Download understanding evaporative dry eye disease

today’s Practice
Understanding
Evaporative
Dry Eye Disease
How does meibomian gland disease affect dry eye management?
By David R. Hardten, MD, FACS
D
ry eye symptoms have long been attributed
to reduced tear production, and use of the
phrase dry eye disease encourages us to target management strategies toward aqueous
replacement. However, recent research1-7 shows that
meibomian gland disease (MGD) is often the underlying cause of dry eye. In these cases, the origin of dry eye
symptoms is not the absence of the aqueous component of tears but rather the presence of an unhealthy
lipid deficiency—a scenario better described by the
term evaporative dry eye disease.
MGD-TAILORED THERAPY
I was recently an investigator for a trial evaluating
the safety and effectiveness of the LipiFlow System
(TearScience) in 139 patients with MGD and dry eye
symptoms.8 The study assessed the factors of dry eye
disease that showed an association with symptoms and
improvement in meibomian gland function.8 Half the
patients were randomly allocated to receive a single
bilateral LipiFlow thermal pulsation treatment, and
the other half received daily warm compress therapy
and were assessed prior to being crossed over to
LipiFlow therapy at 2 weeks. Across treatment groups,
there were no significant differences in age, sex, or, for
women, menopausal status.
We assessed meibomian gland function and dry eye
symptom severity before and 2 weeks after treatment
using a meibomian gland (MG) assessment scale and
self-reported ocular surface disease index (OSDI) score.
The MG scale grades the quality and quantity of material produced by each of 15 meibomian glands located
along the lower eyelid on a scale of 0 (no substance
produced by the gland) to 3 (perfect function). We
Recent research shows that
meibomian gland disease is often
the underlying cause of dry eye.
used the Meibomian Gland Evaluator (TearScience) to
obtain all MG scores. This device assesses MG function
by applying standardized pressure to the lid margin and
simulating a forced blink.
At the end of week 2, we found that patients who
received LipiFlow therapy showed significantly greater
improvement of MG and OSDI scores compared with
the warm compress group. Additionally, patients who
received LipiFlow treatment and had a low pretreatment MG score and a high OSDI score were most likely
to show marked improvements in MG score. In my
opinion, this suggests that LipiFlow therapy effectively
improves subjective and objective measures of evaporative dry eye disease.
FOCUS ON MANAGEMENT
Since carrying out the study, my practice has integrated the Meibomian Gland Evaluator, LipiView
Interferometer, and LipiFlow treatment device into the
management protocol for dry eye disease. We use the
Meibomian Gland Evaluator and LipiView devices to
assess function in general dry eye patients and in preoperative laser refractive and cataract surgery patients.
This allows us to better predict which patients are at
increased risk of new-onset dry eye or worsening of dry
march 2013 Cataract & Refractive Surgery Today Europe 61
today’s Practice
Take-Home Message
• In some cases, the origin of dry eye symptoms is not
the absence of the aqueous component of tears but
rather the presence of an unhealthy lipid deficiency.
• The development of devices such as the Meibomian
Gland Evaluator, LipiView, and LipiFlow reflect the
important change of direction that dry eye management must take if patients are to finally obtain longterm relief from this chronic and irritating condition.
eye symptoms postoperatively. Once an increased risk
is identified, patients can be treated preemptively with
LipiFlow along with eye drops and lid hygiene processes, rather than waiting for symptoms to worsen after
surgery. Screening patients in this manner gives eye care
providers the opportunity to improve postoperative
outcomes and patient satisfaction.
It is important to highlight that LipiFlow therapy is
not intended to replace the usual methods of managing dry eye symptoms. On the contrary, it may be used
in conjunction with other recognized therapies, such as
warm compresses and lubricating drops. The primary
causes of dry eye symptoms are MGD, aqueous-deficient dry eye, inflammatory dry eye, and allergies. We
have found that many patients experience a combination of these conditions, and, as a result, treatment
must be targeted at all three issues. LipiFlow provides
another avenue for improving the MGD portion of
evaporative dry eye in addition to warm compresses
and topical azithromycin. The inflammatory portion
of dry eye symptoms is addressed with cyclosporine,
and antiallergy medications are used to remedy the
allergic component.
Overall, we have observed very good patient
response to the LipiFlow. Patients report fewer symptoms and better quality of life once their symptoms
are reduced. Because the treatment is given as a single
in-office procedure, compliance is not an issue. The
effect of a single LipiFlow treatment may last between
9 and 15 months; a study is under way to determine
LipiFlow’s duration of effect with greater certainty.
The only downside voiced by patients is that it can
sometimes take 1 or 2 months to experience symptomatic improvement, even though gland improvement is almost immediate. However, we find that if
this is explained to patients prior to treatment, realistic
expectations are set, and the patient does not become
frustrated or lose faith in the therapy during the first
month after treatment. It is also paramount to explain
to patients that although LipiFlow improves gland
62 Cataract & Refractive Surgery Today EUROPE march 2013
Ophthalmic physicians are now
more aware of the importance of
the role of MGD in patients with
evaporative dry eye symptoms.
function and often symptoms as well, it is not a cure.
Because MGD can be a chronic condition, periodic
upkeep, much like a thorough dental cleaning, may be
necessary every 6 to 15 months.
EMBRACING CHANGE
The development of devices such as the Meibomian
Gland Evaluator, LipiView, and LipiFlow reflect the
important change of direction that dry eye management must take if patients are to finally obtain longterm relief from this chronic and irritating condition.
Ophthalmic physicians are now more aware of the
importance of the role of MGD in patients with evaporative dry eye symptoms. The fact that effective MGDspecific therapies are now available puts physicians and
patients in a better position than before. It is now up
to ophthalmic specialists to embrace the new understanding of MGD’s role in evaporative dry eye and the
latest advanced treatments to provide the best care for
patients with evaporative dry eye. n
David R. Hardten, MD, FACS, is the
Director of Refractive Surgery, Minnesota Eye
Consultants, Bloomington, Minnesota. Dr.
Hardten states that he has participated in
clinical trials using the LipiFlow and LipiView
devices and has been a speaker for and consultant to
TearScience. He may be reached at tel: +1 612 813 3632;
e-mail: [email protected].
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