A Conversation About LipiFlow

Alice Epitropoulos, MD, and John Berdahl, MD, speak with Marguerite McDonald, MD, regarding their use of LipiFlow (TearScience) to treat meibomian gland dysfunction (MGD). Drs. Epitropoulos and Berdahl explain how they educate their patients about the need for MGD treatment prior to cataract surgery and they detail what is involved with the components of the LipiFlow procedure.

Speaker 1:

Informed Consent: Getting to Yes is editorially independent content supported with advertising by Allergan Eye Care.

Marguerite M.:

This is Informed Consent: Getting to Yes. Welcome, I'm your host, Marguerite McDonald, of the Ophthalmic Consultants of Long Island in Lindbergh, New York. Today we'll be hearing excerpts from conversations I've had with two top ophthalmologists about the words they use to explain meibomian gland disease to patients and how they get their patients to say yes to treating it with LipiFlow. I spoke with Dr. Alice Epitropoulos, founding partner of the Eye Center of Columbus and Clinical Assistant Professor in the Department of Ophthalmology at Ohio State.

Dr. Alice E.:

Thank you Marguerite, thank you for having me.

Marguerite M.:

And Dr. John Berdahl, a partner at Vance Thompson Vision in Sioux Falls, South Dakota and Associate Professor of Ophthalmology at the University of South Dakota.

Dr. Berdahl:

Thanks Marguerite, it's fun to be here.

Marguerite M.:

To begin with, I was wondering how and why you started using LipiFlow for meibomian gland dysfunction. Let's start with John.

Dr. Berdahl:

Well, you may or not know that my partner, Alison Tendler, is the Restasis model. She really runs our really hard core dry eye practice but we all deal with dry eye in our cataract, refractive, and glaucoma practices and it really can have a significant impact on outcome so it's part of the thing that we do every single day. We really brought it in because I was trying to get a modeling gig and we thought LipiFlow would be the best chance. No, I'm just kidding about that actually. Alison felt like we needed to have thermal pulsation as part of a comprehensive dryness program and I was a little bit resistant saying that it's expensive and I'm not convinced that it works although I've heard some good reports from people that I trust but you're the dry eye guru in our practice and so we'll support that.

She brought it in, giving us access to the technology and the more I used it the more I liked it, the more we continued to use it. As the business model evolved from the company we were able to use it more and more and incorporated it into our premium eye well packages.

Dr. Alice E.:

Just to talk a little bit about treatment for meibomian gland dysfunction, traditionally this condition's been treated with a combination of warm compresses, lid scrubs, meibomian gland expression, artificial tears, even prescription drops like azithromycin used off label or even oral antibiotics like doxycycline. Compliance has been a problem because these treatments are in general ineffective because these conventional treatments don't address meibomian gland obstruction. LipiFlow thermal pulsation has become a treatment of choice when there is evidence of meibomian gland dysfunction and compromise to the meibomian glands.

Data shows that if we can get to these patients early, before they have irreversible damage to the meibomian glands then they're going to respond better than if we wait until those glands are non-functional. I also like using BlephEx prior to LipiFlow. This uses a medical grade micro sponge to exfoliate the lids and lashes and this kind of removes the scurf from the lids and lashes. Clinicians can now take a more active role in treating blepharitis instead of relying on patient's ability to perform semi-effective lid scrubs at home. This also helps to prepare their ocular surface, reducing the bacterial load prior to their going for cataract surgery.

Marguerite M.:

Now, I'm sitting in front of you, I'm Mrs. Smith. You have decided that I need LipiFlow before my premium cataract surgery so what would you say to Mrs. Smith, John?

Dr. Berdahl:

Mrs. Smith, you've got three options on how you want to use your eyes after cataract surgery. Standard cataract surgery and you're probably going to wear glasses. We could fix your astigmatism and you'll see good at distance most likely without glasses but you need readers up close, or what you're leaning towards which is number three, which is to try and get elevated, try to have good distance vision and up close vision. The challenge with these lenses is they really need a pristine eye and there's not much room for error in this. We talked about you'll have some dryness and that dryness can not only throw off our preoperative calculations but it can decrease your quality of vision. If we're going to go down this path I think the best way to do it is to include a dryness treatment that includes LipiFlow prior to your surgery to give us the best chance for the best outcome for you for the long term.

Marguerite M.:

What's involved, Dr. Berdahl? What does the LipiFlow procedure involve?

Dr. Berdahl:

Yeah, so it's really straightforward, it's kind of like a massage for your eyelids. There's a device that comes in. We'll numb up your eye. We'll put a little device in there that warms up your eyelid to a specific temperature and that takes the oils in your eyelid, which should come out like olive oil but are really coming out like half melted butter. It will melt those oils, get the gunk out so the good oils can flow from behind and give you a nice, smooth, tear fill to focus the light. Takes about 15-20 minutes. It kind of feels like a nice moment of zen eyelid massage for your eyes.

Dr. Alice E.:

That's the nice thing about thermal pulsation LipiFlow is that it is comfortable for the patients and it is the only FDA cleared treatment for evaporative dry eye disease. Again, I think that having that option available, and we've seen quite a few studies showing the efficacy of that treatment.

Marguerite M.:

Do you have a little setting the expectations talk that you give them about LipiFlow?

Dr. Alice E.:

Yes, I actually do. I think that ... You had mentioned meibography. I think that meibography is an excellent tool to educate our patients about this disease. I can actually show them what their glands look like versus what they should look like and show them that this is a progressive disease and if it's not treated can lead to this irreversible damage to their glands. Again, if I feel like they're a candidate and they have the potential to respond to this treatment I do offer that to them. I'll tell them that in the FDA clinical trials 80% of patients noticed a symptomatic improvement. I also tell them that 20% did not notice any improvement at all.

I'm very, very transparent about that because they're investing some money to have this procedure and I want to make sure that they realize that there's no guarantee with this treatment. 80% is a good success rate and I also tell them this is a long term treatment. Again in the clinical studies 9-15 months patients noticed an improvement for an extended period of time. I have been noticing even longer term improvement, up to a couple years. Again, I tell them that this is the only FDA cleared treatment for this condition that they have. Even in the 20% of patients that really don't notice a symptomatic improvement we're still helping to prevent that progressive damage that can occur.

Marguerite M.:

I've mentioned that as well, that even if they're in that minority that doesn't notice a big difference that we will notice the difference. That we will see less loss of glands and a better tear osmolarity score and better MMP-9, et cetera. You tell them it will last on average how long?

Dr. Alice E.:

I like to kind of quote the clinical trial, I tell them 9-15 months. I also tell them in my experience I've seen patients that have noticed the benefit that's lasted even longer than that. I also tell them that one of the variables is how compliant they are with their post-op regimen.

Marguerite M.:

Do you recommend anything else for your patients with evaporative dry eye disease?

Dr. Alice E.:

I give them a list of instructions to follow post LipiFlow. I like the research verified Omega 3. Again, I recommend the Dry Eye Omega Benefits by PRN. This formulation has gone through more vigorous testing and research than most fish oil supplements and re-esterification is one of the key differences. I also recommend the microwaveable warm compresses. I like the Bruder warm compress, which I think really helps to maintain the patency of meibomian glands. Immediately after the LipiFlow I'll have them use a topical steroid for the first couple weeks and then I also have them do blinking exercises.

With the digital era that we're all in today our blink rate is reduced significantly when we're on the computer, when we're staring at our iPhones. That really aggravates our meibomian gland disease. If I can instruct patients to consciously blink and squeeze their eyes on a regular basis that helps to keep those meibomian glands functioning.

Marguerite M.:

Absolutely. There are several papers about how our multi-screen lifestyle has changed our blink rate from 3-5 times a minute down from 20 times a minute when you're not looking at a screen so you're absolutely right. I try to get my patients to tie the blink to something they do all the time like every time you take the stairs, every time you get in the elevator, every time you change floors remember to blink vigorously because otherwise it will just never get done, and especially right after one of these treatments.

Dr. Alice E.:

Believe it or not there's even an app for it.

Marguerite M.:

There is, that's right. What's that app called?

Dr. Alice E.:

I'm not sure. I'll have to search that. Blinking exercise app, I'm not sure.

Marguerite M.:

I do something similar and my little pitch goes something like this. For patients who are doing everything just right but still suffering, or patients who simply can't stand doing everything I've recommended, which is the much larger group. There is now a 12 minute, computer controlled, pulsating thermal lid massage. Feels like a high end spa treatment and I'm in a chair like the one you're in now tilted back 45 degrees. These little eye cups, these activators are placed on your eyelids. Over the course of 12 minutes your lids are warmed and all the nasty goo in your eyelid glands is massaged out and are not dilated, sedated or patched. Actually, the eye cups let your eyelids and vault over your eyeball.

You can drive away, you feel better right away, and a little bit better every day for six months. At six months you reach maximum benefit from this one 12 minute treatment and you hold the benefit for another six months. The average person gets a year of relief with an extreme range of 6-36 months. The vast majority gets somewhere close to a year in our experience and then they have to do it again or go back on the big regimen. One of the great motivations to do this is to feel better while you're doing less. When you leave we'll give you an appointment for three months in advance and we'll give you a list of what to jettison.

You get to jettison one thing from your regimen each month. Usually we get rid of expensive and annoying things first like prescription medicines with a high co-pay and ointments at night. Then we'll have you back at three months but because there is some patient to patient variability in how you're going to respond to this we ask that if you begin to feel poorly please add back the last thing that you jettisoned. The vast majority of people do feel better, call it the slow miracle. There are a few people, a minority of people who don't feel that much better but we can see that gland drop out has stopped and all your parameters, scientific parameters, have stabilized or improved. That's my little pitch. It doesn't take that long and there's really a very high conversion rate.

Dr. Alice E.:

That's a great way of explaining that to patients, I like that method.

Speaker 1:

Informed Consent: Getting to Yes is editorially independent content supported with advertising by Allergan Eye Care.

Marguerite M.:

Back to you, John. The question is, is LipiFlow a stand along service or is it bundled into your premium packages?

Dr. Berdahl:

A little bit of a hybrid. What we do is if we think that they need it beforehand we tell them we think that they need it beforehand to get the best outcome with their premium eye well package. If they choose to do it they pay their price. If they then continue on into a premium eye well package we rebate them 50% of what the LipiFlow treatment costs. If they do a premium eye well package then they pay a discounted rate for LipiFlow afterwards. If they don't do a premium eye well package then there's not a discount with it. We feel like maybe with a mild focal lens a person would be able to tolerate their dryness but with a multi-focal they really aren't going to be able to. There's not a lot of forgiveness, you got to do a lot of work to get people from the three-yard line into the end zone with multifocals. We want to give our patients every chance to succeed so we try and identify them up front but have a rescue plan afterwards if they're not doing as well as they’d like.

Marguerite M.:

If they have it before surgery they get a 50% discount on it. If they have it after premium they get also a discount of some sort and only pay full price if it's a stand-alone procedure, say, for somebody who's not even continuing to cataract surgery.

Dr. Berdahl:

Or a cataract surgery with a premium package. Yes, that's correct.

Marguerite M.:

I've heard more and more often, John, that it is part of a premium package. In our Dry Eye Center of Excellence we certainly have, we have a lot of surgeons. We actually now have 52 docs and all but three are MDs, those three are ODs, get some of our docs doing package. We also have the, just the disperate Sjogren's dry eye that comes in who has bounced around other practices who's not contemplating any kind of surgery. I found in our part of New York on Long Island that the reduction in the price of the activators had a huge impact on volume. We were able to drop our price and that increased the volume tremendously. Did you find that as well?

Dr. Berdahl:

Exactly the same thing. Not only did patients feel that it was worth it but we started to feel like it was worth it too.

Marguerite M.:

I add a couple of little tiny, different twists. One of the things I say is, especially for the people who are just there for dry eye management. I say, "You know, Mrs. Smith. For people who are doing everything just right ... The soaks, the scrubs, the ointment, et cetera. Everything just right but still suffering or people who can't stand doing all of that," which is the bigger group. I said, "We have this 12 minute computer controlled pulsating thermal lid massage." Then I go on to say pretty much what you say. When I say the big group is the group that hates to do this because that's when everybody smiles and laughs and says that's me because everyone hates to do that routine.

Dr. Berdahl:

What dance I'm supposed to do related to dry eyes, and nobody likes doing it.

Marguerite M.:

Well, I found the information both of you provided extremely valuable and I'm sure our listeners did too. Thank you do much.

Dr. Alice E.:

Thank you so much. I appreciate the invitation.

Dr. Berdahl:

See you later.

Marguerite M.:

Please join us for the next edition of Informed Consent Getting to Yes. I'm Marguerite McDonald.

Speaker 1:

Informed Consent: Getting to Yes is editorially independent content supported with advertising by Allergan Eye Care.