Even Dry Eye Specialists get the Blues.
As a mentor to other dry eye doctors, I am sometimes asked why certain treatments “fail” to improve their patients. Even dry eye specialists can get confused (and depressed) when their best efforts fail to help their patients, and since this question is relevant to that issue, I thought I’d post one of my recent answers.
The question I answered went something like this (paraphrased): “I’ve used frozen, preserved amnion contact lenses (Prokera) to treat a good number of patients with SPK, only to find they continue to have SPK – what am I doing wrong?” The doctor went on to detail some of the dry eye treatments used for these patients, including night ointments and nighttime patching, lots of artificial tears, cyclosporine or lifitegrast, Tyrvaya (the nasal spray that stimulates tear production), lotemax (a topical steroid) for flares and home therapies or Low Level Light Therapy (LLLT) to manage the Meibomian Gland Dysfunction (MGD).
One treatment I discussed in an earlier blog referred to using Amnion membranes to help heal damaged eye surfaces (see here: https://www.eyethera.com/blog/what-to-do-when-the-surface-of-your-eye-gets-broken-scratched-operated-on-infected-or-otherwise-damaged ) - which applies to the Prokera referenced in the question above. Amnion is the tissue surrounding a baby growing in a mother’s womb, and the influence it has on the baby is both nourishing and generally supportive of helping the baby grow quickly and healthfully in that womb. As such, I’ve referred to using these membranes as a means of “putting the eye back in the womb” to help heal surface damage.
https://biotissue.com/products/ocular/prokera/#prokera-form Image of the popular “Prokera Slim.”
Superficial Punctate Keratopathy, or “SPK” is the common finding in many types of eye-surface diseases (and refers to groups of damaged cells on the surface of the eye which are best seen using a microscope and fluorescein dye - see photo)
The photo was taken through the eyepiece of an examination microscope using an iPhone camera after applying a drop of fluorescein dye and using a blue filter. This patient has a geographic area of “torrid SPK” on the illuminated cornea, that looks a bit like a leaning chess rook, with some patchy, more typical SPK to the right of that “rook.” Looking further, we can see a small “divot” or “notch” in the margin of the lower eyelid, which is a common finding following the healing from a stye (this patient had a long history of them). We also see a little “foam” in the pit of that notch (indicating bacterial activity leading to inflammation of the lid and eye). Harder to appreciate in this blue-light image are blood vessels crossing the margin of the lower lid (squiggly lines) and dilated blood vessels on the white of the eye – all indicating degrees of inflammation – in this case a combination of evaporative dry eye disease, rosacea and related blepharitis (irritated eyelids).
- but the main cause remains dry eye disease, which is a many-faceted beast. Anti-inflammatory medications including Cyclosporin (Restasis, Cequa, etc), Lifitigrast (Xiidra) and steroids (like Loteprednol) are used to treat dry eyes because they are good at reducing Aqueous Tear Deficiency (ATD = too little water being produced) but are not great at improving evaporative dry eye from Meibomian Gland Dysfunction (MGD). In my practice and in large clinical studies, MGD is the leading cause of dry eye, though it can couple with ATD. Prokera is great for giving a jump start on healing a dry eye-damaged surface, but unless you deal with all the ancillary, co-contributing issues, the SPK is likely to be only partially improved or to recur quickly. LLLT can help some MGD, but as most MGD is obstructive and most obstructions involve waxy plugs, unless you are clearing these plugs (and a substantially heated expression appears the best way to do it), then you're not going to get very far.
Apart from waxy plugs (common in early stages of MGD), there are scarring issues (well described by Dr. Steven Maskin) that can begin as "periductal fibrosis." This can require probing to make good headway. Rosacea is a common cause of the non-obstructive versions of MGD and here, IPL (Intense Pulsed Light – see my earliest posts on this here: https://www.eyethera.com/blog/not-so-secret-weapon-of-dry-eye-treatment-intense-pulsed-light-or-ipl ) can really shine (and LLLT may play a positive role). Getting appropriate degrees of buy-in from patients, in doing required levels of "homework," is always key to anything else (including Prokeras) you can offer. You mentioned home therapies - I include oral Omegas 3-6-9 capsules, Heat masks and lid crunches (unless the primary issue is Rosacea), and lid hygiene products (HOCL and a cleanser like Zocuwipes or Cliradex products).
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463