Eyeworld

EW CORNEA 60 May 2018 by Rich Daly EyeWorld Contributing Writer The BlephEx treatment (Frank- lin, Tennessee) is not too expensive to purchase and maintain, Dr. Reilly, and patients can be passive in their treatment. He said it works better for seborrheic blepharitis or staph hypersensitivity. Follow-up treatments Among the follow-up treatments is the Moist Heat Eye Compress (Brud- er Healthcare Company, Alpharetta, Georgia), which aims to open oil glands and allow natural oils to flow back into the eye. The treatment is inexpensive and works well if the patient is dedicated to using it as di- rected, Dr. Reilly said. Its disadvan- tages include the need for patients to be active in its use, as well as its provision of only mild compression and no real massage. Hot compresses are more suc- cessful after LipiFlow and IPL, Dr. Gupta said, because they aid in the process of allowing the glands to function better. In addition to the Bruder mask, there are other masks available over the counter that have a gel bead or a micro-type filling, which allows patients to use a mi- crowave to heat them. "I ask patients to hold the heat there for 3–5 minutes and do some gentle massage," Dr. Gupta said. "It's harder for patients to do more than once a day, especially since a lot of the patients who suffer from the disease tend to be younger patients [who are] very active and busy." EW Editors' note: Dr. Sheppard has finan- cial interests with TearLab (San Diego), Johnson & Johnson Vision, Quidel (San Diego), Allergan (Dublin, Ireland), Bausch + Lomb, Topcon (Oakland, New Jersey), and Novartis (Basel, Swit- zerland). Dr. Gupta has financial in- terests with Johnson & Johnson Vision. Dr. Reilly has no financial interests related to his comments. Contact information Gupta: preeya.gupta@duke.edu Reilly: cdreillymd@gmail.com Sheppard: docshep@hotmail.com barriers to the oils coming out," Dr. Gupta said. IPL views Dr. Gupta regularly uses intense pulsed light therapy (IPL). IPL, which is used off-label in these patients, is applied to the lower lid, and patients have to undergo a series of four treatments every 3–4 weeks. Maintenance treatment is given every 6–12 months. "My personal philosophy is if you see MGD, you should treat it because patients can lose function of the glands over time," Dr. Gupta said. "It's not uncommon to see a patient who has had MGD for 15 or 20 years and only became symp- tomatic as other things in their life happen." For example, a 50-year-old female patient with chronic ocular rosacea who never had symptoms of dry eye could become symptomatic over time due to coexisting hor- monal changes and menopause, eye surgery, or contact lens wear, which fits with the emerging understand- ing of dry eye as a multifactorial disease. Managing MGD is a critical part of managing dry eye disease, and patients frequently present with multiple comorbid conditions, Dr. Gupta said. The advantages of IPL to Dr. Reilly include its ability to work not only with heat but also with de- creasing inflammation. Additionally, patients can be passive in their treat- ment, and it works well for rosacea. Disadvantages he has seen include its expense and its contrain- dication in patients with Fitzpatrick skin type 4 or higher because depig- mentation can occur. Other devices The MiBo Thermoflo (MiBo Medi- cal Group, Dallas) performs well in warming the meibomian glands, Dr. Reilly said, and patients can receive treatment passively. However, it takes a well-trained technician to administer, and results can be opera- tor dependent. Additionally, it must be repeated. allows the patient to be passive. Disadvantages he's seen include the need for a well-trained technician and the size of the initial invest- ment in the device. Dr. Sheppard said he uses dynamic light scattering (DLS) to determine which patients are eligible, with outstanding patient engagement and comprehension from the graphic display of meibo- mian architecture. Preeya K. Gupta, MD, associate professor of ophthalmology, Duke University Eye Center, Durham, North Carolina, tells patients it takes 2–4 months to see the full effects of the treatment because the glands are evacuated at the time of the treatment and there is some- times a lag until the glands start producing healthy oil again. The treatment lasts about a year on average, although some studies say the effect can last up to 3 years. "If the treatment works well for patients, I generally tell them to come back for treatment when they start feeling like some of their symp- toms are slowly recurring but not to wait until they are as bad as they were before the initial treatment," Dr. Gupta said. Before the treatment, Dr. Gupta uses a spatula to debride the lid margin of keratinized material that is often found in meibomian gland dysfunction patients. "Debriding the lid margin makes relieving the obstruction more successful because there's less Surgeons discuss comparative advantages they see in various options for lid margin therapy A growing number of devic- es have emerged in recent years to treat the symp- toms of dry eye disease, and eye surgeons' expe- riences have shown they provide differing levels of benefit for various patient types. John Sheppard, MD, professor of ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, has found the LipiFlow Thermal Pul- sation System (Johnson & Johnson Vision, Santa Ana, California), works well when offered as a premium cash pay procedure that incorpo- rates VIP patient care. The device treats the primary cause of evapora- tive dry eye, obstructed meibomian glands. LipiFlow is a single in-office treatment that applies heat at 42.5 degrees centigrade to the aspect of the posterior of the lid with precise- ly monitored pressure. "You have to counsel patients properly that it's not an insurance- based procedure, and they have to maintain their hygiene afterward for the full effect," Dr. Sheppard said. For Charles Reilly, MD, adjunct assistant professor of ophthalmol- ogy, University of Texas Health Science Center at San Antonio, the advantages of LipiFlow are that it warms and massages the glands and Lid margin therapy devices Device focus " My personal philosophy is if you see MGD, you should treat it because patients can lose function of the glands over time. " —Preeya Gupta, MD

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