Published: 2022-10-31

To find consensus in a difficult task between the patient, disease, doctor, and insurance company. What stands in the way of successful treatment of patients with dry eye by using such high technologies as BlephEx and LipiFlow? Review of the paradox in the pathophysiology of the dry eye mechanism and all known methods of treating. 



We spoke with Dr. Benjamin today about a new method for treating dry eyes. However, as usual, we touch on other topics, as well. Even Avicenna.

I have a bit of dust in my eye, but before you take a look let’s talk. I heard a rumor that you’ve got some new stuff?

I’ll look first; then we talk (inspects and assists). Yes, there’s new stuff. I attended the 5-day ASCRS convention (American Society of Cataract and Refractive Surgery). There were 20,000 ophthalmologists from all over the world, their employees, and their managers. They shared their experiences, including new approaches to old problems. Hundreds of pharmaceutical and technological companies showed their achievements, as well. One of the topics covered was the cornea. The surface of the eye is not only responsible for comfort and aesthetic, but also vision. Might I remind you that 90% of the eye’s focusing ability depends on the cornea, and the amount of nerve endings there exceeds even the most sensitive of other organs. Therefore, even the smallest speck in your eye, as in your case, can feel like an entire tree branch. Patients who complain about redness, fatigue, or pain aren’t exaggerating, and this can lead to a loss of vision.

I have a buddy, by the way, whose eyes are always watering. Should he see a doctor?

Yes. The eye is continuously irrigated with tears, which have a complex structure. They consist of three layers – oil, water, and mucous. Ideally, the tear film is distributed smoothly and evenly across the surface of the eye. It is in a similar manner that water beads on the surface of a freshly-waxed car. We don’t want that on the surface of the eye – we want uniform moisture, and the oily layer is responsible for that. It also prevents evaporation. When this layer is broken, the tears not only clump together but also quickly evaporate. This leads to dryness, the eye is irritated, and there’s the sensation of having something stuck in it. If you notice, for example, when you’re looking at the television or computer for too long, your vision starts to blur. You rub your eyes, though, and it fixes itself. This is the first sign of dry eyes.

How do you fight it?

There are several ways. The first is to replenish whatever component of the tear that’s missing. Oil and water, everyone knows, do not mix. Therefore, if you want to use eye drops, you need two different kinds – one oily and one watery. We have both at the office, and I advise patients to alternate throughout the day. The mucous layer, though, is hard to replace.

So artificial tears don’t cover everything?

The product sold in stores is usually watery. In fact, they deplete more than they replenish. Imagine your hands are dry and you splash water on them. This eventually washes away the oils that moisturize the surface. Most people who complain of watery eyes don’t know that this is usually due to dryness. “How can they be dry,” they ask, “when I’m tearing up all the time?” This is because the eye overreacts in response to dryness as the result of million of years of evolution. But it’s a vicious cycle.

Kinda like global warming, which starts to manifest in cold spells.

The more the oily layer washes away, the drier the eye becomes, and this leads to a greater discharge of tears. How do you break the paradox? Use artificial oily tears. Another method is to increase the amount of tears produced by the eye itself. Why, when we cry, does our nose run? It’s from an excess of tears. They are needed in the eyes, though, and not the nose. Thus, we can put collagen inserts into the opening of the tear ducts which retain those tears and dissolve over time.

They don’t feel like a foreign object? Does it hurt?

It’s a bioinert material that takes 30 seconds to put in. It doesn’t hurt at all. The bottom line is that it saves more of the eye’s own tears. You don’t need to constantly buy drops and remember to apply them. Women tend to like this method because it doesn’t interfere with makeup. Men appreciate it, as well, because they don’t like concerning themselves with health in the first place. The inserts are usually paid for by insurance and are quite popular.

This increases the amount of tears, but if the composition is off how do we improve its quality?

There’s a really expensive medication (around $600/mo) that’s not covered by insurance. It reduces the inflammation of the lacrimal glands, and that slightly improves the quality of tears. The process takes about 3 months to see improvement, though, and the drops are used for life. There are situations (arthritis, for example) where you can’t do without them, but this doesn’t apply to the majority of people with dry eyes, which is 30 to 70 million in this country alone. Now we’re finally getting to the point! Everything I’ve said until now is something we’ve discussed before. The oily layer is produced in the meibomian glands. They’re similar to the sebaceous glands of the skin. Over time, they regress and have blockages, inflammation, and collect bacteria, which appears on the eyelids as a slimy, eyelash-enveloping biofilm. Toxins get into the eye, and as a result you have redness, itching, and other symptoms. Neither hot compresses nor shampoo can wash it away, either.

Our readers are getting impatient. They want to hear about this new thing.

Recently, a thing called BlephEx appeared. It removes this biofilm and blockage. Let’s use a teeth analogy. We brush our teeth, use Listerine, and floss, but we still need to see a hygienist to remove the plaque that a toothbrush can’t reach. This same kind of treatment is done on the eyelashes and eyelids, but on the surface. So what do we do about the internal processes, like the shortening and atrophy of the glands? From ages 50-60, folks may not notice it, but a scanner can show their true, deplorable state.

What can be done about it?

The LipiFlow machine heats the eyelid inside and out, and extracts the blockage with a gentle massage. If you care about the health of your eyes, this should be done 4 times in the first year of treatment, and if everything goes as it should then less often in the future. Also, if you start at a younger age, it requires less treatment from the beginning – around 2 times a year.

What constitutes younger age?

The glands start to age between 25 and 30 years old. Warming the glands allows them to return to a clear, more youthful state, which also affects facial rejuvenation. We have been conducting this process in the office for about 7 months now, and the results are simply amazing. We recommend it before cataract surgery. Almost all infections and complications occur because of blockages in the eyelid, and antibiotics are not the best option.

So you use BlephEx and LipiFlow together, right? How do I pay for all this?

Neither Medicare nor Medicaid cover this procedure, similar to dental issues. At the conference, I listened to lectures by scientists who measured the osmolarity of tears (ie, the salinity), and the concentration of substances. Even using BlephEx without LipiFlow improves the osmolarity. Using both is even better. BelphEx clears away what LipiFlow doesn’t get to. This dramatically improves quality of vision.

But this doesn’t entirely depend on the patient, I take it?

No. Avicenna (first century Persian father of medicine) said, “There’s three of us here – you, me, and the disease. And if you are with me, together we can defeat it”. In this case, it’s more like, “There’s you, me, the disease, and insurance, and the four of us must contribute to fight the disease”. As a doctor, I do my bit – I go to conferences, share the latest knowledge, and invest resources, time, and money for the newest technology. It’s hundreds of thousands of dollars. Insurance pays for what it can, but it won’t pay for everything. You too, as a patient, are financially responsible. The idea that “I have insurance and that’s all I need” does not reflect reality. Good results are very important to us, as is our reputation, so we always try to help – but not to the detriment of our practice. We have to at least cover our expenses, even where we meet maximum requirements.

I would hope that not everyone in this country is living paycheck-to-paycheck, although many have difficulty.

There are some patients that have no problems paying full price, but there are others without those opportunities. They need their vision, as well. When people come in, we discuss all options. We want our patients, after the procedures and operations, to have better results than they would with other doctors. We wish everyone else well, but our patients come first. That’s what BlephEx and LipiFLow are for, as well as the other smart machines and latest technology. This isn’t only a financial investment for us; it’s also in physical and mental fortitude. Both parties are satisfied with the results. Life is the same and still beautiful, despite its difficulties.

Interview by Vadim Avrukin

Photo by slightly_different /PixabayStockSnap /Pixabay