BlephEx to Treat Dry Eye Symptoms

John A. Hovanesian, MD; William B. Trattler, MD; and Jennifer Loh, MD; join Marguerite McDonald, MD, to discuss the role of BlephEx (RySurg) in their practices to treat patients with dry eye. Find out more about the safety and efficacy of this procedure and how it works in combination with other treatments. The surgeons also explain how they educate patients about the benefits of BlephEx.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: This is Informed Consent: Getting to Yes, where leading eye surgeons discuss the fair and balanced words they use to help patients say “Yes” to the procedures the surgeons recommend. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York, and today’s topic is BlephEx.

JOHN: Of course, dry eye is part of every practice whether we like it to be or not.

MARGUERITE: Dr. John Hovanesian, a surgeon with Harvard Eye Associates in Orange County, California, and a member of the clinical faculty at the UCLA Jules Stein Eye Institute.

JOHN: I'm cornea-trained, we have two of us who are, we have glaucoma specialists, really the full gamut, 15 doctors. So we see every type of disease from mild to advanced across the entire spectrum.

BILL: My focus is cataract refractive and cornea and of course, I take care of a lot of dry eye.

MARGUERITE: Dr. Bill Trattler, the Director of Cornea at the Center for Excellence in Eye Care, in Miami.

BILL: We have 15 ophthalmologists and three optometrists in my practice. We have one main center.

JEN: I really became fascinated with the idea that we could actually provide patients with a quick and easy in-office treatment to clean their lids and remove what Jim Rynerson described as the biofilm on the lens.

MARGUERITE: This is Dr. Jennifer Loh, founder and director of Loh Ophthalmology Associates in Miami. And Dr. James Rynerson is the inventor of BlephEx, a device for in-office microblepharo exfoliation.

JEN: As I'm obsessed with cleanliness, I thought this was such a really great option for patients.

MARGUERITE: I couldn't agree more. The treatment in your office is done by you, or do you get a technician to do it or do you have a colleague that does it?

JEN: I do the treatment myself.

MARGUERITE: And I do as well, and I think, actually, Bill, I believe, does it and I think the conversion rate is higher.

BILL: One of the other ophthalmologists in our practice also does it for his patients and for patients referred in and then I'm the one who does it in my practice, whether it's by itself or in conjunction with LipiFlow.

JOHN: In my practice the BlephEx treatments are done by an optometrist who kind of specializes in dry eye, and runs a Dry Eye Center of Excellence. In fact, just a few of these patients actually see me for treatment when they come in for dryness symptoms. I will suggest a patient go through BlephEx when I'm seeing them for a cataract consultation, and when I'm concerned about the need for BlephEx just to optimize the ocular surface, and to also rid the eyes and the eyelashes of all this extra debris that harbors bacteria. As you know, in endophthalmitis the main cause of the problem is the patient's own bacteria.

MARGUERITE: So, do you ever do it, John, in combination with something else, or your optometrist? Like, BlephEx LipiFlow, or Maskin probing, or IPL, or any other office treatment?

JOHN: Yeah, it's a great question about how we combine BlephEx with other treatments, because of course BlephEx is a tool that addresses a really important and under-addressed part of the dry eye spectrum, which of course is the biofilms that are on the lids and lashes. So it pairs beautifully with treatments like LipiFlow, which we also offer. One of the nice things about it is you uncap the meibomian glands when you do this exfoliation of the lid margins, so a lot of those glands that have potential to work nicely will now again do so after you've treated with LipiFlow and BlephEx.

MARGUERITE: You know, it's interesting, for a while, our practice offered Lipiflow and BlephEx separately, but since the academy meeting in November of 2017, we almost exclusively do them back-to-back. They are so wonderful together.

BILL: That's pretty much mostly how we do it, as a combination of BlephEx and then followed by that, the LipiFlow works as a great one-two punch.

MARGUERITE: I agree; one plus one equals three. So, when you talk to patients, you're basically talking about BlephEx and LipiFlow, since they're done back-to-back. That's pretty much how I explain it as well. So, could you pretend for a minute that I'm Mrs. Smith, and Bill, you have decided that I need this combined treatment? Pretend I'm Mrs. Smith and tell me what you would say to convince me.

BILL: So, Mrs. Smith, I think we both know that we both like to brush our teeth a couple times a day. Is that not correct?

MARGUERITE: Oh, absolutely.

BILL: You brush your teeth, of course. Well, the reason we brush our teeth is because there's bacteria in our mouth that secrete a film onto our teeth and basically, if you don't brush your teeth, the film builds up and eventually, you could get something called gingivitis or inflammation of your gums. The same bacteria that live in our mouth also live on the eyelashes and they secrete the same film that builds up in our eyelids and on the eyelashes.

Sometimes, it almost looks like dandruff, but that film can clog up the oil glands and basically cover the orifices of the oil glands and cause blockage of the meibomian gland secretions. So, essentially, we have a treatment that can help get rid of that film that's building up and basically clean things off so that the glands can flow more properly.

JOHN: So, for patients who are symptomatic, often by the time they reach me they've been through a variety of different treatments for dry eye. So we're talking about this as kind of secondary or tertiary care, and the conversation is sort of like this. Mrs. Smith, you've got a real problem with the surface fluids in your eye, and that's partly because the glands that produce those fluids are being affected by overgrowth of bacteria, and those bacteria are there because they are living on and living from debris that's on your eyelashes and growing on the edges of your eyelids. It's something that no matter how careful you are in removing makeup, or washing your face, it's nearly impossible for you to remove completely. We can do that just as a dentist can clean your teeth way more thoroughly than you can. We can use a simple device to do a fairly simple, comfortable procedure here in the office that much more efficiently removes these causative films on the lids and on the eyelashes that will comfortably help to reverse the course of this disease, and hopefully make you quite a bit more comfortable.

MARGUERITE: Do you ever find that meibography helps you especially for the asymptomatic patients, John?

JOHN: Yeah, it's extremely important. There are two devices we find very important for especially the asymptomatic patient, because if the patient has no symptoms to undergo an out-of-pocket expense for a procedure that they don't really understand what it's achieving, you have to give them an understanding of their disease. And once people kind of own their disease, they are much more ready and willing to treat it. So meibography's great because it shows the destruction that's already happened in the glands.

Another approach that we're using is a little device called LashCam, L-A-S-H-C-A-M. LashCam is made by the same folks who make BlephEx, and it ties to a cell phone. So it's a little handheld camera that allows very high magnification with great clarity of the eyelids and lashes, and you can show patients directly the crud that's living on their lashes and lids. Once they see that, they understand, and you can show them an after picture as well because it's a dramatic appearance, before and after, with BlephEx.

MARGUERITE: I think you're absolutely correct, John. The more images we can show patients, especially asymptomatic ones, I've had patients gasp when they see their meibography pictures.

JOHN: First, they have no idea that their eyelids were so complicated, and there are these meandering glands that are within them. And then when they realize that a portion of them are dead, and vital to their good eyesight, it is shocking, and it becomes very evident that they have a problem.

MARGUERITE: So, Jen, I'm going to ask you to pretend I'm Mrs. Smith and that you have decided that I need BlephEx and if you could just talk to me and convince me to have BlephEx, please.

JEN: Well, Mrs. Smith, thank you for coming to the office today. On your exam, I noticed that one of the contributors to your chronic dry eye disease that you're expressing to me, and your chronic eye irritation, I see that you actually have what we call blepharitis on the lashes. Now, blepharitis is actually ... the best way to describe it, the best analogy I consider like, dandruff of the eyelashes.

That material can get into your eyes, cause irritation, and also, it actually really effects the oil glands and overall ocular surface health. So, even though there's lots of great eyelid sprays and eyelid washes and things that we can do at home to cleanse our eyelids, there's not as much that you can do for yourself.

It's very, very hard to actually get to the base of your eyelashes without causing some kind of injury to your eye. We are able to actually cleanse your eyelashes so much better with this amazing device. It's like a rotating soft, gentle brush. It's kind of like you're at the spa, and it gently cleans the base of your eyelashes in a way that you at home are not able to do.

It's a safe, effective procedure. It takes me under five minutes and all my patients have left feeling refreshed, cleaner, they had less crusting. While I would still encourage you to do cleansing at home, I really feel like this treatment will help get our headstart on the problem and really help solve a lot of your chronic issues.

On top of that, there's evidence that we're also helping to remove a lot of the [drop out] bacteria that's layering onto the eyelids, which we call the biofilm. So, I also like to describe it like getting a deep cleansing of your teeth. We want to go to the dentist every six months because even though we're flossing and brushing our teeth, we're not doing as good of a job as a dentist.

So, I think this is just as important as a dental cleaning and I really recommend it for you.

MARGUERITE: My explanation to patients is a little different. It goes something like this. You have severe dry eyes and blepharitis, and you've just seen your images of the glands, so what we're going to do is clean your lids first with a unit called the BlephEx. It's a high-speed rotating sponge, a soft sponge rotating at 2,500 RPM, and it's soaked in a professional to-the-trade-only eyelid cleanser. So I will do it, and it takes about 10 minutes. Nothing touches your eyeball, just your eyelids, and it feels good. Most people enjoy it, they think it feels like a high-end spa treatment.

JOHN: I'll explain that the treatment itself just takes a few minutes here in the exam room. It doesn't hurt, although a lot of people say it tickles a bit, and once it's done you will probably fairly quickly start to notice that your eyes are more comfortable. And that typically lasts from six months to a year, where the eyes stay fairly healthy and, although you won't give up your other treatments for dry eye, you'll continue to need to do all the things. This is an important part of the treatment, because it's kind of going to the root cause of the problem.

BILL: Every patient has the exact same thought and question, "Is this going to last for a couple weeks or a couple months?" What we found when we combine BlephEx with LipiFlow, it lasts for at least a year for most patients, if not longer. It's been pretty surprising. What we found is that at one month patients are a little bit better.

We actually see even further improvement at three months and often patients get slightly better at six months. So, it's actually progressive improvement over time following the combined BlephEx and LipiFlow treatments.

MARGUERITE: Do you find that people are upset or disappointed that it's not covered by insurance?

JEN: I price it at $125.00, which I know from reports is a little on the lower side, but I really believe in it so much, I want my patients to be able to have it. I present it as, "This, unfortunately, isn't covered by insurance," but, I say, "It's just like getting your teeth cleaned. It's still beneficial." And I haven't had anyone complain yet.

JOHN: Unfortunately, some of the best and newest treatments we have are not covered by insurance, and this one is included in that. We don't like that, but I only recommend it because I think it's something that will benefit you. And the cost, I explain what it is in our practice. It's $250 that covers treatment of both eyes. And we would expect that this is something we may need to repeat in the future, it depends on how you do, how your eyes are feeling. But if you're doing well, we won't repeat it until we see a need. But it could be as soon as between six months and a year.

MARGUERITE: Well, this has been great. All three of you have delivered on the promise of telling us how you get to Yes, plus a lot more. Does anyone have a final thought before we wrap this up?

JOHN: A study that was done about 20 years ago by Rhett Schiffman showed that patients that have moderate to severe dry eye have an impact on their lifestyle that's similar to the impact of heart failure. And it makes sense if you think about it. If your eyes are uncomfortable you're miserable, and you just don't feel like doing things. And just like if you have heart failure, you don't feel like going places or doing things. The weather, a slight change can dramatically affect the way you feel, and it gets in the way of doing things that you want to. And so we need to take dry eye seriously and address it very proactively, and these advanced treatments do exactly that.

MARGUERITE: Thank you, John.

JOHN: Always a pleasure to work with you, Marguerite.

MARGUERITE: And thank you Bill and Jen.

BILL: Thank you so much.

JEN: Thank you so much for having me. This has been a great experience.

MARGUERITE: I hope that’s true for our listeners as well. And please watch for our next Informed Consent: Getting to Yes podcast.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.