Eyeworld

7 Supported by unrestricted educational grants from TearLab, TearScience, and RPS Using next-generation therapeutics to manage dry eye and meibomian gland dysfunction by Alice Epitropoulos, MD the meibomian glands, determine whether there is dilation or atro- phy, and identify MGD early. We also can use it to show patients what their glands look like versus what they should look like (Figure 1). If we explain that DED can affect their preoperative measure- ments and surgical outcomes, they are more likely to be compli- ant with their treatment even if they do not have symptoms. Conventional treatments such as lid scrubs and warm com- presses are minimally effective in MGD because they do not address meibomian gland obstruction. These are supplemental therapies that can be offered after the obstruction has been addressed. Thermal pulsation is the only treatment for evaporative dry eye cleared by the U.S. Food and Drug Administration and is a very safe and effective procedure. Our retrospective study showed that there was a statisti- cally significant improvement in symptom scores, tear break-up time, and meibomian gland eval- uation scores in patients treated with thermal pulsation. 2 In addition, we recently completed a prospective, multi- center clinical trial showing that re-esterified omega-3 supplements significantly benefited patients with DED. Significant improve- ments were seen in symptom scores, tear osmolarity, MMP-9, and omega-3 index levels.3 We also demonstrated a more stable tear film as evidenced by a signif- icant improvement in tear break- up time. These results support the recommendation that re-esterified omega-3s should be considered in patients with DED and MGD. Aqueous deficiency DED Topical cyclosporine is very ef- fective in patients with aqueous deficiency DED, reducing inflam- mation and increasing goblet cell density. These patients are less likely to experience progression of their disease. 4 Complaints after cataract surgery are often linked to meibomian gland dysfunction and aqueous deficient dry eye D ry eye disease (DED) and meibomian gland dysfunction (MGD) are often the root of what causes many of our patients to be frustrated or dissat- isfied with their cataract surgery outcomes. If we do not treat dry eye and MGD prior to cataract sur- gery, an unstable tear film may adversely affect our biometry, delay healing, and cause subopti- mal results postoperatively. A fail- proof method of identifying MGD and DED is to screen all patients for this condition, especially in our surgical patients. Progressive disorder MGD is the most common form of DED, affecting 85% of all dry eye patients. 1 Because it is a progressive disorder, patients need to under- stand that it can lead to irrevers- ible damage if not treated. Meibography is an excellent tool to examine the structure of Alice Epitropoulos, MD Figure 1. MGD progression leads to gland atrophy. Normal meibography Advanced MGD MGD progression gland atrophy Eric Donnenfeld, MD, has shown that topical cyclosporine also helps improve visual out- comes in patients with multifocal intraocular lenses (IOLs). 5 Treatment of MGD and aqueous deficient DED I see patients 4 to 6 weeks after initiating treatment for MGD and aqueous deficient DED. I remeasure their topography and biometry to make sure the measurements make sense. I don't hesitate to delay treatment until measurements are reliable. Patients should be educated that DED is a chronic, progressive disease; it is often exacerbated after surgery; and treatment is usually continued after surgery. Conclusion Preoperative MGD and DED are extremely common and underdi- agnosed and can adversely affect our surgical outcomes. It's import- ant to maintain a high level of suspicion, even in asymptomatic patients. This requires that we screen and evaluate for these con- ditions preoperatively, which will allow for better quality of vision and overall improved outcomes for our patients. References 1. Lemp MA, et al. Distribution of aqueous- deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472–478. 2. Epitropoulos AT. Evaluation of single thermal pulsation treatment for meibomian gland dysfunction and dry eye. San Diego: ASCRS•ASOA Symposium & Congress, April 2015. 3. Epitropoulos AT, et al. Effect of oral re-es- terified omega-3 nutritional supplementa- tion on dry-eye disease: double-masked randomized placebo-controlled study. San Diego: ASCRS•ASOA Symposium & Con- gress, April 2015. (Manuscript submitted to Cornea) 4. Rao SN. Topical cyclosporine 0.05% for the prevention of dry eye disease progres- sion. J Ocul Pharmacol Ther. 2010;26:157– 164. 5. Donnenfeld ED, et al. Cyclosporine 0.05% to improve visual outcomes after multifocal intraocular lens implantation. J Cataract Refract Surg. 2010; 36:1095–1100. Dr. Epitropoulos is clinical assistant professor, the Ohio State University Wexner Medical Center, Columbus, Ohio, and co-founder, the Eye Center of Columbus.

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