By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

Eyelids and Dry Eye Disease

If only I’d known what I know today when I started managing dry eye disease over 20 years ago! For one, we always thought of dry eye as being a disease of the cornea and conjunctiva and today we realize that for about 86% of cases, DED starts with the eyelids.1 Meibomian gland dysfunction (MGD) affects 96% of glaucoma patients on prostaglandin analogous2, almost 60% of contact lens wearers3 and 85% of people who use digital devices4. This is an incredible opportunity for the profession and yet few patients with MGD are being treated. We are actively treating patients with DED caused by MGD in about 5% of the cases5 and we are not treating the precursor to the disease at an early stage. I will tell you that every patient that presents with chronic dry eye wishes their primary eyecare practitioner treated their MGD to prevent them from tipping into DED.

It starts with diagnosis: Express and Observe

I recommend you purchase a meibomian gland expressor and start testing every patient that you see. I typically use the Mastrota paddle which is manufactured by OcuSoft. Bruder makes a number of expressers and J&J has the meibomian gland evaluator. Learn to spot early biofilm and blepharitis. These two steps will add about 20 seconds to your exam but will generate thousands of patients for the practice with ocular disease that will progress. If left long enough it will become difficult to manage.

Cosmetics and DED

There are numerous agents that have been banned from human use due to having been shown to cause cancer. One such example  is formaldahyde. Although it is allowed to be used in make-up and eyelash extension adhesives. In fact over 20 percent of current makeup products contain formaldehyde or formaldehyde-releasing chemicals. And yet this is just one of many harmful ingredients that women apply to their eyelids, lashes and adnexa almost daily. Bacteria, which can colonize, have the perfect environment with lash extensions and other additives to the eyelids and lashes. It creates a breeding ground for pathogens such as demodex and bacteria. It’s something we all need to be aware of as patients are frequently asking about the risks of makeup and ocular surface diseases. Download the “Never List” of cosmetics for a list of ingredients to avoid. Eyelid tattooing also appears to severely damage the fragile meibomian glands.

In-office procedures

A patient with demodex blepharitis warranting a Blephex procedure

An exciting trend in optometry is in-office procedures ranging from blepharoexfoliation (BlephEx) to IPL (Intense Pulsed Light Therapy) and thermal expression and pulsation options. These procedures are making a difference for patients and I’ve had patients tell me “their eyes haven’t felt this good in decades” after one or multiple treatments, depending on the presentation. Blepharitis caused by bacteria or demodex requires an in-office Blephex procedure as does almost all cases of evaporative DED where biofilm components co-exist. An in-office blepharoexfoliation or Blephex treatment will significantly help these patients. Manage in-between visits with lid margin debridement via the various debriders that are available.

Patients with signifiant telangiectasia of the eyelids do well with an IPL

There are now four in-office thermal treatment options that have or are at the end of the FDA approval process. The first and perhaps longest lasting option is a LipiFlow (J&J Vision) procedure. This combination of heat to the back surface of the eyelids while pulsating out the meibum over 20 minutes typically lasts 3 years with a single treatment according to research conducted at Harvard.6 Patients with MGD do well with this procedure and patients with advanced  MGD and more than 70% gland loss require such a procedure to keep what few glands they have left. New in-office MGD therapies include the i-Lux (Alcon), which heats the back surface of the eyelid while the doctor or technician simultaneously compresses the eyelids to remove the meibum. All of this is viewable through a magnifier built into the device. TearCare (Sight Sciences) involves applying a SmartLid applicator to the outer eyelids while a device monitors heat and the patient can force blink during the procedure to naturally aid in expression over 15 minutes.

Expression of the eyelids with a Mastrota paddle

The newest device is the Thermal 1-Touch (OcuSoft), which applies heat externally at various settings that the doctor pre-determines to heat the eyelids to the appropriate state. Afterwards the meibomian glands can be expressed and the eyelid cleaned. Finally IPL (Eye-Light from Lombart or Lumenis) is an ideal therapy for patients that show evaporative DED, ocular rosacea or MGD with telangiectatic vessels along the lower eyelid. These blood vessels bring inflammatory mediators to the eye and lid margin area. A series of IPL treatments appears to treat these blood vessels as well as help with MGD and evaporative DED. The newest IPL devices no longer require coupling gel and are vastly more comfortable during treatment. It’s time to consider an in-office, patient pay option for your practice given the success patients are experiencing with these technologies.

Summary:
1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5):472-8.
2. Mocan MC, et al. The Association of Chronic Topical Prostaglandin Analog Use With Meibomian Gland Dysfunction. J Glaucoma. 2016 Sep;25(9):770-4.
3. Machalińska A, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea. 2015 Sep;34(9):1098-104.
4. Wu H, The severity of the dry eye conditions in visual display terminal workers. PLoS One. 2014 Aug 21;9(8):e105575.
5. Steinberg D  et al.  Equity Research Americans.  May 18, 2017:1-38
6. Greiner JV.   Long-Term (3 Year) Effects of a Single Thermal Pulsation System Treatment on Meibomian Gland Function and Dry Eye Symptoms. Eye Contact Lens. 2016 Mar;42(2):99-107.

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