Richard L. Lindstrom, MD: Most of us think of dry eye as aqueous deficient or evaporative, and, according to Lemp and colleagues, as many as 86% of patients with dry eye disease have an evaporative form associated with meibomian gland dysfunction (MGD).¹ These are the patients we typically see in our practices, and they are the focus of our discussion today.

What is “the new normal” in dry eye treatment? With significant new diagnostics and therapeutics, clinicians can more effectively pinpoint a diagnosis and target their therapies to address patients’ discomfort and the underlying causes of this disease. In today’s discussion, we share how we use these new tools, how they benefit our patients, and how they help us improve efficiency when treating dry eye in our practices.

First, I’d like to ask the panel if you agree with the findings by Lemp and colleagues. When patients have signs and symptoms of ocular surface disease, do most of them have some form of MGD?

MGD EPIDEMIC

Eric D. Donnenfeld, MD: In my opinion, the percentage is probably higher than 86%. I would estimate that 100% of patients older than age 75 have MGD. It’s an epidemic in the United States.

Arthur B. Epstein, OD: I agree that Lemp and colleagues grossly underestimated what we see in practice. Most of my patients come to me on referral. Other than emergencies, almost 90% are being seen for dry eye and related ocular surface disease, and MGD is ubiquitous in this population. I’m encountering it in at least 95% of patients, even those who have Sjögren’s syndrome or other classically aqueous deficient forms of dry eye. Virtually all have primary or contributory evaporative dry eye caused by MGD.

John D. Sheppard, MD, MMSc: I think the overall prevalence of MGD is yet to be discovered. We know that approximately 60% of people presenting for cataract surgery have dry eye yet don’t know they have it.² Many of them self-treat and suffer unnecessarily. Unfortunately, many patients who present for elective surgery — the nuts and bolts of our profession — have MGD or dry eye disease that can affect their surgical outcomes.

Dr. Lindstrom: Years ago in my practice, we reviewed our charts to find out how many patients had a diagnosis of MGD, blepharitis, or dry eye. We found very few. Dr. Ferguson, why do you think we weren’t making these diagnoses?

Steven J. Ferguson, OD: I think part of the reason is because patients often do not disclose symptoms related to MGD and we practiced more reactionary forms of dry eye management. We began to dig deeper clinically, using technology such as LipiScan (TearScience) to image meibomian glands. Patients often started telling us about symptoms they hadn’t mentioned before, particularly when we identifed presumed non-obvious MGD using gland expression and started asking specific questions. Suddenly, patients admit they’re uncomfortable or their vision is inconsistent. It wasn’t so much that we weren’t listening, but that we weren’t diving deep enough to find those answers.

Dr. Lindstrom: To be honest, speaking for myself, I wasn’t sure I wanted to make the diagnosis, because I didn’t have a good treatment to offer them.

Dr. Donnenfeld, how do you find these patients now? How do you begin your evaluation?

Dr. Donnenfeld: First, I evaluate the eyelids. If we look at the lids and compress them to examine the outflow, we’ll see signs. With LipiScan, I can visualize the meibomian glands, not just the surface, and it is a valuable educational tool. I can show patients what their glands look like while I tell them about their condition. That visual aid helps them understand it better than words alone.

VALUE OF QUESTIONNAIRES

Dr. Lindstrom: In my practice, our technicians administer a simple questionnaire during the initial workup to trigger thinking about dry eye symptoms. Is that something you do, Dr. Yeu?

Elizabeth Yeu, MD: Yes. We use the SPEED questionnaire. We want to keep the questionnaire short simply because the entire process can be somewhat lengthy. We’ve trained our technicians to ask specific questions — about fluctuating vision, for example — while eliciting a patient’s history, and we teach them to be mindful of responses that would indicate the need for a dry eye evaluation for patients who aren’t necessarily seeing us for dry eye.

Dr. Epstein: I love using questionnaires, because a technician can administer it and score it right in front of the patient. Our technicians have tremendous rapport with patients. If a doctor says, “I think you have dry eye,” the patient is sometimes wary, but if a technician broaches the subject, validates the patient’s experience with the questionnaire, and then says, “I’m going to mention this to the doctor, and he’ll discuss it with you,” the transition to a dry eye workup is much smoother.

Dr. Donnenfeld: We’ve been using questionnaires in our practice for a long time, because if you don’t ask, you won’t find out. So, the first key to managing the ocular surface is to ask if there’s disease. Many times, patients don’t understand that dry eye disease is causing their fluctuating vision, irritation, and foreign body sensation. They don’t associate those symptoms with dry eye, so you have to ask them.

Once we ask, that empowers our technicians to perform the tests that enable us to identify dry eye. Our job is to practice smarter, not to spend more time with patients. When we use validating questionnaires and perform the appropriate testing, patients come to us with information that makes diagnosing disease faster and more accurate.

Dr. Lindstrom: I also use validated questionnaires. In addition to eliciting important information, they also serve as a baseline to which we can refer during the course of treatment.

MGD OR AQUEOUS DEFICIENT DRY EYE?

Dr. Lindstrom: Are there specific signs and symptoms that make you suspect MGD rather than aqueous deficient dry eye?

Dr. Donnenfeld: Probably rule number one is that people who have MGD tend to have symptoms that are worse when they wake up in the morning, because the meibomian glands have become blocked overnight. The eyes are irritated, because more soaps and fatty acids have accumulated.

Patients with MGD also tend to have significant vision fluctuations during the day, along with foreign body sensation, irritation, redness, and a whole litany of symptoms. Sometimes you’ll elicit a history of a chalazion, which is pathognomonic of MGD.

Dr. Lindstrom: Why do patients who have MGD have a burning sensation?

Dr. Donnenfeld: That’s a great question. The answer is simply basic biochemistry. The lids secrete triglycerides and bacteria, mostly Staphylococcus, and release lipases. The lipases break down the normal triglycerides into soaps and fatty acids. Clinically, when we see white, foamy material on the lid margins, that is a sure pathognomonic sign of MGD. Patients report a burning sensation because they have soap and acid in their eyes.

Dr. Lindstrom: The eyes also itch, but it’s different from the classic foreign body sensation of aqueous deficient dry eye, which occurs later in the day.

Dr. Ferguson, do bacterial microbes play a role in this disease?

Dr. Ferguson: I strongly believe they do. Lid margin disease may be the first domino in a sequential process that eventually leads to ocular surface disease. Therefore, I pay attention to blepharitis in young people like I never did before. I am proactive in treating any early stage lid margin disease.

In addition, the routine use of LipiScan has been a fundamental change in our practice. We automatically scan every patient, looking for gland atrophy and structural changes to the meibomian glands, rather than waiting for patients to report symptoms. I can predict potential problems for patients with LipiScan and it is a great educational tool.

During my clinical examination, I first look at the lid margins to determine if disease is present. Then, I move on to the meibomian glands and examine the quality of the meibum that I express. Combined with LipiScan, this is a simple and efficient way to evaluate every patient.

CLINICAL SIGNS OF MGD

Dr. Lindstrom: When a patient is symptomatic and we’ve looked at the meibomian glands, what else are we likely to see, Dr. Sheppard?

Dr. Sheppard: There are many signs of MGD, and they vary. We must remember the basics. When patients have an accelerated tear film breakup time, that phenomenon dictates their symptoms, their blink rate, and the clinical pathology.

Under the slit lamp, I look for inspissated glands, capped glands, and redness. One of the most forgotten examination targets is the everted superior tarsus. You may find papillae that bespeak allergy, or scarring that indicates chronic cicatricial inflammation, which predates your examination — perhaps by decades. You can look for vascularization that tells you the inflammation is intense.

When the bulbar conjunctiva is red, patients are unhappy, and that sign precludes safe contact lens use. Mixing MGD with anterior blepharitis with chronic colonization of potentially infectious pathogenic organisms is a recipe for contact lens disaster.

One of the often-forgotten tests is a simple bacterial culture. We have red cap aerobic culture tubes in every room, and the results can be informative. If you see gram-negative organisms colonizing an eye, or if you see multi-drug resistant bacteria, such as MRSA or MRSE, on the surface of the eye, you know the lid disease has progressed to the next level and may lead to an ulcer or a poor outcome for your surgical procedure.

Dr. Epstein: MGD and Staph overpopulation cause a triple whammy that is often overlooked. First, the patient is meibum deficient because his glands are obstructed. Second, he has overpopulation of Staph, which produces lipase, breaks down the tear lipids, and produces soaps through saponification. Third, the soaps break down the tear lipids further and destabilize the entire tear film. We occasionally have failures with some of the more advanced technology we use, and patients become frustrated because we have overlooked the eyelids. To me, reducing bacterial overpopulation of the lids with Avenova (NovaBay) is one of the key elements in managing dry eye.

Dr. Yeu: You make a really good point. That’s why so much of ocular surface disease involves MGD. MGD isn’t the only component of dry eye disease, but whatever the primary etiology is, MGD develops as a result. When there’s an inflammatory aqueous deficient component, the inflammatory mediators are resting on the inferior lid margin. That inflammation will cause posterior blepharitis, starting a cycle of destruction to the meibomian gland architecture.

The congestion that results from modern risk factors also plays a major role. Simply put, we aren’t blinking enough. This is particularly common among contact lens wearers and people who stare at digital displays and computer screens more than 4 hours a day, which puts them at an even higher risk of disease.

The bacterial overgrowth associated with anterior blepharitis leads to posterior lid margin spillover and disease. These factors combined are the reasons why meibomian gland health suffers when the primary cause is dry eye.

Dr. Lindstrom: Our American diet also may be a factor. We are all seeing more young people who have MGD.

Dr. Epstein: The diet has shifted away from omega-3s to omega-6s, and we’re seeing the consequences in our eyes. Our grandparents ate fish caught in plankton-filled oceans and beef that grazed on grass covered fields, both high in omega-3s. Today, beef and farmed fish are fed omega-6-rich corn. Omega-6s tend to be proinflammatory. This is even worse with the fast foods on which younger patients seem to thrive.

POINT-OF-SERVICE TESTING

Dr. Lindstrom: Point-of-service testing for MGD is fairly new. Dr. Donnenfeld, what tests are you using?

Dr. Donnenfeld: Objective evidence-based medicine is the future of all health care, and point-of-service testing is an integral part of that. What’s more, dry eye disease is one of the more difficult diagnoses, and that’s why I believe many eyecare professionals don’t make the diagnosis. It’s challenging, and you can miss it easily.

We have some great tests. I’m a big fan of the TearLab Osmolarity Test, and the company recently announced a new chip will be released next year that measures not only osmolarity but also MMP-9 and IL-1Ra. This test will give us a great deal of useful information.

We also use the InflammaDry test (Quidel Corporation), which measures the matrix metalloproteinase-9. Having a test that shows baseline readings and how patients are responding to therapy helps us practice smarter. Clinical impression is nice to have, but evidence-based tools are extremely important. They make me a better clinician.

Dr. Lindstrom: Do you use all of these tools as well, Dr. Sheppard?

Dr. Sheppard: I do. The battery of diagnostic tests we use for MGD is analogous to a cardiac inventory for cholesterol. Physicians need values for all of the sub-components of cholesterol to decide on a treatment. Similarly, we must evaluate all of the components of a patient’s dry eye disease to choose the appropriate therapy, whether it’s an anti-inflammatory to maintain a healthy tear film or thermal pulsation therapy to directly attack inspissated lipid material.

I also express the meibomian glands to assess the viscosity and turbidity of the secretions. That’s like auscultation of the heart as opposed to static X-rays: a direct dynamic observation provides more information.

When using the LipiScan with Dynamic Meibomian Imaging, I can evaluate the anatomy. If a patient has lost 50% of his meibomian glands, I tell him, “We need to maintain the remaining 50% for the rest of your life to avoid discomfort, poor vision, and potentially significant pathology.”

Dr. Ferguson: We try to simplify our explanations for patients with dry eye and ocular surface disease. For instance, we tell patients that vision begins with tears, and if their vision is fluctuating during the day, it may not be because something is wrong with their eyeglasses, contact lenses, or response to LASIK, but we likely need to stabilize their tear film and dry eye disease.

I also use the analogy that tears are to the surface of the eye as blood is to the body. Just as you would want treatment if your blood were abnormal, so should you consider treatment if your tear film is abnormal. To emphasize tear film abnormalities, we discuss and show patients the results revealed by point-of-service diagnostic testing, such as tear osmolarity and MMP-9 evaluation, along with LipiView (TearScience). These tests are critical to help stage the level of disease severity.

Dr. Donnenfeld: Patients love seeing their test results. It is the best tool for educating them about dry eye disease.

Dr. Epstein: I see many patients on referral, and I tend to spend more time with them because their disease is usually advanced. To me, meibography is worth its weight in gold. I have become quite the aficionado in using this technology and can explain it to patients. I think it really reinforces that they can be helped because they have a problem that is visible and discernible, and that they can understand. Point-of-care testing is certainly helpful. If I had to choose only one, it would definitely be LipiScan.

LEVEL 1 MILD DISEASE

Dr. Lindstrom: I’d like you to consider the following scenario: I am your patient. I have burning, some itching, and mildly fluctuating vision when my symptoms flare. LipiScan shows minimal gland dropout. I’m not disabled by this disease, but I’m symptomatic enough that I would like to be treated. My diagnosis is likely Level 1 or mild disease. How would you begin treatment, Dr. Yeu?

Dr. Yeu: Based on your description of your lid architecture, Dr. Lindstrom, we know that you have healthy meibomian glands. If they are affected at all, the progression has been slow.

I haven’t assessed the meibum, but it’s probably turbid enough that if we don’t take care of it now, the congestion will lead to atrophy, truncation, and further gland dropout.

I would choose a therapy that will increase compliance and has shown good efficacy. LipiFlow thermal pulsation (TearScience) would be a great therapy for you. I would also want to get omega-3s on board to make sure you have the best quality meibum.

Dr. Yeu: Omega-3 fatty acids are a great way to go. In addition, I’m a firm believer in using Avenova, which is the only pure hypochlorous acid, topically to help debride the biofilm. Prior to thermal pulsation, I would mechanically exfoliate the lid margin, and perform light manual expression. When I see a dollop of meibum starting to express, I feel confident the orifice will open.

Dr. Lindstrom: Given what you know about my condition and the recommended therapies, Dr. Ferguson, what do you think my prognosis will be?

Dr. Ferguson: In your case, Dr. Lindstrom, because you have good gland function and a few symptoms, I think your prognosis is good. The treatment goals are both preventive as well as rehabilitative. The combination of LipiFlow with the adjunctive regimen of Avenova and oral omega-3 fatty acids is a good long-term solution.

Years ago, we might have seen you several times a year, because we were treating symptoms. Now, we’re addressing the root cause of these symptoms, so we may only need to see you once a year, post treatment of your meibomian glands. That’s been a remarkable change the last 3 years in our practice with improved treatment outcomes utilizing therapies such as LipiFlow for MGD dry eye and Avenova for chronic lid care management.

Dr. Lindstrom: Dr. Donnenfeld, what are some of the challenges of diagnosing MGD?

Dr. Donnenfeld: Meibomian gland dysfunction causes dry eye; and chronic dry eye will cause corneal anesthesia. Patients with MGD often don’t have the symptoms that patients with dry eye typically have, but their vision may fluctuate, and they may experience a burning sensation.

Patients today are looking for a preventive medicine approach. They want to do intelligent things. They want a holistic approach to their therapy.

Dr. Lindstrom: Dr. Sheppard, how do you motivate patients to adopt a therapeutic regimen?

Dr. Sheppard: In this era of preventive medicine, we strive to prevent disease by educating patients. We can use the analogy of glaucoma and hypercholesterolemia and ask patients, “Would you ignore your 23 mmHg pressure until your optic nerve cupped out? Would you not treat your high cholesterol until after you had a heart attack?” I’m sure their answer would be, “Absolutely not.”

Patients will adopt a self-care mentality if we motivate them through education. Even if they have only mild symptoms most of the time, my role is to motivate them to prevent disease, not passively await a complication or further misery.

Dr. Donnenfeld: We also need to keep in mind that patients are often too busy to do the things we ask them to do. So, we want to offer them a regimen that is intelligent, easy to use, doesn’t disrupt their day, and makes sense to them.

MULTIFACTORIAL APPROACH FOR MULTIFACTORIAL SYMPTOMS

Dr. Donnenfeld: MGD is a multifactorial disease, and no single therapy will take care of everything.

I love hot compresses, and LipiFlow is like a hot compress on steroids. It has great efficacy that is long lasting. Oral nutrition is the best maintenance therapy for these patients. We also want to prevent Staph colonization, so Avenova is important. I routinely prescribe Avenova for my patients — one application when they wake up in the morning and one at night. It takes them about 30 seconds to do that. This is a therapeutic regimen that works simply, holistically, and effectively.

Dr. Epstein: I agree with keeping the treatment as simple as possible to aid with compliance. My regimen is similar to Dr. Donnenfeld’s. I recommend a triglyceride-based omega-3 supplement, 2.5g per day. I also prescribe Avenova, and I teach patients an easy application method. I have them hold the bottle 6 to 8 inches away, close their eyes, spray, spray. After application, they should keep their eyes closed for 15 seconds, then take a tissue, wipe, wipe, and that’s it.

For warm compresses, I recommend an Eye Eco D.E.R.M. heating mask, which maintains heat longer, is inexpensive, and works well.

These are simple first-line therapies. If the patient is doing great, then he or she won’t have any issues, but most patients aren’t blinking and everything isn’t great. In those cases, LipiFlow becomes the obvious treatment approach to use.

LipiFlow is unique in that it is the only technology that applies controlled and appropriate heat directly to the meibomian glands at the back surface of the lids. It also expresses the glands using automated vectored thermal pulsation, so there is no need for manual expression. I’ve found that applying heat to the outer lid surface and manually expressing is time consuming and just not effective.

Dr. Lindstrom: Avenova is quite soothing, even though it is not intended for use in the eyes. Twice a day, I open my eyes and spray three times in each eye. I want the spray to hit the brows and skin, because many of us have trace acne rosacea. In addition, the solution kills bacteria and microorganisms on the skin. After spraying the Avenova, I blink a few times, close my eyes for 30 seconds, and wipe off the excess with a clean towel.

Our technicians usually teach patients how to apply Avenova, but I love to demonstrate it to patients in the office because it feels great. When I demonstrate with it five or six times a day, my eyes feel better. I don’t think you can apply it too often, because there’s no possibility of toxicity.

Dr. Sheppard: It is incumbent upon us to make adherence to therapy easy for patients. Everyone in our practice understands ocular surface maintenance, and we teach our scribes and our technicians how to efficiently educate patients. We have kits available that contain many of the products we recommend. Patients can take out their clean ocular compress, warm it in the microwave, and use it for 30 seconds every day.

Dr. Lindstrom: I use a Bruder Moist Heat Eye Compress.

Dr. Sheppard: The Bruder mask is excellent. We must caution patients not to use washcloths or put water in their eyes. I have cured many people by getting the water out of their personal regimen.

We teach patients a simple plan to enable them to quickly, efficiently, and holistically maintain their eye health on a schedule that works for them.

Dr. Donnenfeld: I would like to add one important caution regarding eyelid hygiene. Many doctors were trained to recommend that patients who have blepharitis or MGD use baby shampoo on the lid margins. We now know that this is probably the worst advice you can give these patients. They already have soap in their eyes, and when they follow this advice, they are adding more soap to the lid margin, which further destabilizes the tear film. Warm compresses are absolutely key, but they must avoid baby shampoo.

NEW APPROACH: EARLIER INTERVENTION

Dr. Lindstrom: We’ve used LipiFlow in our practice from day one, but I didn’t offer it to my patients with mild disease. For me, it was always the treatment of last resort. But I’ve had a change of heart after undergoing LipiFlow myself. It is an amazing treatment — even for patients with mild Level 1 disease. It offers significant symptomatic relief. It feels good, and it’s comfortable. So now I’ve decided to offer this premium treatment to my patients at an earlier stage. Does anyone else feel that’s true?

Dr. Yeu: Early intervention is definitely important.

Dr. Lindstrom: Even if it’s a treatment such as LipiFlow, which many of us used to reserve as a Level 3 or Level 4 treatment?

Dr. Yeu: Yes. I think the perfect clinical analogy for eyecare professionals is glaucoma. When we see a suspicious looking OCT scan but the patient’s visual fields are full, do we not treat? No, we treat those patients aggressively in order to prevent perimetric damage. What’s more, data show that patients do just as well if not better after selective laser trabeculoplasty, a one-time intervention that has incredible efficacy, compared with a drop-a-day regimen, because compliance is no longer an issue.³ Similarly, patients with early MGD, Level 1 or 2, will do better with a therapy that has long-lasting efficacy as proven by various studies.^4-6

Dr. Lindstrom: I’m finding more patients are choosing LipiFlow than I expected. Is anyone else having that experience with the therapies we’re offering for MGD?

Dr. Donnenfeld: When I consider therapies for my patients, I’m looking for the most efficacious and best for the patient. The rate-limiting step for many optometrists and ophthalmologists is the fact that patients must pay out-of-pocket for LipiFlow treatments. My goal is to choose a therapy that will give patients the most bang for their buck. I’ve had LipiFlow therapy myself, and of all the things I’ve done for my eyes, that therapy has given me the most relief. It works quickly, and my effect has lasted for more than 1 year.

When I tell patients about LipiFlow as a treatment opportunity, I let them weigh whether or not this is something they want to do. I offer it on the first visit to every patient who has MGD, because I think it’s the best therapy. Patients deserve to be able to make a decision about their own health care and whether they want to spend money out of their pocket to improve their quality of life.

Another factor we should consider is that we can’t perform premium surgery without a premium ocular surface. How are we going to tune up an eye quickly, whether we’re planning to perform LASIK, implant a multifocal or toric IOL, or use a femtosecond laser to create astigmatic incisions? LipiFlow is going to give us the fastest return on investment for improving the ocular surfaces of these patients who want rapid relief from their symptoms.

LipiFlow has become a mainstay of my therapy, and nutrition and Avenova are my long-term regimens. The latter two therapies take some time to take effect, in my experience, but combining all three is a magical combination that gives patients the best relief and the best ability to see well and feel well.

Dr. Epstein: I think we overestimate patients’ reticence to use a medication or accept a regimen that seems expensive. I’ve found very little resistance. In my practice, we stage how we offer LipiFlow. If someone has mild disease, we begin the discussion right away, initiate conservative hygiene management with Avenova and a triglyceride-based Omega-3, and we offer the option of LipiFlow. If a patient has moderate to severe disease, we strongly recommend LipiFlow, and I find that patients usually accept it. In fact, we use a LASIK model that worked well during my TLC days. If I sense resistance from a patient, I just say, “Let me have one of my staff members explain it to you.” I leave the room while a staff member explains LipiFlow and reviews fees. I would say 8 out of 10 times, patients agree to the treatment.

I think colleagues have an exaggerated sense of how expensive the procedure is, but the cost today is quite low. We also forget that not every patient expects all services to be covered by insurance.

Dr. Lindstrom: Dr. Ferguson, can LipiScan and LipiFlow work well in a typical optometric practice?

Dr. Ferguson: Yes, absolutely. We introduced LipiScan as a routine test for all encounters last September. We identify a meibomian gland abnormality using LipiScan, and we show the patient the meibography and discuss the disease and its chronic nature. On average, I see 50 patients a day in my clinic, and about 1 out of 4 patients need LipiFlow. We perform about 55 to 60 LipiFlow treatments per month. Acceptance rates average about 45%, so it’s an incredible benefit for our patients and practice.

I would like to address our use of LipiFlow for patients who are planning to have LASIK or cataract surgery that includes premium IOLs. We comanage many of these patients, and I personally comanage about 10 patients a month who choose multi-focal implants and another 13 to 14 who are getting LASIK. These patients are making a once-in-a-lifetime investment in their vision. Stable ocular surface health, healthy meibomian gland function, and tear film stability are critical to optimize their outcomes. I also tell patients that they have evidence of a chronic, progressive disease, and they may need treatment again to maintain their ocular health and vision stability.

LipiScan and LipiFlow have been highly effective tools in my optometric practice. Using targeted imaging devices and effective therapeutic treatments enhances my ability to send patients to their surgeons with a healthy ocular surface to help ensure the best possible outcome. If I’m taking care of a patient’s primary eye care needs properly, then that’s my responsibility, and the surgeons I work with appreciate our sensitivity the tear film.

SUMMARY

Dr. Lindstrom: In light of the new diagnostics and therapies available to us, please share what you’re doing today in your practices for patients who present with Level 1 MGD. What advice do you have for our colleagues?

Dr. Yeu: While dry eye seems like a complex disease, we now have various objective pieces of information to help simplify the process of managing these patients. I would encourage our colleagues to have a standardized protocol. Make sure you’re expressing the lids as part of your examination, because your examination of the meibum and the gland architecture will give you a sense of the severity of the MGD.

Dr. Ferguson: Once the patient has undergone LipiFlow treatment, it’s important to extend the long-term benefit of this therapy. My take-home message to patients is to use an oral omega-3 supplement and Avenova daily for lid margin health, and to perform blink exercises regularly, using the recommended regimen created by Donald Korb, OD. There’s also a smartphone app called Donald Korb Blink Training.

Dr. Sheppard: In our practice, we emphasize preventive care and early intervention. We educate, motivate, and prioritize simplification of these important regimens in the patient’s life. We make their treatment accessible with ready-made kits, and we recommend essentially the same preventive regimen for every patient.

An important goal is to reduce the bacterial load in the biofilm of symptomatic patients, and in any surgical patient, symptomatic or not. We have to educate our patients about how they will benefit from these holistic, natural interventions. Who could argue against LipiFlow therapy? Who could argue against using Avenova to kill the bacteria in the biofilm on the lid margins? And when patients understand that, we make it easy for them. The prioritized menu is readily available from the doctor, the staff, the website, and the handout. Everything becomes easy.

Dr. Donnenfeld: Eyecare professionals must pay attention to dry eye disease, and the first step is to ask the patient about their symptoms. Once you ask the patient, then perform the appropriate testing, and do it simply. Delegate tasks to your technicians, so you can spend more time talking to patients about their disease.

Once you’ve confirmed your diagnosis, develop a therapeutic regimen. I agree that we need to make it simple for patients, but at the same time, I don’t believe in using therapies that are palliative. Artificial tears just treat symptoms. I want to treat the cause of the disease, which is why I like oral omega-3 acid in a natural triglyceride form.

I use Avenova because it’s the only product that contains pure hypochlorous acid, and it penetrates biofilm, which is a huge advantage for our patients.

Finally, I find that LipiFlow gives patients the most bang for their buck. They will derive significant relief, and it treats the cause of the disease by opening up the meibomian glands, allowing expression of the clogged meibum.

Dr. Lindstrom: Typically, I start new patients on a therapeutic regimen, see them in a month, and they’re usually better. We’ll often perform another point-of-service test to compare to baseline, and patients love seeing the objective confirmation of improvement. Then, similar to my glaucoma patients, I see these patients every 6 months. Many of them are seniors who will develop cataracts and possibly glaucoma and other pathologies, so it’s good that they’re routinely being seen.

Dr. Epstein, what advice do you have for colleagues with regard to dry eye and ocular surface disease?

Dr. Epstein: Dry eye and ocular surface disease are literally epidemic. We are seeing more of it than ever before — and thanks to digital device use, in a much younger population.

I believe our colleagues, both ophthalmologists and optometrists, tend to over-complicate things, especially in areas where knowledge is expanding rapidly. If there’s ever been a disease that has been over-complicated, it is dry eye, and as we discussed here, these are relatively simple, straightforward, and effective therapies. Avenova is an effective regimen for managing symptoms that cause MGD and blepharitis. With LipiFlow, we can express and essentially reset the glands, and in my experience, the benefits have lasted more than 3 years in many patients. We’ve also had phenomenal results with oral omega-3 supplementation.

A simple regimen works for many patients and literally changes their lives.

Dr. Lindstrom: About 70% of the patients who come to my practice have mild Level 1 MGD, and our discussion today focused on those patients. All of our panelists have found omega-3s, Avenova, and earlier intervention with LipiFlow to be very useful in their practices. That is a big change from the warm compresses, lid hygiene, and artificial tears that I used to recommend — and even use myself.

A final thought: It’s much more fun to care for these patients in my practice now, because I know I really can make a difference in their daily lives. ■

REFERENCES

1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472-478.
2. Trattler W, Reilly C, Goldberg D, et al. Cataract and dry eye: Prospective Health Assessment of Cataract Patients Ocular Surface Study. 2011 American Society of Cataract and Refractive Surgery Annual Meeting, San Diego, Calif.
3. Wong MO, Lee JW, Choy BN, Chan JC, Lai JS. Systematic review and meta-analysis on the efficacy of selective laser trabeculoplasty in open-angle glaucoma. Surv Ophthalmol. 2015;60(1):36-50.
4. Greiner JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Exp Ophthalmol. 2013;41(6):524-530.
5. Greiner JV. A single LipiFlow Thermal Pulsation System treatment improves meibomian gland function and reduces dry eye symptoms for 9 months. Curr Eye Res. 2012;37(4):272-278.
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