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A Leap Forward in
Dry Eye Diagnosis
and Care
New technology helps educate patients about their tear film while also identifying
who will benefit from thermal pulsation treatment.
By D. Rex Hamilton, MD, MS
O
ne of the leading causes of dry eye is meiboment warms the eyelids from the inside, immediately
mian gland dysfunction (MGD).1 When paradjacent to the meibomian glands, to about 40° C, the
tially obstructed, the glands fail to adequately
temperature required to liquefy the contents of the
secrete healthy, clear lipids onto the ocular sur- obstructed gland.3 The system then applies intermittent gentle pressure to the outer surface of the lids to
face, contributing to rapid evaporation of tears and the
tear film’s instability. Over time, as patients become more express the softened meibum (Figure 1). The entire
process takes 12 minutes for either a unilateral or
symptomatic, the ocular surface can become increassimultaneous bilateral treatment.
ingly inflamed and irritated, and the meibomian glands
become obstructed and begin to atrophy.
Recently, we eye care specialists have
acquired new diagnostic and therapeutic
tools that allow us to image and analyze
the lipid layer and treat evaporative dry
eye disease (DED) in ways that were not
previously possible.
Studies have shown a correlation
between the thickness of the lipid layer
and symptoms of DED.2 Tear film interferometry (LipiView Ocular Surface
Interferometer, TearScience) is a noninvasive test for quantifying the lipid layer
thickness. It analyzes approximately 1 billion data points in a matter of seconds.
In my practice, I use the LipiView and
other tests to help me decide which
patients are likely to benefit from the
LipiFlow thermal pulsation therapy (also
Figure 1. LipiFlow thermal pulsation treatment.
from TearScience). This unique treat-
44 Advanced Ocular Care May/June 2012
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L ipi V iew Testing
The LipiView test provides three useful outputs. The
first of these is the average interferometric color unit
(ICU), a measurement of the interference pattern of
light reflected off of the lipid layer (Figure 2). Average
ICU is not a static number. Similar to one’s heart rate, it
is subject to normal fluctuations, but it plays an important role in evaluation of the tear film. There is a strong
correlation between the color on the ICU scale and the
lipid layer thickness, measured in nanometers.
Second, a frame-by-frame graphical representation
shows what is happening to the lipid layer’s thickness
between blinks (Figure 2). It is remarkable to see how
the interblink lipid layer thickness curves differ from
patient to patient. Over time, I believe eye care specialists will learn a great deal more about how to interpret
the myriad information provided by the LipiView
acquisition.
Finally, the system provides a high-resolution video
that the patient and clinician can watch on a large,
flat-screen display. The video illustrates how the eyelids
“grab” the tears and pull them up across the ocular
surface, and it helps patients understand the role of
ocular lipids. The contrast between the rainbow sheen
of tear film with healthy oil levels and the dull gray and
white of an eye with MGD is apparent, even to a layperson. LipiView also helps to identify partial blinkers,
for whom blinks are inefficient and do not adequately
access the tear lake residing on the lower lid.
Whether treatment is initiated or not, the LipiView
display plays a critical role in the patient’s education
about the composition and quality of the tear film, the
Figure 2. The LipiView test provides the average interferometric color unit measurement (A) and a frame-by-frame
graphical representation of what is happening to the lipid
layer’s thickness between blinks (B).
“In my practice, LipiView
interferometry is just one part of
the process of determining
whether a patient will benefit from
thermal pulsation treatment.”
spread of tears over the ocular surface, and the completeness of the blink. It provides something tangible to
show patients, which serves to validate the frustrations
they have been experiencing from their chronic evaporative DED.
Making Treatment Decisions
In my practice, LipiView interferometry is just one
part of the process of determining whether a patient
will benefit from thermal pulsation treatment.
I begin with a Standard Patient Evaluation of Eye
Dryness (also known as SPEED) questionnaire to elicit
the frequency and severity of the patient’s subjective
symptoms. This test is scored on a scale of 0 to 28,
with 0 representing no symptoms. For any patients
who score 8 or more, I recommend a more thorough
dry eye evaluation. I prefer for that evaluation to take
place during a separate appointment to ensure that the
patient has not had any dyes or drops instilled or used
any ocular ointments during the preceding 12 hours.
During the evaluation, the first step is LipiView interferometry. Higher ICU scores indicate a thicker lipid
layer, and thinner measures of the lipid layer indicate a
Figure 3. The Meibomian Gland Evaluator.
May/June 2012 Advanced Ocular Care 45
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80% of our cases, there has been an objective
improvement in the 1-month posttreatment
ICU score, and about 70% of patients experience a reduction in symptoms. One reason
why improvements appear to last longer than
was originally anticipated is that heating from
the posterior lid surface combined with the
12-minute pressure profile does a better job
than expected at flushing out stagnant or purulent material that may have been sitting within
the gland structures for months or even years.
Most of our patients who have used LipiFlow
have tried multiple other treatments, from
warm compresses to punctal plugs, cyclospoFigure 4. Clinical trial results with LipiFlow: meibomian gland function
rine, steroids, and tetracyclines. Initially, espe1 month after treatment.
cially in a tertiary care center like the Jules Stein
Eye Institute, we are treating patients with
deficiency and suggest obstructive MGD.
quite advanced MGD. I do not believe, however, that
My next diagnostic step is the use of the Meibomian
one should consider LipiFlow a “last resort” treatment.
Gland Evaluator (TearScience). This is a simple tool
Obstructive MGD is a chronic disease similar to glaufor applying standardized pressure to the meibomian
coma, and it may not be reversible. Intervening earlier
glands (Figure 3) to evaluate the presence or absence of in the process may help position the patient for better
lipid secretion, as well as its quality, from 15 glands on
long-term success.
the lower lid. If four or fewer of these glands are secreting clear lipids, that is a sign of obstructive MGD.4
CONCLUSION
I also perform lissamine green staining and fluoresWe are still learning the best way to position the
cein tear breakup time (TBUT) as part of the analysis
treatment device on different types of eyes, how to
for DED. By using this comprehensive evaluation, I am
harvest and interpret the rich trove of data LipiView
looking for consistency in the results. For example, if
gathers about the tear film, and how to identify the
the patient is more symptomatic in the eye that has
best predictors of success. Based on our experience
a short TBUT, ICU of 25, and few functioning glands, I
thus far, I am very excited about the new opportunibelieve he or she is an excellent candidate for LipiFlow
ties that LipiView and LipiFlow present for our patients
and will likely benefit from the treatment. If the glands
with DED. n
are mostly functioning well and the patient has an
D. Rex Hamilton, MD, MS, is an associate
ICU of 85, I may decide not to treat with Lipiflow and
clinical professor of ophthalmology and direcinstead use an alternative therapy.
tor of the UCLA Laser Refractive Center at the
UCLA Jules Stein Eye Institute. He has received
RESULTS of LipiFlow treatment
honoraria from TearScience for educational
In a controlled, prospective clinical trial, there was
lectures. He may be reached at (310) 825-2737;
a mean improvement from baseline to 1 month after
treatment with LipiFlow in the meibomian gland score, [email protected].
TBUT, and the SPEED and Ocular Surface Disease
1. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: execuIndex (known as OSDI) questionnaires.5 The patients
tive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
assigned to treatment with LipiFlow had a significantly 2. Blackie CA, Solomon JD, Scaffidi RC, et al. The relationship between dry eye symptoms and lipid layer thickness. Cornea. 2009;28:789-794.
greater improvement in the number of meibomian
3. Bron AJ, Tiffany JM, Gouveia SM, et al. Functional aspects of the tear film lipid layer. Exp Eye Res.
glands secreting clear liquid compared with control
2004;78(3):347-360.
4. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and
patients who were treated with warm compress
gland location. Cornea. 2008;27(10):1142-1147.
therapy (Figure 4). Nine-month results have been pub- 5. Greiner JV. A single LipiFlow thermal pulsation system treatment improves meibomian gland function and
dry eye symptoms for 9 months. Curr Eye Res. 2012;37(4):272-278.
lished,5 and investigators have recently reported 1- and reduces
6. Grenier JV. Improvement in meibomian gland dysfunction and dry eye persists 2 years after single treatment
6,7
2-year results at major meetings.
with thermal pulsation system. Presented at: The ASCRS-ASOA Symposium & Congress; April 19-23, 2012;
Chicago, Il.
My colleagues and I have seen very similar results in
7. Herzig S. Effect of thermal pulsation treatment on subjective and objective measures of dry eye. Presented at:
our first few months of nonstudy treatments. In 75% to
The ASCRS-ASOA Symposium & Congress; April 19-23, 2012; Chicago, Il.
46 Advanced Ocular Care May/June 2012