Last month I discussed the plethora of ocular surface disease (OSD) treatments available today, and this month we’re sticking with OSD by taking a look at the procedures most optometrists routinely perform. There are several of these as well, and they go well beyond punctal occlusion. Let’s dive into all the surgical options and see which ones can greatly help your patients.

IES/NTT Conference

This past month, I co-chaired the Intrepid Eye Society/New Technology and Treatments Conference in Nashville. There were nearly 200 attendees and the Intrepid Eye Society members who served as faculty, along with Ben Gaddie, OD, and Marc Bloomenstein, OD, brought incredible clinical and practice insights. One that struck me was the importance of not only participating in advanced OSD procedures, but even the process required, via instrumentation.

Perception is Reality

These high-demand, advanced procedures serve over 150 million people with meibomian gland dysfunction, dry eye and/or blepharitis. The use of instruments, as Mark Schaeffer, OD, pointed out during the amniotic membrane and instrumentation workshop we shared—like lid expressors or bandage lens forceps, rather than our fingers—are far more impressive to the patient and a better model a patient-pay or insurance-covered procedure. So, start with good instrumentation, which can also decrease complications and increase efficiency. For example, bandage lens forceps prevent stabbing the conjunctiva with sharp jewelers forceps or removing delicate epithelium in the case where the bandage lens is adherent.

Procedures Aplenty

The first procedure that comes to mind due to its long history is punctal occlusion. Impressive recent innovations like tapered 180-day dissolving punctal plugs (Oasis Medical) and cross-linked hyaluronic acid lacrimal occlusion, have provided superior results and a far more positive patient response.

Newer intense pulsed light (IPL) devices that use self-cooling heads (Espancione, Essilor Instruments) remove the need for face gel, practically eliminate the risk of burning a patient, eliminate the “snapping elastic band” pain, treat more skin types and are equally effective in my experience of over 3,000 cases.

A new system involving radiofrequency energy called the Darwin (Oculus) is on the market and, in 2025, an IPL from Lumibird is seeking FDA approval.

Low-level light therapy (LLLT) has allowed doctors to avoid having to surgically remove or inject chalazion. LLLT involves two or three treatments and is very effective on hordeola and early chalazia without the addition of IPL. Perhaps this is due to endogenous heat measured in the lower eyelid 25 minutes after application.¹

Biofilm removal options include microblepharoexfoliation (e.g. BlephEx, NuLids), Optivize (BlephEx) or Rinsada. You can also do a quick biofilm over the meibomian gland orifices with an eyelid debrider (Bruder Healthcare) after a dry eye exam. While this doesn’t have the same biofilm-removing capability of microblepharoexfoliation or irrigation, it certainly delivers an impressive patient response, which further emphasizes how valuable this process is.

For everting the eyelids to provide foreign body removal, concretion removal or meibography, instruments like the Meivertor (Bruder Healthcare) greatly improve efficiency and a professional appearance. Keep in mind that most instruments can easily be sanitized with bead-sterilizer.

Finally, there is amniotic membrane therapy with the use of ProKera corneal bandages (BioTissue) forceps for removal, dry amnion forceps for applying amnion to the cornea and contact lens and bandage contact lens forceps (all provided by Bruder). Amnion placement itself is a major opportunity in appropriate patients, such as those that don’t respond to topical therapy or have neurotrophic keratitis. Innovations such as CAM360 (BioTissue) that provide ProKera without the ring, Apollo (Atlas Medical) dehydrated amnion that maintains significant healing components or lyophilized or freeze-dried (Oculus Biologics) have continued to allow optometrists to better service our patients.

So, when looking at surgical options, consider the incredible opportunity in front of you that involves advanced ocular surface disease. 

Dr. Karpecki is Director of Cornea and External Disease at the Kentucky Eye Institute in Lexington KY.   He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.