Pre- and post-thermal pulsation

August 28, 2019

Patients deserve to have their tear film stabilized before surgery so their vision will be optimized after surgery.

Editor’s Note: Welcome to “Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. "Let's Chat" continues with this three-part blog series by Cynthia Matossian, MD, FACS. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or MultiMedia Healthcare, LLC.

I perform a lot of thermal pulsation therapy in patients undergoing cataract surgery. I feel strongly that these patients deserve to have their tear film stabilized before surgery so their vision will be optimized after surgery. In my last post, I discussed how thermal pulsation therapy can change surgical planning and outcomes. But even knowing that, many surgeons still struggle with how to talk about meibomian gland dysfunction (MGD) and MGD treatment in the context of cataract surgery.

What has helped me tremendously in educating patients are the meibography images from the LipiView device (Johnson & Johnson). These black and white images are easy for anybody to understand. They don’t have to be a scientist. I show them their own pictures and compare to those of normal, healthy meibomian glands. I tell patients that we are fortunate to have a treatment to help the glands, although I am very up-front about the fact that their glands will not look “brand new” again.

When the drop-out is dramatic (Figure 1), it is an easy discussion with the patient. However, I take a different approach when the glands look normal. I review the importance of both structure and function of the glands with patients and point out that the inspissated glands, although they may look “normal,” are not producing meibum.

Then I say, “I have good news. You have great glands-but they are constipated.” It might sound funny, but this is a term patients easily understand. I explain, “We can now intervene, get the impacted material out, and you have a good chance for these glands to start functioning better because you have not lost any of the structure yet.”

Since MGD and inflammation are often concomitant, I also educate patients about tear film markers for dry eye, again using visual aids. The MMP-9 test (InflammaDry, Quidel) is a great educational tool. When the test is positive, I hand the test cartridge (which looks similar to a home pregnancy test) to the patient so they can see the red stripe. At the end of the exam I give them a business card-sized information card with their tear osmolarity score and MMP-9 status.Post-treatment

Three months after thermal pulsation therapy, I bring the patient back for a follow-up exam.  At that point, we repeat the MMP-9 and tear osmolarity testing (TearLab) and share those results with the patient. I don’t repeat the meibography at three months because they are not likely to see a big difference in gland structure that soon. I ask the patient to continue their oral omega-3 supplements and Xiidra (Shire) or Restasis (Allergan) if that is part of their treatment plan.

I always explain to patients that thermal pulsation therapy is not a “one-and-done” procedure. At 3 months, I perform a diagnostic meibomian gland expression and congratulate the patient on how much better their glands are functioning. I repeat meibography annually and plan to do the thermal pulsation treatment every 12-18 months.

Depending on the severity of the disease and the patient’s level of discomfort, I may opt to perform intense pulsed light (IPL) therapy on the lower lids at the 6-month mark if the patient’s skin tone is between Fitzpatrick 1 and 4. (IPL cannot be performed on skin darker than Fitzpatrick 4). Sometimes I will perform a manual expression with TearCare (Sight Sciences) in between LipiFlow treatments. I find that IPL or TearCare can potentiate and extend the effect of the LipiFlow treatment. These treatments are all adjunctive and “stackable” to achieve the desired therapeutic effect and reduce symptoms of discomfort for our patients.