The Dry Eye Zone

Rebecca's Blog

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ASCRS, day one

Arrived! (the night before…)

What a great time of the year to be in San Diego! Lovely and mild. I drove down from Claremont Friday night, after attending Aidan’s glee concert at Pomona on Thursday and spending all day Friday in a joint intensive Dry Eye Foundation work session.

I’m staying at a fun little place not far from the convention center, the Horton Grand hotel. All I knew at the time that I booked was that it was the cheapest one on the convention’s list that still had rooms available, but it reminds me a lot of the hotels in Port Townsend out on the Peninsula west of home… old restored buildings.

The very best thing about this hotel though - and some of my old LASIK buddies will surely relate - is the lighting. One of my vision issues is extremely poor contrast sensitivity, as a result of which dim lighting is torture. I dread arriving at hotels late at night when my eyes are at their worst only to have to fumble all over the room to find switches, and even then, with every one of them on, to have a poorly lit room. At the Horton Grand, the moment I walked in the door, I found two light switches which turned on two nice bright overhead lights. HEAVEN. How many hotel rooms have overhead lighting?


In this blog post:

1. Exhibit hall day 1

First day, notes from seven companies related to dry eye

2. Scientific session on beauty and dry eye

All about eyelash enhancements, cosmetics, and other beauty products and procedures and how they affect dry eye.

3. Scientific session on dry eye (scroll way, way down)

Diagnostics, treatments, pipeline drugs and more… lots of study results presented and discussed.


Exhibit hall (May 4)


Random observations

It’s not as big as, say, Vision Expo West, but it’s… pretty large. More than that, though, it’s opulent. That’s my main memory of ASCRS meetings past. It’s all about refractive surgeries, from LASIK to fancy upsells on your cataract surgery lens implants. There is a lot of money kicking around. It makes for some beautiful booths, a decent amount of free food and drink, and nice thick carpeting.

Scope ophthalmics

A lot of the European and Canadian members of our online groups are familiar with Scope as the source of Hylo eye drops, especially Hylo Forte. These are great examples of typical HA drops available almost everywhere in the world except, for the most part, in the US. Hylo drops are deservedly popular and plenty of people buy them in the US from shady Amazon sellers (yes, this is possible, and it is one of the few examples of how Amazon’s UTTER disregard for the FDA may work in consumers’ favor). I stopped by because I wanted to see if Scope have anything new going on and also to get a read on whether there’s any likelihood of trying to expand into the US market.

… We interrupt this broadcast to explain some minutiae about “HA”…

HA = hyaluronic acid. If that sounds scary (acid?), it’s actually not. In fact, it will probably show up on a product label as sodium hyaluronate, which is a much more user-friendly term. Anyhoo. HA is very good for the cornea. Well-made drops with HA (not all are…) tend to be very popular and even the lesser ones are pretty well liked. The problem? HA is not allowed in over-the-counter eye drops in the USA, thanks to the FDA’s antiquated 1970s standards. Except that the Polichinelle’s secret of those selfsame restrictive standards is that you can actually put pretty much anything you want in an eye drop in the US as long as you list it in the “inactive ingredients” list rather than the “active ingredients” list. We used to do this with the Vitamin B12 in NutraTear and Vitamin A in Dakrina, away back in the day before Freshkote. Allergan does this with the oils in Optive Advanced and Mega 3 and now HA in Refresh Repair. Oasis does it with HA in their drops. TheraTears does it with the trehalose in their newest drop (more on that shortly). So you can do anything you want, really, but the hitch is that if you list your beloved ingredient in the inactives, you can’t make “medical claims” for it. That is, you can’t go around advertising it and telling everyone how great and effective this ingredient is, out of one side of your mouth, when out of the other you’re stating on the label that it’s an inactive ingredient.

Ah me, the complexities of working around a thoroughly uncooperative FDA. Cue the violins.

…And now we return to Scope.

No Hylo line to be seen at ASCRS - instead they are touting their new Optase brand. This new brand follows the now thoroughly predictable “family” of products that is de rigueur for any small eye drop manufacturer: make it a family - take care of the lids. So they are sporting a conventional microwavable compress plus a conventional tea tree lid wipe with HA. But they also have some interesting lubricants including a preservative-free dry eye spray which is expected to come to the US market some time later this year, and a new HA preservative-free drop in development. It’s funny, sprays never really took off in the US but I think they’re a pretty interesting way to deliver some moisture.

Rayner (Drops in Europe)

Rayner is a UK-based intraocular lens manufacturer but they caught my eye because they have some brand new HA preservative-free drops (Aeon brand). They are marketing them specifically for post-surgical use, but I understand they are also available on the UK Amazon site. If you’re in the UK, look ‘em up.

Allergan (Drops and ointment)

Refresh PM, everyone’s heartthrob ointment (for those who actually like ointments) is still on the same timeline as I was told last November, which is reassuring - they fully expect it to be in stores on schedule later this year.

Refresh Repair (Allergan’s newest dry eye drop) is coming out in a version labeled for contacts, which is great! Better, though, is that it’s coming out in a preservative free multi-dose eye drop which is expected in stores this summer. Will they ever cross the two and make the contact lens version preservative-free? Possibly. There are no PF contact lens drops on the US market and I imagine if anyone crosses that line, it will be Allergan.

Preservative-free multi-dose packaging, by the way, is definitely the trend to watch in eye drops. This is a good thing, because we want preservative-free, and bottles are more economical than vials. The downside is that the bottles are more difficult to learn to use… there is definitely a learning curve.

Once we actually have some of Allergan’s new bottle, I’ll be doing a YouTube video with all the preservative-free bottles on the market and how they work.

Random observation

There are an awful lot more suits at ASCRS than there were at ARVO. Just a part of the completely different atmosphere.

Digital Heat Corp (Heat treatment)

This is one of the companies I’ve been interested in because of their “warm compress” device. They have a version for use in-office and a version for home use. They’re expensive, but interesting. It’s a wearable powered device, and limits the heat to just the areas that need them. I’m going to get a sample to try out.

Akorn (TheraTears, drops and lid stuff)

The TheraTears product line has one recent and one brand new addition:

  • Theratears EXTRA, with trehalose, a new eye drop. I’m still waiting for them to get back to me on the trehalose concentration.

  • TheraTears Sterilid Antimicrobial, a hypochlorous acid (0.01%) spray for lids… yes, they’ve jumped on the same bandwagon as everyone else. But I love that they have the concentration of every ingredient on the their list… who does that?

Avenova

Avenova is the classic name brand prescription hypochlorous acid lid cleansing product. It’s an interesting-looking world now that there are so many over-the-counter hypochlorous acid alternatives (I came across, let’s see, I think at least three more new copycats here at ASCRS).

Sun Ophthalmics

Sun is the maker of CEQUA, the new cyclosporine eye drop, and the big question is when is it coming and how much will it cost! Timing looks like July, and it sounds as though they are sensitive to the high cost issues of Restasis and fully intending to make CEQUA more accessible.

Bausch & Lomb

Despite an awful lot of floor space, sponsored areas etc, they had no staff at ASCRS for any over-the-counter products, which surprised me. But from what I could find out it doesn’t sound like they have anything new in the works for their OTC product line, either. I asked about potential for a preservative-free Lumify and that is not sounding likely. None of this is surprising from the company that still puts BAK in two of their artificial tears! Bausch, we’d like to see you start paying attention to the needs of the dry eye world.


Sessions (May 4)


Vampire on the Vanity

This was the killer session! I wish everyone could have been there! Now I am stuck trying to interpret my very messy hand-written notes from a week and a half ago. Hate it when I do that. If any of the presenters happen across this I hope they’ll forgive-and-correct any particularly egregious misquotes.

1. Eyelash enhancements, tattooing, and more.

Dr Matossian started us off with an exhaustive talk on quite possibly every potentially harmful eye-enhancing beauty procedure that’s ever been proudly sported anywhere from a nightclub to the Met Gala, from all forms of eyelash extensions to some quite shocking examples of jewelry implants.

Some of my general take-homes:

  • People get trapped into progressively more harmful eyelash-enhancing products and procedures. They become intolerant of one and move on to the next, in a harmful, addictive vicious cycle.

  • Where you get a procedure done really matters. If you’re going to do it at all, go to someone who does it in an eye doctor’s office and has proper certifications. Beauty parlors… not so much.

  • The length and curvature of our eyelashes is actually determined by nature for optimal protection of our eyes. Longer lashes make ocular surface disease worse! Changing your lashes can actually create a “wind tunnel” that directs particulate matter right into your eyes! (Dr Periman also mentioned how the lid-lash ratio is important.)

  • People commonly fail to clean their lashes and lids when using eyelash enhancements of various kinds, because of the cost of redoing or repurchasing them, and this leads to lots of problems.

  • Watch out for the formaldehydes (among other things)

On eyelash extensions:

  • If done incorrectly, they damage the natural lashes.

  • If you have latex allergy, watch out! One of the unsuspected sources of latex may be gel pads used in the procedure.

  • They are addictive. People don’t want to wash them, because they are expensive to get redone, so debris accumulates leading to blepharitis. The debris in term breaks down the bonds and then you get them done even more frequently.

  • Lash extension cleaners are also toxic (of course).

  • (I can’t remember if this was Dr Matossian or someone during the Q&A, but someone mentioned that they always tell Lipiflow patients to stop getting extensions.)

  • Dr Periman mentioned later how blepharitis patients will often stop lid scrubs after extensions, and so their bleph gets worse.

On false eyelashes:

  • Too much glue is a big problem. (Remember, formaldehyde in the glues.)

  • They are applied 1-2mm above the lash line… exactly where baby lash grown is happening.

  • If you don’t remove them every night, you end up stripping off the new lashes.

On eyelash embellishments

I’m sure some of you saw the pictures from the Met Gala! So here is a little food for thought about what happens when you basically wire stuff onto your lashes:

  • Trauma to the lash and its roots

  • The weight leads to lash baldness

  • Some patients get allergic conjunctivitis from feathers

On LED eyelashes

Two problems - traction allopecia and the glue stripping off new growth.

On mascara

We got to see some beautifully horrific pictures of mascara buildup that actually eroded through to the conjunctiva. Yikes! Takehome: Always remove your mascara.

On lash perming, lifting and tinting

  • Lifting: Potential for chemical burns on eye surface.

  • Tinting: Vegetable based dyes are the least damaging. Tinting is often applied by people who are hair techs not eyelid specialists. Dyes must be tested on skin first in case of reactions. Patient must be upright while it’s done.

On eyelid tattoos

  • Microneedling… if too deep, it damages the meibomian glands and can lead to atrophy. Saw pictures of scary complications that would not heal.

  • Very common in Asia, and very high meibomian gland dropout rates observed.

  • Dr Periman in her later presentation mentioned a case where a tattoo salon blamed the patient. The tattoo inks even at reputable salons have lead, chromium, nickel. These things can permanently damage the MG ‘achitecture’.

On toluene allergy

  • Off-gassing from nail polish is a problem!

  • Even men with chronic blepharitis have had this traced back to their wives’ nails!

  • It doesn’t show for 3-5 days after a manicure

  • Patients get periocular hyperemia and no one connects the dots!

On jewelry implants

Ugh! You just can’t unsee these kinds of pictures:

  • Jewel implants in the white of the eye - that then caused problems

  • Glitter implanted deliberately UNDER the corneal flap created during LASIK

  • Jewel implant in the CORNEA (!)

  • An earring placed by piercing the edge of the eyelid, and which rubbed against the cornea (done in a piercing parlor)

On eye whitening procedures

I am deliberately refraining from even NAMING the whitening procedure that was mentioned at this point - and which goes under at least two different names as I just saw from the website of the physician in question (apparently it’s been re-branded, no surprises there). Why? Simply because I once had a very nasty threatening letter from a lawyer who was engaged in the process of cleansing the internet of any and all references to the AAO’s warning letter about a particular procedure offered by a particular physician (the letter was later retracted, presumably under legal pressure as well). It seems someone once posted a copy of the AAO’s letter on one of my online forums about this, and they wanted all the evidence gone once it had been retracted.

But anyway, Dr Matossian listed a number of the scarier complications associated with an eye whitening procedure, including limbal stem cell complications, infectious scleritis and scleral necrosis. Sigh. It is to be assumed that the patients experiencing those things may not have the beautiful bright white eyes today that they were hoping for, glamorous zip codes notwithstanding.

On scleral tattooing

In scleral tattooing, color is placed in the subconjunctival space. This is done by a tattoo artist who knows nothing about eye anatomy. Not surprising that it may cause issues.

DEEP BREATH!

Dr. Periman (dryeyemaster.com) on cosmetics

So now we have a problem, because at this point things sped up to about 500 mph and I simply couldn’t keep up. My notes aren’t making a ton of sense to me anymore. I probably could have taken some pictures, but at ARVO they drilled into us so incessantly that photography was verboten, that I was afraid to even appear to be aiming my phone at anything. Moving right along, it is clear to me that (1) there is a ton I need to learn about cosmetics and dry eye because hey, while I personally use almost nothing of any kind on my face, that’s not normal - these are issues that affect most women and many men - and (2) The Dry Eye Zone needs to start creating some very simple, very user-friendly resources to help people navigate information about this. Pondering how to make that happen.

Anyway, unfortunately all I can share from this part of the session are some random take-homes extracted gingerly from my scattered notes:

  • It’s not about the brand. Formulations can change at any time. You need to know about ingredients.

  • There’s an infographic that was very helpful… note to self to ask Dr Periman for it.

  • 85% of eye doctors NEVER ask about the use of cosmetics! HOW CRAZY IS THAT? Imagine the patient she discussed who came in and said “Nothing helps my dry eye!” but whose history included the following, every one of which have potential dry eye implications:

    • Brow lift

    • Abnormal lash length

    • Lash growth serum

    • Waterproof mascara

    • Harsh removers

    • Retin-A

    • Neurotoxin

    • Tatooed eyeliner

  • THE CONUNDRUM: Patients who do not remove makeup have higher dry eye symptom scores (SPEED score, specifically) but… eye makeup removers may be toxic too!

  • “Prost” ingredients eg prostaglandins bad for MGs

    • Active ingredient in lash growth serums.

    • Mentioned a particular one that advertises as prostaglandin-free but wasn’t. It was a >$100 product, not a suspicious cheap knockoff.

  • Parabens… bad for MGs and ocular surface

  • Long tables of ingredients to avoid… need to get this. Included acrylamides, alcohols, retinyls, parabens and preservatives suchas BAK, EDTA, phenoxyethanol, MIT

  • “Hypoallergenic” does not mean safe for the ocular surface.

  • “Ophthalmologist tested” really means nothing at all.

  • “Vegan, gluten-free” etc is not even remotely relevant so why advertise eye care products that way?

  • “Gems” or crushed minerals in cosmetics - what that really means is SHARDS, which can get under your lids and cause harm, but doctors cannot see them without infrared.

  • Good resource: detoxmarket.com

  • A key reason we’re in this mess, and why you might want to buy all your cosmetics while traveling abroad? The US has only 11 outlawed ingredients. Europe has 1300.

Dr Shah on botox and fillers

I didn’t get detailed notes on this one at all. I remember that initially we got a great anatomy lesson about the various eye muscles, then information on all the things Botox affects and how, from the goblet cells to the lacrimal accessory glands to the lacrimal glands to the meibomian glands, and how it can cause lid retraction, reduce meibomian gland expression, and affect basal and reflex tearing and mucin production. On the other hand, it’s used for medical treatments. Random highlights… common treatment for benign essential blepharospasm. There was a study that compared Botox to plugs! And it’s been used as a “protective ptosis” or temporary tarsorrhaphy. Another study showed post LASIK patients were happier after botox. Eventually, my eyes crossed and since I think all the Botox stuff is covered pretty well in TFOS DEWS II, I took a break and just listened.

Final take-home though - which I’ve heard often before - where they place a Botox injection is everything. I get a lot of calls from people with poor outcomes so I’m a bit sensitized to this.

On fillers, she discussed among other things hyaluronic acid gel filler for lower lid retraction. For some patients, this may be better than surgery. My takehome again was that skill matters. She presented a horrific case of a poor outcome where the injection was every so slightly off.


Dry Eye

I love the wide range of things that get studied about dry eye these days. Here are some highlights from a Saturday afternoon session on dry eye:

  • A new tear film imager from Israel (Tear Film Imager, AdOM, no regulatory approvals yet) was presented that shows all kinds of fascinating things about tear film composition and dynamics, from tear break-up, to lipid layer thickness, and from their website it sounds like they’re studying more than that as well. I love these advancing technologies… only, they’re just not likely to make it into mainstream practices. I think of all the people who could benefit from non-invasive dry eye testing.

  • Speaking of invasive dry eye testing, we saw data comparing non-invasive versus invasive TBUT testing. (Since fluorescein can destabilize the tear film, TFOS DEWS II recommends the non-invasive version of this test.) It seems fluorescein TBUT tends to be lower than the non-invasive counterpart.

  • From my neck of the woods (Seattle area), Dr Periman presented on increases in MMP9 levels (this is an indicator of inflammation) as the air quality index goes down during forest fire season.

  • Ever think about how fasting affects the tear film? With fasting for health benefits on the rise, Dr Brian Armstrong was interested enough to study the tear film during Ramadan fasting. Patients ranged in age from 23-45 (i.e. young!) and the number with positive scores on Inflammadry testing doubled during Ramadan.

  • Dr Karakus from Wilmer eye (Johns Hopkins) presented data indicating that Sjogrens patients have a higher rate of depression than non-Sjogrens dry eye patients who have a similar severity of dry eye.

  • Dr Patel presented on corneal nerve morphology and mentioned that editorial about pain (to what extent dry eye versus nerve pain) by Anat Galor that’s still sitting on my desk waiting for me to sit down with it….

  • Dr Karakus presented results of a study on the effects of prolonged reading on tear film homeostasis. An interesting point was that osmolarity decreased immediately after reading.

  • Then there were two presentations on the DREAM study. DREAM was a massively large, NIH-funded year-long very sophisticated study of the effect of Omega 3 - specifically, fish oil - on dry eye. Since it was such a large study, people will be continuing to crunch its numbers in various ways forever.

    • The first of these presenters went over the basic results, which stunned everyone last year by showing omega 3 had no more effect on dry eye than the olive oil placebo, and a couple other points like showing that omega 3 levels were not associated with dry eye symptom severity.

    • The second one noticed two interesting things about the dry eye signs vs symptoms issue: 1) Those with severe symptoms had a higher level of “discordance” between signs and symptoms - that is, it was harder to draw a line between how their eyes test and how they feel; also 2) The younger you are, the more likely there is to be a mismatch between signs and symptoms.

  • Dr Vendal presented on dry eye as a huge problem for glaucoma patients taking topical glaucoma medications. They studied 8 patients treated with Prokera, the amniotic membrane treatment, who did well. No mention, however, of which glaucoma medications or whether they were BAK preserved.

  • Then there was a fascinating presentation by Dr Zadok on ocular magnetic neurostimulation treatment for dry eye. They treated 1 eye of 9 patients, and found that it reduced staining as well as symptom scores, and patients used fewer artificial tears. They specifically mentioned a 40+yo male with Sjogrens syndrome who had had LASIK (zowie, what an awful combination) and the positive results they had.

  • Dr Holland presented current clinical results on pipeline drug KPI-121, a nanoparticle loteprednol - basically a two week low dose steroid treatment specifically for dry eye “flares”. They have a third Phase 3 trial ongoing.

  • Next up was TrueTear, the intranasal neurostimulator from Allergan. Dr Passi confirmed the results they were seeing indicated the effect is all on aqueous, not meibomian, secretion, and effects were felt up to 8 weeks after ending treatment. There were some interesting questions afterwards about the possibility of treating one side but seeing results in both sides.

  • Last presentation was about crosslinked amniotic membrane as a dressing for ocular surface disease. We’re certainly seeing more and more uses of AM in dry eye.