adjunct treatments for dry eye disease
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Adjunct Treatments for Dry Eye Disease
An overview o selected products and their uses or the management o ocularsur ace disorders.
AVENOVA DAILY LID AND LASH HYGIENEAvenova daily lid and lash hygiene (NovaBay; Figure 1) is speci ically designed or patients withblepharitis, meibomian gland dys unction (MGD), and chronic dry eye disease (DED). Avenovaunctions by clearing debris and microorganisms rom eyelids and eyelashes and by reducing
in lammation. It is ideal as part o any lid hygiene regimen or DED, blepharitis (including Demodex),a er make-up removal, contact lens wear, and ocular surgery and procedures, according tocompany literature. Avenova contains Neutrox, a pure, proprietary, stable ormulation ohypochlorous acid (0.01%), the same molecule used by white blood cells to inactivate pathogens.
In vitro studies o Avenova demonstrated an antimicrobial kill time o less than 1 minute. Studieshave con irmed Avenova’s broad-spectrum activity against microorganisms, including those mostcommonly ound on eyelids and eyelashes: Serratia marcescens, methicillin-resistantStaphylococcus aureus, Staphylococcus epidermis, and Staphylococcus haemolyticus. Avenovahas also been shown to be e ective against Demodex.
Because it is well tolerated by patients and easy to use, Avenova can be used as a preventivemeasure and can be incorporated into a patient’s daily lid and lash hygiene regimen. Patients withblepharitis and other serious lid and lash conditions have seen results with Avenova in 2 weeks,according to the company. Marked decreases in dryness, redness, itching, and burning have beenreported. Soothing and re reshing, Avenova improves patient compliance. It does not have anycontraindications or side e ects, so patients can eel com ortable using it every day.
Avenova is available in 40-mL bottles and requires a prescription. The recommended regimen istwice daily or 2 weeks or as directed by the physician.
1. Avenova. http://avenova.com/. NovaBay. Accessed March 18, 2016.
April 2016
By Callan Navitsky, Senior Editor; and with expert commentary from Ahmad M. Fahmy, OD, FAAO, DIPL ABO; P. DeeG. Stephenson, MD, FACS; Jodi I. Luchs, MD; Cynthia Matossian, MD, FACS; Rohit Shetty, FRCS, PhD; HarshaNagaraja, MS, FCE; and James S. Lewis, MD
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Jodi I. Luchs, MD • Codirector, Department o Re ractive Surgery, North Shore/ Long Island Jewish Health System,Great Neck, New York • Assistant Clinical Pro essor, Ho stra University School o Medicine, Hempstead, New York • Director o Clinical Research and Director o Cornea and External Diseases, South Shore Eye Care,Wantagh, New York • [email protected] • Financial disclosure: None
CLIRADEX ALL-NATURAL CLEANSERCliradex (BioTissue; Figure 3) is an all-natural,preservative- ree lid, lash, and acial cleanseror the management o symptoms associated
with blepharitis, MGD, rosacea, DED, Demodexin estation, chalazia, and other lid margindiseases.
Unlike traditional cleansers derived rommanmade chemicals, Cliradex provides anatural way or patients to keep their eyelidsand skin clean, com ortable, and healthy,according to company literature. Theproprietary, all-natural ormulation in Cliradex issa e or everyday use as part o a regular ocularand acial hygiene regimen.
Cliradex is derived rom key constituents oMelaleuca alterni olia, a special variety o teatree oil. Over 20 years o research has beenconducted to develop and support thee ectiveness o Cliradex or OSD. In act,Cliradex is the only commercially availableproduct that isolates 4-Terpineol, the mostimportant ingredient ound in tea tree oil. 4-Terpineol has been demonstrated to sa ely ande ectively kill Demodex mites better than tea tree oil and other ingredients.
Cliradex with 4-Terpineol is delivered on a so , single-use towlette, which patients can purchaseonline or through their eye care providers. BioTissue also o ers the Cliradex Complete AdvancedHygiene Kit, which consists o a ormulation or in-office application that boasts a strongerconcentration o the isolated 4-Terpineol than in the Cliradex or home use.
Cliradex o en provides immediate relie through a cool, tingling, menthol-like eeling. Within days,mites begin to disappear and patients’ eyes eel relie , according to the company.
1. Cliradex. http://www.cliradex.com/physicians/. Accessed March 11, 2016.
THE IMPLICATIONS OF EYELID DISEASE ON THE OCULAR SURFACE: CLIRADEX AS A TREATMENTOPTION
BY CYNTHIA MATOSSIAN, MD, FACSBlepharitis a ects millions o people, and Demodex mites can be one o the underlying culprits. Notonly are Demodex mites linked to lid margin disease, but also they can exacerbate preexisting
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conditions such as DED, MGD, and rosacea blepharitis, to name a ew. Unless it isaddressed ahead o time, blepharitis can a ect cataract and re ractive surgeryoutcomes, disappointing patients who o en have high expectations or thesesurgeries. One way to help patients with OSD is to include Demodex in the di erentialdiagnosis.
Blepharitis causes itching, lid crusting, oreign body sensation, luctuations in vision,ocular discom ort, and red, swollen eyes. Demodex is an ectoparasite that resides on skin, o enharmlessly. However, when these microscopic mites multiply out o control, they contribute toblepharitis, rosacea, MGD, chalazia, and ocular sur ace in lammation.
Clinical signs and symptoms. There are several telltale signs o Demodex: waxy collarettes aroundthe bases o the lashes, greasy scales on the lashes and lids, thickened meibum, hair loss in thelashes or eyebrows, and cutaneous pustules around the eyes.
Educating patients with signs o Demodex. There are two schools o thought about how toapproach patients with signs o Demodex. One is to epilate a lash and show the patient the mitesunder magni ication, which can help with compliance. Without trying to scare the patient,physicians must be honest and matter-o - act about the condition.
Figure 4. A patient with Demodex blepharitis and cylindrical dandru (A), superior blepharoconjunctivitis (B),and in erior blepharoconjunctivitis (C). A er 6 weeks o treatment with Cliradex, the patient returned withclean lashes and white, healthy eyes.
Another approach is to show patients the cylindrical dandru along the eyelashes on a slit-lampphotograph. The patients can then see the telangiectasias, the lash loss, the scalloped lidappearance, and the pyramidal extensions around the base o the lash. The physician can explainthat this is a common condition and that everyone has some mites, but that a proli eration o thesemites can cause the undesirable symptoms.
Cliradex is an all-natural lid, lash, and acial cleanser that comes in individual packets. Cliradexcontains 4-Terpineol, which more e ective than tea tree oil itsel in eradicating Demodex. It is alsoless toxic, more com ortable, and more convenient or patients than tea tree oil.
Depending on the severity o the patient’s signs and symptoms, there are several ways to use
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Cliradex. For patients with severe cases o Demodex in estation, using Cliradex Completeadministered in the office may be the best irst step. Cliradex Complete contains a higherconcentration o 4-Terpineol in a cream orm. It is applied along the patient’s lash lines, brushedthrough the lashes, and le on or 3 to 5 minutes with the patient’s eyes closed. A er thetreatment, the cream is wiped o using a Cliradex wipe, and the patient is asked to purchase a boxo Cliradex wipes to use once or twice daily or maintenance treatment. For less severe cases, theclinician may choose to just have the patient use the wipes at home once or twice daily or a periodo 6 to 8 weeks to eradicate the mites and their eggs.
Cliradex can cause mild burning and stinging; however, most patients are ine with the way it eelsas long as they know what to expect. Education begins by demonstrating how to use the product inthe office. The Cliradex tingle can be described to patients as uncom ortable in the beginning sothat they are pleasantly surprised to ind that it is not as harsh as they were expecting. It is alsoimportant that patients be instructed to keep their eyes closed until the solution has ullydried. Some patients do well by putting a cold washcloth on the ace prior to using the Cliradex lidwipes.
Lid margin disease with Demodex in estation is common. Cliradex can be an e ective and easy-to-use treatment option or patients who experience this condition (Figure 4).
1. Cheng AM, Sheha H, Tseng SC. Recent advances on ocular Demodex infestation. Current Opin Ophthalmol. 2015;295-
300.
2. Bhandari V, Reddy JK. Blepharitis: always remember Demodex. Middle East A r J Ophthalmol. 2014;317-20.
3. Liu J, Sheha H, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol.
2010;10(5):505-510.
4. Liang L, Ding X, Tseng SC. High prevalence of Demodex brevis infestation in chalazia. Am J Ophthalmol. 2014;342-348.
5. Huang Y, He H, Sheha H, Tseng SC. Ocular demodicosis as a risk factor of pterygium recurrence. Ophthalmology.
2013;1341-1347.
6. Tighe S, Gao YY, Tseng SC. Terpinen-4-ol is the most active ingredient of tea tree oil to kill Demodex mites. Transl Vis Sci
Technol. 2013;2(7):2.
Cynthia Matossian, MD, FACS • Owner, Founder, and Chie Medical Officer, Matossian Eye Associates, Pennington and Hamilton,New Jersey, and Doylestown, Pennsylvania • [email protected] • Financial disclosure: None
LIPIFLOW THERMAL PULSATION SYSTEMThe LipiFlow Thermal Pulsation System (TearScience; Figure 5) is an inner and outer eyelid thermal-pulsation treatment that directly treats and unblocks the meibomian glands. LipiFlow uses vectoredthermal pulsating eyepieces known as activators, which are precisely designed to providenecessary inner and outer lid contact to apply heat and to massage and evacuate the meibomianglands, allowing them to resume oil production.
The entire treatment takes about 12 minutes per eye, according to company literature. The eye careprovider can determine how o en LipiFlow should be repeated based on evaluation o the patient’sgland unction and structure over time.
Controlled clinical studies have shown that, on average, LipiFlow achieves sustained three oldimprovement in meibomian gland unction, reducing symptoms to approximately hal the
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