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New, Targeted Technology for Treating the Root Cause of Dry Eye Disease (DED)

MiBo ThermoFlo (PainPoint Medical Systems) is new technology targeted at treating the root cause of lipid-deficient dry eye disease (DED): a poor lipid layer resulting from an insufficient amount of meibum secreted onto the ocular surface. MiBoFlo uses thermoelectric heat via a handheld probe that has a double eye pad attached with ultrasound gel applied to the end to facilitate the heat transfer through the lid to the meibomian glands.

Heat at a temperature of 108° is emitted from the probe. A technician can easily massage the lids with the probe alternating between a circular and back and forth motion.

In my colleagues and my DED clinic, we have developed a specific protocol for treatment, which works very effectively. We perform three consecutive treatments. The first is 12 minutes per lid, the second is performed 1 week later and lasts 10 minutes per lid, and the third is performed 2 weeks later and lasts 8 to 10 minutes per lid.

We charge $450 for all three treatments, and it is an out-of-pocket expense for the patient. There are no disposable eye pieces or activators necessary, allowing the cost to patients to be minimum. In our experience, patients are very receptive to the treatment and the cost is not prohibitive.

Additionally, we strongly recommend that patients also begin a regimen of the triglyceride form of omega-3 supplements, such as Dry Eye Omega Benefits from Physicians Recommended Neutriceuticals, at a 2,300-mg dose. The healthier meibum combined with the heat treatment and better meibum flow lends to excellent results in our experience. We make these treatments available in a spa-like environment with music and a special pillow, which makes it a great experience for the patient.

We have preliminary data from a 51-patient study which they underwent three treatments as per our protocol. We evaluated Schirmer tests, tear breakup time (TBUT), osmolarity, and both Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) scores at baseline, 1 month, 2 month and 4 months after treatment. At the 4-month, visit TBUT, osmolarity, OSDI and SPEED scores all showed statistically significant improvement.

Our clinic utilizes both the LipiFlow (TearScience) and MiBoFlo technology. We have found that the latter gives patients an almost immediate improvement in their symptoms after their first treatment, where in our experience, LipiFlow may take 6 weeks. Many patiens appreciate the cost benefit of not having to pay for the disposable activators.

We offer MiBoFlo as a first-line treatment for our lipid-deficient DED patients, combined with the triglyceride form of omega-3s and lipid-based artificial tears. We have had success in patients with meibomian gland dysfunction, meibotitis, and posterior blepharitis. We have also treated pre- and post-LASIK patients, those becoming contact lens intolerant, and patients with acute hordeolum.

CONCLUSION
While practices struggle to find alternate revenue streams, we have found that aggressively treating DED and incorporating MiBoFlo in a successful practice builder.

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Founder and medical director of Hazleton Eye Specialists, Stroudsburg Eye Specialists and The Dry Eye Clinic of Northeast, PA
foreyeys@ptd.net
Acknowledged no relevant financial interest


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Sidebar: Therapeutic Device for DED Treatment Uses Thermoelectric Heat

Cataract and refractive surgeons have recognized that their success in the OR depends on the effective management of dry eye disease (DED). The media, once enamored with LASIK, directs most of its attention to a so-called epidemic of DED. The condition has cost LASIK surgeons hundreds of potential candidates and thousands of hours of needless chair time.

Thermal punctal occlusion and later temporary and semipermanent occlusion were breakthrough techniques decades ago. Optometry and ophthalmology quickly embraced this definitive, affordable, and effective treatment. Topical cyclosporine, an antiinflammatory medication known for its use in high-risk keratoplasty, was reborn as Restasis (cyclosporine ophthalmic emulsion 0.05%; Allergan) and became the first pharmacologic weapon against DED.

Rolando Toyos, MD, released his outstanding results with intense pulsed light (IPL), and I have confirmed its effectiveness in my practice during the past 3 years.1 Dr. Steven Maskin’s probing technique has brought relief to many.2 The LipiView Ocular Surface Interferometer (TearScience), designed by physician-scientist Donald Korb, assesses the quality of the blink reflex and the central corneal lipid layer thickness.3 Its companion device, the LipiFlow Thermal Pulsation System, delivers pulsated heat and compression to the root cause of meibomian gland dysfunction.4

Mike Whitehurst from Pain Point Medical showed me a diminutive and user-friendly device called MiBoFlo. It uses a modest amount of AC current and an embedded computer to consistently warm a silver tab-shaped probe tip to 108˚F. This applicator can warm, massage, and empty clogged meibomian glands during a technician-performed 20-minute session. The tips are removable and sterilizable, and there are no consumables.

During the past 6 months MiBo, has been updated with newer handpieces and probe tips, an improved treatment protocol, and other innovations. When I see a pre- or postsurgical patient with significant meibomian gland disease, I schedule a MiBo treatment knowing I can eat the cost if a patient cannot or will not pay. Patients view MIBO as a true medical intervention and have asked to see my technician directly for the treatment. I am aware of other users charging $100 to $200 a session, often in packages of four. This covers the cost of the unit in a few months.

I use the device as a definitive treatment for evaporative dry eye, either alone or as a supplement to LipiFlow and/or IPL. Preoperatively, I use it to treat LASIK and premium IOL patients whenever there is significant meibomian gland dysfunction. Postoperative patients with surface issues, including transplant patients, benefit from therapy. I have used MiBo to address hordeolum with great success.

I distributed questionnaires to my first 100 MiBo patients, some who were new dry eye referrals and others who had been treated with LipiFlow, IPL, plugs, and Restasis in my practice. At 1 month, 86% felt some level of symptom relief. I believe this technology is an inexpensive and effective addition to any practice trying to treat the more than 23 million individuals who suffer from DED in the United States.5

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James S. Lewis, MD, is in private practice in Elkins Park, Pennsylvania.
He acknowledged no financial interest in the products or company mentioned herein.
Dr. Lewis may be reached at jslewis@jameslewismd.com.

Toyos Clinic website. Intense Pulse Light: For Treating Dry Eye. http://www.toyosclinic.com/procedures/dry-eye-syndrome/ toyos-optimum-ipl-dry-eyes. Accessed May 12, 2014.
Maskin SL, Kantor K. Intraductal meibomian gland probing to restore gland functionality for obstructive meibomian gland dysfunction. http://drmaskin.com/includes/meibomian-probing.pdf. Accessed May 12, 2014.
Finis D, Pischel N, Schrader S, Geerling G. Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for meibomian gland dysfunction. Cornea. 2013;32(12):1549-1553.
Korb DR, Blackie CA. Case report: a successful LipiFlow treatment of a single case of meibomian gland dysfunction and dropout. Eye Contact Lens. 2013;39(3):e1-3.
The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):93-107.