Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions. As this once unappreciated condition garners more attention, the number of promising candidate therapies that should bring dry eye relief grows. They may one day overcome some of the frustrations clinicians face with today’s management strategies. OM: The NuLids System is intended to be used at-home — what do you see as the advantages for this kind of treatment? In 2010, Maskin reported a novel probing technique for treating MGD using a beveled, 2mm solid stainless steel probe directly into meibomian gland orifices. 47 He reported that 24 out of 25 patients had immediate relief in tenderness and all patients had persistent relief 4 weeks later. Repeat treatments were only required in 5 of the patients with an average follow-up of 11.5 months. 47 In 2018, Maskin et al reported post-probing meibography results of 50 eyelids from 28 patients. The authors reported that 36% of lids appeared to have signs of individual gland growth with a mean follow-up time of 10 months, while detailed analysis of 13 lids demonstrated a 6.23% increase in mean individual gland area. The authors recognized not only lengthening of shortened glands but also partial restoration of faded glands and speculated that there was possible new gland growth. 48 Also published in the last year, Incekalan et al. evaluated both effectiveness and speed of relief among 80 eyes of 20 patients treated with either conventional meibomian gland disease treatments (consisting of warm compresses, eyelid massage and cleansing, artificial tears, topical antibiotics, oral omega-3 supplementation, and oral azithromycin) or a combination of conventional treatments above with a single session of intraductal meibomian gland probing performed at first visit. 49 Patients were followed for three months after the initial visit or procedure. OSDI, Schirmer testing, tear film breakup time, Oxford grading of ocular surface, and both meibum expressibility and quality improved in both groups, though the subgroup treated with probing had significantly faster improvement in all measurements. 49 iLux is also a handheld portable device with a disposable tip. However, this in-office instrument is primarily used to treat MGD-associated DED. A practitioner can treat MGD by using LED light energy to heat the inner and outer eyelids via disposable pads. While applying heat and manually controlled expression, the practitioner can view the eyelid margin with a magnifying lens to tailor the treatment for each individual. iLux treatment has produced clinically and statistically significant improvements in the symptoms and signs of MGD. 5 A new comparison study demonstrated that iLux is equal in efficacy and tolerability to Lipiflow (Johnson & Johnson Vision). 5

The meibomian glands are sebaceous glands located within the tarsal plate of the upper and lower eyelids that produce and secrete meibum, a clear oil in non-diseased states, from orifices anterior to the mucocutaneous junction. 4 The muscle force of the orbicularis and Riolan’s muscles contracting during blinking results in dispersal of the meibum from the glands. 5 It is this outermost meibum layer of the multilayer tear film that prevents evaporation of the underlying aqueous components. Kim CE, Kleinman, HK, Sosne G, et al. RGN-259 (thymosin β4) improves clinically important dry eye efficacies in comparison with prescription drugs in a dry eye model. Scientific Reports. 2018 July;8(10500). I was really holding off on that (i.e. booking a Lipiflow treatment). I can honestly say, I don’t feel any tremendous rush to go get that done anymore (with Nulids)…This is a total of one minute out of my day- It’s thirty seconds on each eye. So this has really helped me. Now that doesn’t mean I’m not going to do a lipiflow treatment. I probably will, but I’m just no longer in a rush where I feel like I really need to get that done. Sandy’s DIY Health Advocacy

'Deep cleaning' devices for dry eyes

Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107(4):631-9. Perfluorohexyloctane. NovaTears (Novaliq) is a one-component eye drop containing 100% perfluorohexyloctane. This unique lubricant is a water- and preservative-free lipophilic liquid. NovaTears stabilizes the lipid layer and can improve signs of meibomian gland dysfunction (MGD), as well as symptoms and signs of DED ( Figure 3). 42-44 NovaTears is currently available in Europe and Australia in multidose bottles and is in Phase II clinical trials in the United States. 45 Holland EJ, Whitley WO, Sall K, et al. Lifitegrast clinical efficacy for treatment of signs and symptoms of dry eye disease across three randomized controlled trials. Curr Med Res Opin. 2016 Jul 22:1-7. The self-regulating design halts the movement of the NuLids soft tip if too much pressure is applied to the eye. Treatment takes just 1 minute

Fariselli C, Giannaccare G, Fresina M, Versura P. Trehalose/hyaluronate eyedrop effects on ocular surface inflammatory markers and mucin expression in dry eye patients. Clin Ophthalmol. 2018;12:1293-1300. Steven P, Augustin A, Geerling G, et al. Semifluorinated alkane eye drops for treatment of dry eye disease due to meibomian gland disease. J Ocul Pharmacol Ther. 2017;33:678-85. The “Therapeutic Focus” column presents an optometrist’s firsthand experiences with a new therapy, via answers to questions posed by Optometric Management. Please describe NuLids: How does it work? Sonse G, Ousler GW. Thymosin beta 4 ophthalmic solution for dry eye: a randomized, placebo-controlled, Phase II clinical trial conducted using the controlled adverse environment (CAE) model. Clin Ophthalmol. 2015;9:877-84.

NuLids range for blepharitis and meibomian gland dysfunction

These formulation breakthroughs, in conjunction with the invalidation of patents for Restasis, have opened the door for more, and even generic, CsA options. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3 year retrospective study. Photomed Laser Surg. 2015;33(1):41-6. McNamara NA, Ge S, Lee SM, et al. Reduced levels of tear lacritin are associated with corneal neuropathy in patients with the ocular component of Sjögren’s Syndrome. Invest Ophthalmol Vis Sci. 2016;57(13):5237-43. Toyos R, Briscoe D, Toyos M. The effects of red light technology on dry eye disease due to meibomian gland dysfunction. JOJ Ophthalmol. 2017;3(5):555624. I’ve tried everything on the market for 10 years and read about NuLids but I was skeptical once again that it would work. I would say if you have eyelid issues due to dry eye – RUN don’t walk to get this product!!! I’ve used it a week and it has been terrific! Nancy M, Nulids user

NuSight Medical launches NuLids for the treatment of dry eye [press release]. NuSight Medical. June 20, 2018.

In-home device targets meibomian gland dysfunction/stasis and blepharitis

One commercial application of IPL in eye care is the Optima device from Lumenis, which applies up to 20J/cm 2 of energy to the lids and uses a water-cooled tip for patient comfort. ProKera™ is available as a device that can be placed on a patient’s eye in the office and has a ring that holds the amniotic membrane transplant (AMT) in place. The original ProKera™ is indicated for moderate to severe indications, including neurotrophic PED, severe infectious keratitis, post-PRK haze, and Salzmann nodular degeneration; however, Bio-tissue recently started offering the ProKera™ SLIM and ProKera™ PLUS. The ProKera™ SLIM is indicated for mild to moderate conditions, while the ProKera™ PLUS is recommended for severe indications that require longer treatment. Cyclosporine (CsA).The last decade has seen a tremendous growth in our understanding of the pathophysiology of DED, and treatment options have shifted from solely artificial tear supplementation to disrupting the underlying disease processes such as inflammation. 4 Many new and future dry eye drugs target the cycle of inflammation on the ocular surface that perpetuates this disease. 5 I initially need to perform the procedure every six to eight weeks, while the patient continues doing daily lid hygiene with scrubbing and heat,” he notes. “Eventually I’ll do it three or four times a year and then move to semiannual treatments.

But, by moving this treatment to the home, NuLids helps both the patient and the doctor, giving patients daily relief from DED’s symptoms — and at a reduced cost due to a significant reduction in over-the-counter lubricant and warming mask use. Meanwhile, NuLids creates a new, high-margin revenue stream generated in the patients’ homes while freeing up valuable office space for other more critical treatments. Senchyna M, Green-Church K, Kamat M, et al. Effect of intranasal neurostimulation on total tear lipid and total protein concentrations in subjects with dry eye. Optom Vis Sci. 2017. E-abstract 175289 Leonardi A, Van Setten G, Amrane M, et al. Efficacy and safety of 0.1% cyclosporine A cationic emulsion in the treatment of severe dry eye disease: a multicenter randomized trial. Eur J Ophthalmol. 2016;26(4):287-96. Klarity-C (cyclosporine/chondroitin sulfate 0.1% ophthalmic emulsion, Imprimis Pharmaceuticals) is a new compounded non-preserved topical BID eye drop used for DED management. It combines the active ingredient CsA 0.1% with lubricants in a chondroitin sulfate emulsion. Its unique benefits are the higher concentration of cyclosporine and the chondroitin sulfate vehicle. Chondroitin sulfate is a lubricant that also has mild anti-inflammatory properties and can minimize instillation irritation, which is a common patient concern. 10,11 Both Klarity-C and Restasis increase tear production and improve tear film instability and ocular surface staining, although Restasis has a better impact on goblet cell density. 11 Like plaque on your eyelids, it clears bacteria and biofilm on the outside of your eyelids and eyelashes. Should I use Nulids before or after warm compresses?Piwnica D, Rosignoli C, de Ménonville ST, et al. Vasoconstriction and anti-inflammatory properties of the selective α-adrenergic receptor agonist brimonidine. J Dermatol Sci. 2014;75(1):49-54. Rynerson JM, Perry HD. DEBS—a unification theory for dry eye and blepharitis. Clin Ophthalmol. 2016;10:2455-67. But when your eyes feel dry and gritty every day — as a result of aging, underlying health conditions, certain prescription drugs or long hours staring at a computer screen— your doctor may suggest a stronger treatment. A traditional treatment involves placing tiny devices called punctal plugs into your tear ducts to keep your natural tears in your eye. Reducing dry eye symptoms and signs may be yet another application for Botox (botulinum toxin type-A, Allergan). While intraglandular injection of Botox is off-label, injection into the lacrimal gland and near the punctum can reduce lacrimal and tear drainage, respectively. 35 In a study of intractable DED patients, Botox injection into the medial part of the eyelid improved symptoms and signs and reduced tear cytokine levels. 36 O’Neil EC, Henderson M, Massaro-Giordano M, et al. Advances in dry eye disease treatment. Curr Opin Ophthalmol. 2019;30(3):166-78.