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Dr. Robert Fintelmann completed his doctorate at the University
of Ulm in Germany, an ophthalmology residency at Wills Eye
Institute in Philadelphia, PA, and a Corneal and Refractive
Surgery Fellowship at the University of California, San Francisco.
Dr. Fintelmann has performed thousands of cataract surgeries,
over 2,000 vision correction procedures (LASIK, PRK, and ICL),
& hundreds of corneal transplants. His experience includes:
laser-assisted cataract surgery, full corneal transplants, partial
thickness corneal transplants (DSAEK, DMEK, DALK), along with
minimally invasive transplants of either the anterior or posterior
portions of the cornea. In clinic, he enjoys treating ocular surface
disease (dry eye), and helping patients achieve relief from their
chronic eye irritation.
Dr. Fintelmann is a board-certified Diplomate of the American
Board of Ophthalmology and serves as an examiner for the oral
board exams. He is a fellow of the American College of Surgeons
and a member of multiple professional organizations, and he
performs research & publishes articles in peer-reviewed journals.
Robert Fintelmann, M.D., FACS
3. 3/20/2024 3
Dr. Kevin Helmuth, received his doctorate from the
Pacific University College of Optometry. He
currently serves as the Director of Clinic Operations
at the AZ College of Optometry where he also
works as an Associate Professor.
Prior to coming to Midwestern University, Dr.
Helmuth spent nearly 12 years working in Native
American health facilities. He previously served as
the Director of Optometry for the Gila River Indian
Community, Hu Hu Kam Memorial Hospital in
Sacaton, Arizona; and the Chief of Optometry for
the Creek Nation in Okemah, Oklahoma.
He has a clinical and research interest in Dry Eye.
Kevin Helmuth O.D.
4. 3/20/2024 4
Financial Disclosures
Neither Dr. Fintelmann nor Dr. Helmuth have any financial disclosures to report.
<a href='https://newvitruvian.com/image/pocket-clipart-poverty/1092570.html'>Image credit</a>
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Objectives
• Discuss new dry eye therapies that will be coming to the marketplace soon
• Re-visit Meibomian Gland Dysfunction and therapies to address it
• Review the special challenges that are unique to treating dry eye
• Discuss the importance of developing a standardized method of evaluating dry eye
patients
• Review some effective tools that assist in patient communication
• Examine a method for not losing site of the big picture in this complicated condition
• Understand the importance of incorporating a multi-disciplinary approach
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Medications New Technology
CEQUA (cyclosporin A 0.09%)
• Highest concentration of Cyclosporin A
• Uses a novel nanomiceller technology which
allows it to penetrate the tear layer better
• Purportedly shows quicker results than either
Restasis or Xiidra in corneal staining and tear
production
KLARITY-C (cyclosporine/chondroitin sulfate 0.1%
ophthalmic emulsion, Imprimis Pharmaceuticals)
• Compounded, preservative-free, BID
Xiidra (lifitegrast 5%)
Multiple Other Meds in Clinical Trials:
KPI-121 (0.25% loteprednol etabonate ophthalmic
suspension, Kala Pharmaceuticals)
Thymosin β-4. RGN-259
TearCare
• Automated heat device applied to the lids
• $5500 after rebate
• $250/procedure renewable costs
• 12-15 minute tx followed by manual expression
New Therapies
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Medications New Technology
VITAL TEARS (Autologous Serum)
• Ordered as a single 2–3 month supply or as an
on-going subscription.
• Provided in 3 ml aliquots.
• The drops last 1 week in refrigeration and 6
months frozen
COSMESIS DISCUSSION
Digital Heat Inc.
Therapy Update
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Re-visiting MGD treatment
Lipiflow and ILux
• Lipiflow is well established
• Studies and experience shows improvement of signs and symptoms when glands are present
• Promoting it as a silver bullet which would make money hurt its implementation
• Cost is a barrier (definition of success crucial)
• Results take time
• Does not fix all of the problems
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MGD treatment
Lipiflow and ILux
• Price created incentive for competition
• Ilux has the same goal
• Works in smaller fissures
• Smaller device
• Disposable first cheaper now more expensive than lipiflow
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MGD treatment
Intense Pulsed Light (IPL)
• Used for years in dermatology
• Suggested use in dry eye to address inflammation
• Exact mechanism of action unknown
• Best results in patients with rosacea
• Treatment parameters vary
• With/without expression
• Midface versus full face
• Different machines
• With/without probing?
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MGD treatment
IPL
• Broad spectrum light source
• xenon bulbs
• 500-1200nm wavelength
• FDA approval 1995
• Taken up by pigment
(melanin, hemoglobin, artificial pigment e.g. eyeliner tattoo)
• Different filters and pulses
• Good safety profile when used as intended
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MGD treatment
IPL
• Complementary to lipiflow
• Works in inflammatory conditions
• Improvement in more advanced cases
• No renewables/Price point
• Several treatments necessary
• Improvement noted earlier
• # of treatments done at MWU
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• Multiple probes are available 1mm, 2mm,
2.5mm, 4mm or 6mm. Start with 2mm.
• For clogged meibomian glands, particularly
those inducing a feeling of pressure/discomfort.
• Takes 5-30 minutes
• Use lidocaine on the lid margin
• Provides both immediate and long-term effects
on symptoms and signs
• Longevity of effect variable, retreat in 6-18
month time frame or possibly beyond.
• Price considerations
Probing of the Meibomian Glands
Maskin Meibomian Gland Intraductal Probe
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The Difficulty of Treating Dry Eye
Addressing other pathology is crucial
• Conjunctivochalasis variable in presentation and contribution to symptoms
• Can be addressed in clinic with cautery
• Improving surface prior to intervention results in smoother recovery
• EBMD, radial keratotomy, pterygium and scars
• Affect test results
• May need to be addressed surgically to get desired outcome
• Lid position
• Can be underlying pathology
• Work with surgeon who understands dry eye
• Limbal stem cell deficiency
• Mistaken for dry eye
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Standardization
Evaluation
The Diagnosis of Dry Eye is mostly based on symptoms
Our template standardizes approach to the patient, teaching, treatment and outcome evaluation.
• standardized grading scales e.g. staining, meibomian gland expression, redness scales, NIKTBUT,
lissamine green, fluorescein etc.
• Immediate availability of these scales e.g. pictures within the E.H.R. that provide grading assistance for
doctors and students alike.
• better teaching environment by synchronizing exam protocol and messaging to students/patients.
• Improved assessment of therapy success since both signs and or symptoms can improve
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Standardization
Use of technology
• Meibography
• NIKTBUT
• Tear film analysis
• Ocular surface analysis
Provides communication tools to convey diagnosis and problems to patients
Provides visualization of findings to students and doctors
Underlines multifactorial and interconnected nature of Dry Eyes and its effects on vision and surgical
outcomes
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Standardization
Treatment
• Treatment tables
• Standardize treatment, facilitate decision making
• Graphical analysis over time
• Emphasize treatment effect, enhance compliance
• Chronological record of treatment
• What has been done? What worked?
Easier to integrate new treatment options while keeping established options on everybody’s mind.
Provides framework for better and more impactful research opportunities.
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Case history
Personal ocular/medical History
OSDI / SPEED questionnaire
Oculus 5M
Meibography (dropout/truncation)
NIKTBUT
Tear meniscus
Conjunctival Injection
Tears
Zone Quick and/or Schirmers
Fl-TBUT
Cornea/Conjunctiva
Corneal staining (Fluorescein/Lissamine)
Conjunctival staining (Fluorescein/Lissamine)
Conjunctivochalasis
Corneal/Conjunctival filaments
Other corneal pathology
Lids
Floppy eyelids
Blepharitis (Cylindrical?)
Lid position
Lid retraction
Lagophthalmos
Blink type
Blink rate
Meibomian gland expression
Meibum quality
Line of Marx
Telangiectasia
Other
Dry Mouth
Rosacea
Contact lenses
Systemic meds score
Compliance rating
Standardizing your Evaluations
For Dry Eye Work-Ups
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Case history
Personal ocular/medical History
OSDI / SPEED questionnaire
Tears
Fl-TBUT
Cornea/Conjunctiva
Corneal staining (Fluorescein/Lissamine)
Conjunctival staining (Fluorescein/Lissamine)
Lids
Blepharitis (Cylindrical?)
Meibomian gland expression
Meibum quality
Other
Systemic meds score
Compliance rating
Standardizing your Evaluations
For Dry Eye Follow-Ups
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The importance of a treatment table
Managing the Chronic Patient
Not losing the forest for the trees
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The personalized treatment plan
Managing the Chronic Patient
Building Compliance Through Improved Patient Communication
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Interdisciplinary approach
Rheumatology
Psychology
• Dry Eye patients suffer from greater depression, anxiety and one case reported higher suicidal ideation
• Dry Eye patients have shown reduced quality of life in multiple studies
Two Depression Screening Questions to ask your patients.
1) During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless?
2) During the past 2 weeks, have you often been bothered by little interest or pleasure in doing things?
32. 3/20/2024 32
References
1. J Vis Exp. 2019 Apr 1;(146). doi: 10.3791/57811
2. Toyos R, et al. Photomed Laser Surg. 2015;(33)1:41-46
3. Clin Ophthalmol. 2019 Jan 22;13:189-198. doi: 10.2147/OPTH.S191588. eCollection 2019
4. Graefes Arch Clin Exp Ophthalmol. 2019 Mar;257(3):591-599. doi: 10.1007/s00417-019-04241-1. Epub 2019 Jan 15.
5. Cornea. 2019 Mar;38(3):311-317. doi: 10.1097/ICO.0000000000001854
6. Eye Contact Lens. 2018 Nov;44 Suppl 2:S404-S409. doi: 10.1097/ICL.0000000000000550
7. The British Journal of Dermatology. 2018;179(2):282-289
8. BMC Psychiatry. 2018 May 16;18(1):131. doi: 10.1186/s12888-018-1715-x
9. Brain Behav. 2016 Oct 13;6(12):e00586. doi: 10.1002/brb3.586. eCollection 2016 Dec.
10. Sci Rep. 2016 Mar 1;6:22480. doi: 10.1038/srep22480.
11. Curr Eye Res. 2016 Aug;41(8):1044-1049. Epub 2015 Dec 7.
12. Curr Eye Res. 2016 May;41(5):590-9. doi: 10.3109/02713683.2015.1056804. Epub 2015 Sep 4
13. Canadian Agency for Drugs and Technologies in Health; 2018 Feb 8
14. www.webmd.com/skin-problems-and-treatments/news/20120830/are-mites-causing-your-rosacea#1
15. Joint Bone Spine, 2016 Dec;83(6):681-685. doi: 10.1016/j.jbspin.2015.10.005. Epub 2016 Jan 13
16. Mickles,Chandra OD, MS, Review of Optometry, Dry Eye Drugs: New Approaches to an Old Problem, March 15, 2019
17. Maskin SL. Intraductal meibomian gland probing relieves symptoms of obstructive meibomian gland dysfunction. Cornea 2010;29(10):1145–1152.
18. Fermon S, Hindi Zaga I, Alvarez Melloni D. Intraductal meibomian gland probing for the treatment of blepharitis. Arch Soc Esp Oftalmol 2015;90(2):76–80.
19. Nakayama N, Kawashima M, Kaido M, Arita R, Tsubota K. Analysis of Meibum Before and After Intraductal Meibomian Gland Probing in Eyes With Obstructive
Meibomian Gland Dysfunction. Cornea 2015;34(10):1206–1208.
20. https://dryeyeandmgd.com/dry-eye-and-mgd-treatments/lipiflow-treatment-leading-cause-dry-eye/
21. http://www.eyelidsurgery.co.uk/ectropionentropion-surgery/
22. https://www.atlasophthalmology.net/photo.jsf;jsessionid=0AC5E47D464510B839F301A57DA39A59?node=625&locale=pt
23. https://psychologybenefits.org/2015/01/29/4-tips-for-preventing-and-coping-with-hiv-related-short-term-memory-loss/
24. http://shine365.marshfieldclinic.org/wellness/feeling-anxious-worried-or-panicky/
25. https://www.dawn.com/news/1454338
26. https://www.seebetterflorida.com/lumenis-optima-ipl/
New tech or meds come out almost monthly. Difficult to keep up.
New tech or meds come out almost monthly. Difficult to keep up.
Need to research the various types of machines and costs.
Get specifics on price details for various machines and post them perhaps at the end of the lecture.
What do we charge for midface versus full-facial. What are the potential benefits?
We use the lumenis M22. What counts is the how much power is delivered to the target tissue. Lumenis uses a triple pulse with a 50millisecond delay to divide this power into three blasts. But because divided into three, it is more comfortable than a more powerful single pulse (need to confirm this with the reps)
Not covered by insurance, increased tbut from 5 secs to 13 secs baseline vs 3 months f/u. Also significant decrease in conjunctival hyperemia, eyelid neovascularization and OSDI. , Question of meibomian gland growth? (6% increase in gland growth post procedure 1-2 yrs later. (Maskin 2016/2018). Question of FML use post treatment x 1 month. 76% of pts experience 1 day relief of symptoms with probing group.
These are the tests that we do each exam. We highlight them in red within our E.H.R. so that the students know immediately which ones to do (at a minimum).
If compliance is poor and patient is still symptomatic, this might be an indication to include. These are values of the items that we’re checking every visit. Have two graphical displays. Graphs of those items checked each time and graphs of those checked at least once annually in dry eye work up. We think of it similar to how we look at glaucoma. There are certain tests we want to do annually.
Now if everyone was taking Skittles as seen here, then there wouldn’t be a problem, but that’s not what’s happening. Examining their med list helps you to better understand the landscape surrounding your patient’s dry eye case.
You’re unlikely to seek a change in meds, but it helps both you and the patient to know what you’re up against.
Standardized grading systems embedded within the E.H.R. Need to have our standards for each one. What standard will we use?
Our graphs run from right to left for timeline. Best if can set up E.H.R. so that all are going up or going down. We attempted, but were unable to do this with NG. These are the tests done at least annually. If there isn’t an accepted scale then we need to create our own with photographic representation of such. E.g. line of marx. We could take photos of 20 patients and then pick the ones that best represent the four categories.
If could scroll further to the right you’d see the result of the procedure. If consider having a dry eye patient for life, you’re going to want to know what you did and how it turned out at your fingertips as you consider additional procedures without having to do too much digging.
Provide written copy and send to their patient portal. Would it helpful to have them fill out a usage log? It would be great if you could provide them a checklist that they can use to record how often their doing it.
e.g. boxes that are checked off. Then you could transfer this info into the compliance score. But how many would not fill it out? Would it make compliance any better?
