Eyeworld

I JUNE 2019 | EYEWORLD | 47 flammation at the lid), Dr. de Luise said tea tree oil is effective, but he thinks Cliradex (Bio-Tis- sue) formulation is less irritating. Systemic strategies, such as doxycycline and minocycline, are effective adjuvants to MGD treatment, he said, liquefying inspissated meibum. "Cyclines should be considered as part of a total treatment plan for MGD unless contra- indicated. The bioavailability of minocycline is better than that of doxycycline and does not have to be 'loaded and stepped down' as does doxycycline," Dr. de Luise said. As for other pharmaceutical therapies (Restasis, Xiidra, Cequa), Dr. de Luise said they don't directly intersect with the underlying etiol- ogy of MGD. "What is still unavailable and remains necessary is a topical agent that can potentially reverse the dysfunctional physiology of these complex fatty acids in the meibum," he said, adding that some pipeline strategies seek to address this issue, such as NOV03 (perfluoro- hexyloctane, Novaliq). Lisa N m, MD, JD Inflammation at the lid margin (blepharitis) is most often caused by an issue stemming from the meibomian glands, but that's not the only source, Dr. Nijm said. Patients might have ocu- lar rosacea, atopy, staph infection, or Demodex, which need to be considered as a source of tear film disruption. Dr. Nijm begins her examination with an overall assessment of the eyelids, the skin, the lid margins, and meibomian glands with gentle expression of the glands at the slit lamp. She will then evert the lids, perform fluorescein evaluation of the tear film, tear meniscus, and tear breakup time and do a detailed examination of the conjunctiva and cornea. While her initial evaluation is mostly performed at the slit lamp, she is particularly excited about one diagnostic tool in the pipeline. LacriScience is coming out with a handheld device to measure and quantify osmolarity and MMP-9 that Dr. Nijm thinks will streamline the diagnostic process. customized expression is preferable. If these treatments don't work, Dr. Periman said she will perform intraductal Maskin probing of the glands. Dr. Periman has used iLux (Alcon) in a demo capacity. She has clinical experience with TearCare and likes its patient-satisfying, thermal meibum-melting, and customized-expression features. She also mentioned intranasal neurostim- ulation with TrueTear (Allergan). More neural stimulation devices are in development. Once inflammation and MGD are controlled, she said, "Neural stimulation keeps the streams of meibum, lacrimal fluid, and goblet cell mucins flowing." Vincent de Luise, MD "Most evaporative dry eye disease is MGD," Dr. de Luise said. "That said, it remains incumbent upon the ophthalmologist to assess the eyelid margin (lashes, lash roots, meibomian gland or- ifices, and meibum phase state [liquid, viscous, or inspissated]) and to assess tear film anatomy and function (tear meniscus height and quality, tear film breakup time, corneal vital dye stain- ing, ideally with lissamine green or fluorescein)." With MGD, there will be debris in the tear film and a decreased tear film breakup time, Dr. de Luise said, as well as inflammation, cheesy meibum, and/or capped/blocked glands. If the meibomian glands appear healthy with poor tear film spreading and decreased tear film breakup time, it could be a biofilm issue. There is no "best" treatment for MGD, Dr. de Luise said, but there are several useful strategies and technologies. First, he discusses incorporating more omega-3 fatty acids into patients' diets. Next, Dr. de Luise addresses the mechanical component of MGD. "Opening the meibomian gland orific- es mechanically with direct pressure, Maskin probes, so-called golf club spuds, or other fine instruments, and liquefying viscous or inspis- sated cheesy meibum with hot compresses is helpful," he said. Because Demodex harbors Bacillus oleronius in its hindgut (the latter of which can create in- About the doctors Vincent de Luise, MD Assistant clinical professor of ophthalmology Yale University School of Medicine New Haven, Connecticut John Hovanesian, MD Harvard Eye Associates Laguna Hills, California Lisa Nijm, MD, JD Assistant clinical professor of ophthalmology University of Illinois Eye and Ear Infirmary Chicago Laura M. Periman, MD Director of Dry Eye Services and Clinical Research Evergreen Eye Center Seattle continued on page 48 From left: Irregular corneal staining in patient with moderate evaporative dry eye Irregular corneal staining in a patient with Sjogren's disease Careful examination of lids and lashes will reveal signs of blepharitis and possible Demodex. Source (all): Lisa Nijm, MD, JD

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