What makes “enough,” ENOUGH and is there such a thing as “too much?” PART 3
First, I want to apologize for not posting last weekend - I was in Chicago at the annual national eye convention (put on by the American Academy of Ophthalmology) that is actually a global convention and is generally considered to be at the top of the world’s educational system for eye surgeons. I have never come away from one of these meetings without learning something - as the newest medications, technologies and best “look into the future” is commonly saved to present during these events. I’ve had to miss the last few of these meetings in person due to the pandemic, but I did tune in virtually and was happy to learn from some of the best. I will reveal some of what I learned in future blog posts - but today, I want to pick up where I left off on what makes “enough,” ENOUGH!
So is there such a thing as too much antibiotics (like Doxycycline or Azithromycin) for fighting dry eye-related infections and inflammations? The short answer is yes - as these can change out bad germs (resistant) for good germs (that promote good health) as antibiotics don’t know the difference between good germs and bad - they just wipe out whatever germs are susceptible. They also can cause other side effects (too numerous to cover in full - and each patient’s case should be carefully considered by the treating doctor so as to avoid predictable bad outcomes) and can sometimes provoke allergies to antibiotics across the class (so small doses even for short times may leave certain patients unable to ever take any similar-class antibiotics for life). This is not to say that all antibiotics are “bad” - just that all antibiotics should be carefully considered in the context of each patient before prescribing them. In general, good lid hygiene can go a long way towards avoiding eye and eyelid infections (see my earlier posts).
How about treatments like IPL and heated expressions?
Taking IPL first, while this is a terrific treatment for most with dry eye disease, there are limits to what it can treat and the strong suit is inflammation. Unless the root of inflammation is understood (and is in the wheelhouse of what IPL can treat), then while IPL may have some short-term benefits, it is possible that it will wear off sooner than later and by delaying progression, it may cloud the ability to determine the driver of this inflammation (and delay the ultimate treatment). It also can have diminishing returns at some point, so success should be periodically measured and future treatments should be planned according to the rate and degree of that success. Poor, but steady progress may mean staying on course until a plateau is reached. Small steps forward, followed by equal steps backward may mean it is time to completely re-evaluate the treatment strategies. Maintenance is almost always required and timing those extra treatments can also be critical to avoiding larger steps backwards and lead to greater needs for multiple sessions to gain back that lost ground. Too much IPL is when it is no longer helping or when it is being used as a crutch without fixing the main drivers of the disease.
Heated expression is likewise a terrific treatment - but only when it is up to the task of melting the obstructions and then adequately expressing them. If the waxy clogging is of a melting point higher than the heat used - then a liquid form of the oil is never achieved and the ability to express is negated. Once liquid, if the amount of pressure used to express is not sufficient to adequately purge these liquid oils from the glands, then once the heat stops, the oil cools and turns solid again - blocking the glands and leaving insufficient treatment benefits. If the clogging is from dense, non-waxy products like keratin or scar tissue, then heat and expression pressure alone is not the answer. These cases may better respond to Maskin Probing - often in concert with some or all of these light and heat technologies (see my earlier posting on this). Once the waxy products are fully expressed, then heated expression may still have some value (purging the subsequent oil gland products that may still be less healthy and making room for newer, fresher, healthier oils to be made and expressed with normal, strong blinking. At some point, this will also plateau in benefits and will commonly have diminishing benefits as that plateau approaches. Too much heated expression (be it Lipiflow, iLuc, TearCare, Mibo or my favorite off label use of radiofrequency) is when it isn’t working.
As I usually say, each case needs to be evaluated carefully and treatments picked logically.More important is the ongoing evaluation of treatment progress and then re-evaluating - as the twists and turns of the road are uncovered. Picking dry eye specialists who have a full range of diagnostic equipment and treatment options is also almost as important as finding one with a good education and experience. Heeding their advice and working closely together is likely to yield the greatest results. Find a good dry eye doctor.