather than the “bad oils.” This usually comes down to consuming and digesting enough quality Omega oils 3, 6 and 9 to nourish the MGs, as well as promoting the production of oil from these MGs, with strong regular blinking throughout the day. Lastly, providing adequate eyelid hygiene, to prevent germs from subsisting on these oils in quantities that can turn these oils into soapy, chunky residues. Those with poor oil absorption issues (absent or reduced gallbladder function, inflammatory gut problems, etc) may need help varying from adding Lipase supplements to adding anti-inflammatory medications and taking lower frequent doses in a schedule of oil intake that is compatible with the degree of absorption available.
To reduce inflammation getting into the oils, taking oral antibiotics like Doxycycline or Azithromycin can often be helpful (but not until the oils are mobile). An adjunct to - or even a replacement for - the antibiotics, can be IPL, and I recommend my patients seek out dry eye specialists who can provide IPL treatments when appropriate (not all skin types are IPL appropriate and there are certain exclusions to IPL therapy. A dry eye specialist who can offer IPL is usually well versed in all this).
Anti-inflammatory diets can be another useful adjunct, as can a lifestyle where sun protection, adequate exercise, limits on caffeine and alcohol, spicy foods and other “rosacea triggers” are observed. Meditation, yoga and other stress relieving activities can also have positive benefits.
Catching Rosacea early and dealing with it effectively is most helpful, as once Rosacea is well entrenched, the larger, active blood vessels that produce the “rosy” appearance become harder to shut down. Careful examination - and treatment - of Demodex, may mean additional hygiene steps, but can really pay off. Since Rosacea is a genetically “programmed” tendency towards inflammation, the treatments are usually required in differing amounts and degrees, for a lifetime. Prescriptive topical and oral medications, IPL and other office-based treatments are often required as “maintenance” that vary with the degrees of Rosacea-related disease. Such interventions are sometimes only needed yearly - but sometimes multiple pulses of therapy are required many times a year, and the intervals can vary over time according to genetics, age, environment, adherence to “homework” and by the skill and technologies employed by the treating doctor.
If the Rosacea is limited to the eyes (Ocular Rosacea), it can generally be handled by an experienced eye doctor, but if it affects broader areas of the face and body, then it is often necessary to work with a team that would include the Dermatologist, and may include Gastroenterology, Rheumatology and Neurology. Since we as a rule are living longer and using our eyes more than prior generations, taking good care of our eyes becomes even more critical - and Rosacea is a common problem with good treatment options that help ensure that our eyes can last (comfortably and usefully) for as long as we do.
Because I’ve posted extensively on details of my recommended Omega oil supplements, lid hygiene, treatments for Demodex, etc, I will steer those interested into reading my posts from the beginning - or you can use the “search” bar (in the blue “gauze” under the leading lady’s eyes) to hopefully find what you’re looking for.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Rosacea and Dry Eyes Part 10: more on treatments (& Demodex)…
Helm CJ. Treatment of ocular Demodex infestation with topical ivermectin cream. Am J Ophthalmol Case Rep. 2022 Apr 21;26:101551. doi: 10.1016/j.ajoc.2022.101551. PMID: 35509284; PMCID: PMC9058595.
The following consists of a report on the off-label use of a common treatment for rosacea that can be applied to the lids and lash area as described from the article below. It was the basis for much of my treatment before Xdemvy became commercially available (just one year ago this month) and can be found in my earlier post, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease
Treatment of ocular Demodex infestation with topical ivermectin cream
“Ivermectin 1% cream was approved by the FDA in 2014 for the treatment of rosacea, a Demodex-associated condition.32 The cream was found to be well tolerated in FDA studies, leading to skin irritation and a burning sensation in less than 1% of patients when used during a 12-week study period.33, 34 Topical ivermectin 1% cream has been reported to be effective in treating ocular rosacea,35,36 and was recently found by Choi et al. to be effective in treating Demodex blepharitis.37 In their study, ivermectin 1% cream was applied weekly. However, the findings of this case series suggests that even a single application of ivermectin 1% cream has a very potent and prolonged effect that lasts for several months, making weekly application unnecessary.
The patients in this series reported that the cream caused temporary ocular stinging and burning, which was mitigated by instillation of a topical anesthetic. The symptoms did not recur after the anesthetic wore off. Temporary blurred vision was also reported, but no one felt unsafe to drive after 30 minutes. An increase in dry eye symptoms commonly occurred a few days after treatment.
In summary, this case series presents compelling anecdotal evidence of the effectiveness of a single or double application of topical ivermectin 1% cream in producing a prolonged, months-long reduction in the clinical signs of Demodex infestation. Further investigation of the off-label use of topical ivermectin 1% cream for ocular demodicosis is warranted to confirm its efficacy and to develop protocols that extend the duration of treatment effect.
The treatment consisted of instilling a drop of proparacaine into each eye. The exam chair was reclined. A dry cotton-tipped applicator was used to evert the lashes. Another cotton-tipped applicator with ivermectin 1% cream (Soolantra, Galderma, Ft. Worth, Texas, USA) was used to apply the cream to the base of the eyelashes, taking care to keep the cream off of the ocular surface (Fig. 1). After ensuring that the eyelash bases of both the upper and lower eyelids were saturated with the cream, it was applied to the surrounding upper and lower eyelid skin. The cream was left in place for 10 min, after which a sterile saline-soaked eye pad was used to remove the excess cream from the eyelids. Dry cotton-tipped applicators were used at the slit lamp to remove excess cream, and the remainder of the cream around the lashes was left in place. Artificial tears were instilled if the patient was experiencing ocular burning or irritation.”
My “take home” message about Demodex and Rosacea, from my personal experiences and this post, is that Demodex is a common irritant that will aggravate rosacea and its related inflammation - both on the face and on the lids (which can spill over as inflammation onto the eyes). Ivermectin 1% cream and the newer eye drop, Xdemvy, have proven of value in reducing the load of Demodex and the related inflammation. Since inflammation is a foundational aspect of dry eye and related ocular surface diseases, it is often important to address this common mite. Protocols continue to evolve around “best practices” and may require customization according to the degree of its effect on the individual patient.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Rosacea and Dry Eyes Part 9
As this is a focus on dry eye disease, it is necessary to include more on the Treatment of Ocular Rosacea- (with another nod to the J. Hopkins Review Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003 ) *(I’ve put my comments in parenthesis with a leading asterisk to help annotate the actual published reporting. The bold faced type is my emphasis and not from the published articles).
Patients with mild ocular rosacea often present with a dry gritty feeling in the eyes; they can usually be treated by lid hygiene and lubricating eye drops. Patients with more severe ocular rosacea present with burning or stinging of the eyes, crusting of the lid margins, or formation of chalazia and hordeola. They frequently need topical or systemic antibiotics, or cyclosporine.
Topical cyclosporine 0.05% ophthalmic emulsion *(Restasis, with now a variety of compounded and more generic formulations available) has been shown to be more beneficial than artificial tears in the treatment of ocular rosacea (low quality evidence).76,100 For the more severe ocular rosacea, referral to an ophthalmologist is prudent.
Physical Treatment of Rosacea - above referenced J. Hopkins Article
• Telangiectasia *(I discussed these fine, red, “spider lines” caused by dilated superficial blood vessels in the lead blog of this series, with photos that demonstrate them).
Reduction in telangiectasia is not to be expected with any of the currently available topical agents for rosacea. However, these features frequently become a psychological burden and can substantially impact rosacea patients' quality of life.
Destruction of dilated vessels by vascular lasers or intense pulse light is the primary therapy to reduce telangiectasia. Light energy is absorbed by hemoglobin in cutaneous vessels, leading to vessel heating and coagulation.
Most commonly used for the treatment of erythema and telangiectasia in rosacea patients are the pulsed dye laser (PDL, pulsed dye laser, 585–595 nm) and intense pulse light (IPL) devices.101,102
-
According to the latest Cochrane Systematic Review, pulsed dye
laser and intense pulsed light therapy were each associated with erythema and
telangiectasia improvement, but without difference between treatments (moderate
quality evidence).76
________________________________________________________________________________________
Drawing from published data and discussions in Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ko HS, Suh YJ, Byun JW, Choi GS, Shin J. Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ann Dermatol. 2017 Oct;29(5):543-547. doi: 10.5021/ad.2017.29.5.543. Epub 2017 Aug 25. PMID: 28966509; PMCID: PMC5597646.
The recurrence rate of rosacea was not known very well, but has been reported as 60% in 6 months after withdrawal of the drug *(minocycline - which is a tetracycline-derivative similar to doxycycline). It is not known which treatment can reduce relapses of rosacea effectively.
The objective *(of this study) was to identify whether 595 nm-pulsed dye laser (PDL) treatment reduced recurrence rate among rosacea patients who were treated with oral minocycline.
One hundred and seven Korean patients with rosacea who started treatment with oral minocycline (100 mg/d) with or without PDL (2∼4 sessions) were evaluated retrospectively.
Cox proportional hazards model showed that the combined use of PDL with oral minocycline appeared to be a significant protective factor for the hazard of recurrence of rosacea (hazard ratio, 0.492; 95% CI, 0.257∼0.941; p=0.032).
Patients were categorized into 2 groups according to the treatment modality:
– Group 1: Oral minocycline (100 mg per day) alone
– Group 2: Oral minocycline (100 mg per day) plus 595 nm-PDL (total 2∼4 sessions)
The PDL (Pulsed Dye Laser) (595 nm, VBeam; Candela/Syneron, Wayland, MA, USA) settings were: fluence, 10.0 J/cm2; spot size, 7 mm; pulse duration, 10 milliseconds; and passes, 2 with 10% overlap of treatment spots. The settings were standard subpurpuragenic settings, including published guidelines and company-recommended ones at the time of the study7. *(Important to note from the above quoted, earlier J. Hopkins report, that PDL was found equal to IPL - or Intense Pulsed Light. As a provider who owned and operated a VBeam PDL prior to switching to a Lumenis M22 IPL system, my general sense is that IPL is likely safer over and around eyelids - but is also similar in results to PDL at the common treatment levels for rosacea. It is worth another look at my earlier post on IPL here https://www.eyethera.com/blog/do-results-of-ipl-treatment-vary-by-technique-and-by-the-filters-used-amp-does-it-regenerate-withered-glands ).
Pulsed dye laser (PDL) has been suggested to be used adjunctively with oral and topical rosacea regimens for more complete symptom resolution6. PDL shows a therapeutic effect by photo-thermolysis targeting oxyhemoglobins within cutaneous vasculature7,8. PDL is effective for erythema, flushing, telangiectasia and even inflammatory lesions in patients with rosacea6,7,8. Biopsy specimens which were taken from patients with rosacea 3 months after PDL therapy showed that nerve fiber density and number of substance P immunoreactive nerve fibers were decreased9,10. However, exact relationship between this and the therapeutic effect of PDL has not been demonstrated yet.
The multiple Cox proportional hazards model showed that PDL treatment added to oral minocycline was an important protective factor for a hazard of the recurrence of rosacea (HR, 0.492; 95% CI,
0.257∼0.941; p=0.032). The treatment duration with oral minocycline was not a significant prognostic factor for the recurrence of rosacea (p>0.05).
This study showed that the 1 month-recurrence rate after oral minocycline alone was 17.2% and the 6 month- recurrence rate was 66.8%, which is similar to the results of previous report.
In the present study, the 1 month-recurrence rate was 3.2% and the 6 month-recurrence rate was 49.2% after PDL in combination with oral minocycline therapy.
Generally, two to four laser treatments are required to achieve best outcomes for rosacea6. Patients with total 2∼4 sessions of PDL were only included in this study. When we evaluated data including patients with a single session of PDL, the recurrence rates between groups were not significantly different (data not shown). It means a single laser session is not enough to see the therapeutic effect.
_______________________________________________________________________________________
*(My personal take on this mirrors my clinical observations. 4 IPL treatment sessions are generally required for optimal control of rosacea. Adding Doxycycline - or any Tetracycline-derived oral antibiotic such as Minocycline - can enhance the treatment value. This appears to lead to a higher level of improvement in some cases, but to a more lasting benefit in most cases. It also speaks to my general recommendation for “maintenance” IPL treatments every 6-12 months regardless of whether a tetracycline is used adjunctively - and some may benefit from even more. I’ll cover a little more on Rosacea treatments in the next blog posting!)
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463
Rosacea and Dry Eyes Part 8
Treatment continues to point back to the immune system, starting at a genetic level and then to the gut…
Woo YR, Han YJ, Kim HS, Cho SH, Lee JD. Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis. Int J Mol Sci. 2020 Nov 10;21(22):8427. doi: 10.3390/ijms21228427. PMID: 33182618; PMCID: PMC7696644.
Treatment of Rosacea- Johns Hopkins Review Article
Historically, rosacea was treated by bloodlettings and application of leeches on rosacea-affected skin.67 Rosacea therapy has changed since then, but a curative treatment approach has not yet been developed. Thomas Bateman's quote holds true to date: “The perfect cure of [acne] rosacea is, in fact, never
accomplished” (from Delineations of cutaneous diseases, 1812).
Most current guidelines are based on the identification of the rosacea subtype to select the appropriate therapy. However, in reality there is often an overlap of clinical features across rosacea subtypes in each patient, requiring several therapeutic strategies for optimal outcome. Thus, there is no single best way to treat all rosacea patients.68-70
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
I think it is clear that until we can manipulate the genes responsible for Rosacea and reorganize the gut flora around an individual’s immune system, that Mr. Bateman’s quote is likely to remain true. Fortunately, there have been many headways made into the treatment of Rosacea since 1812!
I believe this review article applies well to the ocular rosacea I see in my practice - particularly in regards to the “life-long treatment intervention.” For most, this is pretty simple - but for some, it can get quite complex. The simplest can be practicing ample lid hygiene, including control of the stubborn mites called Demodex. (see my earlier posts on these topics, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease and https://www.eyethera.com/blog/why-do-some-people-produce-pasty-meibum-part-4 (among others in earlier posts). Continuing in our review of this article, I’ve pulled some general recommendations as follows, below:
Treatment of Rosacea- Johns Hopkins Review Article
General recommendations include a gentle skin care regimen to maintain skin hydration and barrier function, and photoprotection (sun exposure avoidance and sunscreen with a sun protection factor of 30 or greater).
Additionally, cover-up or color-correcting powders can be helpful to mitigate the psychosocial impact of rosacea. Since the psychosocial impact of rosacea tends to be underestimated by physicians, this issue should be raised with every patient and considered in the therapeutic plan.
Several topical drugs including topical metronidazole, azelaic acid, ivermectin, and brimonidine tartrate are approved for rosacea by the United States Food and Drug Administration (FDA).
The only (FDA) approved oral drug for rosacea is low-dose doxycycline. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
Treatment of Rosacea- Johns Hopkins Review Article
- ...the only oral agent approved by the FDA to treat inflammatory rosacea lesions is a modified-release doxycycline (40 mg once-daily), which was approved in 2006.75 This once-daily 40 mg doxycycline dosing (30 mg immediate-release and 10 mg delayed-release beads) provides anti- inflammatory, without antimicrobial effects; in vivo microbiological studies demonstrated no long-term effects on bacterial flora of the oral cavity, skin, intestinal tract, and vagina.92-95
- Based on most current evidence, oral tetracycline (moderate quality evidence) and doxycycline (high quality evidence) were both associated with improvements in papulopustular rosacea compared with placebo.76 There was no difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse events with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence).76,94
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
In my practice, I find that there has been little difference between the 40mg dose noted above and the (much) cheaper 50mg dose (without the different absorption profile). In my estimation, this difference in dosage and absorption is not significant for most, as doxycycline is largely absorbed through the liver pathway and has a lasting effect in oil glands (so that in some cases, even 50mg every other day can still have treatment value for rosacea patients). Azithromycin can have similar benefits for some rosacea patients (and can be available as a topical eye-drop preparation), so choice of which antibiotic (and by which route) can be customized by the physician for their patient.
For those who don’t do well with longer-term antibiotics (due to allergies, side effects, or as a preference), IPL can be a great option and can be used with or without antibiotics. Cost is often an issue, as most insurance programs will cover the antibiotics but will not cover IPL treatments. I’’ve posted extensively on IPL and will summarize this with some references, in my next posting (and can cover some of the other dermatological treatments recommended in the above review article). For more on doxycycline please also see my earlier post in this series, here: https://www.eyethera.com/blog/rosacea-and-dry-eyes-part-6 ).
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463