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A new device provides dynamic images of the meibomian glands and allows ophthalmologists to assess meibomian gland health and function from a new perspective.
Take-home message: A new device provides dynamic images of the meibomian glands and allows ophthalmologists to assess meibomian gland health and function from a new perspective.
By Lynda Charters; Reviewed by Preeya K. Gupta, MD
Durham, NC-A next-generation device (LipiView II, TearScience) is changing how ophthalmologists look at meibomian glands, literally.
The technology-which became commercially available in January 2015-is a breakthrough in dry eye treatment. In addition to measuring the thickness of the lipid layer using interferometry as the first-generation technology (LipiView) did, this new device now has the ability to take dynamic images of the meibomian glands.
“The ability to see the meibomian glands informs ophthalmologists about the health of the glands,” said Preeya K. Gupta, MD, assistant professor of ophthalmology, cornea and refractive surgery, and clinical director, Duke Eye Center at Page Road, Durham, NC.
The visualization capability has two components: dynamic illumination, which consists of multiple sources of infrared lighting, and adaptive transillumination.
“By having multiple light sources this new technology eliminates the major issue of glare-induced image degradation, which results in a higher-quality image,” Dr. Gupta said.
“The handpiece that everts the lower eyelid contains a light source that illuminates the meibomian gland from behind,” Dr. Gupta added.
This novel device can summate these two images and create what is essentially a high-definition picture of the meibomian glands, she explained.
This visualization ability is important, and perhaps the most exciting aspect of this technology, according to Dr. Gupta. While traditional meibographers are used in research, the opportunity to see the meibomian glands is not available in mainstream clinical practice.
“The ability to actually see the glands is important because a great deal of information about the health of the glands then becomes available,” she said. “The availability of [this device] now makes imaging of the meibomian glands easy while providing high-quality images.”
In patients with meibomian gland dysfunction (MGD), chronic inflammation of the meibomian glands over the years results in progressive truncation of the glands, dilation of the inner lumen, and increased tortuosity of the glands.
This knowledge, which was not accessible to clinicians in the past, allows Dr. Gupta to describe the degree of meibomian gland atrophy present and to stratify patients clinically as having mild, moderate, or severe meibomian gland disease.
In addition to treating patients with previously diagnosed dry eye disease, she also uses the device to screen patients for disease that may still be clinically “under the radar.”
“Dry eye is a multifactorial disease that encompasses environmental factors and lacrimal gland function, but the meibomian glands play a large part in dry eye disease,” she said. “Being able to detect a decrease in the lipid layer thickness indicates a high probability that a patient has dysfunctional meibomian glands.
“And now we can easily screen patients for the presence or absence of meibomian gland disease, which may allow for earlier intervention in the disease course,” Dr. Gupta explained.
Once meibomian gland disease is diagnosed using the device, therapeutic intervention can be offered with thermal pulsation (LipiFlow). This FDA-approved thermal pulsation device was designed to treat MGD and evaporative dry eye, Dr. Gupta explained.
The thermal pulsation device is placed between the eyelids and the back of the lid rests on the heating element in the device, she noted.
“This unit actually heats the meibomian gland structure,” Dr. Gupta said. “A precise degree of force is applied on the anterior surface of the lids to help relieve the obstruction in the meibomian glands in order to facilitate better flow of oil.”
Dr. Gupta uses thermal pulsation as one of her primary treatment in patients with MGD, as well as in patients who have been refractory to the more traditional treatments for dry eye disease, such as artificial tear supplementation and hot compresses.
“In my clinical experience, I have found that the treatment works best for patients with mild to moderate MGD,” she said. “Patients with severe disease need multifactorial therapy. The majority of patients I treat notice a benefit with [thermal pulsation], with studies in the literature having reported about 86% experiencing some degree of benefit, ranging from mild to life-altering as some patients have described.”
Dr. Gupta noted that she has been offering thermal pulsation earlier and earlier in the treatment course to patients.
“In many cases, patients do not have time or are unwilling to routinely instill artificial tears and may have found that topical therapies are ineffective for them,” she said.
The application is an in-office treatment that takes 12 minutes and is not covered by insurance.
Preeya K. Gupta, MD
Dr. Gupta is a consultant for TearScience.