LipiFlow for the Treatment of Dry Eye Disease

Marguerite McDonald, MD, invites Alan Carlson, MD, and Casey Claypool, OD, to the podcast to discuss the use of LipiFlow (Johnson & Johnson Vision) for the treatment of dry eye disease (DED). Drs. Carlson and Claypool share insights into how to educate patients about LipiFlow and when to introduce this treatment. Learn more about the importance of treating DED early, and not only focusing on treating symptoms.

MARGUERITE: Welcome to Informed Consent: Getting to Yes. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York and this is the podcast where I question leading eye surgeons about how they get their patients to say yes to the treatments they recommend. What exactly are the fair and balanced words they use?

Today’s podcast is about LipiFlow, which can be challenging to explain to patients. Talking with me about how they solve this problem are two leading ophthalmologists. Dr. Alan Carlson, professor of ophthalmology at Duke University School of Medicine in Durham, North Carolina, where he's been a faculty member for 22 years.

ALAN: Thank you so much, Marguerite. It's great to join you.

MARGUERITE: And Dr. Casey Claypool, Chief of Optometric Services at Empire Eye Physicians in Spokane, Washington.

CASEY: Thank you for having me, Marguerite.

MARGUERITE: Before we discuss LipiFlow specifically, I’d like for each of you to tell me about your practice. Alan, what are you doing at Duke?

ALAN: It's an academic practice. It involves a lot of teaching, it involves a lot of the more complex patients, some of the tougher cases, rather than, say, the straight cataracts. I typically do the cataracts associated with severe uveitis in combination with the retinal surgeons.

It's largely a surgical practice. I remember telling some of the folks that TearScience over a decade ago that even if this works I wasn't sure if I wanted to get involved in it, because I pretty much saw myself as a surgeon at least four days out of the week, and I didn't see myself becoming a dry eye doctor.

The reality is that you cannot be a busy surgeon without seeing dry eye patients, and very likely potentially making them worse as you offer them surgery. Just like I'm not a glaucoma specialist but I don't want to miss glaucoma, I'm not a retinal specialist but I don't want to miss treatable retinal problems, and now dry eye has become a greater recognized issue with surgical patients, so I'm more proactive rather than reactive in treating a dry eye patient.

MARGUERITE: What about you, Casey?

CASEY: I'm in a mostly surgical practice. There are 3 ophthalmologists and 2 optometrists. When I first went into practice 6 years ago, we had two ophthalmologists, Mark Kontos and Chris Sturbaum, and then I came on board. We do primarily anterior segment with the retina now with our retinal surgeon, and we have a high volume of referred patients from our comanaged optometrists and several ophthalmologists that send us patients as well. We see a lot of disease, a lot of dry eye, and a lot of happy patients afterward. It's a fun job.

MARGUERITE: Each of you got involved with LipiFlow pretty early, isn’t that right?

ALAN: Oh, yeah. I was working with the company years before it became FDA approved. They're not too far from us, so I've actually spent quite a bit of time at the facility working closely early on. They're very responsive to the recommendations that I had to offer at that time.

CASEY: When I was first hired, Mark and Chris, we talked about launching a dry eye clinic and a dry eye center of excellence. I was tasked with the responsibility to find a platform to best help treat patients. We knew we had plenty of patients, and we clearly had a lot of dry eye with our surgeries, but we also had a lot of patients just coming to see us wanting more options to treat their dry eye. We investigated, looked at different options, and decided to purchase the LipiView and the LipiFlow system back, yeah, almost about four and a half years ago now.

MARGUERITE: Would you ever propose it to someone who's asymptomatic? Do you reserve it just for your more severe patients? Do you introduce it early and to people who are completely without complaints but in whom you have detected dry eye, ocular surface disease, blepharitis, via your exam or tear osmolarity or InflammaDry or however? When do you introduce LipiFlow?

CASEY: That's a great question. We screen heavily all of our patients, whether it be with questionnaires or imaging. Our technicians know to image. We love the meibography with LipiScan and there are other platforms out there, but we love meibography to image patients.

All of our LASIK patients and nearly all of our cataract patients receive imaging prior to their surgical consult. We find that really helps in aiding the discussion with the patients. I do introduce it to many asymptomatic patients to let them know what's going on.

But it's amazing, you know, Marguerite, and I'm sure you see this too, how many of these patients we think are asymptomatic but they're not. Once you start to ask them the right questions, the symptoms come tumbling out. That, I'd say, happens in about 90% of the patients that we think were asymptomatic. There actually is a symptom.

ALAN: Somebody said to me "You wouldn't offer expensive LipiFlow to somebody that wasn't symptomatic, would you?" I said, "Of course I would, in the same way that I would offer glaucoma treatment to the asymptomatic but progressing glaucoma patient." There is no single chronic progressive disease that isn't more readily, effectively, and efficiently treated earlier in the course of progression.

Dry eye is no different, and one of the big mistakes we make in treating dry eye is that we focused on symptoms. In other words, if somebody with eight out 10 dry eye or Meibomian gland disease or ocular rosacea, comes in, but they tend to be fairly stoic and have one or two out of 10 symptoms, they tend to get one or two out of 10 treatment.

Similarly, if somebody comes in with one or two-plus dry eye disease, but a nine-plus, nine out of 10 symptoms, we treat based on symptoms. That's a mistake. We really need to treat early, before we see gland dropout, architectural changes, interior migration of the mucocutaneous junction or the line of Marx as it becomes more irregular and thickened, staining with lissamine green. Yes, I'd bring this up very early.

CASEY: Just Saturday, I was talking with some fellow optometry friends of mine about a recent LASIK consult we had who the patient was asymptomatic in her contact lenses, yet I looked at her glands, as we always do, and she'd lost over half of her glands already. I began to ask her some more questions, and sure enough, she had what she called normal end-of-day dryness with her contact lenses. Again, once we started to tease out symptoms, we found much more there, and then of course we treated her and she did LipiFlow and did fantastic with it.

ALAN: The other thing, too, is having such a busy surgical practice, not only bringing this up, but documenting it prior to surgery. This way, you're setting an expectation. They can choose not to have this prior to surgery, and they can have their LASIK, they can have their cataract surgery, they can have their corneal surgery. If they come back and they have dry eye, possibly even made worse by the surgery, by the LASIK, by the irrigation of cataracts by the post-op drops, all those things can make them more aware of their dry eye.

But you've documented that, and you set an expectation. If you have that discussion after surgery, even if it's documented, but you didn't bring it up to the patient, they may process that as more of a complication rather than something they could have expected.

MARGUERITE: I couldn't agree with you more. I bring it up to asymptomatic patients all the time if they meet my criteria. I say to them, "This is a problem we have in medicine, because exactly right. The person with high blood pressure doesn't feel a thing till the stroke. The person with high cholesterol doesn't feel a thing till the heart attack, et cetera." It's been documented that half of people with ocular surface disease, clinically significant ocular surface disease, have no symptoms.

CASEY: I definitely never want patients to feel like I'm selling them something, and I believe our patients feel that. They feel that we're presenting them with information. We just say, "Hey, look, this is what you have going on. This shows what your disease is, and these are the best ways to treat it."

MARGUERITE: You know, I so agree with you about the importance of meibography. You can say, "You have advanced Meibomian gland disease and dry eye." "Yeah, yeah, yeah." I mean, they listen to your little speech, but you show them a normal meibography picture and then you show them their picture and it's like a brick in the face. Their jaw drops and then they're much more receptive to anything that you propose. Would you agree?

CASEY: Completely. Completely. Many will ask the technicians and say, "How can I treat this? How can I fix this?"

MARGUERITE: Exactly right. Which brings me to the next thing. I'm Mrs. Smith and I'm sitting in front of you and your office is full and there's some people waiting to see you, but you want to tell me about LipiFlow quickly, in a well-balanced way, but to get me to say yes.

CASEY: Mrs. Smith, we see you have these symptoms, and as you can see from this picture your glands are blocked. These glands are designed to produce an oil that lubricates the eye. I may tie in some of the symptoms they have here at that point.

Then I say, "You have this condition, and if we leave this alone, these glands continue to die off. Just like with anything in the body, if we don't use it, we lose it. My goal is to try and unclog these glands so we can save what you have and get the ones you have working to work better. The best way to treat it, there's a treatment called LipiFlow that will unclog your glands. It's an in-office treatment, very safe, very effective. We've done it for years. This is the best way to treat your disease."

Then at this point I will gauge their receptive nature off of the cost, too. I'll throw in, often, the cost and say, "This costs about $1,000 for both eyes and it's not covered by your insurance." Then I can gauge their response. There are some patients that just can't afford it. Then I may say, "Here, this is the best way to treat this," and then we'll go in and say, "If and when you can do this, let's do it, but here's some of the things we can try, like compresses, your fish oil supplements and so on," because I'm a big believer, of course, in all that.

You can gauge. I'm sure you've seen the this too. Some of the patients you just know can't do it. I still present to them to let them know this is the best way to treat your disease, because we never want to make that cost decision for the patient. Then I will, 95% of those patients I'll continue and say, "It's not covered by your insurance." Then I'll start to explain just briefly how the treatment works.

I'll say something to the effect of, "We place this device in your eyelid, it sits there for a few minutes, and it will unclog the glands. It heats them up, massages them. It feels more like it's therapy on your eyelids, and that will remove the obstructions so your glands can work better." Then I just leave it at that and then see what questions they may have. Of course we may discuss it further, but I'll try and address especially the preventative nature of the disease.

ALAN: What I like to do is I'll try to find out how symptomatic they are. Very commonly, the technician won't even document that. They're there for cataract surgery. They're there for their DMEK triple for Fuchs' dystrophy, but yet you look at them, you see the irregular lid margin, you see some maybe ocularization. You ask them how they're doing, and they want to talk about their vision. "What about your eyes?"

As you talk about this to them, they'll almost always bring up symptoms that they have attributed to, say, just getting older. They're really there for something else, and their vision, they've noticed that, but these other symptoms they just associate with getting older. When you talk to them about being able to help those, and not only help those but make them better prepared for their upcoming surgery, that's a really good discussion.

Then they may bring up, "Why haven't I heard about this before?" Then we go into that discussion, that not everybody is attuned to looking for this. That's when I may show them their Meibomian glands, their Meibomian gland imaging. I may ask them about previous chalazion if they've got irregular lid contour. Those things come up fairly commonly.

Then I'd show them a very short video, about 45 seconds, of an actual patient undergoing LipiFlow close up with high resolution, showing that third two-minute segment where the glands are really being ratcheted with vector thermal pulsation. They get pretty excited about it. Then as we pursue that, we document that discussion and we determine if they want to do it that day.

MARGUERITE: Do you find that when you propose it to them and it's an out-of-pocket expense, it's not insignificant, and then after that you're talking about premium channel surgery, femto, multifocal, EDOF, whatever, do you ever get pushback, like, "Hey, how much out-of-pocket can I spend?" How do you deal with that kind of thing?

ALAN: You know, it's sometimes the case. If we do preoperative LipiFlow, we do femtosecond laser, and we do a multifocal or combinative lens, for both eyes it's $8,800 out of pocket. I'm surprised that the acceptance is so high, because as your patients validate, they feel that this is their eyes, they're having surgery earlier with higher expectation, a lot of these are my post-refractive patients from 18 to 20 years ago, things like that, so they've already got that confidence. They just want the best.

Now, if somebody comes in and says, "I just want what insurance covers," then we're going to do that, but I'm also not going to ignore the glands. I'm going to work on those glands and I'm going to get those glands addressed somehow, even if it's not with LipiFlow, even if I've got to do manual expression. I'll tell them, I'll say, "The LipiFlow that we talked about is a lot more effective, it's a lot more comfortable, but I'm honoring the financial situation here. If you let me, I'm going to work on your eyelids and do some Gary Fouts-style manual expression, try and get those glands open and functioning again."

CASEY: I like to discuss cost with the patient so they aren't surprised later. At the same time, I hate discussing cost with the patient, and I want to remove myself from that. I do present it just so they know, and we do a similar thing with most of our premium lens patients as well.

We found that to be the most successful in our demographic, in our market. Spokane's primarily a blue-collar working environment. We found that helps coming from the doctor so the patient knows what they're getting into financially, ahead of time.

MARGUERITE: As far as the actual treatment, do you put the activators in and leave a technician behind, do you stay there the whole 12 minutes?

CASEY: Yeah. The doctor will debride prior with a spud. We have our technicians insert and sit with the patient and remove. We found that that helps with chair time. It's fantastic for continuing to see patients, helps with the profit margin for sure. The patients are very receptive to that. They want to know the doctor's involved, so we're there at the very initial outset, but having the technician there, we've done that that way for about three years.

ALAN: I'm actually doing the lid preparation, I'm doing the lid examination, lissamine green if needed. I'm inserting the activators and all that.

Now, I do leave a technician with them during that 12-minute procedure, and they know where I am if there's any type of issue, because I don't want one of the lids to pop out or anything like that. I like to have a patient feel like there's somebody in the room, especially if you're doing both eyes at the same time. Usually a relative's also in there with them as well.

ALAN: Even the patients volunteer. "Oh, this is like a spa-like treatment for my eyelids." When you say that, you know you've created that right response and that atmosphere for the patient.

MARGUERITE: You know,I do something similar. After the American Academy of Ophthalmology in November, where I ran into a bunch of people who operate a dry eye center of excellence, and many of them had started to do BlephEx before the LipiFlow, so microblepharoexfoliation, and I almost never do them separately now. It's a one-two punch. You take that high-speed rotating sponge, 2,500 RPM, in the professional to the trade-only eyelid cleanser, and you clean off those lids. Patients like it, it feels good. Those orifices are open. You've gotten all the biofilm off.

Then immediately after that, you do the LipiFlow. I put in the activators and I leave and the technician takes them out. BlephEx 10 minutes, LipiFlow 12 minutes. Way less than half an hour, and I'm not the one in there for the 12-minute LipiFlow, so it's time-efficient for me.

MARGUERITE: Well, we’re about out of time for this episode. Thanks so much to both of you.

CASEY: Thank you again for having me, Marguerite.

ALAN: Thank you so much.

MARGUERITE: Before we go does anyone have anything to add?

CASEY: I for one am very passionate about this condition because I was contact lens-intolerant, and frustrated that as an eye doctor, even though I was doing what I knew to treat myself years ago, it still wasn't enough. That's partly why I'm so passionate about this condition. I was one of my first patients when we purchased this technology, and it was just life-changing for me.

I think it's important as doctors, we realize that we are the gatekeepers for the eye and we need to educate patients on their conditions even though that might not be their primary complaint, it's amazing how many of these dry-eye patients are out there that need education. That's one of my goals, is to help doctors understand this shift in paradigm of prevention, and educating patients on their MGD.

MARGUERITE: Thanks for that Casey. I get LipiFlow done routinely also, and when you can share that with the patient it makes a huge difference. And I hope we’re making a difference for our listeners and their patients as well. Thanks so much for listening.