InMode’s Envision platform transformed DR BRUCE DORNN’S practice beyond recognition, along with many other Canadian optometrists. Now the technology is available in Australia, presenting an opportunity for independents to offer a unique service patients can’t find anywhere else.
It’s no secret that dry eye services represent one of the key ways for independent optometry practices to differentiate their business. Many do so in the hope of improving their financial performance, but imagine if you could increase net profitability by half a million dollars.
That’s what happened for Dr Bruce Dornn – the principal optometrist at his full-scope independent practice in the Canadian province of Manitoba – after “a paradigm shift” in his dry eye practice centred on the use of a novel non-surgical technology platform.
The instrumentation by medical technology company InMode – and soon to be available in Australia – encompasses three elements designed for the eye: bipolar radiofrequency (RF), intense pulse light (IPL), and minimally invasive fractional needling technology, which Dornn says has significantly elevated his approach to dry eye disease (DED) that was once built on artificial tears and prescription eye drops.
“We’ve completely shifted away from using a medical form of treatment – which is expensive in the long run, often comes with side effects and doesn’t have the best outcomes percentage wise – to now using a non-pharmaceutical treatment that rejuvenates the patient’s meibomian glands and helps them produce their own healthy tearfilm,” he explains.
“I’m now getting an 85-90% success rate in DED using this technology with patients paying $2,000 out-of-pocket for four treatments overall – but it’s a long-term, healthier solution. In turn, we’ve increased our profitability by half a million dollars, that’s net, not gross, so it’s had a major impact. I’ve been doing this for 20 years and we plateaued on revenue from spectacle sales, until we introduced the InMode Envision technology. Now, we’ve had a significant jump in what we can earn as a primary eyecare practice.”
InMode is a publicly listed company headquartered in Israel. Founded in 2008, it’s well known among plastic surgeons, gynaecologists, dermatologists and ENTs, but is a relative newcomer to the Australian eyecare market.
InMode Australia managing director Mr Dennis Cronje says RF technology is the genesis of InMode’s technology. RF is the basis of around 90% of its instruments and involves the selective and controlled rise in tissue temperature from a high frequency alternating current to heat the dermis skin layer, stimulating the production of collagen. The company’s portfolio also includes light-based energy and laser technologies, helping health professionals offer minimally invasive procedures and improve existing surgical procedures.
As one of its latest offerings, Cronje expects Envision will be of significant interest to independent Australian optometrists. It is described as a new in-office standard revolutionising ocular care procedures for meibomian gland dysfunction (MGD) and the symptoms of DED. The non-surgical ophthalmic platform features:
• Forma-I: bipolar RF – a thermal technology designed to deliver targeted bipolar RF energy to small delicate ocular zones, directly on the upper and lower lid, to address the symptoms of DED caused by MGD
• Lumecca-I: intense pulse light (IPL) – delivers precise spot-size IPL procedures to treat inflammatory conditions in smaller zones
• Morpheus8: minimally invasive fractional needling technology – a clinically proven fractional technology to treat tissue. RF energy is delivered to multiple depths through bipolar arrays of microneedles targeting the Fibro Septal Network (FSN) and results in localised heating for collagen stimulation, elastin production, and coagulation/tightening of tissue.
“Envision is the combination of RF energy but being able to deliver it bipolar that allows the user to apply it directly over the eye, very discreetly and effectively,” Cronje explains.
“The ability to then combine that with light-based energy to treat some of the other underlying ocular conditions, and then introducing Morpheus8 around the eyes, fits with a new direction we took as a company a few years ago to focus on medical conditions with an aesthetic side to them.”
Where EnVision shines
Dornn says Envision’s small-size applicators – and precise depth control – allow for highly efficacious procedures in the small, more delicate subdermal layers of the periorbital region.
“Envision is a complete suite of devices perfectly suited for eyecare. It has been developed for use on eyelids, which is really important to understand because a lot of technology is great on thicker skin, but your eyelids are the thinnest skin on your body and you’ve got a cornea underneath that’s completely avascular, so if you’re applying too much energy, you’re going to have problems,” he says.
“Firstly, we have the Forma-I, featuring bipolar RF, which means I can do an RF procedure directly on top of an upper or lower eyelid with no shield. That’s a big deal. That’s saving me a lot of time in a busy clinic, and it’s very delegatable to ancillary staff.”
Secondly, in the Lumecca-I, Dornn says eyecare professionals have access to an IPL technology specially designed for use on eyelids. With a small spot size, the user can treat close and adjacent to the eyelash margin, which for some IPL models, can be difficult.
“Previously, that meant you had to be very careful – staying around 2 mm away from the lash margin – whereas now with the Lumecca-I, I can get right in on the lid margin. You can tell InMode has done the R&D and made devices that are very specific to eyecare – Envision is a complete departure from anything else.”
For Dornn, the third and final applicator – the Morpheus8 – is an indication of where optometry, at least in Canada, may head in future. He says the treatment could be used in the early stages of dermatochalasis (excess eyelid skin).
“Thereby avoiding a blepharoplasty later down the road – this is really appealing to my patients. Lots of people want to avoid surgeries, especially blepharoplasty which can be an uncomfortable procedure and cause other problems like severe dry eye.”
Integrating the platform into your workflow
Dornn was an early adopter of the Envision system when he began using it four years ago. Today, he says the platform is used by around 150 Canadian optometry practices, with their US counterparts excited about its launch in their own country.
In his practice, DED is given equal consideration to other conditions like glaucoma and macular disease. It now means every adult patient is screened with meibography and a non-invasive tear breakup test (NIK-BUT).
Ultimately, there are two types of DED patients that visit the practice: those who are late-stage and symptomatic seeking immediate care; or those who are asymptomatic with early warning signs only identified through the screening process. Dornn’s practice has also dispelled the myth DED is a disease of the elderly, with issues such as increased screen time, blue light and lower blink rates bringing down the average age of his DED patient to 46 years.
“To me, it’s important to identify asymptomatic patients. I want to make a diagnosis early before they have symptoms or signs of damage. The outcomes are better and patients are happier,” he says.
“I show them the diagnostic images and illustrate how poorly they’re producing tears. I say we can wait a year, two years, but we’re going to lose some gland tissue, or we can treat this early and everyone’s going to be better off. Patients respond, they get it, and I have a lot of enrolment with this in my practice, I am extremely busy with this work.”
Integrating new technology into the practice workflow is a challenge for any practice, but Dornn has established a protocol that works well for him. He treats four to five DED patients per day that are slotted into his regular schedule, seeing up to 25 patients per week.
After being diagnosed, patients return for treatment. On that day, they are checked in by the practice staff, their eyelid skin is prepped, and the Forma-I procedure is performed by a non-clinical staff member – a significant cost saver for the practice.
Dornn then performs a manual gland expression, followed by Lumecca-I on the lids (when indicated).
“What people don’t realise is the majority of dry eye cases (85%) are really MGD – glands are blocked, and we need to unblock them. What’s so genius about the bipolar RF with the Forma-I machine is that it heats the gland very precisely 2 mm right into the dermis where the glands are. It’s far more effective than anything we’ve had before.”
In many cases, Dornn then combines treatments on the same day, starting with Forma-I bipolar RF followed by Lumecca-I IPL.
“I put a stainless steel shield on the patient’s eye and perform IPL on the upper and lower lids; when your glands get blocked, like any other part of your body, inflammation ensues. So bipolar RF (Forma-I) is treating the blockage, we’re heating and stimulating collagen growth and with the IPL I’m treating more superficially and trying to deal with the inflammation and any neovascular blood vessels. It’s the perfect combination.”
Patients usually receive four treatments each spaced one month apart. At $500 per treatment, dry eye care via the Envision platform is a major source of revenue for the practice. Dornn then builds on this by selling hot/cold compress kits, omega 3 supplements, skin care products and sunscreen for IPL patients.
“We provide everything they’re going to need for pre- and post-treatment, which really increases our bottom line,” he adds.
Although Envision could have a place in ophthalmology clinics, Dornn believes the platform adds the most value in primary eyecare clinics that are more focused on the ocular surface.
“Before I had the Envision platform, I’d never had an ophthalmologist refer a patient to me in 20 years of practice. Now I have oculoplastic surgeons referring to me, as well as rheumatologists with Sjogren’s and arthritic patients, and GPs with dry eye patients. Early adopters of this technology may find themselves getting busy quickly.”
NOTE: For Australian practices wanting to learn about how to integrate Envision into their practice, Dr Bruce Dornn has developed detailed training modules for optometrists and their staff: https://eyerevive.podia.com/