This article was originally published in a sponsored newsletter.

We now have eight dry eye and ocular surface disease therapeutics to treat loss of homeostasis of the tear film, corresponding inflammation and, ultimately, damage to the cornea. The current therapeutics approved by the FDA that affect dry eye and the ocular surface are:

• 0.05% cyclosporine in an emulsion (Restasis, Abbvie)
• 0.09% cyclosporine in a nanomille delivery system (Cequa, Sun Ophthalmics)
• 0.1% cyclosporine in a water-free semifluorinated alkane delivery vehicle, perfluorobutylpentane (Vevye, Harrow)
• 5% lifitegrast in a solution (Xiidra, Bausch + Lomb)
• varenicline nasal spray as a neurostimulator to increase basal tear production (Tyrvaya, Oyster Point, Viatris)
• 0.25% loteprednol in a mucus-penetrating particle for episodic dry eye (Eysuvis, Alcon)
• 100% perfluorohexyloctane to reduce evaporative loss of tears (Miebo, Bausch + Lomb)
• 0.25% lotilaner ophthalmic solution to treat Demodex blepharitis and the associated irritation and inflammation (Xdemvy, Tarsus)

We typically use these therapeutics to address the chronic inflammation or excessive evaporation associated with ocular surface disease. While we continue medications to reduce inflammation and progression, we also need to recognize and address the damage that occurs to the meibomian glands as a result of the chronic desiccative stress. The obstruction needs to be dealt with because, otherwise, the evaporation will continue to exceed the supply of tears.

This is where intense pulsed light (IPL), radio frequency, low-level light therapy and thermal expression can be introduced to help the meibomian glands produce a greater supply of meibum and reduce evaporative loss. Lumenis has FDA approval for the treatment of dry eye disease with their IPL unit, and additional studies to gain approval with other modalities are ongoing.

Multiple thermal pulsation devices for the treatment of meibomian gland dysfunction have also been FDA-approved, starting with TearScience LipiFlow (automated vectored thermal pulsation) by Johnson & Johnson Vision. The Systane iLux, a hand-held unit (Alcon), gained approval next, followed by intelligent SmartLids by Sight Sciences’ TearCare system. SmartLids appropriately heats the upper and lower lids using SmartHub and uses a clearance forcep for manual expression. The newest addition to the market is MGrx (OcuSci) which is a hand-held device that heats all instruments including a debrider, a massager to warm the lids and a heated expressor. The heating is controlled automatically, while the debridement, heat massage and expression are accomplished manually. These procedures will have an associated “per treatment” cost, except the MGrx, which does not have an activator or disposables.

These thermal expression procedures have shown benefits to patients with meibomian gland dysfunction.They help the damage that occurs in chronic dry eye patients and add a revenue stream to your clinic.

Douglas K. Devries, OD has a degree in financial management from the University of Nevada and graduated from Pacific University College of Optometry. He is co-founder and managing partner of Eye Care Associates of Nevada. He is an adjunct clinical professor of optometry at Pacific University and residency program director. He dedicates the majority of his clinical practice to ocular surface disease.