Autologous Serum Eye Drops

[THE armada]

Curious as to opinions of opthomologists about the efficacy and safety of autologous serum eyes drops to treat chronic dry eye.

Along the same lines, any opinions on the surgical stenosising of the lacrimal puncta in an effort to avoid constantly having to replace plugs that fall out.

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[orbitsurgMD]

Curious as to opinions of opthomologists about the efficacy and safety of autologous serum eyes drops to treat chronic dry eye.

Along the same lines, any opinions on the surgical stenosising of the lacrimal puncta in an effort to avoid constantly having to replace plugs that fall out.

Autologous serum drops are a hideousy expensive and complicated way to wet the eye. The cases where I have seen these used were with patients whose doctors had exhausted every available commercial drop and were at the end of their rope, due to patient dislike or intolerance for anything else. In these cases, the patients did not need autologous serum drops either, what they needed was a psychiatric consultation.

The drops have to be compounded at a hospital pharmacy, have only a very limited shelf life and require scrupulous preservation by refrigeration. They are expensive.

I have yet to see anyone in more than a decade who really needed this. Maybe severe autoimmune conjunctivopathies with extreme dry eye or post-burn or Stevens-Johnson Syndrome patients merit their use, but those are not common. Unpreserved eye drops with or without methylcellulose thickeners in single-use dropettes are sufficient for most people who have sensitivities to preserved eye drops.

Punctal stenosis is a way to ****** evacuation of tears from the eyelids. It also ******s evacuation of bacteria and mucus and debris. ("It's awfully dry in this room, I think I'll go down the hall and plug up the toilet.") It works to keep applied drops available to the eye surface a little longer. Of course, if the primary problem is tear-film deficiency, it does nothing to address that problem.

I rarely need to do this procedure. I also almost never put plugs in anymore either. Most people with tear-film deficiency benefit more from treating their root cause of the deficiency, whether it be age-related decrease in basal secretion, blepharitis, rosacea, Demodex, chronic inflammation or whatever else ails them, and augmenting low aqueous secretion with wetting drops.

My $0.02. I know I could make more money doing differently, though.

 

[toulouselautrec]

I've made autologous serum tears in our clinic twice in the past few months (for the same patient with Stevens-Johnson) with the guidance of our cornea specialist. It's not hard, but it's tedious. Our S-J patient has had good response to it. Last year, I made some for another patient with a severe alkaline burn with less impressive results (but the pt still had subjective improvement of sxs).

As a resident with limited understanding of billing, I think that currently it can't be billed for, but I could be wrong. I don't know what insurance companies would pay for this. It may be a thankless job, but it can make a lot of difference in people with severe ocular surface disease...these people probably should be going to a cornea specialist anyways. It's been tried on many different causes of severe dry eye or persistent epithelial defect with good results, including post-LASIK dry eye. Ultimately, though, it's tedious not just on the doctor but the patient as well...I can't see people being able to keep up using these for years and years. So, overall, it's probably a low-incentive kind of thing for docs to do...

 

[SAcornea]

i beg to differ with the oculoplastics post, but autologous serum tears (AST) do work in severe dry eye, are cheaper than restasis and lotemax (pts pay approx 200 for 3 mos supply), and have been proven in randomized clinical trials to speed healing of epithelial defects and improve dry eye symptoms. case reviews have shown efficacy in dry eye, neuropathic corneas, and SLK.


Br J Ophthalmol. 2004 May;88(5):603-4.
Comparison of autologous serum eye drops with conventional therapy in a randomised controlled crossover trial for ocular surface disease.

Cornea. 2001 Nov;20(8):802-6. Links
Controlled study of the use of autologous serum in dry eye patients.

Cornea. 2007 Dec;26(10):1178-81.
Autologous serum eye drops for treating persistent corneal epithelial defect after vitreoretinal surgery.

Cornea. 2008 Sep;27 Suppl 1:S25-30. Links
Autologous serum eye drops for the treatment of dry eye diseases.

 

[THE armada]

I appreciate the responses. Any significant safety concerns with the eye drops.

 

[shredhog65]

The most important safety problem with autologous serum drops is keeping the "sterile". Since they are made by hand out of a patients spun serum contamination can be an issue. They are essentially a culture medium so they can not be kept long. As a resident, we had patients come in to have their serum spun every 1-2 weeks. Also, they can harbor pathogens so the compounding pharmacist/ physician needs to be careful and anyone who comes in contact with them needs to be aware of what they are.

My own personal experience with Autologous serum drops is only in SJS and burn injury. Patients generally improved but the results were inconsistent and they were never 100% effective. In my opinion they are a good option in the right patient, but are a huge pain for the physician, patient, and pharmacy/ lab to deal with.

 

[GAA]

I would have to agree, SERUM DROPS WORK REALLY WELL!.
At our institution (Big University cornea department) there is a nurse that works for the Cornea and Oculoplastics department and she prepares the drops for the patients. The cost is about 75 dls for 2-3 months supply (not covered by insurance). In severe dry eye I have seen much better results with this drops compared to Restasis, etc.

Most of the good results in my experience are with SJS and neurotrophic Keratitis and exp. keratopathy.

 

[orbitsurgMD]

i beg to differ with the oculoplastics post, but autologous serum tears (AST) do work in severe dry eye, are cheaper than restasis and lotemax (pts pay approx 200 for 3 mos supply), and have been proven in randomized clinical trials to speed healing of epithelial defects and improve dry eye symptoms. case reviews have shown efficacy in dry eye, neuropathic corneas, and SLK.

. . .

Cornea. 2001 Nov;20(8):802-6. Links
Controlled study of the use of autologous serum in dry eye patients.

[Bolds mine.]


This report is a small clinical study without controls of 14 eyes using umbilical cord serum, not autologous serum. There are no control eyes, patients or treatment cited in the study methods.



SAcornea:

I don't doubt the efficacy for the types of cases you cite, but the cases where I have seen it used, it was plainly unnecessary. And while you may have access to facilities to make it at that price, the patients I have seen getting these compounded paid much more than what you are quoting.

You must also consider the costs of pre-treatment screening, following protocols for screening for blood-borne pathogens (e.g. Lubeck, British Committee for Standards in Hematology, etc.) prior to drawing blood for serum separations.

These have been in use since at least the mid-1980s, BTW.

I am not sure why you would compare serum drops to Restasis or Lotemax; are you suggesting they be used as an anti-inflammatory agent to increase basal tear secretion?

I think by now I have seen more people quit Restasis than continue with it. Cost probably has something to do with it, but a surprising number who gave it a fair trial thought it didn't help much, and these were reliable patients.

OP:

As a blood product, there are the usual considerations of handling any product of human tissue that may contain pathogens. Since it is a compounded material, and lacks true uniformity as in a manufactured drug product, the FDA does not approve autologous human serum drops as a drug, rather it its seen as a medical treatment.

 

[OMD]

Orbit,
You state in one post that you want to attack the root cause of DES, which I agree with. In another, you cite the high failure rate you've experienced with Restasis. If the patient has aqueous deficiency (not a quality issue from rosacea, blepharitis, demodex, etc), why avoid plugs when they can help the patient avoid artificial tears (the cost and the hassle)? Yes, placing plugs pays some and it may be overused by some, especially when the cause is a quality, not quantity, issue, but when basal secretion is low, they can be in the best interests of the patient, both convenience and financial in the long run.

 

[orbitsurgMD]

Orbit,
You state in one post that you want to attack the root cause of DES, which I agree with. In another, you cite the high failure rate you've experienced with Restasis. If the patient has aqueous deficiency (not a quality issue from rosacea, blepharitis, demodex, etc), why avoid plugs when they can help the patient avoid artificial tears (the cost and the hassle)? Yes, placing plugs pays some and it may be overused by some, especially when the cause is a quality, not quantity, issue, but when basal secretion is low, they can be in the best interests of the patient, both convenience and financial in the long run.

I do prescribe Restasis, BTW. But I don't use it in place of other treatments for the focal quality issues you mention. My observation is only that, not an attack. Patients frequently give up on the drop, sometimes when they might try a little longer with some hope of improvement (reasons given are various, some of which are discomfort, some of which are frustration with perception of no improvement and at least some of those complaints are motivated by cost: if something that expensive doesn't work better than everything else, it isn't any good, etc.)

I also use occlusion, where I really think it will make a difference. The patient with rosacea, blepharitis, punctal phimosis and tear film deficiency who admits to using wetting drops only twice a day and is doing nothing to treat their blepharitis is generally not the patient that needs plugs. But I can't tell you how many of those kinds of folks I see coming in with plugs in or who have had plugs placed by someone else that have since been expelled.

A little history is in order, too. If I see a patient who has dry eye findings (low Schirmer, Lissamine uptake, etc), I ask how frequently they are applying drops. Usually the daily frequency is 0-2 times a day. That is most patients. I suppose I could plug those folks--a lot of doctors do, figuring that patients just won't apply drops more frequently even if asked--but I really think they deserve a better trial of drops, even of Restasis if appropriate.

I think early occlusion makes sense in patients who live alone or with only a same-aged partner who have dry eye and arthritis. Look at the patient's hands. Ask if their hands give them trouble. Those patients may give even a good history of compliance--maybe to please you--but you know that drops have to be difficult for them. But I don't agree with early use of plugs as an aid to laziness, for people who won't use artificial tears appropriately when they clearly could and should.

And I don't want to give the impression that I think autologous serum treatment is useless, I don't. But in far more cases than I like to admit, I have seen them used in patients that really didn't need them any more than they needed any other kind of unpreserved drop. For the pemphigoid patient, or S-J-S, burns, rheumatoid keratoconjunctivopathy, it is probably the way to go. For the post-LASIK patient with a clear flap, no surface disease, 20/20+ vision but who is on antidepressants with known anticholinergic side effects, no.

 

[OMD]

I also use Restasis and I understand that you are just making observations. I am only trying to understand others reasoning when making their decisions. I know this is a thread for serum but I have no experience with that and don't plan on it. Any patient needing that kind of corneal care will go to a local cornea specialist who can decide what to do.
As far as the tears go, I just think the plugs can be a long-run cost saver in the aqueous deficient patient, not to mention easier. It's not just aiding laziness. If there is a more convenient method to improve someone's quality of life, that isn't cost-prohibitive, (with the obvious assumption that they may benefit - which is my, and I think your, main sticking point), why not?

 

[THE armada]

Anyone with an opinion on the surgically stenosing the puncta of the eye?

 

[vader922]

orbits: if you are a doctor I thank god you are not mine! You really should do more research. You cite the umbilical cord research from 2001. How about checking the data more current from the SERUM drops. Or do you not know there is a difference??

FYI, I have numerous eye issues, repeated lasers for CNV due to ocular histoplasmosis, visudyne, etc. etc. I have had chronic dry eye since I was a teenager. This was treated as Rosacea for over a year until my dermatolgist did a biopsy which came back NOT Rosacea, but Collagen Vascular Disease. I have had ulcerations on the cornea due to my dry eye despite pumping 2 gallons of water into my room and wearing goggles to bed at night. I have used every drop on the market and even some compounded ones in the last 15 years. I take megadoses of Omega 3 per my Cornea Specialist and this gave the best response, but not enough. CAUTERIZATION TWICE which just reopened both times, and due to my other inflammatory eye complications my opthamologist became worried about continuing to recauterize. Subjectively I am in extreme agony, objectively my corneas become damaged.

I thank God my own Cornea Specialist suffers from dry eye and knows what it feels like to some degree. Maybe one day you will.


"the patients did not need autologous serum drops either, what they needed was a psychiatric consultation.:

I can't believe you said that after reading your posts which show lazy research on the subject.

BY THE WAY, I only have to pay 65.00 for my autologous serum drops from a compounding pharmacy and my hospital lab has an agreement with my cornea specialist and does the lab work for FREE.

and to the poster who asked about punctal occlusion...both upper and lower were occluded and while they stayed closed I had some relief. I am willing to try a third time after much research on the reopening issue. One doctor in Miami has had excellent result in people like me by putting them on anti-inflammatory drugs for 2 weeks prior to the surgery and then NOT taking ANY antiinflammatory herbs or drugs for 2 weeks after. His success rate exceeds everyone elses..

 

[orbitsurgMD]

orbits: if you are a doctor I thank god you are not mine! You really should do more research. You cite the umbilical cord research from 2001. How about checking the data more current from the SERUM drops. Or do you not know there is a difference??

FYI, I have numerous eye issues, repeated lasers for CNV due to ocular histoplasmosis, visudyne, etc. etc. I have had chronic dry eye since I was a teenager. This was treated as Rosacea for over a year until my dermatolgist did a biopsy which came back NOT Rosacea, but Collagen Vascular Disease. I have had ulcerations on the cornea due to my dry eye despite pumping 2 gallons of water into my room and wearing goggles to bed at night. I have used every drop on the market and even some compounded ones in the last 15 years. I take megadoses of Omega 3 per my Cornea Specialist and this gave the best response, but not enough. CAUTERIZATION TWICE which just reopened both times, and due to my other inflammatory eye complications my opthamologist became worried about continuing to recauterize. Subjectively I am in extreme agony, objectively my corneas become damaged.

I thank God my own Cornea Specialist suffers from dry eye and knows what it feels like to some degree. Maybe one day you will.


"the patients did not need autologous serum drops either, what they needed was a psychiatric consultation.:

I can't believe you said that after reading your posts which show lazy research on the subject.

BY THE WAY, I only have to pay 65.00 for my autologous serum drops from a compounding pharmacy and my hospital lab has an agreement with my cornea specialist and does the lab work for FREE.

and to the poster who asked about punctal occlusion...both upper and lower were occluded and while they stayed closed I had some relief. I am willing to try a third time after much research on the reopening issue. One doctor in Miami has had excellent result in people like me by putting them on anti-inflammatory drugs for 2 weeks prior to the surgery and then NOT taking ANY antiinflammatory herbs or drugs for 2 weeks after. His success rate exceeds everyone elses..

I sympathize with your complaints, and from what you say, you probably need the drops you use. See your doctor about what you should do, not this board.

I am not sure what you are referring to when you attribute a citation to me or my post; I have not made one here.

Your quoted cost of $65 for a prescription sounds reasonable, especially for a compounded product. Unfortunately, many patients do not enjoy such a discounted price. Fortunate for you that way.

You need to orient yourself a little. As you don't know me, and this is a forum board, I really do not think it is appropriate or correct for you to use this as a place for ad hominem comments. I do not give medical advice here. You should not seek medical advice here. And what you read here is not to be construed as medical advice. Most of the posters and readers are commenting on particular aspects of their professional experience to other professionals.

Your writing that you wish I should suffer dry eye symptoms because you construe my anonymous opinions about the use and misuse of certain therapies as somehow unsympathetic or ignorant is especially unfortunate. It really makes you look poorly. If it was your attempt to persuade, you have fallen far short of that. What made you choose to unearth this more than one year dormant thread for your post is particularly strange.

 

[DKofLV]

You should not seek medical advice here. And what you read here is not to be construed as medical advice. Most of the posters and readers are commenting on particular aspects of their professional experience to other professionals.

maybe i'm missing something....where did he/she post seeking medical advice?

 

[orbitsurgMD]

maybe i'm missing something....where did he/she post seeking medical advice?

The poster is obviously a patient of an ophthalmologist somewhere with an agenda, not a clinician and not likely one in training, either. Resurrecting a long-dead thread--more than one year from the last post--on StudentDoctorNetwork with an inappropriate post I take as personal criticism, pseudonyms notwithstanding, from someone who has no knowledge of me or my practice or really anything at all about managing ophthalmology patients is really inappropriate.

I refrained from saying what I thought, that the poster is a monomaniacal disease-fixated internet lurker lacking both timing and perspective. Perhaps the poster was someone just looking for a fight. Who knows? But the criticism implied I was giving advice when I was not. What else do you think they were referring to? And why come to a student/resident/attending site when you are not in the field?

I don't mind telling anyone who thinks that SDR is a medical advice site to go elsewhere. And ad hominem (or ad pseudonym) attack has no place here either.

 

[DKofLV]

The poster is obviously a patient of an ophthalmologist somewhere with an agenda, not a clinician and not likely one in training, either. Resurrecting a long-dead thread--more than one year from the last post--on StudentDoctorNetwork with an inappropriate post I take as personal criticism, pseudonyms notwithstanding, from someone who has no knowledge of me or my practice or really anything at all about managing ophthalmology patients is really inappropriate.

I refrained from saying what I thought, that the poster is a monomaniacal disease-fixated internet lurker lacking both timing and perspective. Perhaps the poster was someone just looking for a fight. Who knows? But the criticism implied I was giving advice when I was not. What else do you think they were referring to? And why come to a student/resident/attending site when you are not in the field?

I don't mind telling anyone who thinks that SDR is a medical advice site to go elsewhere. And ad hominem (or ad pseudonym) attack has no place here either.

cant argue that point my friend, especially since they created a forum name just for that post...but I think I misread what both of you were writing. either way, this forum is turning into a OMD versus OD type of battle...yikes!

 

[VA Hopeful Dr]

The poster is obviously a patient of an ophthalmologist somewhere with an agenda, not a clinician and not likely one in training, either. Resurrecting a long-dead thread--more than one year from the last post--on StudentDoctorNetwork with an inappropriate post I take as personal criticism, pseudonyms notwithstanding, from someone who has no knowledge of me or my practice or really anything at all about managing ophthalmology patients is really inappropriate.

I refrained from saying what I thought, that the poster is a monomaniacal disease-fixated internet lurker lacking both timing and perspective. Perhaps the poster was someone just looking for a fight. Who knows? But the criticism implied I was giving advice when I was not. What else do you think they were referring to? And why come to a student/resident/attending site when you are not in the field?

I don't mind telling anyone who thinks that SDR is a medical advice site to go elsewhere. And ad hominem (or ad pseudonym) attack has no place here either.

I've seen other posters come into threads that were on sensitive topics and do exactly what this guy just did.

You've got someone with a condition that some number of doctors couldn't/wouldn't handle, so they do internet research. SDN will eventually pop up. They come in, accuse all involved of being uncaring and spiteful, wish their disease on everyone, then get banned/bored and never return.

Good times

 

[Wendy80]

Wow this orbitsurg guy is something else! Poor bedside manner AND lacks the necessary knowledge as a eye doctor. Big deal you are an eye surgeon who makes lots of money. Good thing you do because your personality sucks. You are also a very yucky man that no doubt is not well liked in real life by his patients with your patronizing arrogance and judgement. Your opinions on here are worthless.

Calling patients lazy? Perhaps they used few drops because at a certain stage drops don't do anything. They help mild dry eye, barely moderate dry and not at all severely dry eyes. May still be good to use for the eyes, but no help for the pain. Sometimes the eyes are worsening but patients don't know because the cornea becomes numb to the pain so they don't know to put in the drops. Non compliance with Restasis? When you are at the point of Restasis, you WILL give it a real try. If a patient stops, there is good reason. Either major irritation occurred or it failed to work. It doesn't work for all people you know. Jeez I am teaching you the very basics you should know from dry eye 101! We need to send you back to school for some knowledge my dear, and perhaps you can also learn a little compassion and understanding?

Patients who ask for serum drops need a psychiatrist? Really? You think it's fun and games for them? It doesn't make sense to you that they would have tried the less expensive options already? The easier options? To me it seems logical (common sense for you) that they would have already, no one goes through the trouble and expense of this because it's fun and they don't know what to do with their time. WHO are you to say it's unnecessary? You do not know the patients pain. It's can't always be measured. the tbut and shirmer test are often worthless, every ophthalmologist knows this.

You keep focusing on the cost as if you are so concerned, it's the patients money to use how they wish. The patients health is priceless. None of them do it because they have money to burn and this is the way they choose to do it. And you keep speaking of how cumbersome the process of making the tears is. What about the patients excruciating pain, eh? Why don't they come first?

Then the way you talked down to the poster,Vader 922, the poor guy whose clearly been to hell and still suffering, how disrespectful are you! Putting words in the guys mouth. He never once said he hoped you get dry eye disease. He simply said that maybe one day you will know, meaning that you could use some empathy! He never wished it on you. It can happen to anyone that's all he's saying. I am sorry Vader you not only suffer with pain but had to deal with this loser shmuck!

Shame on you. Its "doctors" like you that give other doctors a bad name. Your supporters on here are not much better, learning to be jerks, but for now, you take the cake for being the nastiest.

 

[DrZeke]

Wow this orbitsurg guy is something else! Poor bedside manner AND lacks the necessary knowledge as a eye doctor. Big deal you are an eye surgeon who makes lots of money. Good thing you do because your personality sucks. You are also a very yucky man that no doubt is not well liked in real life by his patients with your patronizing arrogance and judgement. Your opinions on here are worthless.

Calling patients lazy? Perhaps they used few drops because at a certain stage drops don't do anything. They help mild dry eye, barely moderate dry and not at all severely dry eyes. May still be good to use for the eyes, but no help for the pain. Sometimes the eyes are worsening but patients don't know because the cornea becomes numb to the pain so they don't know to put in the drops. Non compliance with Restasis? When you are at the point of Restasis, you WILL give it a real try. If a patient stops, there is good reason. Either major irritation occurred or it failed to work. It doesn't work for all people you know. Jeez I am teaching you the very basics you should know from dry eye 101! We need to send you back to school for some knowledge my dear, and perhaps you can also learn a little compassion and understanding?

Patients who ask for serum drops need a psychiatrist? Really? You think it's fun and games for them? It doesn't make sense to you that they would have tried the less expensive options already? The easier options? To me it seems logical (common sense for you) that they would have already, no one goes through the trouble and expense of this because it's fun and they don't know what to do with their time. WHO are you to say it's unnecessary? You do not know the patients pain. It's can't always be measured. the tbut and shirmer test are often worthless, every ophthalmologist knows this.

You keep focusing on the cost as if you are so concerned, it's the patients money to use how they wish. The patients health is priceless. None of them do it because they have money to burn and this is the way they choose to do it. And you keep speaking of how cumbersome the process of making the tears is. What about the patients excruciating pain, eh? Why don't they come first?

Then the way you talked down to the poster,Vader 922, the poor guy whose clearly been to hell and still suffering, how disrespectful are you! Putting words in the guys mouth. He never once said he hoped you get dry eye disease. He simply said that maybe one day you will know, meaning that you could use some empathy! He never wished it on you. It can happen to anyone that's all he's saying. I am sorry Vader you not only suffer with pain but had to deal with this loser shmuck!

Shame on you. Its "doctors" like you that give other doctors a bad name. Your supporters on here are not much better, learning to be jerks, but for now, you take the cake for being the nastiest.

Which bridge did you come out from under?? 5.5 years later. Quite the vengeful attitude.