To The Point
Putting the "Eye" in IPL
Hosts Leslie and Jackie are joined by guest Damon Dierker, OD, FAAO, to share their experiences with intense pulsed light therapy for treating inflammation in patients with dry eye and meibomian gland dysfunction and discuss the procedure's limitations and positive cosmetic benefits.
Hosts Leslie and Jackie are joined by guest Damon Dierker, OD, FAAO, to share their experiences with intense pulsed light therapy for treating inflammation in patients with dry eye and meibomian gland dysfunction and discuss the procedure's limitations and positive cosmetic benefits.
Speaker 1 (00:06):
Ocular surface disease, it's complex, chronic and progressive, but rife with opportunity for the enterprising optometrist. The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it. So let's get To the Point.
Jackie Garlich (00:26):
Welcome to another episode of the To the Point podcast. I am Jackie Garlich and I'm joined by my cohost Leslie O'Dell. And today we are very excited to have another guest with us. We are joined by Dr. Damon Dierker.
Jackie Garlich (00:41):
Dr. Dierker is the Director of the Optometric Services at Eye Surgeons of Indiana and an adjunct faculty member at the Indiana University School of Optometry. He practices consultative optometry with special interests in ocular surface disease and retinal disorders. He has developed a dedicated dry eye clinic within his practice, and helps colleagues across the country, in this area with dry eye bootcamp educational programs. Additionally, he serves as president of the Indiana Optometric Association. We, he's a busy guy, but he made time for us. We're so happy to have you here. Welcome.
Dr. Damon Dierker (01:22):
Yay. Thank you. I'm excited to be here. I, I have a wife and two young boys and I occasionally sleep, but, um-
Leslie O'Dell (01:28):
Jackie Garlich (01:28):
Dr. Damon Dierker (01:28):
... I, um, 2020 has been a busy year for sure.
Jackie Garlich (01:31):
Yeah, it's been, it's been a year that's for sure. Well, one of the things we want to talk about today is IPL, but I'd also like to get, just like your background at your office. And, you know, the, one of the aspects of, main aspect of this podcast is to help people who really want to grow and build a dry eye practice and you have the, a thriving dry eye clinic. And so I wanted to maybe, just pick your brain on how you got there. And I know that's probably a very loaded question, but, how did you, how did this whole thing begin for you?
Dr. Damon Dierker (02:09):
Yeah, so when I got hired at Eye Surgeons in 2002, I actually did a retina fellowship. So my first several years is pretty much, I ignored the ocular surface as, uh, annoying thing to get to before I got to the retina. And now I still have a lot of patients with retinal disorders, but probably around 2012, I was seeing how many patients were having dry eye symptoms in my clinic or referral center clinic. How was it impacting cataract surgery outcomes? How is it impacts glaucoma and retina patients?
Dr. Damon Dierker (02:41):
And there really wasn't anybody in Indianapolis taking dry eyes seriously, the cornea specialists don't want anything to do with it. There really wasn't a dry eye center. So what I wanted to do is, you know, large patient population we have hundreds of referring doctors, is I really wanted to get good at dry eye because I felt like that was such a huge unmet need.
Dr. Damon Dierker (03:01):
So I took that upon myself to talk with colleagues, talk with industry folks, read as much as I can in the journals and just over time build something from the ground up. And then one of my major goals still after doing that, and that continues to be a work in progress, it always will be, is I didn't want to have to have everybody go through that same process, right?
Dr. Damon Dierker (03:25):
So that's where we came up with the Dry Eye Boot Camp education program to be able to hopefully shave a couple of years off that process for people because there's such a huge number of patients that are already in your practice that need care. And I really want to help others learn from my experience and others' experience in similar settings to be able to do this in whatever practice setting you're in.
Leslie O'Dell (03:50):
And you do that so well. And that's kind of where we started with this podcast was where, you know, how do you find a dry eye patient. And that's what I was, you know, saying to Jackie was they're in your practice and they're not that hard to find. Um, it's almost, you know, dry eye until proven otherwise.
Dr. Damon Dierker (04:07):
Well, you gotta know what to do with them too, right? Is, you can find them, but you have to have a plan for what happens then. So I really think you need a protocol. I'm a big fan of questionnaires. I like point of care diagnostics. But it's a system, it's the same thing every time. And we have to make this part of our routine. And it's not something that, in my training 20 years ago, was ever part of the routine.
Dr. Damon Dierker (04:33):
And I think even students coming out now, they're not ready to make it part of the routine. But it, you know, screening for MGD, screening for dry eye, both signs and symptoms needs to be as common as recording the CD ratio. You know, screening for glaucoma, looking at an IOP, looking for macular degeneration, and we need to be doing the same thing. And the, the reality is dry eye and MGD is 10 times more prevalent than any of those things. So these patients are everywhere in your practice and they really affect contact lens wear, your optical remakes, patient satisfaction. And you can really, I think, grow your medical practice through dry eye.
Jackie Garlich (05:13):
Yeah, I totally agree. I started doing, the SPEED questionnaire for every patient. In the beginning I was thinking I was just going to do it for just my people that I'm, have like identified as my dry eye people, but it has actually been extremely helpful for pointing out everyone (laughs) has problems, you know.
Dr. Damon Dierker (05:30):
It's, it starts, it starts the conversation that you're going to take this seriously. And they've not been to a practice maybe where they've had that sort of care. And I think you start that process early. And then even if they have this SPEED score of zero, they don't have any perceived symptoms or they decided to ignore the questionnaire. You still want to screen for signs. You still want to press on their glands. You want to put some force in, in the eye. So again, it needs to be a part of your, and you can't just decide, well, I'm going to do dry eye today, right? It doesn't work like that. It's, it's so common.
Jackie Garlich (06:03):
Dr. Damon Dierker (06:04):
And, and you, you, so that's, that's why you can't pick and choose who you give a SPEED questionnaire to, right? Because it's how-
Jackie Garlich (06:09):
Dr. Damon Dierker (06:09):
... how would you ever decide, you know. So I, I any- anyone that's new to me gets it. Other than, you know, if their, the first time seeing me their immediate one-day cataract postop, or if they come in and they have trauma and their eyes hanging on their cheek, then I'm probably not going to give them a SPEED questionnaire, but everybody else gets one.
Jackie Garlich (06:28):
Leslie O'Dell (06:29):
Jackie Garlich (06:30):
(laughs). So, um, alright. One of the things, and I've talked to you about this, like on the side before about, um, just IPL and incorporating IPL in your practice. And that is, um, something that I think is growing in interest. I don't think it had been that prevalent before, and I don't actually know the numbers of how many people have IPLs in their office. But I'm curious, um, maybe you can talk a little bit about IPL and why that is a useful thing in the setting of MGD.
Dr. Damon Dierker (07:02):
So we know that, in dry eye, inflammation is present in all forms. And the in-office treatments that I've had and done, when I started building my dry eye practice, after I developed a protocol with the questionnaire and my diagnostics, the first thing I added was a blephex. And we have multiple ways we can manage the lid margin. I also use AB Max and something, a system called ZEST. And then added different MGD, obstruction removal things. We've got four offices, we've got LipiFlow, tear care and iLUX. If they all worked very well.
Dr. Damon Dierker (07:44):
But those are managing biofilm, are managing an obstruction. When you add IPL to the mix or intense pulse light, that is the anti-inflammatory treatment. So if we know that inflammation is at the core of the disease and it's what's driving symptoms, it's what's driving progression. Now we have an in-office treatment that targets inflammation and it allows all of those other treatments to work even better.
Dr. Damon Dierker (08:14):
So what I find now is that when I take the boot camp approach, which is inflammation first, IPL is one of the first things that I'm going to be reaching for. And I can use that in conjunction with other anti-inflammatory treatments, nutraceuticals, lifitegrast, cyclosporine, etc. But there's a lot of patients that just don't want to use eye drops or they've, the eye drops are expensive or they burn or they just don't want to take them, they forget to take them.
Dr. Damon Dierker (08:42):
And what we use topical formulations to treat inflammation. Now we have a way with IPL where a lot of times that is their anti-inflammatory treatment. A lot of these folks that still have an, an a nutraceutical longterm but it's targeting the disease in a different way. And when I combine that with my other therapies, it, it just works so well that the thing that is overwhelmingly seen in the literature and I see it in my clinic is how patients like the treatment.
Dr. Damon Dierker (09:16):
95% of the patients say, I love this. I'm so glad I did it. So there's not very many other things we do in eye care that have a, you know, a 90% to 95% positive patient satisfaction rating.
Jackie Garlich (09:31):
Dr. Damon Dierker (09:32):
But that's where we're at with IPL. And it's, it's really fun. You know, there's a lot of things in our world right now that aren't a lot of fun.
Leslie O'Dell (09:38):
Dr. Damon Dierker (09:39):
... wearing a mask all day-
Leslie O'Dell (09:40):
Dr. Damon Dierker (09:41):
... and doing social distancing is not fun. From the very beginning when you start doing IPL, it's fun, because you are helping these patients not only feel better, they look better too. So then if you have this positive cosmetic benefit when you're targeting these abnormal blood vessels and pigments that once you explain to the patient, we're going to treat your inflammation, we're going to help your dry eye symptoms. And never going to have to deal with the side effect that your skin's going to look a lot better. And you're going to have less fine lines and less sunspots and those prominent vessels on your face, we can help that as well. Then it, you know, there, you never have to sell the procedure. You just have to explain what you're doing and the patient buy-in and adoption has been great.
Leslie O'Dell (10:28):
Definitely, I think that that whole cosmetic gain is a huge win. It, you've def- you've definitely change the whole, like you're saying, buy-in from the patient. Once you say that there's some kind of positive gain, they're like, sign me up. (laughs). And I do agree that it is a fun procedure. Now, do you pair that sometimes with other meibomian gland clearing treatments? It sounded like you might-
Dr. Damon Dierker (10:54):
Leslie O'Dell (10:54):
... sometimes do that first.
Dr. Damon Dierker (10:55):
Yeah. So there's a lot of things you can do. We know that IPL in looking at how Toyos developed protocols and how it's been done traditionally has been, you know, three or four sessions spaced out by 2 to 4 weeks and manual gland expression after every treatment. And that is something that I don't do. Um, based on talking with colleagues, the more recent literature is that almost every IPL will ha- will do 4 sessions of IPL. And if there's significant gland obstruction that I determined before we started the IPL, I will pair on that fourth session. I'll either do a LipiFlow, an iLUX, or a tear care along with the micro blepharitis foliation procedures. So we really hit all of those things, but we target inflammation first. Then we do our micro blepharitis foliation and treatment four, and then follow that with her obstruction removal.
Dr. Damon Dierker (11:59):
I would say that's probably 80% of my patients fall into that. The other 20%, if we're just starting with IPL, they have rosacea, they have lid margin telangiectasia. They have meibom that is maybe not perfectly clear, it's a little bit cloudy, but it's not terribly sick. Um, but they don't have a lot of obstruction. So there's some patients I occasionally will just do IPL only without any sort of expression, either manually or with a, a device, but that's in the, in the minority for sure.
Dr. Damon Dierker (12:35):
And I, I see that probably going forward best practice would be someone that you see that has symptomatic dry eye with MGD. Uh, they have some gland blockage, they have some lid margin telangiectasia. The gland quality secretion is not great is you do four sessions of IPL. You do an obstruction removal after you've treated the biofilm. And then probably doing a touch up IPL every 6 to 12 months, and then additional obstruction removal, uh, as needed based on your clinical exam and, to some extent, patient symptoms.
Leslie O’Dell (13:13):
So, just so I, because I wanted to ask you this earlier. So you have kind of modified the Toyos protocol a bit, and you're not doing the manual expression after the IPL. Is that what you are saying?
Dr. Damon Dierker (13:28):
I am rarely doing manual expression after IPL, because I feel like the four sessions of IPL with a more robust gland obstruction removal after that antiinflammatory treatment works, they're synergistic. So if I can treat those abnormal blood vessels, if I can reduce the Demodex burden, if I can modulate how those glands are working and then, and I can improve the, the quality of that, meibum secretion. And then I remove the obstruction at the back end of that. I think that works very well.
Dr. Damon Dierker (14:09):
What we don't know is, was it better to remove the obstruction first and then do IPL? We don't have those head-to-head. Certainly I plan to experiment with that a little bit, but a lot of our colleagues in the space, you know, Doug DeVries, Laura Periman, Whitney Houser, others that are, are doing this quite a bit say, you know, I really think treating the inflammation first and then doing the obstruction removal at the end makes the most sense. So I, I think that IPL can't do everything for you, but it can do a lot.
Jackie Garlich (14:42):
And are you then, so, so with IPL, I was telling Leslie this story actually, that I got a super piece of advice from you and you may or may not remember giving this to me but (laughs) when you were in a cab. And I was like, I just like really want to buy like this and that like, I feel like I need this. And, and I was like, well, what do you think I should do? And you were like, you shouldn't buy anything. Do you remember that?
Dr. Damon Dierker (15:09):
Yeah, it was after an ad board.
Jackie Garlich (15:11):
Dr. Damon Dierker (15:11):
We were going somewhere else.
Jackie Garlich (15:14):
Dr. Damon Dierker (15:15):
And I remember that conversation is you got to have a, you gotta have a protocol first.
Jackie Garlich (15:18):
Dr. Damon Dierker (15:18):
You got to figure out how you're going to, you know, identify these patients. And then you don't buy everything at once. And I would say that, you know, IPL, I definitely recommend it, but I also recommend that you find a way to remove gland obstruction.
Jackie Garlich (15:33):
Dr. Damon Dierker (15:34):
And if you're, if you're removing gland obstruction and you're doing that early enough, unless they have rosacea, you maybe, you maybe won't need an IPL. But, you know, I'm in a tertiary care center, a dry referral center. I am seeing patients that have seen three or four doctors, have been on every sort of treatment. There's a lot of IPL going on. If I'm in my general clinics, I'm definitely using IPL but I don't have to, I, if you do these things early enough and you treat proactively, you just don't have to do as much to be able to manage a patient.
Jackie Garlich (16:10):
Dr. Damon Dierker (16:11):
And so that's why don't go and buy every single tool-
Jackie Garlich (16:14):
Dr. Damon Dierker (16:14):
... that you have, that's out there until you figure out what's your patient base how are you going to present this. And start, you know, you got to build it but you don't have to build it over years, like I did. I think you can have us, you know, a 6 to 12 month plan of how you're going to incorporate dry eye. But I would do a couple of other things, specifically establishing protocol, finding a way to manage the biofilm, finding a way to remove gland obstruction, have those tools in your tool belt 'cause you're going to use those so often. And then to get the whole enchilada, you, you add the IPL, then, then you can help almost everybody that comes in with your typical dry eye, MGD, rosacea sort of appearance.
Leslie O'Dell (16:59):
So that's one question that I had is the, almost everybody, because IPL is limited in, in our skin tone, I think is part of our limitations. And then someone was just bringing up about avoiding it if there is permanent eyeliner tattoo that you don't want to be doing IPL near that, or for the risk of hair loss I guess if you get too close to an eyebrow or eyelashes.
Dr. Damon Dierker (17:24):
Yeah. So the IPL, the light is going to be absorbed by any sort of pigmentation, whether it's the, you know, blood vessel or pigment in your skin or a hair follicle or permanent eyeliner. So if you have a lot of pigments, you have to use less energy. And then there's going to be changes in your facial tone. So therefore, what's the unit that I'm using, which is luminous, you know, Optima M22 IPL.
Dr. Damon Dierker (17:58):
We are not going to be able to treat heavily pigmented individuals. And so in my patient population, which is probably 80% to 90% Caucasian in central Indiana suburbia, uh, most of my patients are eligible and, and candidates for IPL, if I see other clinical features. Other parts of the country, you may have some patient populations they're just too heavily pigmented to be able to treat. So you do have to take that into consideration.
Dr. Damon Dierker (18:31):
As far as the, the eyeliner, you know, we're never going to get close enough in our normal methods with how we use the protective eye covering where that's going to factor in. There's sometimes you can use, you know, laser grade shields and put those directly on the globe, and you could get as close as you want, but I just avoid anything like that. So it's never an issue and it's not a absolute contraindication. And certainly it's not a big factor in my patient population with the eyeliner.
Jackie Garlich (19:05):
You just talking about that eye shield, um, bring up another thought. Have you, have you been using this? I know that Laura Periman does this for like chalazions, hordeolums. Do you use the IPL for this? And it is that in an acute setting or?
Dr. Damon Dierker (19:20):
I've done it with the end of probably five and I've been happy with the results. I will tell you that I am not an expert in the settings and other things you can do with a mask and probe or other more invasive things. So I would definitely talk with Ahmad Fahmy or Laura Periman if you want to dig in a little bit more on the management of chalazia with IPL, because I think it's, it's cool, it's interesting.
Dr. Damon Dierker (19:48):
But I think there's still a lot we don't understand. There's not a lot in the literature and people are just trying to figure it out. So I, I do it on occasion. Uh, what I have seen, you know, some of these patients that have history of chalazia that have just really vascularized layers and they say their biggest complaint is my eyelids are red. It's not even my eyes. It’s just, I'm worried about how red my eyelids look. And that's where I will use a cornea shield and go as close, you know, within maybe 2 millimeters of the lash line and treat as close to the lid margin as possible 'cause I really want to target those vessels.
Dr. Damon Dierker (20:23):
But for probably 90% of my population, we just use sticky shields and we're not getting quite that close. And all of this vasculature in your face is connected. So if I'm shooting even, you know, several millimeters below the lash line, uh, I'm going to have a positive effect. And then there's probably two thirds of our patients are going to do more than just tragus to tragus. So in a typical patient, we're going to treat along V2, you know, from ear to ear more or less.
Dr. Damon Dierker (20:54):
But most people want to have the positive cosmetic benefit as well. So we're going to treat their full face. Unless it's a male that wants to be able to grow a beard at some point, 'cause you're going to be able to decrease with certain settings (laughs), uh, if you hit a hair follicle many times, it may not want to grow back for awhile. So you have to-
Leslie O'Dell (21:14):
It also, it's, it also-
Dr. Damon Dierker (21:15):
... care for that.
Leslie O'Dell (21:15):
... does not smell so good. (laughs).
Dr. Damon Dierker (21:17):
Yes, you have to, probably those patients that you want to do, the hair removal, you should wait until the end of the day. (laughs).
Jackie Garlich (21:24):
Leslie O'Dell (21:25):
My experience was with a gentleman that I was going across the bridge of his nose and didn't realize that he had a few stray hairs there. And I've, I just caught that smell of burning flesh and thought, oh.
Dr. Damon Dierker (21:36):
And they say, and they say, well, what is that? I say, that's you. (laughs).
Leslie O'Dell (21:39):
Dr. Damon Dierker (21:39):
(laughs). No, the, yeah, so you all hit hair follicles or, you know, females that have little fine hair on the cheek and you know, yeah, you'll get a little bit of smell from that but it's, it's not a big deal. But the key there with IPL, it's not just one treatment, it's really a, a series of treatments. So you have to set expectations that this is going to be a process, we're going to do, uh, I like to do four treatments. I know some centers will do three, uh, but I like to do four, is a standard spaced out by 2 to 4 weeks.
Dr. Damon Dierker (22:12):
And I tell patients you'll feel good after the first one, but there will last maybe a day. And then after the second one, it'll last a little bit longer. But as this, as we continue to treat these abnormal vessels, um, after the third session, and especially after the fourth, we're going to have that prolonged effect where they're going to have less inflammation, their MMP-9 scores with InflammaDry are going to be down. They're going to have less corneal staining. Their tear breakup time is better. I mean, really all of the different metrics that we measure in a dry eye patient can be improved with IPL.
Jackie Garlich (22:51):
Um, so touch a little bit. If you have some experience on some of the, the latest research I've been seeing about IPL, when it comes to Demodex blepharitis, have you seen some positive there in your clinic?
Dr. Damon Dierker (23:03):
So we know that IPL definitely has a impact on Demodex load. And I'm into, I'm going to definitely go back and listen to you guys' episode on Demodex 'cause I'm intrigued about that.
Jackie Garlich (23:17):
Leslie O'Dell (23:17):
Dr. Damon Dierker (23:17):
I've, but I, I don't see it in my hands as a primary treatment for Demodex. I think we have other ways to treat that. We know that rosacea patients and patients with recurrent chalazia have much higher levels of Demodex. So it's going to help those patients that are going to have the biggest benefit from IPL. But if, if someone, their main issue is Demodex blapheratis. I'm not reaching for my IPL as a primary therapy.
Dr. Damon Dierker (23:45):
The IPL is really going to be for patients that have MGD symptomatic dry eye, with or without rosacea. Usually we're going to want to find, you know, lid margin telangiectasia. But I think if you look at most the, of your patients, almost everybody has that. But interesting in the literature, people have had reports of very good symptomatic improvement, even in patients that don't have lid margin telangiectasia.
Dr. Damon Dierker (24:14):
So there's still some things about mechanism of action that we don't understand entirely with IPL, but there, there's multiple things that it does. And one of those is it does try those little Demodex buggers, but it's-
Jackie Garlich (24:26):
Dr. Damon Dierker (24:26):
... not a primary, primary treatment in my, in my clinic for that.
Jackie Garlich (24:30):
So you, you said, uh, do you use, do you use this in like a package with like, do you package this with a thermal therapy on those patients that you know are going to need that?
Dr. Damon Dierker (24:40):
That's what I do. Is we package it, we let them know exactly what that's going to look like. I make my recommendation. And then what I've evolved to over time and I think it's the best way to do this as it's our job to be the eye doctor, to tell a patient what they have, to make a recommendation about the best way to treat their problem.
Dr. Damon Dierker (25:02):
And then I will lay out, we're going to do IPL. Then on the fourth session, we're going to do a couple of other things, including, uh, treatments to remove blockages from your glands. And then I leave the financial piece to a staff member. I make a hand-off. And that then be the one to talk about, this is what it is going to cost. These, these are your options in terms of, uh, payments, including, you know, health savings accounts and care credit and other things.
Dr. Damon Dierker (25:31):
It's really not my job to do that part of it. So if you're in a clinic where you have an ability to have a staff member help you out there. If you know, if you go to the orthodontist, you know, I just had Invisalign done a year or two ago, the orthodontist doesn't talk to me about payment options, right? They, they've got a team that does that.
Dr. Damon Dierker (25:50):
That's where we have to evolve to as a profession is utilize somebody on your team to be able to do the things that aren't doctor work. Those are things that can be delegated, and I think it really sets our job as to, we want to talk with the patient. We want to make a diagnosis, we want to recommend treatment, and then leave everything else to staff as much as possible.
Leslie O'Dell (26:14):
Which, uh, is great. You know, that's great advice. Um, because that's where most, I mean, not most, I would say that's where a lot of doctors kind of get tripped up on themselves and then they start getting hung up on costs and then they actually sorta change the recommendation. So I do what, you're, what you're recommending as well. I, I try to always recommend the best thing regardless of, of price to the patient because you can't, much like you can't decide who to give your SPEED survey to, you can't really decide who is to invest in a treatment. But what you can do is lay out the best treatment, you know, provide them the resources, whether it's through financing or payment plans so that they can achieve, you know, success and, and a better out.
Dr. Damon Dierker (26:56):
Yeah. I mean, it's not fair to the patient. I mean, why would I want to make a judgment as to what the patient will or won't do. If they go to another health care professional, that's not the way that those encounters look. So we have to get out of that habit as optometrists. We need to be doctors and we need to give the patient great advice. Yes, we want to have the potential to give options. But if I think the best option is IPL, I start with that. And if for some reason they can't or won't do that, well, then we move to another option. I don't give them here's three options, Mrs. Smith, you decide which one you want to do. I think how would Mrs. Smith have any idea what's the best treatment for her? It's our job to figure that out. It's our job to make that strong recommendation.
Dr. Damon Dierker (27:46):
And then, yeah, there's, not everybody gets a recommendation for IPL in my clinic. Not everybody gets recommendation for LipiFlow or tear care or iLUX. I just do what I think is best. And sometimes best is giving them a lubricant drop and a warm compress, but that's going to be for very early disease. And when you're talking about, you know, level two, level three disease, they're going to need more if they want to have a definitive treatment and it's our job to provide that advice.
Speaker 1 (28:22):
And now for the To the Point wrap up. Thanks to Dr. Dierker for a great podcast. And highlighting the fact that inflammation is present in all types of dry eye disease. Intense pulse light, or IPL, manages inflammation associated with dry eye disease and meibomian gland dysfunction. Often IPL can enhance the outcomes of our more traditional meibomian gland clearing treatments, such as LipiFlow, tear care, and iLUX. IPL can also be used along with topical antiinflammatory medications as IPL targets inflammation in a different method. IPL offers high patient satisfaction ratings and is fun for the eye care provider.
7/23/2020 | 29:15