Eyeworld

SEPTEMBER 2019 | SUPPLEMENT TO EYEWORLD | 5 with capping and plugging, Dr. Kim said. He recom- mends scraping the lid margin with a Maloney spatula, using topical anesthesia. "Frequent- ly, after you do this, you will see the gland express, which will also improve your results with thermal pulsation and/or intense pulsed light therapy," he said. Overlooked signs "One of the signs that is often missed in diagnosing MGD is the presence of a foamy tear film," said Henry Perry, MD (Figure 1). "Many times, when we see it, it is exaggerated and easy to note, but to me, even one little bubble in the tear film is diagnostic of a patient who has problems with their meibomian glands." "Eyelash loss is another overlooked sign of MGD. A lot of cosmetic agents on the market designed to help your lashes grow contribute to MGD," said W. Barry Lee, MD. 3 In addition, cosmetic eye- lash procedures—such as lash extensions, lash permanents, and lash tinting—are associ- ated with MGD, said Cynthia Matossian, MD. "When you see patients with extraordi- narily long and unrealistic eyelashes, look for MGD," she said. The everted superior tar- sus also provides outstanding information, encompassing al- terations in vascular integrity, epithelial inclusions, pigment aggregation, deep substantia propria scarring depicting severe chronic inflammation, follicles indicative of chronic hypersensitivity reactions, and acute papillary changes seen with allergy, viral infec- tion, and toxicity, said John Sheppard, MD. Staining steps After gland expression, staining is performed with lissamine green or fluorescein. "In MGD we are going to find more staining inferiorly vs. aqueous tear deficiency, where we see more staining interpalpebrally," Dr. Holland said. Then he uses fluorescein to look for epithelial defects of the cornea. "Patients often think their vision loss is entirely due to cataracts," said William Trattler, MD. "When you place fluorescein in the tear film, you will often determine that your patients have a rapid tear film breakup time. Upon questioning your patients, they often confirm that they are experiencing fluctuation of their vision. In many cases, this fluctuation is contribut- ing to difficulties with their vision." Recognizing MGD Asymptomatic MGD can lead to challenges with treatment compliance. "Thus, these patients are less willing to take our advice, despite the fact that it will benefit their outcomes," Dr. Sheppard said. Clinicians need to incorpo- rate meibography into their Figure 1. 55-year-old man with moderately severe posterior blepha- ritis evidenced by a prominent "foamy" tear film on the lower eyelid margin. The foam is created by free fatty acids combining with inflammation, leading to saponification or soap formation. Source: Henry Perry, MD basic ocular surface diagnostic algorithm. MGD influences corneal epithelial integrity and therefore biometric accura- cy and should be central to routine cataract evaluations, he said. Clinicians can begin by simply expressing the meibo- mian glands during routine slit lamp examination, Dr. Kim said. "Once they realize that the prevalence is there, there may be more incentive to invest in imaging devices like meibography, as well as treatment devices like thermal pulsation and intense pulsed light therapy," he said. Staff engagement Dr. Kim recommended that practices educate the staff as a team about MGD because technicians will be heavily in- volved. "When we decided to implement premium cataract/ intraocular lens technology in our office, we had educational meetings with our staff where we planned how it would be implemented in the practice," Dr. Kim said. "It is not like you are saying, 'I'm going to be a dry eye practice.' It's saying, 'I'm going to pay more attention to this condition within the practice population that I currently see,' as it can have a significant impact on your patient outcomes with cataract and refractive surgery." n References 1. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684. 2. Epitropoulos AT, et al. Visible meibo- mian gland structure increases after vectored thermal pulsation treatment in dry-eye patients with meibomian gland dysfunction. 2019 ASCRS ASOA Annual Meeting. 3. Mocan MC, et al. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. J Glaucoma. 2016;25:770–774.

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