Download Howard Barnebey, MD

By Howard Barnebey, MD
Treating a Glaucoma
Patient’s MGD
and reduced lipid layer thickness. We
also image the meibomian glands which
provides the structural evidence we need
to share with the patient.
In this case study, a comprehensive dry eye examination
and subsequent treatment with LipiFlow have positive outcomes.
(A)
Ocular surface disease (OSD) is common among glaucoma patients. Medications may be
contributing factors to OSD, or the prevalence may simply result from the same factors that
contribute to patients getting glaucoma. Whatever the cause for this correlation, it’s important for us to diagnose and treat OSD for patients with glaucoma, regardless of whether they
are symptomatic. The most important reason for this is that I want my glaucoma patients to
be alert to any fluctuations in their vision, and ocular surface treatment helps to eliminate
one potential cause of those fluctuations.
Howard Barnebey, MD,
is medical director of
Specialty Eyecare Centre
in Seattle.
A serious
look at the
eyelids and
tear film is
part of our
comprehensive
exam.
2
Patients often don’t have complaints about
MGD impacts lipid layer thickness and tear
(B)
comfort or vision fluctuation because they film quality, and the resulting cornea damaccept these changes as normal. For this reason, age can be revealed through staining. When
many practices have patients complete screen- the glands are plugged, we observe functional
ing questionnaires to uncover their experiences changes through diagnostic gland evaluation
with ocular surface problems. Patients
who score 7 points or higher on the Figure 1. Initial and 1-month follow-up
questionnaire receive a dry eye evalua- LipiView results (OD treated, OS untreated)
tion. In my practice, we’ve chosen a difOD
OS
ferent approach. A serious look at the
eyelids and tear film is part of our com7/26/2013
prehensive exam. It does require discipline when there are time constraints,
Visual acuity
20/25
20/25
but OSD is a priority for us, so we’ve
made time to include it as part of our
Lipid layer thickness
54 nM
85 nM
exam routine.
MGD is a Problem
Meibomian Gland Dysfunction (MGD)
is at the root of dry eye disease for many
of my patients. Like glaucoma, MGD can
be detected by observing functional and
structural changes to the glands. Early
functional change (e.g., mild obstruction) can lead to observable structural
change (e.g., drop out), if MGD goes
undetected.
Blink
11/19
4/19
IOP
­15
20
Lipid layer thickness
84 nM
72 nM
Blink
5/16
3/13
IOP
16
26
8/30/2013
ophthalmologymanagement.com | 800-306-6332
A Glaucoma Patient with MGD
Presentation
A 67-year-old patient with significant
pseudoexfoliative glaucoma presented
with complaints of dry, red and achy
eyes. His vision sometimes fluctuated
as well, particularly after hours of computer use.
The patient had undergone trabeculectomy on both eyes 14 years prior
and cataract surgery with Restor (Alcon)
IOLs in both eyes 7 years later. He was
using cyclosporine ophthalmic emulsion
(Restasis, Allergan) and timolol, but it
sounded to me as though deficient tear
film may have been affecting his comfort
and vision.
Exam and Testing
Testing with LipiView showed that the
lipid layer was diminished, particularly
in the right eye (54 nM OD, 85 nM OS)
(Figures 1 & 2). The intraocular pressure
(IOP) was better controlled in the right
eye, but both eyes had mild conjunctival
injection.
Treatment with LipiFlow
In my practice, we were early adopters
of LipiView and LipiFlow. When this
patient came in, we were in the process
of putting together a dry eye evaluation
and workup plan. Our LipiFlow machine
was new, and we were learning how to
make that technology a routine treatment for dry eye in the practice.
Because the patient had a significantly thinner lipid layer in the right eye,
I ordered LipiFlow treatment on that
eye. Today, we would most likely treat
both eyes using LipiFlow. We were very
interested to see the treatment outcomes
of this new technology.
Figure 2. Untreated
right eye
Outcomes
At a follow-up visit several days later,
the patient said his eyes felt better, but
I wasn’t sure if significant improvement
had occurred. At 1 month, LipiView
objectively showed us that the lipid layer
had improved dramatically, from 54 nM
to 84 nM (Figure 3). I now rely on a
number of secreting glands to determine
improvement.
At 4 months, we began to see the
downside of treating the right eye alone.
There was a marked difference between
the two eyes. The treated right eye was
comfortable with minimal conjunctival
injection, while the left eye was red and
the patient reported discomfort.
The patient’s IOP had also increased
significantly in the left eye, from 20 to 26
mmHg, while the right eye remained stable. Although this change is not directly
attributable to treating just one eye with
LipiFlow, I did wonder if treatment of
the ocular surface was affecting timolol
compliance or how well it penetrated. I
switched the left eye from timolol alone
to dorzolamide and timolol (Cosopt,
Figure 3. Right eye treated
with LipiFlow
Merck) and brimonidine (Alphagan,
Allergan) for IOP control. Ultimately, it
wasn’t enough, and the left eye required
a canaloplasty.
Lessons Learned
MGD diagnosis has evolved rapidly in
the last few years. As an early adopter of
the LipiFlow technology, the similarities
to glaucoma have surprised me.
The use of metrics and technology for
the diagnosis of MGD is new. Now that
they are available, we’ve developed an
effective protocol to offer our patients a
much higher standard of care and early
intervention.
As an experienced ophthalmologist, I
was initially skeptical about the LipiFlow
treatment. Today, I understand and trust
the technology and want to offer its
benefits to my patients. n
ophthalmologymanagement.com | 800-306-6332
Sponsored by