Eyeworld

MAY 2019 | SUPPLEMENT TO EYEWORLD | 11 Meibography reveals meibomian gland thickening and drop out that this disease is occurring earlier, across both genders, because of environmental triggers and lifestyles, and we also know that this population is very prone to flares because of the additional exacerba- tions associated with screen time." Preeya Gupta, MD, noted that the patient has exposure problems because of reduced blinking and pointed out that they should ascertain the effect of the reduced blink on the meibomian glands. "A normal blink is needed to express some of that meibum, so if he continues in the gam- ing world he's going to have stasis in the glands, which eventually leads to obstruction and ultimately to atrophy of the meibomian glands," Dr. Gupta said. She went on to describe the patient as very high risk and said she would manage him with a chronic anti-inflammatory topical therapy, blinking exercises, and a serious conversation about the disease to get him to appreciate its effects. The panel agreed that this is the type of patient who tends to ignore the disease until it has progressed much further along. Edward Holland, MD, pointed out that patient edu- cation will be very important to convince this patient to take breaks and to learn how to blink. "Studies show that these patients will not give up their devices, so since they won't change their behavior, we have to get them to under- stand the disease, get them to modify their behavior in terms of taking breaks and using artificial tears, and potentially treat their acute flares," he said. Dr. Donnenfeld suggested that there are simple environ- mental changes that can be implemented prior to thera- peutics. "You can increase the humidity in the room with a humidifier, or you can have the patient lower the device screen, so they are looking down, which can help reduce symptoms," he said, adding, "Of course, they may still need therapeutics." Elizabeth Yeu, MD, said any amount of staining in a patient this age is a major red flag. "When you see staining in a young patient oftentimes the surface is OK, but their osmolarity is quite elevated. Younger patients have a great compensatory mechanism with over-tearing to help pro- tect the surface, but if there is any kind of architectural damage that will put them into a moderate or moderate/early severe stage," she said. As far as treatment, Dr. Holland said he would direct the patient to use artificial tears and to modify his be- havior—change the angle of his screen and take breaks. If he is highly symptomatic, Dr. Holland might recommend a topical corticosteroid. "With a male patient this age, I would be sure to limit prescription refills to ensure that he returns for follow-up, and I would check in on this patient fre- quently," he added. The group agreed that meibomian gland imaging would be helpful, and Dr. Lissamine green conjunctival staining with 2+ meibomian disease Holland pointed out that even those eyecare providers who do not have the prerequisite imaging technology could simply look at the glands and perform expression to evalu- ate the quality of meibum. With respect to potential MGD therapy, Dr. Yeu said she would choose something that would help the patient have better egress, such as an esterified omega or one that is rich in gamma-linolenic acid (GLA). "Depending on the level of disease, other types of in-office intervention such as motorized cleansing of the lid margin or thermal pulsa- tion could be helpful to get the patient started in the right direction," she said. Dr. Donnenfeld recom- mended blepharoexfoliation to remove the biofilm that forms on the lid margins prior to initiating meibomian gland therapy, and the panel agreed that they would see this patient for follow-up at 3 to 4 weeks. Depending on how of- ten and how severe the flares are they might initiate a course of corticosteroids. n

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