Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download 2016 Press Book
Document related concepts
Transcript
PascaleCommunications,LLC TradePressClipbook 2016 Tearscience Publication ArticleTitle KOL Date Optometric Physician Off the Cuff: The Best of 2016 Art Epstein OD December Ocular Surgery News Tiny thoughtlets to ring in the New Year Darrell White, MD December Advanced Ocular Care Eyelid Heat Treatment Leads to Fast Sarah Henderson, December DED Resolution BS Advanced Ocular Care/ Glaucoma Today Identification and Prevention of Dry Eye Disease Sheri Rowen, MD and Steven Vold, MD December Advanced Ocular Care The Future of Dry Eye and MGD Technologies Joe Boorady, OD December Advanced Ocular Care Business Perspective Joe Boorady, OD December Ocular Surgery News Children with blepharitis often require Richard Lindstrom, December specialized care MD Ophthalmology Management New and Notable at AAO News Optometric Scan for MGD Scott Schacter, Management OD Ocular Surgery News BLOG: Microblepharoexfoliation and Hovanesian, MD biofilms: The future of dry eye and blepharitis treatment? December December November Women in Optometry Vision, Beauty, and Health are (Review of Optometry Intertwined Supplement) Bridgitte Shen Lee, November OD Ophthalmic Professional Three's a Charm Horizon Eye Center November Review of Ophthalmology Treating Dry Eye: Beyond Drops Sheppard, MD November Review of Ophthalmology Managing Dry Eye Patients Step by Step Mark Milner, MD November Ophthalmology Business The “opportunity” in dry eye is the Patti Barkey November chance to improve patient Review of Optometry outcomes All In On Dry Eye Jennifer Lyerly, OD November Optometry Times How to establish value in the minds of contact lens wearers Crystal Brimer, OD November CRSToday Business Perspective Joe Boorady, OD November Ocular Surgery News VIDEO: LipiFlow, LipiView help Matossian, MD educate patients on meibomian gland dysfunction November Ocular Surface News How long should/can a patient go between Lipiflow treatments? Scott Schacter, OD November Optometry Times Newsletter Incorporating meibomian gland imaging Eric Botts, OD Advanced Ocular Care Rationale for Aggressive Management of MGD Preeya Gupta, MD October ME Live Optimizing the Ocular Surface Ivan Mac, MD October Ophthalmology Times Looking beyond the surface of cornea, OSD mechanisms Periman, MD October White, MD October Ocular Surgery News Corneal basement membrane dystrophy: Dry eye disease’s sticky wicket October Tearscience Publication ArticleTitle KOL Date Review of Cornea and Contact Lenses The Chicken-and-Egg Problem of MGD and Contact Lens Wear Arthur Epstein, OD October Optometry Times The Power of the Celebrity Spokesperson O'Dell, OD Optometric Office HEALING THERAPIES FOR PATIENTS WITH DRY EYE Gina Wesley, OD, October MS, FAAO Primary Care Optometry News Identify type of dry eye to ensure successful therapy Whitney Hauser, OD October Vision Monday Saving Boomers' Sight October EyeWorld Battling dry eye with nutritional supplements Whitney Hauser, OD Clifford Salinger, MD Ophthalmology Management ‘A different layer of caution’ exists Cynthia Matossian, October MD; Greg Parkhurst, MD; and Shachar Tauber, MD Ocular Surgery News Blog BLOG: A Year of Relief From a Single LipiFlow Treatment Darrell White, MD October CRSToday Do You Need a Helping Hand? Robert J. Weinstock, MD October Primary Care Optometry News Explore ocular surface in patients with visual complaints Marc Bloomenstein, OD FAAO TearScience: Meibomian imager well News received 9/15/16 Primary Care Optometry News October October September Ocular Surgery News Speaker relates approach to dry eye Sam Garg therapy September Review of Cornea News Brief on duration study and Contact Lenses News September Optometric Office Gina Wesley, OD, September MS, FAAO Sharing is Caring Ocular Surgery News VIDEO: Speaker gives update on dry Keith A. Walter, eye therapies MD September Ocular Surgery News Prevention measures, patient education mitigate postop dry eye and dissatisfaction Alice Epitropoulos, September MD, FACS Optometric Management Get in Front of It Whitney Hauser, OD September Advanced Ocular Care The Vicious Cycle of MGD and Glaucoma Robert Noecker, MD September Advanced Ocular Care Meeting the Eye Care Needs of Student Athletes Bridgitte Shen Lee, September OD CRSToday Europe The Best Ways to Spend Your Money Michael Lawless Ophthalmology Times Europe Portable device offers rapid highdefinition meibomian gland imaging Preeya Gupta September EyeWire TV Coverage of duration study release News September MarketScope TearScience Study: LipiFlow Improves MGD, Dry Eye through 12 Months Press Release August Tearscience Publication ArticleTitle KOL Date Ophthalmology Web TearScience Announces Long Term Press Release Study Results for LipiFlow Treatment August EyeWire A Single LipiFlow Treatment Demonstrates Sustained Improvement in Gland Function and Symptoms in Patients with MGD and Dry Eye Press Release August Ophthalmology Management Three Beneficial Diagnostic Options Donaldson, MD, August Epitropolous, MD, McDonald, MD, Matossian, MD Ophthalmology Management Changing Dry Eye Treatment Donaldson, MD, August Epitropolous, MD, McDonald, MD, Matossian, MD Glaucoma Today What Every Glaucoma Doctor Should Sheri Rowen, MD Know About DED Ophthalmology Times Portable device offers rapid highdefinition meibomian gland imaging Just Use Warm Compresses? Preeya Gupta, MD August Ophthalmology Management Giving Birth to a Dry Eye Clinic Patti Barkey, August Sheetal Shah MD, Zachary Smith Ophthalmology Management When Beauty Doesn't Blink Periman, MD and O'Dell, MD Advanced Ocular Care Beauty Does Not Have to Hurt Leslie E. O’Dell, July/August OD; Amy Gallant Sullivan; and Laura M. Periman, MD Advanced Ocular Care Antiaging Eye Care and Aesthetics Bridgitte Shen Lee, July/August OD Advanced Ocular Care Optimize the Ocular Surface Barry Lee, MD Advanced Ocular Care A Dry Eye Decision Tree Jason Schmit, OD July/August Ophthalmology Management August K.D. Barnebey August (Clinical coordiantor at Specialty Eye Care Centre) August July/August Review of Optometric Invest in Technology to Grow Your Business Dry Eye Services Peter Cass, OD July Ocular Surgery News Testosterone cream may provide relief from MGD-related dry eye Brian S. Boxer Wachler, MD July Optometric Management Bloomenstein, OD July DED Symptom Solutions Ocular Surgery News Are Dry Eye Spas Worth Adopting? CRSToday Adjunct Treatments for Dry Eye Disease Optometric Office One to One - TearScience's Joe Boorady Mitchell Jackson, MD Rohit Shetty, FRCS, PhD; and Harsha Nagaraja, MS, FCE July Joe Boorady July July Tearscience Publication ArticleTitle KOL Date Optometric Office Buzz - TearScience Creates Dry Eye News Education Site July Ophthalmology Management MGD’s Multimodal Treatment Epstein, Mac, Epitropolous July Supplement Ophthalmology Management A Deeper Understanding of MGD Epstein, Mac, July Epitropolous, Supplement Rosenfeld, Barnett, Sindt Millennial Eye Full Speed Ahead (video interviews) Joe Boorady July Optometric Management Screen for Lid Hygiene Melissa Barnett, OD July Advanced Ocular Care AccessWire Is It MGD? (MGD general education) New Treatments for Contact Lens Intolerance On The Rise Hauser June Art Epstein, OD June Review of TearScience LipiScan Debuts Ophthalmology Review of Optometry Diagnostic Technology - New MGD Imaging Device News June News June Ocular Surgery News Treating dry eye in the surgical patient: One doctor’s simple algorithm Darrell White, MD June Advanced Ocular Care Making the Ocular Surface a Priority Matossian, MD June Optometric Office New Product Gallery - LipiScan News June Optometry Times Descemet, Munson, Bowman, and more Tracy Schroeder Swartz, OD June CRSToday The Value of Objective Data in Evaluating DED Pepose, MD June Wachler, MD June Ocular Surgery News Testosterone cream may provide relief from MGD-related dry eye Optometric Management OD Notebook - DryEyeandMGD.com News mention June Contact Lens Spectrum Product Spectrum News June Ophthalmology Management Starting Your Dry Eye Center of Excellence Sheppard, MD June Ophthalmology Management Your DED Search-and-Destroy Mission Matossian, MD June Ophthalmology Management When DED Hits Home McDonald, June Periman, Solomon, Davidian, Becker June Darrell White Ocular Surgery News Blog: Dry Eye at ASCRS Review of Optometry Improve Your Understanding of Meibomian Gland Function -—and Dysfunction Leanna Olennikov, May OD, Derek Cunningham, OD, and Walter Whitley, OD, Review of Optometry Tools of the Trade: Current Techniques to Treat Meibomian Gland Dysfunction Gregory Moore, OD May Optometric Office Kading, OD May Bye Bye Dry Eyes Tearscience Publication ArticleTitle KOL Kieval, MD Date CRSToday Marketing Your Practice Across Multiple Generations May Review of Ophthalmology The Form and Function of Meibomian Abelson, MD Glands Review of Ophthalmology Dry Eye: What’s New in Diagnostics & Treatment Sheppard, Latkany May Ocular Surgery News/ Ocular Surgery News Europe CRSToday Europe Use of Diagnostic and Therapeutic Tools Improves Dry Eye Detection and Management Piovella, MD May Across the Pond - Surgical Sense Lee, MD May Primary Care Optometry News Emerging best practices improve Gaddie, OD ocular surface outcomes in glaucoma patients May May Ocular Surgery News TearScience Releases Dynamic Meibomian Glad Imager News May Ophthalmology Times In-office treatments for MGD may provide relief News May Ophthalmology Management Quick Bits - TearScience Launches DryEyeandMGD.com News May Ophthalmology Web TearScience Launches LipiScan for HD Meibomian Imaging News May EyeWire Today TearScience Introduces LipiScan for News Rapid High-Definition Meibomian Imaging May Ocular Surgery News VIDEO: Surgeon talks about new device for meibomian gland imaging Preeya Gupta, MD May Ocular Surgery News VIDEO: TearScience introduces LipiScan meibomian gland imager Joe Boorady May Optometry Times How MGD Can Work for Your Practice Whitley April CRSToday Optimize the Ocular Surface Lee April Eyetube OD Review of Ophthalmology How to Develop a Dry Eye Center Caring for the Eye’s Gatekeepers Hauser Abelman April April Ocular Surgery News Looking Back at a Year of LipiFlow White March CRSToday Automating Follow-up Care Hovanesian, MD March Ophthalmology Times In-office MGD treatments may provide relief but lack formal studies Vanessa Caceres March Ophthalmology Times When Old, New Technologies Converge for Dry Eye Diagnosis Glasser March Ophthalmic Professional In Brief - TearScience Sales Spiked in 2015 News March Ophthalmology Management Dry eye algorithms from the trenches McDonald, MD March Ophthalmology Management It's Not Your Father's Cornea Care March Rhee, MD Tearscience Publication ArticleTitle KOL Date Ophthalmic Professional What You Need to Get Started Patty Barkey, CEO March of Bowden Eye & Associates Ophthalmic Professional Our Unique Approach to Dry Eye in Rural Georgia Shah, MD February Ophthalmic Professional Taking Ocular Surface Treatment to the Next Level Donaldson, MD February Ophthalmic Professional Overview of a Successful Dry Eye Center of Excellence Sheppard, MD February Ophthalmic Professional Deciphering the Dry Eye Code Jackson, MD February Advanced Ocular Care A Conversation on Dry Eye Diagnostics Cunningham, OD and Claypool, OD February CRSToday Europe Across the Pond: My Algorithm for DED Epitropoulos February CRSToday Europe Across the Pond: OSD - A Review Fahmy, OD February Ocular Surgery News Wide Range of Treatments Available Lam, MD to Optimize Ocular Surface February Optometric Management Diagnosing Dry Eye Barnett, MD February Optometric Management The Medical Economics of Dry Eye Devries, MD February Healio.com VIDEO: Surgeon discusses advantages of standard operating protocol for managing dry eye diseases Yeu February Healio.com Dry eye a common but still oftenoverlooked condition Hafezi February EyeWorld Targeting better care for patients with Gupta evaporative tear dysfunction My Algorithm for DED Epitropoulos February Healio.com VIDEO: Surgeon gives tips for Epitropoulos treating lid margin, dry eye disease January CRSToday More Options in Dry Eye Therapeutics Stonecipher January Karpecki January CRSToday Review of Optometry The Dry Eye Deluge 1/15/16 Ocular Surgery News OSN round table, part 2: Optimization Trattler of the ocular surface January CRSToday OSD: A Review Fahmy January Millennial Eye Dry Eye Disease: Creating More Awareness Alice T. January Epitropoulos, MD; Neda Shamie, MD Eyeworld Management oft the Irregular Cornea Tips for Using Topographic Ablation Karl Stonecipher, MD Advanced Ocular Care 2015: OSD Year in Review Ahmad M. Fahmy, 12/15/15 OD, FAAO, Dipl ABO January 12/12/2016 Optometric Management Article Date: 12/1/2016 DIAGNOSTIC FOCUS SCAN FOR MGD LIPISCAN PROVIDES HIGHDEFINITION IMAGES OF THE MEIBOMIAN GLANDS SCOTT SCHACHTER, O.D. A 16YEAROLD male presented for his annual exam complaining of watery eyes. His history revealed up to 5 hours per day of video game usage. After a brief explanation regarding the technology, we gathered stunning images of his meibomian glands using LipiScan, from TearScience. OVERVIEW The LipiScan Dynamic Meibomian Imager captures and stores digital images of the upper and lower meibomian glands. The device works quickly; total time from patient data entry to completed image acquisition of the lower lids can be well under 90 seconds. Image capture itself takes about 5 to 10 seconds per eye. The autofocus feature ensures sharp, HDquality images, which are placed in a shared folder and can be viewed in exam rooms. The device also has a small footprint, at 16 in. x 12.4 in x 18.4 in. PROCEDURE Patient data is entered; he or she places his or her chin in the rest, looks up, and the lower lid is everted using a small tool. Image capture occurs with the push of a button. TRAINING A TearScience trainer spent the day working with staff members, who were able to acquire quality images by the end of the day. PRACTICE BENEFITS/ROI http://www.optometricmanagement.com/printarticle.aspx?articleID=115103 1/2 12/12/2016 Optometric Management We decided to undergo a period of scanning every patient. During this time, we discovered apparent meibomian gland dysfunction (MGD) in patients as young as age 12. As a result, we are now identifying the disease earlier and, thus, intervening earlier. We also are able to track disease progress through time. Patients have been very interested in seeing their images. It has been my experience that they are more likely to “buy in” to the importance of treatment and followup visits when they can see and better understand their condition. The patient’s right lower lid image with LipiScan. In catching and addressing patients’ MGD earlier, we offer a high level of care. We also have seen increased revenue via the use of LipiFlow, also from TearScience, a debridementscaling technique, nutraceuticals, warm compresses and lipidbased artificial tears. LipiScan is billable to insurance carriers if you establish the medical necessity. It may be reimbursable under CPT code 92285 in some markets. However, check with your local carrier. PATIENT OUTCOME With the LipiScan, I was able to see that the aforementioned patient was missing most of his meibomian glands. I educated him on the importance of taking breaks from video games every 20 minutes, prescribed blinking exercises and nonpreserved artificial tears q.i.d. OM DR. SCHACHTER is founder of Advanced Eyecare and the Eyewear Gallery Optometry in Pismo Beach, Calif., where he specializes in contact lens and dry eye treatment and diagnosis. He also serves as administrator, California Central Coast Area for Vision Source and as adjunct clinical professor at Marshall B. Ketchum University in Fullerton, Calif. Dr. Schachter is a Bausch + Lomb contact lens expert and a CORE speaker and key opinion leader for Allergan. Visit tinyurl.com/OMcomment to comment. Optometric Management, Volume: 51 , Issue: December 2016, page(s): 60 http://www.optometricmanagement.com/printarticle.aspx?articleID=115103 2/2 FORWARD THINKING BUSINESS PERSPECTIVE Ophthalmic leaders discuss trends, new treatment options, and compliance issues. BY STEPHEN DAILY, EXECUTIVE EDITOR, NEWS, BMC As ophthalmic companies search for new and innovative ways to solve unmet needs, technological advances are playing a direct role in the types of drugs and devices being developed and the way treatment regimens are administered. Although the focus ultimately remains on improving visual acuity, the ophthalmic industry has devoted more resources in recent years to drugs and devices that achieve this objective in a faster, safer, and less invasive manner. The FDA’s recent approval of small-incision lenticule extraction using the VisuMax laser (Carl Zeiss Meditec) as well as microinvasive glaucoma surgery (MIGS) devices (iStent Trabecular Micro-Bypass Stent [Glaukos] and Cypass Micro-Stent [Alcon]), corneal inlays (Kamra [AcuFocus] and Raindrop Near Vision Inlay [ReVision Optics]), and corneal collagen cross-linking (KXL System; Avedro) has provided surgeons with effective new treatment options. In addition, drug candidates that employ new mechanisms of action, along with sustained-release drug delivery tools, aim to address the problem of poor adherence to prescribed medical therapy. As part of CRST’s series on the future of innovation in ophthalmology, we spoke with leaders of ophthalmic companies that represent different specialty areas to discuss which trends they expect to see in ophthalmology over the next decade. JAMES MAZZO Global President of Ophthalmology Carl Zeiss Meditec JOSEPH BOORADY, OD President and CEO TearScience CRST: When considering the future of ophthalmic technology and innovation, where do you believe the next decade will take us? What trends will change the way patients are treated? James Mazzo: I think, anytime you look at a trend, you have to look at what are the demographics. Obviously, you 68 CATARACT & REFRACTIVE SURGERY TODAY | NOVEMBER/DECEMBER 2016 VINCE ANIDO JR, PHD Chairman and CEO Aerie Pharmaceuticals MARK BAUM Founder and CEO Imprimis Pharmaceuticals have an aging population, and you have the baby boomer generation growing older as well. I look at categories such as presbyopia, retina, glaucoma, and dry eye. Why? Unmet needs are going to affect those populations, and companies are going to invest in them. (See Watch It Now for an interview with Mr. Mazzo.) The one I just started talking about in a previous session (at the Ophthalmology Innovation Summit) is software James Mazzo discusses how changing demographics are going to affect the future of ophthalmic technology and innovation. bit.ly/crst1116_mazzo development. As we start to look at the technologies— and there are large pieces of capital equipment sitting in a doctor’s office—the last thing [physicians] are going to want to do is remove that capital. So, can we start to develop software in which we can just update that piece of capital equipment? I look at it from a category of demographics and unmet needs in treatment. I also look at how do we take advantage of what we’ve already created and make it better? That would be software. Joseph Boorady, OD: Thinking about technology and innovation in the next decade, I believe we will see continued advances in cataract and refractive surgery, including better procedures and technology to improve outcomes and visual performance. We will also see advancements in MIGS devices for glaucoma and exciting innovations in drugs and delivery systems for retina. But, I remain most bullish on the advances in dry eye and meibomian gland dysfunction, where TearScience has contributed. All of the procedures and technologies just mentioned require a healthy ocular surface to provide stable vision and comfort from the common onset of [dry eye disease] symptoms that accompany these procedures and conditions. A healthy tear film also provides an important barrier to infection. (See Watch It Now for an interview with Dr. Boorady.) Vince Anido Jr, PhD: We’ve had a tremendous amount of investment going into ophthalmology over the last 7 to 10 years, and so it’s all now coming to fruition. You’ve got new chemical entities, like ours, coming out in terms of new treatments for glaucoma. We see other companies “ Single drug bottles of eye drops will go the way of the proverbial horse and buggy.” —Mark Baum doing that as well. We’ve seen a huge amount of venture investing going into devices, and whether they’re MIGS or whether they’re drug delivery systems, they are all trying to solve various different problems. I think all of those are now just coming to fruition. We see a couple of the MIGS [devices] out on the marketplace now. We expect a third [MIGS device] coming out over the next few years. We expect new drugs to come out over the next year or 2. All of that is just simply going to continue fueling a lot of the R&D investment. Whether it’s the venture guys that are doing it or whether it’s pharmaceutical companies that are doing it or some of the startups like us and Glaukos or Ophthotech, we’ll continue to be able to get funding so that we can continue to look for new solutions that we think will help the patients. FORWARD THINKING WATCH IT NOW Mark Baum: I believe that, generally, single drug bottles of eye drops will go the way of the proverbial horse and buggy. New ways of delivering postsurgery prophylaxis against inflammation and infection will dominate the cataract surgery market. New chemistries of combinations of medicines that ease the burden of patient compliance will continue to gain momentum. New delivery modalities will also proliferate outside of a front-of-the-eye practice. Companies that have invested in new technologies will have the opportunity to thrive, and others that have not innovated or that have fought to stop progress will be penalized. CRST: Do you believe there’s an emphasis on moving patients along sooner to a surgical solution for diseases, or do you believe drug regimens will remain a focus? Mazzo: To address your question, let’s look at retina. The only way a drug is going to get to the back of the eye is through a device. I don’t know if it’s surgical, but I think a drug delivery type of mechanism is going to be the future. Also for dry eye, the way that you really get through the tear film and get [the treatment] to where it needs to be is going to be some type of a device. NOVEMBER/DECEMBER 2016 | CATARACT & REFRACTIVE SURGERY TODAY 69 • InnFocus MicroShunt (InnFocus [Santen is acquiring InnFocus]) • Hydrus Microstent (Ivantis) • iStent Inject (Glaukos) • iStent Supra (Glaukos) • Visco360 (Sight Sciences)a M I G S • Xen (Allergan) There is an increasing number of treatment options in these three areas. ABiC • CyPass Micro-Stent (Alcon) GATT • iStent Trabecular Micro-Bypass Stent (Glaukos) Kahook Dual Blade (New World Medical) Trab360 (Sight Sciences) • Trabectome (NeoMedix) E A SE Kamra (AcuFocus) • Raindrop Near Vision Inlay (ReVision Optics) AY S DR Y E Y E D IS Restasis (cyclosporine ophthalmic emulsion 0.05%; Allergan) Xiidra (lifitegrast; ophthalmic solution 5%; Shire) NL FORWARD THINKING THE GROWTH OF COMPETITION CORNEAL I • Presbia Flexivue Microlens (Presbia) KEY Not yet FDA approved. 70 CATARACT & REFRACTIVE SURGERY TODAY | NOVEMBER/DECEMBER 2016 Abbreviations: MIGS, microinvasive glaucoma surgery; ABiC, ab interno canaloplasty; GATT, gonioscopy-assisted transluminal trabeculotomy. Editor’s note: The categorization of subconjunctival procedures (eg, InnFocus MicroShunt and Xen) as MIGS is in flux. a For glaucoma indication. It’s going to be a combination of both pharmaceutical and devices. That’s why I’m pleased at Zeiss; we obviously are leaders in devices, so we can look at our devices to be complementary to the drugs. Then, of course, before you get to any treatment, you’ve got to diagnose it. I would say you should be careful of trying to treat before you diagnose, as you could mistreat and that’s where you have escalating costs and unhappy patients. Let’s get the diagnostic machines ready and then be ready to treat. Boorady: There are certainly elements of disease that are best served by surgical procedures and devices. In arterial disease, drug agents are essential, but when blockage is present, a stent is needed. If you were to rely on drugs first, you might lose the patient. I do think there are similarities with many ophthalmic conditions, where intervening with devices or surgery earlier in the disease process should be an emphasis. Clinicians have newer technologies that can safely get directly to the root of the problem while also addressing systemic processes and downstream sequelae with appropriate drugs. The LipiFlow [TearScience] is a great example. [Meibomian gland dysfunction] was a disease that, for decades, was treated with heat and massage from the outside of the lid, requiring potentially unsafe amounts of pressure on the globe with only [a] marginal, fleeting effect. Modern engineering was tapped to effectively heat the inner lid directly adjacent to the glands. LipiFlow then applies gentle pressure simultaneously to express blockage and potentially necrotic tissue with a phased peristaltic pressure profile while protecting the delicate structures of the cornea, globe, and lid. The combination of ingenious patented concepts, new materials, and classic lens design safely removes obstruction by a well-understood mechanism of action. LipiFlow has now been shown to provide patients with a year of improvement from a single 12-minute procedure in a large, randomized multicenter trial.1 It solves an issue in need of a mechanical solution and in turn maximizes [the] effectiveness of drugs and supplements thereafter. WATCH IT NOW Joseph Boorady, OD, shares why he is bullish on the future of dry eye and meibomian gland dysfunction technologies. FORWARD THINKING “ You’re not going to be able to get rid of drugs just because you’ve got a surgical intervention.” —Vince Anido Jr, PhD bit.ly/crst1116_boorady With the advent of MIPS [Merit-Based Incentive Payment System] and other quality metrics, better patient outcomes earlier in disease processes will be a necessity. This will especially be the case with self-pay procedures where physicians provide effective and lasting treatments and control pricing—procedures that will provide great outcomes while at the same time contribute to practice growth. Anido: If you focus only on where the venture investing is going, you’d think, “Oh my God, everything is going to some sort of a surgical solution. Right?” There’s an awful lot of information about the MIGS and drug delivery systems. The facts are that, while all those are quite effective, we’ve never seen a therapeutic market go to zero as a result of surgical intervention. If you take a look at the cardiology space and things like that, certainly, the pharmaceutical component of it continued to move forward. We don’t think that it’s going to have a negative impact on ophthalmic pharmaceutical products. In fact, all of these drugs, while they do something positive for the patient, they don’t really treat the underlying disease. For example, one we know well in glaucoma, a lot of these [devices] don’t treat the fibrosis and the trabecular meshwork, so you’re not going to be able to get rid of drugs just because you’ve got a surgical intervention. (See Watch It Now for an interview with Dr. Anido.) Baum: Ophthalmologists will always make the best call for their patients based on the respective individual needs of the patient. More and more care will be delivered by NOVEMBER/DECEMBER 2016 | CATARACT & REFRACTIVE SURGERY TODAY 71 FORWARD THINKING WATCH IT NOW Vince Anido Jr, PhD, explains why it is necessary for the therapeutic market to complement surgical intervention. bit.ly/crst1116_andio ophthalmologists in their office—whether it is a surgical intervention or the administration of a drug regimen. My hope is that power is restored to the ophthalmologist as a “giver of care” and that middle parties lose power over decisions connected to the care of patients. CRST: In what ways are companies focusing on decades-old patient compliance issues? Mazzo: I agree that patient compliance has been, and will continue to be, a significant issue when treating patients with chronic diseases. To help, our effort at Zeiss is to make it easier for clinicians to diagnose and manage patients and, equally important, to aid clinicians in patient[s’] education about their disease and its progression. Diagnostic images and exam-to-exam changes can be used to consult with patients about their condition and need for treatment and/or therapy. Simple, but impactful, images as well as careful counseling holds one of the keys to improving patient compliance. Boorady: We’re seeing innovation to solve for patient compliance in several areas. There are intraoperative injections and new drug and therapy delivery devices in the works to overcome the shortcomings of patient noncompliance. TearScience is highly focused on compliance issues. For over 100 years, the efficacy limitations inherent with warm compresses are compounded by horrific compliance. Compliance was right behind efficacy as the motivation for the development of LipiFlow. After years of experimenting 72 CATARACT & REFRACTIVE SURGERY TODAY | NOVEMBER/DECEMBER 2016 “ Compliance ... will continue to be a significant issue when treating patients with chronic diseases.” —James Mazzo with multiple heat and energy sources to safely remove meibomian gland obstruction, including [infrared, radio frequency,] ultrasound, heat paddles, steam, and laser, to name a few, we realized that just heating the meibomian glands did not remove obstruction, and in fact, within seconds after the heat source was removed, the blockage recongeal[ed]. It was only with inner lid heat and simultaneous expression that we achieved significant long-term results and thereby eliminate[d] compliance challenges. Anido: All of us worry about compliance, and so from a drug perspective, we try to get everything down to a oncea-day product. We think that that’s where you have the highest compliance. For example, we have a combination of our drug Rhopressa (netarsudil) with latanoprost, both of those once a day, we call Roclatan (netarsudil-latanoprost), because then we think you’ll get pretty good compliance when you have two drugs in one bottle and the patient doesn’t have to have that second drop. Certainly, we see a lot of drug delivery systems that are out there, whether they’re surface delivery systems like the punctal plugs or the rings or the ones that are injected or inserted, that we think will enhance compliance to some degree. At the end of the day, if you could focus it only on once a day, or if you can bypass that and put it in the surgeon’s hands to be able to do it intracamerally or to the back of the eye—a solution with a long-acting device of some sort—we think all that will enhance the compliance. Baum: Our mission is 100% committed to high-quality innovation but also access and affordability. We fulfill our mission by combining medicines into new combination topical and injectable formulations. The upshot for the patient is that we relieve them and their physician of compliance challenges that we all know are pervasive. We also do this while saving patients and the government a lot of money. It’s a true win-win for everyone. n 1. Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye [published online ahead of print July 26, 2016]. Clin Ophthalmol. doi:10.2147/OPTH.S109663. It may be time to expand our thinking on MGD detection and treatment. BY PREEYA K. GUPTA, MD In recent years, it has been increasingly recognized that meibomian gland dysfunction (MGD) may be the leading cause of dry eye disease.1 Meibomian gland obstruction and reduced meibum production play a central role in destabilizing the tear film, resulting in symptoms of eye dryness, irritation, inflammation, and ocular surface disease.2 Yet MGD remains an underdiagnosed entity. In part, this is because not all cases of MGD can be identified based on morphologic changes.3 Recognizing more subtle cases sometimes requires an understanding of the functionality of the glands themselves.4 Studies have reported a wide range of MGD prevalence, from as low as 3.5% to as high as 70%.5-10 Because these studies used different definitions and approaches to identifying MGD prevalence, there is not a clear picture of how many patients might have MGD requiring treatment. However, a number of ophthalmic, systemic, and therapeutic risk factors have been identified. One intriguing question that has arisen regarding MGD risk factors is whether the increased use of digital devices is a causative factor. This may be one of the reasons behind an apparent epidemiologic shift in the characteristic types of patients affected by MGD, with younger patients now more likely to experience its effects. The subtle morphology in many cases of MGD, the apparent increase in its prevalence, and the shifting demographics of the disease all argue for a more aggressive approach to treatment. My rationale for this statement is set forth in the remainder of this article. Greater awareness of MGD is undoubtedly needed. Its association with dry eye disease has been well documented, as noted.1 Beyond eye dryness, however, MGD is also an important cause of visual symptoms in its own right, including eyelid irritation, redness, swelling, and other symptoms. One consequence of better MGD diagnostics is a greater realization of MGD prevalence in populations we previously thought were not much affected. This, coupled with an increase in the use of digital devices, is causing a shift in the demographic profile of the typical MGD patient. The classical thinking is that an elderly patient with a history of recent ocular surgery might be the most likely to experience MGD. In my practice, however, men and women in their 30s and 40s are now the most likely to have MGD. The role of digital devices in this shift has not been clearly or definitively elucidated, but it is my sense that staring at a digital device reduces the blink rate, which in turn yields less stimulation of secretion by the meibomian glands, leading over time to development of MGD. The changing demographics of MGD presents a clinical challenge. Because the thinking has been to look for signs and symptoms in older individuals, the disease may be underreported and underdiagnosed among those outside the classic patient profile. The danger here is that, because MGD is progressive and chronic, failure to recognize it and intervene early may lead to worse outcomes. In addition, because MGD can lead to instability in the tear film, and because the tear film is an important refracting surface, undetected MGD can affect the accuracy of keratometry and biometry readings. When MGD is missed, therefore, it may lead to suboptimal refractive outcomes after refractive or cataract surgery. CHANGING DEMOGRAPHICS One obvious reason for what seems like a recent rise in MGD prevalence may be the availability of better diagnostics and better treatments. Our enhanced ability to detect MGD allows us to intervene early in its course. Access to better diagnostics has also led to increased awareness of MGD in the eye care community, with the result that more patients are being diagnosed and treated. SCREENING AND ADVANCED DIAGNOSTICS A questionnaire can be a useful adjunct to quickly screen and identify patients in need of additional evaluation for MGD. Expanding the pool of patients who fill out the Ocular Surface Disease Index or Standard Patient Evaluation of Eye Dryness questionnaires could help to identify unknown MGD in nonclassic patients, such as young patients and those with early symptoms of MGD. OSD BACK TO BASICS RATIONALE FOR AGGRESSIVE MANAGEMENT OF MGD OCTOBER 2016 | ADVANCED OCULAR CARE 37 OSD BACK TO BASICS “ I have a pretty low barrier to suggest additional workup for MGD if questionnaire responses are suggestive of disease. Once MGD is identified, additional clinical tools can help to build the patient’s profile. I have a pretty low barrier to suggest additional workup for MGD if questionnaire responses are suggestive of disease. To that end, meibography with Dynamic Meibomian Imaging on the LipiView II (TearScience) has become an indispensible tool for diagnosis and patient education. The old adage that a picture is worth 1,000 words is definitely true. Imaging also helps to assess the severity of the MGD. Both of these factors can be important for educating young or seemingly asymptomatic patients that they have gland atrophy that must be treated. This is especially important if there is a disconnect between the patient’s signs and symptoms, which is often the case with dry eye disease, whatever the cause. Meibography is performed at baseline assessment. Other tests may be performed during an initial encounter and then repeated over time to provide an index of the effectiveness of treatment. These include lipid layer analysis with the LipiView II, tear osmolarity testing (TearLab), and the InflammaDry point-of-care test (Rapid Pathogen Screening). WATCH IT NOW Preeya K. Gupta, MD, speaks with Mark Kontos, MD, and Brandon Ayres, MD, about the challenges associated with ocular surface disease. There is often a lag time between when treatment is started and when patients start to feel relief from their symptoms, so these tests can help to reassure patients that treatment is in fact working. THOUGHTS ON TREATMENT Once MGD has been detected and quantified, our final goal is to provide the patient with a treatment approach that has been shown to be safe and effective. The LipiFlow Thermal Pulsation Device (TearScience) has been shown in multiple peer-reviewed reports and multicenter clinical trials to effectively clear obstruction in the meibomian glands.11 Removing the obstruction and returning the gland to normal function is key to treating the underlying problem and relieving symptoms. There can be a lag time between initiation of treatment with thermal pulsation and the consequent normalization of the tear film (in my experience, between 2 and 4 months). Therefore, it is prudent to set expectations for patients so that they can be assured the treatment needs time to work. The approach to MGD must be individualized for each patient. As with aqueous deficient dry eye disease, different factors on different days may have different effects on the health of the ocular surface in the patient with MGD. There is no one-size-fits-all strategy to address MGD, although it is safe to say that an aggressive approach to identifying it early and intervening appropriately is likely to achieve the outcomes our patients desire. n 1. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929. 2. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52(4):1930-1937. 3. Foulks GN, Bron AJ. Meibomian gland dysfunction: a clinical scheme for description, diagnosis, classification, and grading. Ocul Surf. 2003;1(3):107-126. 4. Blackie CA, Korb DR, Knop E, et al. Nonobvious obstructive meibomian gland dysfunction. Cornea. 2010;29(12):13331245. 5. Schein OD, Munoz B, Tielsch JM, Bandeen-Roche K, West S. Prevalence of dry eye among the elderly. Am J Ophthalmol. 1997;124:723-728. 6. Lekhanont K, Rojanaporn D, Chuck RS, Vongthongsri A. Prevalence of dry eye in Bangkok, Thailand. Cornea. 2006;25:1162-1167. 7. Lin PY, Tsai SY, Cheng CY, et al. Prevalence of dry eye among an elderly Chinese population in Taiwan: The Shihpai Eye Study. Ophthalmology. 2003;110:1096-1101. 8. Uchino M, Dogru M, Yagi Y. The features of dry eye disease in a Japanese elderly population. Optom Vis Sci. 2006;83:797-802. 9. Jie Y, Xu L, Wu YY, Jonas JB. Prevalence of dry eye among adult Chinese in the Beijing Eye Study. Eye (Lond). 2009;23:688-693. 10. McCarty CA, Bansal AK, Livingston PM, et al. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology. 1998;105:1114-1119. 11. Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a singledose vectored thermal pulsation: a review. Curr Opin Ophthalmol. 2015;26(4):306-313. Preeya K. Gupta, MD Assistant professor of ophthalmology, division of cornea and refractive surgery, Duke University Eye Center n Clinical director, Duke Eye Center n (919) 660-5071; [email protected] n Financial disclosure: consultant to Allergan, Biotissue, Shire, and TearScience n http://bit.ly/gupta1016 38 ADVANCED OCULAR CARE | OCTOBER 2016 BLOG: A year of relief from a single LipiFlow treatment By Darrell White, MD October 5, 2016 While it may not yet be a golden era in the treatment of meibomian gland disease and associated evaporative dry eye disease, I don’t think anyone would contest that we have exited the Dark Ages. Much of this can be attributed to early work done by Dr. Donald Korb in the mid-00s and subsequent insights we have from Caroline Blackie and her group within TearScience. Add this to what we know about re-esterified fish oil and MGD, and we now have some ammunition to bring to the battle. There have been more actionable studies published in the first 9 months of 2016 in the DED world than in the last 9 years total. The latest comes from Dr. Blackie along with Ed Holland, and it looked at the effect of a single vectored thermal pulsation — LipiFlow — on meibomian gland function and patient symptoms compared with traditional warm compresses and lid hygiene. Eighty-six percent of treated patients had a 2.5 times improvement in gland function and a greater than 50% decrease in DED symptoms. An early diagnosis of disease was associated with a greater degree of treatment effect. What does this mean in the trenches of our DED battle? LipiFlow works. Not only that, but there are now data that show a prolonged effect of a single treatment for an entire year in an overwhelming majority of patients. The subtler finding of an early diagnosis effect is compelling as well. I think this study gives us ample reason to aggressively look for MGD in even the mildest of cases of DED and to then give serious consideration to more aggressive treatment. Hat tip to Drs. Blackie and Holland for putting to rest the notion that LipiFlow is just an expensive warm compress. This is a real treatment for a real disease that provides a real, lasting benefit for patients with DED symptoms associated with MGD. Our experience at SkyVision bears this out. http://www.healio.com/ophthalmology/cornea-external-disease/news/blogs/%7B9c85fa2c-a103-4c2c8715-9b16b5efe932%7D/darrell-e-white-md/blog-a-year-of-relief-from-a-single-lipiflow-treatment MEETING NEWS COVERAGE TearScience: Meibomian imager well received September 29, 2016 LAS VEGAS – The TearScience LipiScan, which was launched in May, has been well received among eye care providers, according to company executives. They also shared recent study results with Primary Care Optometry News here at Vision Expo West. According to TearScience President and CEO Joseph Boorady, OD, clinical study results involving 404 eyes of 200 patients showed that a single treatment with the LipiFlow can sustain improvement in meibomian gland function and reduction in dry eye symptoms over 12 months. “The whole group had a 50% reduction in symptoms and tripled the gland scores, sustained over 12 months,” he told PCON. The earlier the patients were treated in the disease, the better the outcomes, Brian Regan, TearScience vice president of marketing and market development, added. The LipiFlow measures tear film and blink quality and provides dynamic meibomian imaging. The recently released LipiScan provides high-definition meibomian imaging. – by Nancy Hemphill, ELS, FAAO http://www.healio.com/optometry/business-of-optometry/news/online/%7B07a73f27-e263-4652b8b8-8e167ecf978f%7D/tearscience-meibomian-imager-well-received 12/13/2016 Reviews Supplements Review of Cornea & Contact Lenses September 2016 http://bt.editionsbyfry.com/publication/index.php?i=334997&m=&l=&p=1&pre=&ver=html5#{"page":4,"issue_id":334997} 2/5 COVER FOCUS THE VICIOUS CYCLE OF MGD AND GLAUCOMA Meibomian gland dysfunction can have an impact on the effectiveness of glaucoma treatment, and glaucoma therapy can affect the meibomian glands. BY ROBERT J. NOECKER, MD, MBA Glaucoma is a serious condition that warrants close attention and careful management to avoid progression and vision loss. But failure to account for the health of the rest of the eye while attending to glaucoma could be detrimental to the patient’s outcome. In particular, the health of the glaucoma patient’s ocular surface can have implications not only for that patient’s vision, but also for the efficacy of the glaucoma treatment you prescribe. Glaucoma becomes more prevalent with age, and so does meibomian gland dysfunction (MGD).1,2 Naturally, there is crossover of the patient populations affected by these conditions, and many glaucoma patients are affected to some degree by ocular surface compromise.3,4 This comorbidity is increasingly being recognized because of our improving diagnostic acumen with ocular surface issues. MGD was likely always an issue among glaucoma patients, but improved diagnostics and increased understanding of dry eye disease and its implications for ocular health have expanded the recognition of MGD as an important entity to consider in this population. In this comorbid relationship, MGD can affect the treatment of glaucoma, and the treatment of glaucoma can affect any MGD that may be present. MGD AND GLAUCOMA TREATMENT Questions about ocular surface health in respect to glaucoma tend to concern how the ingredients in the topical medication bottle may be harmful to the ocular surface. Less well appreciated may be that tear film insufficiency may affect the efficacy of glaucoma medications—especially if the ocular surface disorder is significant enough to compromise the patient’s adherence to the dosing schedule. Many medications used in glaucoma therapy contain preservatives. The one that is most concerning for the ocular surface and MGD is benzalkonium chloride (BAK). On the positive side, BAK can disrupt the ocular surface 42 ADVANCED OCULAR CARE | SEPTEMBER 2016 epithelium and potentially improve the penetration of the active ingredient.5,6 However, BAK can also have cytotoxic effects,4 and in an eye with a compromised tear film, the irritating nature of BAK can have deleterious effects on comfort and vision.7,8 In some cases, the active ingredient itself, rather than the preservative, can be the irritating element. One of the side effects of the prostaglandin class of glaucoma drugs is burning upon instillation.9 This may be attributable to a vasodilatory effect of the drug or it may be secondary to an undiagnosed ocular surface insufficiency. Regardless of the mechanism for this side effect, patients take these topical therapies chronically, and their built-up cumulative effect over the course of decades will almost assuredly have an effect on the health of the ocular surface. Over time, mild MGD is likely to be exacerbated into more severe forms by glaucoma treatment, the net effect being that eye drops that are already irritating become more so. In glaucoma, where patients’ compliance is already a complicated issue, any additional reason for patients to avoid their drops is a concern. IMPROVED DIAGNOSTICS Luckily, in recent years our ability to detect even mild forms of MGD has vastly improved. In addition, a wealth of treatment options for both MGD and glaucoma provides adequate options to design interventions that treat glaucoma while having the least possible effect on the ocular surface. In our clinic, where technicians do most of the workup before the specialist’s interaction with patients, we have incorporated a suite of useful but easy-to-integrate screening and testing protocols. The Tear Osmolarity Test (TearLab) is an important component of ocular surface management, as it provides a quantitative index for tear film irregularity and instability. If indicated, we can also perform analysis with the LipiView II Ocular Surface Interferometer (TearScience) to detect MGD. During the eye care provider’s examination, a careful slit-lamp DO NOT FORGET THE GLAUCOMA Among the reasons to address MGD in glaucoma patients is that a compromised ocular surface may impair the ability of glaucoma medications to penetrate into the eye. Topical formulations are engineered to penetrate the ocular surface of a healthy human eye with osmolarity of about 290 to 300 mOsm/L. Hyperosmolarity, if present, could yield unknown effects in a drug’s ability to pass through the corneal surface. Thus, treating MGD may be good for the patient’s glaucoma as well. With regard to adjusting glaucoma treatment in the presence of MGD, there are basically two approaches: to take away factors that may be offending the ocular surface, or to add factors to make the ocular environment better. Patients may benefit from a combination of both. Glaucoma patients should be counseled on good ocular ergonomics when using a computer (looking down instead of straight on, looking away occasionally to blink and refresh the eye). They should be made conscious of the potential for fans and forced air to dry the eye. There may be other exacerbating factors that can be removed as well, such as systemic medications or the use of makeup around the eye. Generic formulations of glaucoma medications all contain BAK, so an in-class switch to a preservative-free or non-BAK option may be in the patient’s best interest. A fixed-combination medication may be an option if prostaglandin use is undesirable due to tolerability issues or if an additional therapy is needed. For patients with severe MGD, topical glaucoma therapy may not even be an option, especially if the ocular surface issue is limiting the efficacy of the drops. However, these patients’ glaucoma definitely must be addressed. To achieve intraocular pressure lowering in patients who cannot tolerate topical medications, another intervention strategy may be needed. Selective laser trabeculoplasty with the Selecta II laser (Lumenis) is a consideration, and surgery may be a consideration based on the particulars of the patient. At the very least, if the MGD is interfering with glaucoma therapy, this is a rationale for escalating therapy to a more aggressive approach. COVER FOCUS examination is performed, during which the meibomian glands are expressed to gauge the quality of the meibum. Thin and olive oil-like expression indicates healthy secretion, whereas thick and toothpaste-like suggests MGD. We also listen attentively to patients’ recounting of their symptoms. A report of blurry vision, for instance, will lead us to ask when it occurs. If it occurs around the time of instillation of a glaucoma medication, this can indicate a potential issue with the drop or an irregular tear film. If it occurs at other times of the day, MGD may be the more likely cause. Typical signs of MGD such as redness and irritation on the eyelids are also of interest. Dynamic Meibomian Imaging (TearScience) can also serve a useful role in educating patients about the health of their ocular surface. Serial meibography with this device can occasionally unveil whether there have been changes to the meibomian gland structure as a result of treatment. In addition, repeated imaging demonstrates to patients that the treatment is having an effect, even if their symptoms are not yet alleviated. The benefit of motivating patients to stay on track with their MGD therapy should not be underestimated. Patients need to take an active role in MGD management to achieve greater success. CONCLUSION Glaucoma specialists are trained to treat this chronic medical condition aggressively and completely. Getting the intraocular pressure to a safe level is of utmost importance to slow and prevent progression. And yet our patients may have other ocular issues to consider, and those issues may be detrimental to quality of life in addition to being a hindrance to treatment. Coexisting ocular surface disease warrants consideration when a glaucoma treatment plan is devised because the ocular surface issue deserves treatment in its own right. Improving the ocular surface by treating MGD does more than balance and improve the effectiveness of the glaucoma intervention; it may also improve patients’ well-being if it allows them to enjoy the benefits of good vision without compromise. n 1. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000;118:9:1264-1268. 2. Friedman DS, Wolfs RC, O’Colmain BJ, et al. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol. 2004;122:4:532-538. 3. Fechtner R, Budenz, D, Godfrey D. Prevalence of ocular surface disease symptoms in glaucoma patients on IOPlowering medications. Poster presented at: The 18th Annual Meeting of the American Glaucoma Society; March 8, 2006; Washington, DC. 4. Noecker R. Effects of common ophthalmic preservatives on ocular health. Adv Ther. 2001;18(5):205-215. 5. Majumdar S, Hippalgaonkar K, Repka MA. Effect of chitosan, benzalkonium chloride and ethylenediaminetetraacetic acid on permeation of acyclovir across isolated rabbit cornea. Int J Pharm.2008;348(1–2):175–178. 6. Keller N, Moore D, Carper D, Longwell A. Increased corneal permeability induced by the dual effects of transient tear film acidification and exposure to benzalkonium chloride. Exp Eye Res. 1980;30(2):203–210. 7. Noecker RJ, Herrygers LA, Anwaruddin R. Corneal and conjunctival changes caused by commonly used glaucoma medications. Cornea. 2004;23(5):490-496. 8. Kahook MY, Noecker RJ. Comparison of corneal and conjunctival changes after dosing of travoprost preserved with Sofzia, latanoprost with 0.02% benzalkonium chloride, and preservative-free artificial tears. Cornea. 2008;27(3):339343. 9. Prum BE, Rosenberg LF, Gedde SJ, et al. Primary Open-Angle Glaucoma Preferred Practice Pattern Guidelines. Ophthalmology. 2016;123(1):P41-P111. Robert J. Noecker, MD, MBA In practice with the Ophthalmic Consultants of Connecticut in Fairfield, Connecticut n Assistant clinical professor, Yale University School of Medicine, New Haven, Connecticut n Clinical professor of surgery, Netter School of Medicine, Quinnipiac University, North Haven, Connecticut n [email protected] n Financial disclosure: consultant to Tear Science n SEPTEMBER 2016 | ADVANCED OCULAR CARE 43 A Single LipiFlow Treatment Demonstrates Sustained Improvement in Gland Function and Symptoms in Patients with MGD and Dry Eye TUESDAY, AUGUST 23, 2016 TearScience announced the publication of a seminal prospective, multicenter clinical trial showing that a single LipiFlow treatment can deliver sustained mean improvement in meibomian gland function and dry eye symptoms through 12 months. The study also concluded that early LipiFlow intervention for meibomian gland dysfunction is associated with improved treatment outcomes, according to a company news release. The mean improvement of meibomian gland function and dry eye symptoms have been frequently studied, documented and reviewed.2 What is novel about this study is that the effect of a single LipiFlow treatment was monitored and, on average, sustained through the 12-month study period. At 12 months, 86% of patients had received only a single LipiFlow treatment and did not require additional prescription therapy for dry eye symptoms. "The sustained results shown in this study are evidence that LipiFlow's inner-lid heat with combined vectored pulsation is uniquely effective. LipiFlow provides long-term improvement in meibomian gland function and dry eye symptoms. Whether alone or complemented with other prescription interventions, LipiFlow optimizes outcomes for dry eye sufferers," Joseph Boorady, CEO of TearScience, said in the news release. "Because MGD is chronic and progressive, it has long been suspected that early intervention is likely to yield increased benefits," Edward J. Holland, MD, a study investigator and author of the publication, said in the news release. "Our study findings strongly suggest that screening for MGD and treating underlying gland dysfunction is an appropriate protocol for all patients, even in the absence of dry eye symptoms." All device-related adverse events were anticipated, transient, nonserious ocular events that resolved without sequelae. The type and rate of nonserious and transient adverse events related to the LipiFlow System in the study were consistent with prior studies. The study, "The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye," was published in Clinical Ophthalmology.1 http://eyewiretoday.com/2016/08/23/a-single-lipiflow-treatment-demonstrates-sustainedimprovement-in-gland-function-and-symptoms-in-patients-with-mgd-and-dry-eye 12/13/2016 Ophthalmology Management Article Date: 8/1/2016 Changing Dry Eye Treatment Old standbys still help, but the latest dry eye therapies are life changing Dr. Donaldson: Just as we’ve witnessed the development of new diagnostic technologies for dry eye, we’ve also seen new medications and therapies that allow us to bring even difficult cases under control so patients can lead better lives. Some therapies are in use already, and many more are in the pipeline. From the Dependable to the Exciting Dr. Donaldson: If MMP9 testing is positive, most of my patients begin treatment with a combination of cyclosporine (Restasis, Allergan) and loteprednol (Lotemax, Bausch + Lomb). I’m instituting cyclosporine much earlier than I did a few years ago in an effort to decrease inflammation before it causes longterm tissue damage on the ocular surface. The goal is to break the cycle of inflammation and worsening dry eye, so treating preemptively instead of telling everyone to use artificial tears until late in the disease course is a more effective approach. Lifitegrast (Xiidra, Shire) was approved in July for the treatment of signs and symptoms of dry eye disease in adults. We also have many exciting treatments in the pipeline for dry eye, one of which is the Oculeve Intranasal Tear Neurostimulator (Allergan), which is a noninvasive nasal device designed to increase tear production in patients with dry eye disease. There are at least 10 other drugs in the pipeline for dry eye. It’s very exciting to follow their progress and envision all of the new options for our patients in the future. We’ll have more help for patients who have been struggling for a long time. While we’re making big strides in understanding and diagnosing dry eye, our arsenal of treatments is moving ahead at a swift pace as well. Prokera Amniotic Membranes Dr. Donaldson: We have many new treatment modalities. One is the use of amniotic membranes such as Prokera (BioTissue). How is it working for your patients? Dr. McDonald: On an average day, I put in two to four Prokera amniotic membranes. It’s for desperate dry eye patients, and it works beautifully. http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114620 1/3 12/13/2016 Ophthalmology Management Prokera is a ring of polymethyl methacrylate with amniotic membrane suspended across the center. You insert it and leave it on the eye for 5 to 7 days. Usually we do one eye at a time. I’ve found that most patients get weeks or months of relief. Once in a while, I get a patient who is very dry with 4+ filaments, and I have to put in the amniotic membranes again and again — two or three sets in a row — to make the patient feel comfortable for a few months. I was taught that I should splint the lid with tape when using Prokera, but I’ve never had to tape any of my patients, and it stays in. Patients usually prefer to forgo the tape. Dr. Donaldson: I tape everybody. I joke with my patients that it makes quite a fashion statement. I basically use a halfwidth piece of plastic medical tape that fits lengthwise over the upper lid to create a tape tarsorrhaphy. It’s actually minimally noticeable and reasonably acceptable aesthetically. This limits upper lid excursion so that the patient blinks halfway and there is less rubbing over the surface of the Prokera ring. The thinner Prokera Slim has been a huge advance in comfort, as well. I really haven’t had a patient complain of discomfort with Prokera since I’ve been using the Prokera Slim in combination with a tape tarsorraphy. Dr. McDonald: BioTissue just came out with the Prokera Slim Clear. It has a 6mm hole in the center, over the visual axis. It is designed so that the eye can see fairly normally. There is a little less amniotic membrane on the surface of the eye, but it is much more tolerable — especially for people who are trying to work. I’m still doing one at a time with the new design, but I’m planning to see if it’s possible to send people to work with two of the Prokera Slim Clears in place. LipiFlow Dr. Donaldson: In our clinic, we’ve had great results with LipiFlow (TearScience), which uses thermal pulsation with innerlid technology. It is the only FDAcleared device for MGD that has been shown to restore gland function. LipiFlow has been extensively reviewed in 5 multicentered studies and 31 peer reviewed reports. Dr. McDonald: I started to use BlephEx (RySurg) right before performing a LipiFlow treatment; that really helps express all of the altered meibum. This “onetwo punch” works well because once we’ve used the BlephEx to remove that thin fibrovascular membrane — an almost invisible layer that’s closing off the meibomian gland orifices — we’re able to get even better results from LipiFlow. Dr. Epitropoulos: Conventional options, such as warm compresses and artificial tears, are very good supplemental treatments, but they aren’t therapeutic because they don’t address meibomian gland obstruction. Once I’ve addressed the meibomian glands using LipiFlow, not only does the patient get relief from dry eye, but supplemental treatments have a better chance of working as well. LipiFlow is becoming one of the treatments of choice when there is evidence of meibomian gland dysfunction. Data show that if we can get to these glands early, they will respond better than if we wait until the glands are atrophied and nonfunctional. In FDA clinical trials, an overall improvement in dry eye symptoms was reported in 76% of patients in the Lipiflow group.1 Subsequent clinical trials have shown that a single LipiFlow treatment is capable of delivering a sustained improvement in gland function and reduction in dry eye symptoms for up to 12 months in controlled studies and up to 36 months in uncontrolled studies.2 I also tell patients that about 20% don’t notice any improvement in their symptoms, but if we can address the meibomian gland obstruction, I think we’re still helping to prevent progressive damage. Dr. McDonald: To all my patients, I say, “It’s a slow miracle. It does work. You will get a little bit better every day, but it takes 6 months to reach maximum benefit; you will hold the benefit for an average of a year, with a range of 6 to 36 months (though almost everyone gets at least a year of benefit).” I have them come back 3 months after LipiFlow, and inevitably we see a better tear osmolarity score and a negative MMP9 test. That concrete evidence shows patients that it was worth them spending out of pocket for a procedure not covered by their insurance. It really enhances their perceived value of the treatment. And by the time they come back 6 months after the treatment, they feel the improvement. Intense Pulsed Light Therapy Dr. Donaldson: Intense Pulsed Light (IPL) therapy is a newer treatment for dry eye. We’ve adapted it from dermatologists, who noticed that dry eye sometimes improved after rosacea patients were treated with IPL. What has been your experience with IPL? http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114620 2/3 12/13/2016 Ophthalmology Management Dr. Matossian: I have been using IPL for many years. It works very well. We put a bib on our patients that we call “the lobster bib,” then we apply lidocaine gel across the cheeks. Next, I spread a copious layer of ultrasound gel from ear to ear and cover the patient’s eyes with protective goggles. Using a handheld device, I proceed with the IPL from tragus to tragus to close off the abnormal telangiectatic blood vessels that are leaking proinflammatory mediators and strangling the meibomian glands. By killing those off, we improve the health of the meibomian glands. Immediately after treatment, I manually express the meibum, moving from the lateral area of the lower lid to the inner canthus. With a cottontipped applicator and my thumb, I work all the meibomian glands; I can see what’s coming out. I comment on the color, the consistency, and the amount. Over time, qualitative improvement of the meibum is clearly visible. Dr. Donaldson: How many treatments do you typically need to achieve a good response? Dr. Matossian: I start with a series of four single treatments every 4 to 5 weeks. Thereafter, it’s one treatment about every 6 months for maintenance. IPL is an outofpocket procedure. Dr. Donaldson: It sounds like it works very well. It’s rewarding to treat people who have been suffering without relief, sometimes for years. Other Treatment Approaches Dr. Donaldson: Traditional treatments, such as warm compresses and artificial tears, can still be used to improve signs and symptoms. In my practice, we also use MiBoFlo ThermoFlo (MiBo Medical Group) as an adjunct to manual expression for temporary relief of MGD symptoms. Better Therapies = Happier Patients Dr. Donaldson: It’s exciting to think of all the therapies we’re employing for dry eye patients. This wasn’t happening a decade ago. All of these therapies are making a profound difference. One of my patients made a video about how our Ocular Surface Center made life so much more comfortable for him. After 15 years of suffering with dry eye, finally, in our practice, the ocular surface staff listened and understood. These therapies are helping people with a frustrating chronic disease they previously thought they’d have to struggle with for life. ■ References 1. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 2012;31:396404. 2. Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a singledose vectored thermal pulsation: a review. Curr Opin Ophthalmol 2015;26:306313. Ophthalmology Management, Volume: 20 , Issue: August 2016, page(s): 22, 23, 25, 26 http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114620 3/3 Portable device offers rapid high-definition meibomian gland imaging Reviewed by Preeya K. Gupta, MD August 01, 2016 Morrisville, NC—A recently introduced high-definition imaging device for evaluation of meibomian glands (LipiScan, TearScience) measures lipid layer thickness and evaluates blink dynamics with an efficient, easy to use device for clinical practices, said Preeya K. Gupta, MD, assistant professor of ophthalmology, Duke University. “Despite being smaller and easier to accommodate in a clinic, it still takes very high resolution meibomian gland images,” she said. “I use it as a screening tool in my office to help identify patients who might have meibomian gland dysfunction (MGD) or who may have been misdiagnosed or underdiagnosed in the past.” She also uses it to screen both refractive surgery and cataract surgery candidates to identify coexisting MGD that can lead to dry eye. Before the development of imaging devices specifically for evaluation of the meibomian glands, it was difficult to determine if a patient had gland atrophy and other signs of gland dysfunction such as dilation or tortuosity, Dr. Gupta said. “Now you can identify anatomically whether or not there is gland dysfunction or atrophy. As a clinician it has provided a lot of information about the meibomian glands that we really didn’t have access to in the past.” It is not only helpful for making a diagnosis but for framing treatment expectations in discussions with patients, she added. For example, if the images showed very severe gland atrophy, she could explain that the treatment goal is to preserve the few remaining glands, and that it could be an uphill battle. But if the patient had relatively minor gland atrophy accompanied by symptomatic dry eye or MGD, she could outline the specific treatment steps likely to produce improvement. The device uses a patented technique that takes high-definition images of the glands using a transilluminator and near-infrared technology, said Joseph Boorady, OD, president and chief executive officer of Tear Science. The device and its predecessor (LipiView, TearScience) have a transilluminator, which everts the eyelid and uses a proprietary infrared light source to image the lid, he said. “The infrared light allows the camera on the lid to take very high quality, high definition images of the glands.” “In order to accurately diagnose MGD, which still today is vastly misunderstood and underdiagnosed, you need to look at two things: structure and function. Look at the structure of the meibomian glands and [whether they are] secreting lipid or not,” Dr. Boorady said. Historically, doctors would transilluminate the eyelid and use a slit-lamp to evaluate the meibomian glands when they wanted to look at the structure. However, the patented imaging technology developed by the company provides a high-resolution view of the glands in under 10 seconds per lid, Dr. Boorady said. Function can then be assessed using the slit-lamp along with the company’s handheld meibomian gland evaluator or by manual expression. Until relatively recently, tools for evaluating the meibomian gland had largely been found in research settings and tended to be more sophisticated and complex than was necessary for the typical clinical practice, Dr. Boorady said. The new product was developed in response to demand for a dedicated, smaller, and less expensive device that produced high quality images. "It’s been an easy instrument to integrate into clinical practice because it’s not invasive and it’s easy for technicians to use and become familiar with,” Dr. Gupta said. “As a clinician, what I’m focused on is whether a device going to give me good images, and also [whether] it easy for my staff to use. I would say this device definitely captures excellent images…but it’s much more portable and compact and easier to integrate, especially into higher volume practices and busy clinics.” Dr. Gupta noted that the device is less expensive than one of the company’s previous developments (LipiView II), and clinicians could purchase multiple devices for different office locations or more than one in a large clinic. The device’s small footprint also makes it unlikely to disrupt patient flow, regardless of the practice size and number of devices on site. Introduced at the 2016 American Society of Cataract and Refractive Surgery (ASCRS) symposium, the device has had better than expected sales so far, Dr. Boorady said. “I believe [physicians] are looking for an easy and cost effective way to get images so that they can screen a lot more patients in their offices,” he said. “We believe we’ve filled that niche. More screening and more identification of MGD will lead to more treatment, which is why we want to help doctors identify this dysfunction.” http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/portable-deviceoffers-rapid-high-definition-meibomian-gland-imaging?page=0,0 A failure to treat the surface before surgical procedures can slow healing. BY W. BARRY LEE, MD Ensuring the health of the ocular surface before moving a patient to the OR is fundamental to achieving an optimal surgical outcome. In the context of cataract and refractive surgery patients, each procedure yields a cutdown of the corneal nerves— although the mechanisms for achieving this are distinct. There is debate over whether mechanical or laser-based incisions are more damaging, but both procedures introduce the possibility of inducing neurotrophic dry eye. Ensuring that the ocular surface is healthy before cataract or refractive surgery also reduces the possibility of inaccurate biometry and keratometry. Because about 75% of the eye’s refractive power occurs at the ocular surface, any abnormalities increase the possibility that readings will be incorrect and that, as a result, the IOL power or laser ablation pattern may be incorrect. Another consideration with regard to the ocular surface is that lingering postoperative dry eye disease (DED) or meibomian gland dysfunction (MGD) portends slower healing. One could argue that the delayed recovery of visual ability is more consequential for patients undergoing surgery specifically for refractive purposes, yet other categories of patients, for example, those undergoing procedures to fix a corneal structural defect (eg, corneal collagen cross-linking [CXL] or keratoplasty), require equal consideration of the health of the ocular surface preoperatively. CONSEQUENCES OF DELAYED HEALING The first 3 to 5 postsurgical days are crucial for a successful outcome after keratoplasty. During the early postoperative period, the epithelial layer heals over the transplant while the surgical abrasion resolves. Thus, the risk of rejection and infection are highest during this period.1 For the patient with untreated DED or MGD, however, that healing period is potentially extended, so the risk of rejection or infection is higher. Any patient undergoing a keratoplasty procedure who has aqueous deficiency has to be treated with some modality to improve tear production, whether it be cyclosporine ophthalmic solution 0.05% (Restasis; Allergan), punctal plugs, or the frequent use of artificial tears before the transplant. In patients with MGD, the need for proper treatment preoperatively may be more pressing, because affected meibomian glands can act as a reservoir for microbes, which can heighten the risk of infection. With respect to CXL, the ultraviolet light used during the procedure can affect the ocular surface of an eye with untreated DED. In this scenario, there is a risk of causing discomfort during and after the procedure as well as the potential to slow healing and extend the time it takes for the topography to normalize, especially if epithelium-off CXL is performed. DIRECTED TESTING My protocol for evaluating surgical candidates’ ocular surfaces does not change too much based on the procedure planned. In my colleagues’ and my practice, we start most patients with the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and our technicians can evaluate the results to determine if an additional workup is warranted. If the SPEED questionnaire is suggestive of DED and/or MGD, then the patient will be moved directly to analysis with the LipiView Ocular Surface Interferometer (TearScience), regardless of the surgical indication. In particular, the Figure 1. Severe inspissation of the meibomian glands was discovered with frank obstruction of several glands. JULY/AUGUST 2016 | ADVANCED OCULAR CARE 17 CORNEA/EXTERNAL DISEASE OPTIMIZE THE OCULAR SURFACE CORNEA/EXTERNAL DISEASE system’s Dynamic Meibomian Imaging is important for identifying gland morphology. In our experience, anything more than 50% blockage indicates a need to delay surgery and initiate treatment. For patients undergoing cataract and refractive surgeries, we have found the InflammaDry test (Rapid Pathogen Screening), which tests for the presence and activity of matrix metallopeptidase 9, to be important, because it gives us a sense of the level of inflammation present at the ocular surface. Another point-of-care test, tear osmolarity testing (TearLab), has been shown to be effective in identifying patients with a higher likelihood of an unexpected refractive error resulting from inaccurate biometry.2 Topographic mapping may also provide clues to the status of the ocular surface with dropout regions or irregular mires on Placido disc images. Managing patients’ expectations through education is especially important for individuals receiving premium lens implants. During the examination portion of the ocular surface assessment, it is important to look at the lid margins. Something I do now that I did not do earlier in my career is to express the lid margin of the meibomian glands. I am looking for an olive oil consistency as an indication of properly functioning glands; anything else, and I am directed to investigate for potential MGD. For example, “soapsuds” or the presence of oil globules in the tear film as well as inspissated meibomian glands are pathognomonic of MGD. Less high-tech diagnostics also play an important role in the workup. We use vital dye staining (lissamine green) and a tear meniscus evaluation as the basis for understanding the nature of the tear film. Overall, these diagnostic modalities add to the clinical impression; I am not sure if one in particular is more important than the next. Figure 2. Postoperatively, the keratoplasty was stable, and the appearance of the lower eyelid had improved, with no signs of meibomian gland inspissation 6 months after the LipiFlow treatment of the eye shown in Figure 1. 18 ADVANCED OCULAR CARE | JULY/AUGUST 2016 AT A GLANCE • Ensuring the health of the ocular surface before performing any surgery is key to achieving optimal visual outcomes. • An unhealthy ocular surface negatively affects preoperative measurements, because about 75% of the eye’s refractive power occurs at the ocular surface. • The author recommends examining the lid margins and expressing the lid margins of the meibomian glands. CASE EXAMPLES No. 1 MGD is extremely important to identify and treat prior to cataract surgery or corneal transplantation. Left untreated, it increases the risk that microbial agents will enter the eye during surgery, thus creating a heightened chance of endophthalmitis. A 52-year-old man was scheduled for corneal transplantation due to advanced keratoconus. During the preoperative evaluation, severe inspissation of meibomian glands was discovered with frank obstruction of several glands (Figure 1). A LipiFlow treatment was performed, and the patient was scheduled for a deep anterior lamellar keratoplasty 4 weeks later. A postoperative photograph shows a stable keratoplasty and much improved appearance of the lower eyelid with no signs of meibomian gland inspissation 6 months after the Lipiflow treatment (Figure 2). Figure 3. A slit-lamp examination showed a peripheral Salzmann nodule. CONCLUSION The ocular surface’s health is one of the most important factors in the success of surgery and a positive visual outcome. Whether the patient is undergoing cataract surgery or a corneal transplant, the surgeon has to look at the ocular surface to understand how it may affect outcomes and then initiate aggressive treatment to optimize the surface prior to surgery. Identifying problems beforehand means not having to do as much explaining afterward. n 1. Sugar J, Montoya M, Dontchev M, et al. Donor risk factors for graft failure in the cornea donor study. Cornea. 2009;28:981-985. 2. Epitropoulos A, Matossian C, Berdy G, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-1677. W. Barry Lee, MD Partner at Eye Consultants of Atlanta Comedical director of the Georgia Eye Bank, Atlanta n [email protected] n Financial disclosure: member of the speakers’ bureaus for Allergan and Bausch + Lomb; consultant to Shire n n CORNEA/EXTERNAL DISEASE No. 2 Evaluating the corneal surface via a review of corneal topography and biometry, in conjunction with a careful slit-lamp examination of the ocular surface prior to cataract surgery, is extremely important. If they are not treated in advance, corneal diseases such as epithelial basement membrane dystrophy and Salzmann nodules can have an impact on cataract surgery outcomes. A 72-year-old woman with a decreased visual acuity of 20/80 OS presented for cataract surgery. The slit-lamp examination showed a peripheral Salzmann nodule (Figure 3), and corneal topography revealed significant irregular astigmatism with a normal topography and a clear cornea in the right eye. Biometry showed an average keratometry value of 42.87 D. The nodule was removed using a superficial keratectomy; after 6 weeks, the corneal surface normalized, and the cornea appeared clear. The corneal topography normalized, and repeat biometry showed an average keratometry value of 44.75 D. This led to the selection of an IOL power that was 4.00 D higher than originally planned. Without removal of the nodule prior to the cataract surgery, the patient would have experienced a hyperopic surprise with irregular astigmatism, leading to an unsatisfactory visual outcome. 12/15/2016 ONETOONE: TEARSCIENCE'S JOSEPH BOORADY, OD | OO Archives | Archives | Optometric Office Issue Date: Optometric Office July 2016 ONETOONE: TEARSCIENCE'S JOSEPH BOORADY, OD Richard Clompus, OD, FAAO Joseph Boorady, OD, president and CEO of TearScience, has spent over 20 years in the ophthalmic industry as an executive. Boorady held the role of senior vice president of sales, service and marketing at Carl Zeiss Meditec, Inc, U.S. At Zeiss, he was responsible for all commercial activities of medical devices in ophthalmology, neurosurgery, ENT, spine, dental and radiotherapy. Prior to Zeiss, Boorady held the position of COO of Eyemaginations, was the executive director of SUNY College of Optometry and has owned and operated multiple clinical facilities. Richard Clompus, OD: Dry eye has become a major complaint for many patients. Treatment methods for evaporative dry eye and meibomian gland dysfunction (MGD) are moving beyond eye drops to meibomian gland therapy. TearScience has been at the forefront of new technology to diagnose and treat MGD. How does the new LipiView II instrument help diagnose dry eye? Joseph Boorady, OD: Dynamic meibomian imaging (DMI), available on both the LipiView II and the recently launched LipiScan, provides high quality imaging of the meibomian gland structure. LipiScan is fast and has a small footprint, which creates the opportunity for eyecare professionals (ECPs) to easily introduce routine assessment of meibomian gland health. LipiView II with DMI includes additional function metrics evaluating lipid layer thickness and blink dynamics. RC: There has been significant interest by optometrists in the LipiFlow instrument to treat MGD. Does this treatment system integrate well into primary care practice? JB: LipiFlow has been met with enthusiasm by the optometric community. The LipiFlow research began 10 years ago. We started with front surface heat devices and found they are not effective due to the cooling effect of the lid. Our research evolved LipiFlow to today’s proven innerlid heating. LipiFlow has demonstrated unmatched clinical results while setting the standard in MGD and all dry eye treatments. We have focused on making DMI and LipiFlow affordable with smooth integration into the primary ECP’s practice. Our business model has shifted to affordability and simple integration. Now, with LipiScan, speedy high definition images can be obtained in any standard workup. RC: When do patients typically feel relief of symptoms following a LipiFlow treatment session? JB: Studies have shown an increase of approximately three times in meibomian gland function and 50% symptom improvement after a single 12minute LipiFlow treatment. Results vary, but typically, patients feel symptom relief within a couple of weeks, increasing in impact for approximately nine months. However, symptom relief is subjective. The SPEED (Standard Patient Evaluation of Eye Dryness) questionnaire and gland evaluations should be conducted before and after LipiFlow treatments to better manage MGD. We are also very pleased about our outstanding results from a recent multicenter, randomized clinical study for LipiFlow patients reinforcing more than 30 sponsored and unsponsored clinical studies demonstrating LipiFlow efficacy. RC: Are there any words of advice you can offer to our colleagues who would like to increase dry eye care in their practices? JB: We now know that MGD is involved in 86% of all dry eye cases and is an unrecognized cause even before symptoms ever show up. It is highly comorbid with cataract and refractive procedures as well as contact lens wearers. My advice to our colleagues is to look and screen all patients for MGD. We have made it convenient to do a 10second image of each lower lid with the LipiScan and/or a simple push on the lid with a Korb MGE (Meibomian Gland Evaluator) while observing the lid margin at the slit lamp to determine function. It’s now time to optimize care for your patients simply by incorporating MGD into your routine protocol. http://www.optometricoffice.com/OO/OOArchives/5683.aspx?format=2 1/2 And, does it matter? BY WHITNEY HAUSER, OD The answers to the questions above are, respectively, “probably” and “absolutely.” Dry eye disease (DED) affects between 20 and 30 million people in the United States, and, of those, meibomian gland dysfunction (MGD) accounts for 86% of cases.1,2 With those statistics in mind, MGD is not always the diagnosis, but it should be in the differential for most ocular surface complaints. The best way to identify MGD and manage it successfully is to follow three steps: Listen, look, and then lead. LISTEN The first step in evaluating MGD is the most crucial and the most commonly overlooked. Listen to the patient. It sounds painfully simple, but many practitioners believe they can quickly tick that box and then move on to the physical examination. However, really listening to a patient involves more than jotting down a chief complaint and the corresponding history of present illness. Obtaining a thorough case history can be time-consuming, but, ultimately, it makes the exam itself more efficient and will likely help pinpoint the problem more accurately. The patient says, “My vision gets blurry.” Blurred vision can originate from innumerable refractive and pathologic causes. However, it is also among the most common symptoms elicited from patients about their MGD. Visual disturbances associated with MGD can strike any time throughout the day, although many patients identify exacerbations in the early evening or after extended use of digital devices. A 2014 study evaluated light scatter in patients with aqueous tear deficiency (ATD) or MGD using the Optical Quality Analysis System (OQAS; Visiometrics). The OQAS supplies an objective measurement of optical aberration and loss of transparency.4 Patients with MGD not only had higher mean OQAS light scatter indices than those with ATD, they also experienced momentary decreases in light scatter after blinking. Blinking had little or no influence on the ocular scatter index in patients with ATD. Even when participants with ATD had similar tear breakup time to those in the MGD group, they had overall less scatter.5 This finding suggests that MGD may pose unique challenges to visual quality. The patient says, “I can’t wear my contact lenses comfortably as long as I’d like to.” About half of the 35 million contact lens wearers in the United States are suspected to have DED.4 Many of them are undiagnosed, and they attribute their daily struggle to just another aggravation of contact lens wear. In reality, long-time contact lens wearers have a greater prevalence of MGD than nonwearers.5 A 2009 study found an association between contact lens wear and the number of functional meibomian glands. Furthermore, the number of glands was proportionate to duration of wear.5,6 Unfortunately, many practitioners are distracted by patients’ complaints of burning, irritated eyes and decreased wear time, and they consider these symptoms likely to be contact lens-related complications. However, they also resemble symptoms of MGD. Changing lens material, modalities, and/or care systems will not likely yield relief for these patients and will take up significant chair time. Aggressive treatment of the MGD, on the other hand, may prolong comfortable lens wear for both the day and the long run. COVER FOCUS IS IT MGD? LOOK In recent years, the collective consciousness of eye care providers has been raised with regard to lid health. This trend is due to a greater understanding of the role that meibomian gland function plays in DED as well as an influx of products to manage lid hygiene concerns. • Lid positioning. Proper lid apposition to the globe is crucial for the accessibility of the meibum to the other components of the tear film. Positioning may be hindered by conjunctivochalsis, entropion, ectropion, and increasing laxity in the skin with age. Poor apposition may also occur after oculoplastic surgery such as blepharoplasty. Lid movement plays an integral role in the pumping of meibum out of the glands; lid tension is required to accomplish this movement.7 • Lid and gland appearance. Staining with lissamine green dye can identify devitalized cells on the cornea and conjunctiva. Additionally, it is valuable for highlighting the devitalized cells that accumulate at the mucocutaneous junction (MCJ). The MCJ forms between the dry, keratinized skin of the eyelid and the wet mucous membrane of the palpebral conjunctiva. The stained surface cells at the MCJ are also known as the line of Marx. The presence of MGD and other inflammatory conditions such as blepharitis are correlated with anatomic changes to the MCJ and the line of Marx. Examples include increases in the width, height, or position of these landmarks. Chronic tear instability can drive the surface cells of the MCJ anteriorly as the disease state progresses. The keratinized cells on the lid margin connect to form a MAY/JUNE 2016 | ADVANCED OCULAR CARE 29 COVER FOCUS meshwork of keratinized (or cornified) epithelium.8 Debridement of the MCJ and of the generalized buildup of debris on the lower lid margin may provide significant symptom amelioration and improvement in meibomian gland function.9 A golf club spud can be used to mechanically reduce the thickened layer of cellular debris. The improvement in gland function and reduction in patient symptoms achieved with debridement scaling of the MCL and keratinized lid margin has been demonstrated in multiple patient populations including patients with Sjögren symptom with MGD. Comparing gland expression before and after debridement can reinforce the benefits to the practitioner and deliver relief to the patient.10 • Lid hygiene. Options for lid hygiene have exploded. Surfactant wipes and foams, hypocholorous acid solutions, tea tree oil products, and hyaluronic acid moisturizing cleansers have all found their ways into practices across the country. Each one potentially provides different benefits for patients. A popular course of therapy for patients with MGD includes a lid hygiene regimen and a bottle of artificial tears. Some practitioners find this plan too conservative, but both clinical experience and research support lid hygiene as a therapeutically effective treatment for MGD. Studies have shown improvement in tear breakup time (30% of patients normalized to 10 seconds or greater) and patient symptoms (88% of patients) as well as improvement in gland patency.11,12 LEAD Patients with MGD often leave their eye care providers’ office with the catch-all diagnosis of DED, which does not truly define their condition. Patients require leadership and direction from their doctor. Education specifically geared to the chronic, progressive, and often inflammatory foundation of MGD is essential to ensure that patients understand and acknowledge the nature of their problem. Removal of barriers for the patient furthers compliance. Pitfalls for MGD patients’ compliance include difficulty in forming good habits and lack of product availability. Offering written and web-based instructions can help patients revisit the doctor’s directions at home and reinforce new behaviors. A study at the University of Alabama School of Medicine found that simple, standardized instructions provided to patients after surgery led to a shorter recovery period after surgery. Other studies have encouraged use of both written and verbal instructions to achieve the best compliance.13 Compliance with recommendations such as use of warm compresses is necessary for success. If patients do not accept the need for MGD therapies, these practices do not gain traction, and failure frustrates both doctor and patient. Selling over-the-counter goods such as heated masks and 30 ADVANCED OCULAR CARE | MAY/JUNE 2016 lid cleansers in the office can help to eliminate barriers for patients to find and purchase these products independently. Consider offering nutritional supplements as well. Often practitioners have particular preferences, but patients may settle for store brands if left to compare products on their own. Having supplements accessible in the office not only ensures that patients use the prescribed treatment, but it also helps make certain that they get the doctor’s preferred MGD treatment. CONCLUSION The “listen, look, and lead model” is applicable to any medical condition. Patients come to their doctors with symptoms and hope they have found one who will listen to their complaints and examine them thoroughly. Once a diagnosis is made, the patient wants and needs leadership to find resolution and relief. Considering its chronic and progressive nature, MGD is no different and demands the same attention and direction as other commonly seen conditions. Offering patients clear direction and a therapeutic plan is essential to their acceptance of the disease state and symptomatic improvement. n The author would like to thank Caroline Blackie, BOptom, MPhil, OD, PhD, FAAO, for her contributions. 1. Karpecki P. The evolution of dry eye. Review of Optometry. January 15, 2015. 2. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. 3. Moore Q, Pflugfelder S. Blink-related changes in light scattering in meibomian gland dysfunction. Paper presented at: Association for Research in Vision and Ophthalmology Annual Meeting; May 4, 2014; Orlando, FL. 4. Gatinel D. Documenting the need for cataract surgery in eyes with good visual acuity. Cataract & Refractive Surgery Today Europe. May 2009:68-71. 5. Nichols JJ. Contact Lenses 2008. Contact Lens Spectrum. January 2009:24-32. 6. Arita R, Itoh K, Inoue K, et al. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology. 2009;116(3):379-384. 7. Geerling G, Tauber J, Baudouin C, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050-2064. 8. Knop E, Knop N, Millar T, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011;52(4):1938-1978. 9. Korb DR, Blackie CA. Debridement-scaling: a new procedure that increases meibomian gland function and reduces dry eye symptoms. Cornea. 2013;32(12):1554-1557. 10. Ngo W, Caffery B, Srinivasan S, Jones LW. Effect of lid debridement-scaling in Sjögren syndrome dry eye. Optom Vis Sci. 2015;92(9):e316-320. 11. Guillon M, Maissa C, Wong S. Eyelid margin modification associated with eyelid hygiene in anterior blepharitis and meibomian gland dysfunction. Eye Contact Lens. 2012;38(5):319-325. 12. Romero JM, Biser SA, Perry HD, et al. Conservative treatment of meibomian gland dysfunction. Eye Contact Lens. 2004;30(1):14-19. 13. Written Medical Instructions Increase Surgical Patient Compliance. MRC Medical Research Consultants. July 31, 2014. http://www.mrchouston.com/written-medical-instructions-increase-surgical-patient-compliance. Accessed April 26, 2016. Whitney Hauser, OD Assistant professor at Southern College of Optometry, Memphis, Tennessee n (901) 229-2137; [email protected] n Financial disclosures: board member for Paragon BioTeck and TearLab and a speaker for and/or consultant to Akorn, Allergan, BioTissue, Science Based Health, Lumenis, NovaBay, Shire, and TearScience n 12/15/2016 Ophthalmology Management Article Date: 6/1/2016 When DED hits home OM ASKED FIVE PROMINENT OPHTHALMOLOGISTS: STEPHANIE B E C K E R , M D ; M A R Y D AV I D I A N , M D ; M A R G U E R I T E M C D O N A L D , M D ; L A U R A P E R I M A N , M D ; A N D J O N AT H A N S O L O M O N , M D , T O DISCUSS THEIR OWN PROBLEMS WITH DRY EYE DISEASE AND H O W T H E Y D I S C U S S T H E I R S I T U AT I O N W I T H T H E I R D R Y E Y E PAT I E N T S . The conversation that ensues about dry eye disease is yet more proof that physicians are also flesh and blood: We get sick, we seek medical attention, we adhere to medical instruction. Because we were smart enough to choose ophthalmology, our knowledge base is key to our health and happiness — a base we choose to share with our patients. Hence dry eye, while it may impact us, does not define us. Please enjoy, and share your feedback with us! — Marguerite McDonald, MD, FACS OM: Do you discuss your dry eye problem with your patients? Dr. Solomon: Yes, often. I find a personal touch allows for better discourse. It opens the door to a greater level of understanding. There’s stigma attached to certain medical conditions; dry eye has its share, and a lot of it is surrounded by a fair amount of misunderstanding. I don’t have the traditional dry eye situation, but I treat myself proactively. I am candid about my management and my willingness to tailor treatment options to an individual. It is of value for me to share my approach to my eye care. I describe my situation and my symptoms. OM: When you speak about your situation, do you find patients become more adherent? Dr. Solomon: Whenever you describe a personal scenario, it brings the conversation down to a personal level, to become less formal. It’s between friends as opposed to someone lecturing to a subordinate. That’s important. OM: Dr. McDonald, your thoughts? Dr. McDonald: I don’t tell absolutely every patient, otherwise I’d be seeing three people a day. But if they have moderate to severe dry eye and they say something like, ‘Gosh, all this takes a lot of time,’ or, ‘I really hate using the gel. It gets on my pillow case.’ I’ll say, ‘You know, I have OSD too. I use ointment every night. I hate it too. But that’s the only way to feel really good in the morning.’ I will do that especially if I sense anger and noncompliance. We all wish we were 18 again and could jump into bed after brushing our teeth. Ointment at night is a mainstay if you have moderate to severe dry eye. So, I’ll talk about it if I think it will lift the person’s spirits: ‘Gosh, my doctor does this. I guess I can find the time to squirt a little lubricant in my eyes.’ Patients don’t want to be just a number. Any little thing that helps you bond really goes a long way. I also think some people still feel dry eye is an imaginary disease like restless leg syndrome. Some doctors roll their eyes about that one because it’s the diagnosis of exclusion. ‘Oh, I saw her the other day. She complains and what’s the matter with her?’ These patients are used to doctors who blow them off. When they find one who doesn’t, who empathizes with them, they are so grateful. http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114334 1/5 12/15/2016 Ophthalmology Management Dr. Davidian: I agree. I think it helps them to know that we’re real people too. We’re not immune from any of this. We may have suffered from the same symptoms and have gotten relief. When I encourage patients to start Restasis I hear, ‘Well, is that really safe? I hate taking any drug. How do I know what side effects that’s going to have?’ I tell them, ‘I also infrequently take medications, but I have felt very comfortable taking this. There is no evidence that it gets systemically absorbed and enters your bloodstream. I feel it’s extremely safe. It has really helped me.’ When they hear that, I think it helps to encourage them to consider starting it. I also hear, ‘Well, I just don’t have the time to do it every day. I’m too busy.’ I say, ‘Don’t think I’m any less busy than you. If you want relief, you need to be compliant. I take my Restasis, and I put it in a Dixie cup or even next to my toothbrush in the bathroom. Then, I have a visual cue because I know I’m going to brush my teeth every morning and every evening, and I’m going to see my Restasis vials there, and it’s going to trigger me to remember that I need to use it. And you need to do things like that to try and be compliant.’ I’ve made the left turn now. I’ve also had LipiFlow treatment, and I bring that up. If I think a patient is an appropriate candidate, I tell them what my experience was like, that it was painless, that I was able to drive myself home at the end of the day in the dark after seeing 50 patients and was totally comfortable. I also say there isn’t one magic bullet that will solve their problem overnight and make them feel better. Dry eye is, in fact, multifactorial. I think this reinforces the point that we doctors are real people who deal with all the same issues and the stresses. I say, ‘I also have to work at it and I do multiple things on a daily basis, and you have to kind of learn how to condition yourself to accomplish certain things on a daily basis. When you do, you will feel comfortable. Dr. Becker: I discuss my dry eye with my patients all the time. I let them know that I can totally relate to the dry eye issues they are having, and their concerns, since I have the same ones. I say I have the same symptoms and complaints, and the same issues with not wanting to ‘take medicine’ or ‘be a patient.’ I tell them that I have tried every single thing on myself that I would be using with them, so I ‘get it.’ Dr. Periman: I educate my patients that chronic DED (CDED) is a multifactorial disease that deserves a multidisciplinary approach. Particularly with more severe disease, the list of medications and home care they are required to do can be overwhelming. If patients understand the reason for each intervention, compliance and success are enhanced. Each patient is educated with a combination of technician time, physician time as well as written materials explaining each modality. Each patient leaves with an efficient one page checklist that organizes the treatments, dosing frequencies and home care. This helps ensure accurate relay of instructions to the patient, saves on callback questions and also saves the physician a significant amount of chair time. In our clinical experience, we have found that when the patient brings back the form in followup, there is a high likelihood the instructions were carefully followed and the patient has experienced improvement. The physician will give out gold stars for good compliance as a simple, fun and rewarding way to keep the patient engaged in their own care. A minority of patients are frustrated and struggle to cope with their chronic disease. We have found this subset can benefit from objective measures, sympathetic or empathetic statements and words of hope and comfort. For example: 1) Show the patient their diagnostic information, confirming they have a real disease; 2) I occasionally share that I also am a CDED patient and I understand their suffering; 3) I emphasize that new treatments are coming and I will not give up doing everything I can to help them. When the patient feels seen and heard, the body posture changes to a more relaxed form, they are more receptive to treatments and the therapeutic relationship flourishes. Treating the whole patient is very rewarding to me. It’s worth the comfort. When you give that to the patient, they relax because their body posture changes and it becomes a therapeutic relationship; I love that. OM: Please tell us how you keep adherent. Dr. McDonald: If I stop treating myself, I instantly do worse. My eyes get red, and I start to have burning. So, my motivation is 100% staying functional, having good vision, looking normal, having nice white eyes. http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114334 2/5 12/15/2016 Ophthalmology Management Dr. Becker: I am very motivated to keep up my regimen, otherwise my eyes are miserable. I have a whole bunch of tricks to remind me to take my drops. One is the cell phone alarm. I also leave a bottle of tears taped to my computer monitor so I remember to take them when I am working. I also leave a bottle of tears in the extra cup holder of my car to remind me to take them when I am driving, since the car’s heat and air conditioning makes my eyes feel dry. Dr. Solomon: I never had issues with blurry vision, a primary symptom. I never had intermittent blurry vision as my primary symptom. I have perfect vision. I’ve never had surgery. I’m prepresbyopic. That’s why it never dawned on me to think I had issues. I thought everybody woke up with a little bit of light sensitivity when they walked into the bathroom and their eyes were always a little irritated. So it’s serendipitous that I found out about my own ocular surface. Late in my training, I put a lubricating drop in my eyes and I realized that there was a degree of relief throughout the day. It was such an odd experience realizing that I had less irritation at the back of my head. I thought, I may actually have dry eye issues. I was very aggressive. Practicing on the West Coast, everything is about quality of life and doing things to improve it. It is interesting for patients to realize that the reason we’re going about this is to try and minimize the impact on daily routine. I use oral supplements as well, and if my eyes feel irritated that’s my way of reminding myself that I need to be on my omega3s, that I’ve got to be on my joint supplements. I get my drops in. It very much is regimented. You have to be willing to kick into that routine, which is very tough for somebody who is starting to understand the importance of medications and vitamins and so on, which is tough for Generation X. There is a gender difference here too. I think men just don’t do it well and are compliant with some of these treatments. Women tend to do better about adherence. I use it as my canary in the coal mine. When my eyes aren’t feeling well whether right or wrong, it’s usually an indication that holistically I need to be a little bit better about improving my general health. Dr. McDonald: I have a theory as to why men are a little less compliant. When you’re a female and your mother takes you to an Ob/Gyn when you start to menstruate, she basically says you will be going every year. The Ob/Gyn is sort of like your GP when you’re a teenager and otherwise healthy. You’re used to going to doctors and being told what to do. Men are not. The first medicine they’re put on is dry eye medication and they’re like, ‘What?” This messes with their idea of who they are. They have an idea of who they are. ‘I don’t take medicine. I’m strong. I’m healthy,’ and this really upsets them. Dr. Solomon: I’m glad you said it and not me. OM: How do you keep motivated? Do you share your tips with patients? Dr. Davidian: For me, I tried to deny that I did have a serious dry eye problem, and what finally pushed me over the edge was about a little over a year ago I started having difficulty wearing my soft contact lenses because I was so dry. I thought, ‘I can’t do surgery comfortably with glasses on.’ I started taking Restasis, tears and omega3s and the whole gamut of treatment, and it did make a difference. As Marguerite said, when I fall behind because I go away or something happens and I get crazy busy, I feel the difference. I’m aware of the difference, which is proof that the treatment plan, when you do it in regimented fashion, helps make a difference. And that’s what I tell my patients: I’m a reallife person and I face all those same stresses, but I can tell you I notice the difference when I fall behind and so I use these little tricks to give me visual cues. OM: That’s so normal to be in denial. If, and when you tell your patients that, how do they react? Dr. Davidian: They kind of nod. They’re just processing it and, ‘Uhhuh, I fought back for a long time too, it wasn’t a big deal or it wasn’t as bad as I thought it was. But now I’m really having a hard time coping. And oh, look, she has that same experience.’ OM: Dr. Periman? Dr. Periman: I do a lot to take care of my body. Mother Nature increases the amount of maintenance work and selfcare we must do as we age. I’m OK with that. The maintenance work looks different at http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114334 3/5 12/15/2016 Ophthalmology Management every age and in every chronic condition. Patient compliance and success seem to improve when you can explain and link the treatment plans to an important selfcare habit, like flossing and brushing your teeth. Dr. Becker: My eyes have been really dry forever. I was absolutely in denial. And really angry about it. Even in college and medical school, I was miserable and couldn’t tolerate contact lens wear. I try to do all the right things like working out, eating healthy and have always been healthy, so this is like my Achilles’ heel. OM: How long do you give a product to work before you switch to something else? Dr. McDonald: If it’s an artificial tear, you’ll know within the first one or two applications if you like it or not. Whereas with something like Restasis you have to hang in for months. It really is dependent on the medicine or the therapy. OM: So, you’re looking at this from a professional vantage point, not necessarily from the confines of the FDA approval. Dr. McDonald: Yes. Usually FDA guidelines actually bear some resemblance to the truth, but I will go offlabel if I think it’s going to help somebody and I think it’s safe, for sure. Dr. Becker: I usually give any therapeutic regimen about six weeks — but patients have a ‘fall out’ rate faster than that when they are frustrated. So, I usually see patients after two weeks of any therapeutic change, other than starting Restasis, which I give six weeks. It takes a lot of conversation to explain to patients that these aren’t magic fixes, so they need some time. Discussing pathophysiology of dry eye is really helpful. OM: Do you treat yourself? Dr. McDonald: No, a colleague does. Dr. Solomon: I have a colleague look at my eyes on a regular basis and just confirm my symptoms or lack thereof and to make sure that I’m in a place where I need to be. Dr. Davidian: My partner looks at my eyes. OM: Why? Dr. Davidian: To make sense of what we’re experiencing and what’s actually happening. Dr. Periman: It would be disingenuous of us to not do it that way. OM Marguerite McDonald, MD, is a cornearefractive surgeon, Ophthalmic Consultants of Long Island, Lynbrook, NY.; clinical professor, NYU Langone Medical Center, NY; adjunct clinical professor, Tulane University, New Orleans. Email her at [email protected]. Stephanie Becker, MD, is in private practice at Total Eye Care in Hicksville, N.Y. Jonathan D. Solomon, MD, is in private practice at Solomon Eye Associates in Greenbelt, Md., and is a consultant to the FDA’s Ophthalmic Device Panel. http://www.ophthalmologymanagement.com/printarticle.aspx?articleID=114334 4/5 MEETING NEWS COVERAGEVIDEO VIDEO: Surgeon talks about new device for meibomian gland imaging May 8, 2016 NEW ORLEANS — At the American Society of Cataract and Refractive Surgery meeting, Preeya K. Gupta, MD, discusses the use of LipiScan, a meibomian gland imaging device from TearScience that identifies meibomian gland atrophy in cataract, refractive and dry eye patients. http://www.healio.com/ophthalmology/cornea-external-disease/news/online/%7B7e62af59-4376-4d849a3a-7a22197dd1e9%7D/video-surgeon-talks-about-new-device-for-meibomian-gland-imaging In-office MGD treatments may provide relief but lack formal studies By Richard Davidson, MD March 15, 2016 Denver—Although in-office treatments for meibomian gland dysfunction (MGD) can be helpful, patients also need to know that they must take a role in managing this chronic condition, said Richard S. Davidson, MD. Ophthalmologists must also systematically and consistently follow a treatment plan for patients with MGD to provide relief, said Dr. Davidson, associate professor and vice chairman, University of Colorado Health Eye Center, Denver. A solid treatment approach for MGD is crucial because the condition may well be the leading cause of dry eye, Dr. Davidson said. These patients often experience discomfort, and they make up a significant portion of office visits. “We probably all cringe on certain days when we see another burning, itching patient,” Dr. Davidson said. Additionally, an unhealthy ocular surface can affect surgical outcomes. At-home treatment has been the mainstay for MGD, and this has included warm compresses, eyelid scrubs, and gland expression performed by the patient, Dr. Davidson said. However, these treatments come with their own challenges, including poor compliance, inadequate heat levels, and patients only able to self-express the upper portion of the gland. Overview of in-office treatments These challenges have led to several in-office treatments for blepharitis that Dr. Davidson outlined. One such device that helps with making the diagnosis is an interferometer (LipiView, TearScience) that takes precise measurements of tear film thickness, takes dynamic meibomian imaging, and allows the user to quantify lipid level of tear film. “This is helpful for analytical patients because you can show them a number,” Dr. Davidson said. The treatment arm of LipiView is Lipiflow, which applies heat to the inner eyelids. The device liquefies meibomian gland contents and facilitates the release of secretion from the meibomian glands. The treatment lasts about 12 minutes. A couple of studies have analyzed Lipiflow results, including one with 40 eyes in 20 patients that found that meibomian gland secretion scores increased at 1 month and lasted for 3 years. The same study found that tear breakup time increased from baseline to 1 month but was not that different compared with baseline at 3 years, Dr. Davidson said. Another treatment for patients with MGD (BlephEx) consists of a medical-grade disposable microsponge that is applied to the edge of eyelids and lashes. The device removes debris and exfoliates eyelids. The treatments last about 6 to 8 minutes, and patients must maintain good eyelid hygiene and return for treatment every 4 to 6 months. “In theory, it looks pretty good, but there is no data to show it’s beneficial,” Dr. Davidson said. A fourth device (MiBoFlo ThermoFlo, MiBo Medical Group) is a thermoelectric heat pump that liquefies the meibum and facilitates the expression of gland secretions. Heat is applied to the outside of the lids, breaking down hardened material inside the glands. The treatment takes up to 12 minutes each eye. One study showed improvement in 73% of patients who had had previous Lipiflow, Dr. Davidson said. Yet, another MGD treatment is intense pulsed light, for which there is a paucity of published data for ophthalmic indications, Dr. Davidson said. However, some research has shown a reduction in artificial tear usage, a decrease in the Ocular Surface Disease Index score, and a reduction in lid margin edema and vascularity. Patients must return for maintenance treatments every 6 months to a year. Finally, Dr. Davidson addressed intraductal meibomian gland probing, in which one study reported 96% of the 25 patients included had immediate post-probing relief. However, the treatment can be painful, he added. One drawback that may hurt in-office treatments for MGD is cost and reimbursement, Dr. Davidson said. http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/news/office-mgd-treatmentsmay-provide-relief-lack-formal-studies?page=0,3 COVER FOCUS MY ALGORITHM FOR DED Our experts’ go-to therapies deconstructed. BY NEDA SHAMIE, MD; ALICE T. EPITROPOULOS, MD; ELIZABETH L. YEU, MD; P. DEE G. STEPHENSON, MD; SHERI ROWEN, MD; AND CATHLEEN MCCABE, MD NEDA SHAMIE, MD Individualize treatment. n Assess inflammation. n Prescribe a 2-week course of steroids plus 3 to 6 months (and often longer) of cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan) twice a day. n Increase the patient’s intake of omega-3 fatty acids. n Look for comorbid conditions (eg, conjunctivochalasis, incomplete blink reflex, etc.). n Patients who rely daily on artificial tears deserve a closer evaluation to rule out dysfunctional tear syndrome or monitoring for progressively worsening symptoms. A customized approach is important. The patient may have significant meibomian gland dysfunction (MGD), ocular surface inflammation as a result of underlying allergies, or possibly conjunctivochalasis or other mechanical abnormalities that can contribute to ocular surface disease (OSD). The most likely scenario is a combination of factors. After determining the presence of inflammation, based on clinical presentation or the use of InflammaDry (Rapid Pathogen Screening), I prescribe a 2-week course of steroids. My preference is loteprednol etabonate ophthalmic ointment 0.5% (Lotemax; Bausch + Lomb) administered at bedtime, with at least 3 to 6 months of therapy with cyclosporine. I also advise my patients to increase their intake of omega-3 fatty acids through supplementation; Physician Recommended Nutriceuticals is my preferred brand. In addition, I suggest to my patients that they add more omega-3 fatty acids to their diet. If significant rosacea is present, I prescribe 50 mg/day oral doxycycline for at least 3 months or topical azithromycin (AzaSite; Akorn) nightly. If there is trichiasis, I remove those lashes. If the patient has conjunctivochalasis and symptoms of discomfort remain despite aggressive treatment of the 60 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2016 ocular surface, I proceed with conjunctival resection. For patients with severe punctate epitheliopathy or dry eyes related to neurotrophic keratopathy, I recommend autologous serum drops. I offer the option of a PROSE (prosthetic replacement of the ocular surface ecosystem) scleral lens to patients who experience little to no improvement with topical treatments. ALICE T. EPITROPOULOS, MD Assess the patient for an unstable tear film. n Initiate early treatment. n Administer the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. n Increase the patient’s intake of omega-3 fatty acids. n Tailor treatment to the severity of the disease. n Prescribe a topical corticosteroid with cyclosporine. n The tear film is the most important refractive surface of the eye. Instability can render biometry unpredictable, delay healing, and lead to suboptimal results after surgery. Evaporative DED is the most common form of OSD.1 In my opinion, this condition is what causes some patients to be frustrated, dissatisfied, or unhappy with the results of cataract or refractive surgery. MGD is a progressive disease. If not treated, it can lead to glandular atrophy and loss of function. In my experience, meibography using the LipiView II Ocular Surface Interferometer (TearScience) is an excellent tool with which to identify these patients early, and it also serves as a great opportunity to educate patients and guide the discussion about the disease. I think LipiView II is what will take LipiFlow (TearScience) thermal pulsation to the next level. Patients can now see what their glands look like ver- ELIZABETH L. YEU, MD Listen to the patient. n Assess the causes of OSD, which are likely multifactorial. n from a patient with recurrent corneal erosion syndrome who experiences unilateral, sharp pains and tearing. P. DEE G. STEPHENSON, MD Listen to the patient. n Administer the SPEED questionnaire. n Evaluate tear osmolarity and use the InflammaDry test. n Treat with cyclosporine, omega-3 fatty acids, and topical steroids. n Consider new treatments for blepharitis such as the BlephEx (RySurg). n COVER FOCUS sus what they should look like. Conventional treatments do not address meibomian gland obstruction. There are several traditional but valuable ways of evaluating DED. I have found tear breakup time, (TBUT) corneal topography, and fluorescein staining to be most helpful. Options have changed dramatically during the past several years owing to the improved specificity and objectivity of point-of-care testing. OSD results in hyperosmolarity, which in turn contributes to an unstable tear film, the hallmark of DED. Treatment should be tailored to the severity of the disease. Reducing inflammation is the primary goal of treating moderate to advanced DED. Cyclosporine is extremely effective in my patients with DED, because the drug increases natural tear production and slows disease progression. A topical corticosteroid can rapidly reduce inflammation and work synergistically with cyclosporine. I also recommend omega-3 fatty acids, because they reduce inflammation and increase tear production.2 I prefer re-esterified nutritional supplements from Physician Recommended Nutriceuticals, because they are a highquality, purified, triglyceride formulation and I find them to have excellent tolerability and absorption. Blepharitis is a common diagnosis associated with DED. Conventional treatments such as cleaning the lids with baby shampoo can sometimes exacerbate symptoms. A new approach, Avenova (NovaBay Pharmaceuticals), uses hypochlorous acid in saline, which is a bactericidal component found in white blood cells. I have found this treatment to be extremely effective for patients with MGD and blepharitis. DED decreases surgical predictability and can adversely affect outcomes. I never hesitate to delay surgery until the ocular surface is healthy enough to generate accurate measurements. DED can be extremely burdensome to both the patient and the doctor. It is a real disease, and the treatment is ever changing and long term. A good game plan is a must, along with patience, empathy, and listening to the patient describe his or her symptoms. Nearly all of my patients complete the SPEED questionnaire. It is important to determine what type of disease the patient has or if it is a combination. I perform a corneal evaluation using fluorescein staining and a conjunctival evaluation with lissamine green as well as TBUT testing. I also assess the meibomian glands. I examine the lid margins for Demodex, greasy lashes, and lash loss. Treating the inflammatory component of the disease is important. I prescribe cylosporine, omega-3 fatty acids, and topical steroids to reestablish the tear film. I use punctal plugs if needed. An evaluation of the meibomian glands and the oil layer of the tear film is crucial. I use the LipiView II and LipiFlow treatment as needed. I perform a DED workup on preoperative cataract patients and treat the disease aggressively so that optimal preoperative testing can be performed. BlephEx is a great new addition to the treatment options for blepharitis. This in-office procedure helps improve MGD and symptoms of DED by removing the excess bacteria biofilm and inflammatory exotoxins along the lid margin. SHERI ROWEN, MD The diagnosis and management of dry eye disease (DED) have blossomed in the past several years. Bearing in mind the patient’s symptomatology is just as important as incorporating the diagnostics and clinical examination into the big picture. For example, the timing and qualities of the patient’s discomfort can be very revealing. The patient with OSD who complains more of a burning sensation first thing in the morning from MGD is very different from one who suffers from fluctuating foreign body sensation that worsens throughout the day due to aqueous-deficiency issues. Likewise, a patient with MGD who feels bilateral burning in his or her eyes differs The importance of lid hygiene is underrecognized. n Early recognition of MGD is needed. n Glands should be expressed manually at the initial office visit. n We ophthalmologists have missed the importance of lid hygiene. With the rapidly increasing prevalence of dysfunctional tear syndrome, we need to take a second look. Every JANUARY 2016 | CATARACT & REFRACTIVE SURGERY TODAY 61 COVER FOCUS patient should be evaluated in his or her 20s to 30s to determine who will be at risk for plugged glands. Every patient who walks into our practices should routinely have the following diagnostic tests performed. First, a SPEED questionnaire to determine if symptoms exist. If positive (> 6), these patients should have their tear osmolarity tested. InflammaDry should also be performed to assess inflammation, along with fluorescein staining (with a fluorescein strip only and balanced salt solution to evaluate the staining), and TBUT should be measured. If patients are suffering from inflammation, I direct them to use cyclosporine drops twice daily and omega-3 supplements as needed for anti-inflammatory effect and to improve the composition of the oil film. I add loteprednol etabonate as well. If only the glands are affected, I will have the patient imaged using the LipiView II to examine the meibomian glands and assess the oil layer. The Keratograph corneal topographer (Oculus) can also evaluate TBUT. I examine the lid margins for flaking and anterior blepharitis, and if it is present, I institute lid scrubs and warm compresses. I have found that Avenova is effective at killing Staphylococcus. I believe that every patient should have manual meibomian gland expression performed at the initial office visit. This will reveal the preliminary level of blockages and the composition of the oil, which will range from olive oil to complete blockage with no oil expressed. I cannot stress enough how important this step is and how rarely it is performed. The dysfunction and blockages of the meibomian glands very often precede the signs and symptoms, and we clinicians must start to focus on early diagnosis and prevention. This would mimic the dental hygiene model: we would evaluate and then express meibomian glands early to prevent long-term blockages, dilation, truncation, and permanent atrophy. Early treatment with LipiFlow or intense pulsed light can be instituted to unblock the meibomian glands, and their manual expression every 3 months with a cotton swab will prolong the effect until the glands finally produce normal oil. This process can take as long as 2 years in patients with severe disease. Following treatment with cyclosporine for at least a month, a Schirmer test can be performed; if results are low, plugs can then be placed. I find that pretreatment with cyclosporine helps to reduce the inflammatory mediators that are residing in the tear lake. In 86% of patients, the meibomian glands will be affected, and as soon as they are expressed to assess the quality and quantity of the secretions, they can start performing again.1 Until now, expression was not a part of the normal eye examination, but we can make a big difference by just recognizing MGD, especially earlier in patients’ lives. Owing to limited and partial blinking, especially with digital devices, the meibomian orifices actually become keratinized, eventually leading to blockages. These can be released 62 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2016 through light debridement with a spud or BlephEx and with expression. I predict routine meibomian expression with control of inflammation will become the new norm for eye examinations and lid hygiene, with the creation of a new specialty of ocular hygienists. CATHLEEN M. M C CABE, MD n Top 13 Practice Pearls No. 1. Early recognition and treatment are key. Look carefully for signs and symptoms even in younger patients. This is especially important in patients prior to refractive or cataract surgery to improve the quality of measurements and the outcome of surgery. This also helps avoid the misconception that patients have about the cause of the problem if DED is only identified, discussed, and treated after surgery, even though it was present before. No. 2. An intake questionnaire (in my practice, we use a modified SPEED questionnaire) empowers technicians to perform important testing (tear osmolarity, staining of the conjunctiva, and cornea) prior to seeing the doctor. No. 3. Evaluation of the quality and quantity of meibum can be easily performed in the office with pressure on the lower lid. No. 4. Low-tech equipment, such as a slit-lamp photograph taken with a smartphone camera, can be very useful in educating the patient on the problem. No. 5. Patients’ understanding of the symptoms of DED (tearing, fluctuating vision, burning, redness) can improve their compliance with treatment and follow-up. Educational posters and videos in the waiting room and exam rooms can be very helpful. No. 6. High-quality, bioavailable omega-3 fatty acid supplements are a powerful aid in improving MGD. I also discuss sources of omega-3s (fatty fish, walnuts, chia seeds, etc.). I usually advise the patient that it can take 4 to 6 weeks to notice an improvement in DED, and I will re-evaluate him or her around this time. No. 8. No. 9. To help patients with symptoms exacerbated when reading or on the computer, I recommend the “20/20 rule”: every 20 minutes put in a lubricating drop and close your eyes for 20 seconds. For presbyopes, I also recommend looking at distance (approximately 20 feet). There are apps available for smartphones and tablets that will remind patients to put in drops at regular intervals. Time Out (available in the Apple App Store) will fade the computer screen out to a color at set intervals for a set amount of time (eg, every 20 minutes for 20 seconds). For patients with more severe DED symptoms who have difficulty instilling drops, lubricating gel in a tube (Systane or Genteal [both from Alcon]) used in smaller amounts during the day can be effective. I warn the patient that his or her vision will be blurry for 1 to 2 minutes after instillation. A gel formulation can be much easier to administer for patients with difficulty extending their neck, because it can be instilled with the head in an upright position. No. 10. Microwave-heated compresses, such as the Bruder Moist Heat Compress, make complying with warm compress treatment easier for patients. An inexpensive alternative is to put several clean washcloths in a bowl with water, heat the bowl of water in the microwave, and serially remove the compresses to maintain a warm temperature on the lids. Reheating a baked potato in the microwave after pricking the skin also works well. early, treat early, and follow up frequently in cases of DED, in hopes of preventing the more end-stage disease we frequently see presenting to our clinics. n 1. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. 2. Bhargava R, Kumar P, Kumar M, et al. A randomized controlled trial of omega-3 fatty acids in dry eye syndrome. Int J Ophthalmol. 2013;6(6):811-816. Neda Shamie, MD associate professor of ophthalmology at the University of Southern California (USC) Eye Institute, Keck School of Medicine at USC n medical director at the USC Eye Center-Beverly Hills n medical director at Tissue Banks International n [email protected] n financial disclosure: consultant to Alcon, Allergan, Bausch + Lomb, Nicox, Shire, and Tissue Banks International n COVER FOCUS No. 7. Alice T. Epitropoulos, MD cofounder and owner of The Eye Center of Columbus partner at Ophthalmic Surgeons & Consultants of Ohio n clinical assistant professor at The Ohio State University Department of Ophthalmology n (614) 221-7464; [email protected] n financial disclosure: consultant to Allergan, Bausch + Lomb, NovaBay, PRN, Shire, TearLab, and TearScience n n Elizabeth L. Yeu, MD private practice at the Virginia Eye Consultants in Norfolk, Virginia assistant professor in the Department of Ophthalmology at Eastern Virginia Medical School n [email protected] n financial disclosure: consultant to Abbott Medical Optics, Alcon, Allergan, Rapid Pathogen Screening, Shire, and TearLab n n P. Dee G. Stephenson, MD founder and director of Stephenson Eye Associates in Venice, Florida associate professor of ophthalmology at the University of South Florida in Tampa n president of the American College of Eye Surgeons n (941) 485-1121; [email protected] n financial interest: none acknowledged n n No. 11. Briefly explaning how cyclosporine works (by down-regulating receptors on inflammatory cells to interrupt the inflammatory cycle that exacerbates DED) helps patients to understand the importance of compliance with twice-daily dosing and the reason for the 2 months of treatment required before they notice an improvement in symptoms. I schedule the follow-up visit at 2 months and emphasize that treatment will be long term. No. 12. In cases of very severe and persistent DED, I have found serum tears and Prokera Slim amniotic membrane (Bio-Tissue) therapies to be very effective. No. 13. Effective evaluation and treatment of DED can be achieved without high-tech diagnostic and treatment tools. It is a great service to the patient to look Sheri Rowen MD NVision Centers in Newport Beach, California (410) 402-0122; [email protected] n financial disclosure: in-house consultant to Alphaeon Strathspey Crown; she also disclosed a financial relationship with Ace Vision Group, Allergan, and Bausch+Lomb n n Cathleen M. McCabe, MD cataract and refractive specialist practicing at The Eye Associates in Bradenton and Sarasota, Florida n (941) 792-2020; [email protected]; Twitter @CathyEye n financial disclosure: speaker for Abbott Medical Optics, consultant to Allergan, and speaker for and consultant to Alcon and Bausch + Lomb n JANUARY 2016 | CATARACT & REFRACTIVE SURGERY TODAY 63 MEETING NEWS COVERAGEVIDEO VIDEO: Surgeon gives tips for treating lid margin, dry eye disease January 21, 2016 WAIKOLOA, Hawaii — At Hawaiian Eye, Alice T. Epitropoulos, MD, gives an overview of the many new – and old but still efficacious – treatments for lid margin and dry eye disease. http://www.healio.com/ophthalmology/cornea-external-disease/news/online/%7B98ca22f7-ec21-44b795a5-7b0ef422bcd3%7D/video-surgeon-gives-tips-for-treating-lid-margin-dry-eye-disease
