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.
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.
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.
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.