Diagnostic Instrumentation

A Tool to Treat Dry Eye & Add Aesthetic Optometry Services

By Derek N.  Cunningham, OD

April 10, 2019

Dry-eye patients need care for their ocular condition, but what if, in the process, you were able to provide them and others with aesthetic optometry services?

An instrument that my shared OD-MD practice acquired six years ago, and helped pioneer the use of, enables me to improve medical care of dry-eye patients while adding aesthetic optometry services.

Need of Additional Instrumentation
We started noticing that the majority of dry eye patients had significant eye lid telangiectasia or increased vascularity. There were no good treatments for this in the past, and traditional warm compresses and lid scrubs can make these patients worse.

Check First with Your State OD Board

Scope of practice for optometry and IPL in many states is an uncertain area. This is not a laser, and does not fall under traditional surgical definitions in many states.

Because of the current grey areas, it is best to check with your state board on the specific language for IPL (if it exists). There is no need for this step if you work in conjunction with an MD.
Derek N. Cunningham, OD

There was little research available on how to help these patients at the time, but in doing research for our aesthetics clinic, we noticed that patients receiving IPLs for aesthetics purposes reported fewer symptoms of dry eye. I  heavily researched the potential mechanisms of action and came up with an eye treatment protocol. We eventually used this protocol for an FDA study on IPL and rosacea-related dry eye.

We decided to acquire the M22 Optima IPL, an instrument manufactured by Lumenis that emits short wavelength blue light that targets photophores, which include melanin, hemoglobin and water. The traditional use of this light is the get rid of sun spots, freckles, color imperfections in skin, fine lines and mild wrinkles. It gives more of a porcelain type appearance the skin.

I was intrigued by what it could do to small blood vessels that seem to be highly prevalent in the lids of dry-eye patients. I targeted the blood supply to the meibomian gland in the lower lids in hopes of cauterizing the telangiectasia and stimulating pro-growth factors. It worked better than we thought it would, and we soon started using it on general dry-eye patients and not just rosacea patients. To our surprise, we got similarly excellent responses.

Since we have started performing the procedure, we have participated in several FDA studies for IPL and dry eye. Other purpose mechanisms of action include a possible phototherapeutic effect on the meibomian gland or even targeting and eliminating demodex.

Scope of practice for optometry and IPL in many states is an uncertain area. This is not a laser, and does not fall under traditional surgical definitions in many states.

Because of the current grey areas, I advise all optometrists to check with their state board on the specific language for IPL (if it exists). There is no need for this step if you work in conjunction with an MD.

Vendor Trains Staff to Use Instrument
For aesthetic optometric use of the M22 Optima IPL, initial training for all of our staff and doctors was supplied by Lumenis. This training involves a full day of clinic, where a specialist comes in from Lumenis to train both our staff and doctors. From there, there is a lot of practice on each other.

Lumenis will train the staff on operation of the machine, maintenance, patient education and marketing. Any qualified staff member can operate the unit under an MD’s supervision. For non-MD offices, a licensed and qualified operator is required. For most states this is an aesthetician, RN, NP, and often an OD.

For the IPL eye protocol, it did not exist at the time we acquired the instrument. Once I developed what I thought was best-use protocols, I helped train the Lumenis reps on what I was doing, as well as our staff and physicians. The key is not only training on how to manually perform the IPL, but also the energy setting, and most importantly, how to properly express the glands after each treatment.

We have found that the outcomes are far better when the glands are expressed using a pressure controlled, well-directed forceps. This ancillary device did not exist at the time, so we developed one called the Cunningham Meibomian Gland Expressor® from Storz surgical instruments, and use it on all IPL patients.

Enhance Profitability
The needed investment for this instrumentation was around $60,000. There are no disposable costs, so the machine is easily profitable with very few treatments per month.

This is not a managed-care-covered service. It is all out-of-pocket for the patient.

We have found through experience and studies that initially four treatments are best for most. For this reason, we sell a package of four eye treatments for $1,400, or four full-face treatments (including eye) for $2,000. Touch-up IPLs are then sold individually as needed. Because of the cosmetic benefit, roughly 80 percent of patients will elect for a full face treatment.

On average we will perform 12-15 IPLs a week.

Educate Patients
I explain to patients that dry eye is an inflammatory eye disease. This inflammation damages the glands in the lower eye lid, leading to decreased oil production, loss of eyelashes and scarring and thickening of the lid margin. The oil is required to protect the ocular surface from drying out, and is even important for good vision.

I explain to the patient that the inflammation is caused by a cascading effect of the small blood vessels that your body produces in response to inflammation. They are weak and leak inflammatory products. Although tears may temporarily make your eye feel better, they do nothing to address the cause of the inflammation.

I tell them that the only procedure we have found to be successful at addressing the cause of this inflammation is IPL. It will destroy the small blood vessels that cause the inflammation and may even promote your glands to function better. As an added bonus this is the only dry-eye treatment that has a significant aesthetic benefit.

Practice-Growth Opportunity
The M22 Optima IPL is the most-used device in our dry-eye clinic. We have all major available therapeutic treatments available in the U.S. for dry eye, and this is the one we use the most by far. We see all the other therapies as synergistic, rather than competitive. It is not uncommon for us to recommend both IPL and a treatment like Lipiflow, for instance. We also never perform dry-eye therapies until a patient has had the inflammation addressed with a steroid or a long-term therapy like lifitigrast.

We require all of our cataract patients to go through our dry-eye clinic due to the high prevalence of dry eye in this group. We also implant roughly 80 percent of our cataract/lens exchange patients with presbyopia correcting lenses, and dry eye is especially problematic with these patients.

We have a dry-eye specialty referral clinic, so most patients who are referred here have already failed topical attempts at relief. Usually this means that they have just tried artificial tears, but some are referred in having tried every drop and medication they could find. From a medical standpoint, these patients are already treatment failures and have significant disease. We are seeing more and more every month.

We do not directly promote our aesthetics clinic, but we certainly talk about the aesthetic benefits of the IPL when brought up. Once patients experience the IPL they usually continue to come back for more treatments, even if their eyes feel fine. (aesthetics is a powerful driver for having patients return to clinic)

We talk about our research on social media and post pictures of the devices. We also highlight positive social media reviews when patients discuss the IPL. We have education about IPL on our web site and educate our referring optometrist/ophthalmologists routinely on IPL.

Most of our marketing is internal to the dry-eye patients who are referred in. We have never needed to market it. The demand is already high. As soon as we talk about it on social media, or put an update on our web site, we get a lot of calls for it.

 

Derek N. Cunningham, OD, is a partner at Dell Laser Consultants in Austin, Texas. To contact him: dcunningham@dellvision.com

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