Putting a lid on evaporative dry eye

Take Home

Thermal pulsation therapy may enhance the diagnosis and management of meibomian gland dysfunction. Surgeons, however, must conduct a careful pre-treatment evaluation and articulate likely results with patients.

Anterior Segment Techniques By Ernest W. Kornmehl, MD, FACS

Dry eye is ubiquitous. Its causes are manifold and varied and include long-term contact lens wear, medications, aging, pregnancy, and meibomian gland dysfunction (MGD).

MGD is now recognized as the leading cause of dry eye.¹ MGD is commonly associated with inflammation and pouting glands, but is most often “non-obvious”² without any signs of inflammation noted with standard clinical evaluation techniques.

Diagnosing MGD

It is crucial to be able to diagnose MGD. Many patients who present with the typical complaints of dry eye will have normal tear secretion or a mixed form of dry eye with tear insufficiency and MGD.

Classic signs of MGD include pouting or inspissated meibomian glands, crossing telangiectasias, and eryrthema of the lid margins often associated with rosacea. A cotton swab often is used to express the meibomian glands in order to determine the nature and quality of the expressed secretions.

However, most patients with MGD have the non-obvious form of MGD. How do ophthalmologists make this diagnosis? One such technology (LipiView, TearScience) is available to make the diagnosis easier, along with a therapeutic device (LipiFlow Thermal Pulsation System, TearScience) that is designed to assist in the management of patients with MGD.

How it works

The technology features an interferometer that measures the thickness of the lipid layer and evaluates the ocular surface via digital images. It is helpful to both patients and physicians when low readings are measured and documented in patients with non-obvious MGD.

The meibomian gland evaluator applies standardized pressure (0.3 psi) to five consecutive glands-allowing a controlled, reproducible method to assess gland secretions.

The thermal pulsation system applies controlled warmth (up to 42.5° C) to the inner eyelid surface with intermittent pressure to the outer surface for 12 minutes. The procedure is relatively painless, with patients able to return to work immediately after the treatment. Patients may have mild ocular injection for 1 to 2 hours immediately following the procedure. It is important to note that the activators applied to the lids come in one size only, and placement may be uncomfortable for patients with small palpebral fissures.

Published data

The system demonstrated significant improvement in meibomian gland secretion at 2 and 4 weeks in a non-significant risk, prospective, open-label, randomized, crossover, multicenter clinical trial.³ This same study also documented a greater reduction in dry eye symptoms compared with a warm compress system (iHeat, Advanced Vision Research), with no significant difference in the incidence of non-serious adverse events.

Greiner recently documented that a single treatment with the thermal pulsation system provides sustained improvement in meibomian gland function scores and Standard Patient Evaluation of Eye Dryness scores at 3 years.⁴ Tear break-up times and the Ocular Surface Disease Index were no longer significantly increased at the 3-year time point.

Personal experience

I have performed this thermal pulsation procedure since October 2012 and have found it to be a useful adjunct in the management of dry eye in my practice. It is important for patients to understand that the treatment is not a cure and that the amount of symptomatic improvement they will have is dependent on how advanced the disease is prior to treatment.

Patients also must understand that they may continue to require other therapies (topical drops, cyclosporine [Restasis, Allergan], punctum plugs, or doxycycline) after the treatment, depending on the level of disease before treatment.

It took 4 weeks for me to develop an understanding of what kind of result could be expected based on patients’ pre-treatment level of disease. Patients with mild to mild/moderate MGD have significant relief of symptoms with the treatment alone. Those with moderate to moderate/severe disease often have relief of symptoms with the treatment plus other therapies, such as punctum plugs, cyclosporine, or doxycycline.

Some patients with severe disease may not have any symptomatic relief at all. The benefit they receive from the treatment is maintaining the small number of glands they have left. This must be explicitly stated to these patients prior to their treatment. I have noted that several patients with severe disease had significant improvement in their symptoms after three treatments in 9 months. This may be a result of the patients having very thick secretions that did not melt after the first treatment.

Severely obstructed meibomian glands can involve higher melting points.⁵ Multiple treatments over a short period may be of benefit, but the cost is prohibitive and a clinical trial would be necessary to support this observation.

I have also had a patient referred with a persistent epithelial defect (PED) with MGD and aqueous tear deficiency with maximum medical therapy. The PED healed within 1 month status/post-treatment.

Clinical trials have demonstrated the efficacy of the thermal pulsation system. However, if one peruses multiple Internet sites there is considerable patient dissatisfaction. This is likely the result of patients having expectations that are too high for their level of MGD.

It is mandatory that physicians clearly articulate the results that patients are likely to obtain with the treatment. Patients with mild to mild/moderate disease have the most relief, in my experience, but may be most reluctant to undergo the treatment because of cost considerations. These are also the patients who are not likely to require other therapies.

Patients with moderate-to-severe disease will often require other therapies. I currently provide re-treatment to patients with mild-to-moderate disease every 12 months. Patients with moderate-to-severe disease may require treatments more frequently.

The thermal pulsation therapy has proven to be an important addition to my armamentarium in the management of MGD and dry eye. It requires a careful and meticulous pre-treatment evaluation so that the level of disease can be documented and the likely result articulated to patients.

References

1. Nichols KK, Foulks GN, Bron JK, et al. The international workshop on meibomian gland dysfunction: Executive summary. Invest Ophthalmol Vis Sci. 2011;52:1922-1929.

2. Blackie CA, Korb DR, Knop E, et al. Nonobvious obstructive meibomian gland dysfunction. Cornea. 2010;29:1333-1345.

3. Lane SL, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012;31:396-404.

4. Greiner JV. Long-term effects of a single LipiFlow thermal pulsation system treatment on meibomian gland function and dry eye symptoms. American Society of Cataract and Refractive Surgery. Chicago, IL: 2012.

5. Bron AJ, Tiffany JM. The contribution of meibomian disease to dry eye. Ocul Surf. 2004;2:149-165.

Author info

Ernest W. Kornmehl, MD, FACS, is editor of the Anterior Segment Techniques column. Dr. Kornmehl is medical director at Kornmehl Laser Eye Associates, Wellesley and Brookline, MA, and clinical instructor, Harvard Medical School and associate clinical professor in ophthalmology, Tufts School of Medicine, Boston. He did not indicate a financial interest in the subject matter.