Eyeworld

meibography summit: Better understanding of meibomian gland dysfunction and how to integrate meibography in diagnosis and treatment planning 8 | SUPPLEMENT TO EYEWORLD | SEPTEMBER 2019 glands, biofilm, inflamma- tion, and the tear film," Dr. Karpecki said. "You have to have all of these tools to address all four elements, and that is when you really start seeing great success." "I think the cornerstone of MGD treatment is lid hygiene, and I think thermal pulsation and blepharoex- foliation are the best way to treat these patients," said Henry Perry, MD. "I have also looked in terms of Demodex blepharitis, and we have used blepharoexfoliation to remove the cylindrical dandruff. That surprisingly removed 80–90% of the Demodex with one treat- ment in 1 month." 2 Interest in Demodex is also increasing in Europe, with the appearance of tea tree-impregnated compresses combined with a tear film regenerator as an effective and well-tolerated therapeutic option, said Béatrice Cochen- er-Lamard, MD, PhD. "In addition to a proce- dural treatment like evacua- Increased understand- ing of MGD helps clinicians make the most of today's therapies I n addition to guiding diagnosis of ocular sur- face disease (OSD), the ASCRS Preoperative OSD Algorithm plays an important role in identifying meibomian gland dysfunction (MGD) and directing treatment in the preoperative setting. "It is a much more ag- gressive, multifaceted ap- proach to improve tear quality quickly in these patients be- cause we want to get them into the operating room," said Marjan Farid, MD. "A signif- icant part of that is treating MGD aggressively, oftentimes with a procedural therapy, such as thermal pulsation, to get the oil glands flowing bet- ter and improve tear breakup time before surgery." Shifting focus Previously clinicians focused on treating inflammation and increasing the tear film, said Paul Karpecki, OD. However, for evaporative dry eye, which accounts for 86% of all dry eye, "you also have to treat the obstructed meibomian glands as well as the biofilm. 1 So evaporative dry eye requires management of obstructed tion of meibomian glands," said Cynthia Matossian, MD, "at-home treatments like lid scrubs with tea tree oil, tea tree and coconut oil combina- tions, or hypochlorous acid all help potentiate the effect of the actual treatment." Minimum treatments When asked about the mini- mum MGD treatments they would recommend, Sum- mit participants agreed that clinicians need to remove the biofilm and express the mei- bomian glands and suggested other treatments. They also shared their responses on the role of in-office devices for MGD treatment (Figure 1). "I am hoping clinicians still use the treatment algo- rithm from DEWS II as a guideline for treating MGD," said Terry Kim, MD. 3 He thinks practices should be able to offer level I and II therapy, at the very least. Dr. Kim explained that lipid-based tears and lid margin hygiene therapy are important for patients with MGD and recommended using a microwavable heat mask and cleaning debris from the eyelid margins with microblepharoexfoliation therapy. In addition, he pre- scribes topical corticosteroids for acutely inflamed eyes and pulsed corticosteroid thera- py for patients with dry eye flares. Standard treatments for MGD include omega-3 nutritional supplements and combination therapy that may include azithromycin, lipid-based tears, or oral doxycycline, said Edward Holland, MD. "I have not been impressed with home lid hygiene or lid heat thera- pies," he said. "I do think the devices we now have, such as microblepharoexfoliation of the lid margin to remove the biofilm as well as thermal pulsation or anterior ther- mal treatment to the lids, are useful." High-quality omega-3 has been shown to be effective in dry eye disease and MGD, and the majority of dry eye algorithms have included omega-3 as a primary therapy for dry eye disease and MGD, said Alice Epitropoulos, MD. 4–7 She explained that it also helps restore the quality of the meibum after mechani- cal treatment, such as thermal pulsation. Targeting MGD with advanced treatment options "It is a much more aggressive, multifaceted approach to improve tear quality quickly in these patients because we want to get them into the operating room." —Marjan Farid, MD

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