Developing a Specialty Ocular Surface Disease Practice Lid Disease

11/8/15
OCULAR SURFACE DISEASE
A COMPREHENSIVE
APPROACH TO THE
DIAGNOSIS AND TREATMENT OF DRY EYE
Jack Schaeffer OD FAAO
Schaeffer Eye Center
Birmingham, Alabama
Developing a Specialty
Ocular Surface Disease
Practice
Lid Disease
Dr Jack L. Schaeffer
financial disclosure form
Alcon
Allergan
AMO / Abbott
Bausch and Lomb
Ciba Vision
Cooper Vision
Essilor
Hoya
Inspire
Optos
Optovue
Zeis Vision
Lid Disease
We cannot treat the dry eye until we
understand and treat
LWE
MGD
Blepharitis
Epiphora
IT IS ALL ABOUT THE LIDS
What is OCuSOFT® Lid Scrub™?
•  Mildeyelidcleanserthateffec4velyremovesoil,debrisanddesquamated
(dead)skinfromtheeyelids
•  Recommendedforrou4nedailyeyelidhygieneandmaintenance
•  Ocusoft lid scrubs BID 1 week preop cataract surgery eradicated
Staph epidermidis equal to topical 5% Betadine intraoperatively¹
¹Jackson M. Endophthalmitis Prophylaxis: Ocusoft Lid Scrub Plus vs. Topical Betadine
(ESCRS Barcelona 2010 presentation and OSN supersite)
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Lorna
• 
• 
• 
• 
Right eye
Cramping
Irritated
Redness and aching, worse over two days
•  Used eyelid scrubs and hot compresses
•  No improvement
Demodex
Lorna
—  Slit lamp examination
—  Lids / Lashes
—  1+ cylindrical collarettes
—  2+ blepharitis
—  Conjunctiva
—  OD 2+ injection, OS 1+ injection
—  Cornea
—  Clear OU, no infiltrates, no PEK
—  A/C – clear, no cells, no flare
Lorna – 5 day Follow Up
• 
• 
• 
• 
• 
Significant improvement
Eyes feel better
Collarettes resolved
Trace blepharitis
Trace meibonitis
• 
• 
• 
• 
• 
Plan
Discontinue tea tree oil
Continue warm compresses
Continue Omega 3 (2,000mg / day)
Continue non-preserved artificial tears as needed
Impression / Plan
•  Demodex blepharitis / meibonitis
•  Cataracts
• 
• 
• 
• 
• 
Treatment
15% tea tree oil to upper and lower eyelids qhs OU
Warm compresses 5-10 minutes daily to bid OU
Continue Omega 3 (2,000mg / day)
Non-preserved artificial tears as needed
Demodex
•  Cylindrical dandruff
•  Associated with
–  Intermittent trichiasis
–  Meibomian gland dysfunction
–  Conjunctival inflammation
–  Corneal vascularization
–  Infiltration
–  Superficial opacities
–  Nodular scarring
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TypesofDemodex
•  65knownspeciesof
Demodex
•  Humans
Symptoms:
–  DemodexFolliculorum
–  DemodexBrevis
Demodexmitesat400x
magnifica2on:
(A)D.folliculorumadult
(B)Larva
(C)D.brevis.
DemodexWork-Up
•  Carefulslitlampexam
•  Externalphotos
•  Microscope
Demodex
•  Pa4entEduca4on
–  Discardfacialmakeup
Demodex
Signs:
–  Itching(especiallyam)
–  Burning
–  Foreignbodysensa4on
–  Crus4ng
–  Lidhyperemia
–  Blurryvision
–  Cylindricaldandruff
–  Madarosis
–  Lidmargininflamma4on
–  MGD
–  Cornealscars
Demodex Diagnosis
•  Epilate two lashes with cylindrical dandruff from each eyelid.
•  Place the lashes on a slide, one for each eye, and examine them
using the light microscope.
•  Fluorescein 0.25% drops can improve the visibility of the mites.
Demodex
•  Pa4entEduca4on
–  Washhair,face,nostrils,externalearandneckwith
TeaTreeshampoodaily.
–  Beddingandpillowcasesshouldbewashedwithhot
wateranddriedinaheateddryeronceaweek.
–  Ifspousehassimilareyeirrita4on,recommendsame
homelidscrubregimen.
3
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DemodexFolliculorum
Demodex
•  Ubiquitous obligatory ectoparasites of man
•  Two forms: D. brevis and D. folliculorum
•  Lifecycle of 14.5 days
•  Negatively phototaxic
•  Move in dark environment, stop with
bright ones
–  Locatedinthelashfollicle
–  Consumeepithelialcellsatthe
hairfollicle
–  Causeslooseormisdirected
lashes
–  Micro-abrasionscausedbythe
mite’sclawscausesreac4ve
hyperkera4niza4onwhich
leadstocylindricaldandruff.
–  Liveinclusters
Lacey N et al. Demodex Mites – Commensals, Parasites or
Mutualistic Organisms? Dermatology 2011;222:128–130
19
Demodex
DemodexBrevis
•  Locatedinthesebaceousandmeibomianglands
•  Sebumistheirmainfoodsource
•  D.Brevismechanicallyblockstheorificesof
meibomianglandsleadingtomeibomiangland
dysfunc4onandrecurrent/refractorychalazia
•  Livealone
•  84% of patients at 60, 100% over 70
•  Increased incidence with:
•  Age
•  Immunocompromised
•  Skin disorders (Rosacea)
•  Eye environment- increased pH and
amino acids
Lacey N et al. Demodex Mites – Commensals, Parasites or
Mutualistic Organisms? Dermatology 2011;222:128–130
22
Demodex
•  Blepharitis secondary to demodex
consuming epithelial cells
•  Micro-abrasions causes reactive hyper-
keratinization which leads to cylindrical
dandruff
Demodex Treatment
•  50% TTO in-office weekly, 10% TTO
wipes bid OU
•  5% TTO ointment massage
Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in
Demodex Blepharitis J Korean Med Sci. Dec 2012 27(12), 1574-9.
Liu J et al. Pathogenic role of Demodex mites in blepharitis
Curr Opin Allergy Clin Immunol. Oct 2010; 10(5):
23 505–510.
Gao YY et al. Treatment of Ocular Itching Associated With Ocular Demodicosis
by 5% Tea Tree Oil Ointment. Cornea. Jan 2012: 24
31(1), 14-17.
4
11/8/15
Demodex® Convenience Kit
Demodex Treatment
•  First and only kit to remove Demodex mites in-office and
promote ongoing eyelid hygiene.
•  Includes:
–  Demodex® Topical Solution
–  OCuSOFT® Lid Scrub® PLUS
–  Tears Again® Ointment
–  Tears Again® ADVANCED Eyelid Spray
–  BlephBrush™
•  Commercially available:
•  Cliradex- 25% TTO wipe
•  OcuSoft Demodex kit (for in-office)
25
Oust Demodex® Cleanser
OcuSoft Tea Tree Kit
•  Contains Tea Tree Oil + Buckthorn seed oil
•  Ung QHS
•  OcuSoft Cleansers
•  Home treatment for Demodex
•  Extra strength foaming cleanser
–  Tea tree oil
–  Moisturizer
–  Preservative blend (anti-bacterial).
27
Baby Shampoo…..really a myth
Itisthetradi4onalmethodtaughtinschoolbutishasdisadvantageswhich
include:
2
9
• 
• 
• 
• 
RequiresMixingandDilu4ng(Convenience?)
PoorPa4entCompliance(actuallyisirrita4ngtoeye)
LongTermUseWillMaketheSkinDry
MoreProfessionalTreatmentsareAvailable
5
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Lid Disease- Infection
Doctor number 3
•  68 YO female
•  Pain discomfort 2
years OU
•  Treatment
•  Restasis BID
•  OD > OS
•  3 rd doctor
Something feels scratchy
•  A 63 year-old female
presents with a history
of recurring irritation
OS. •  SLE reveals superficial
corneal abrasions
•  Eversion reveals
•  What is it, what do
you do?
Concretions (lithiasis)
•  White to yellow nodules superficially buried
within and beneath the palpebral conjunctiva
•  Asymptomatic unless enlarge, protrude •  Pathophysiology- inclusion cysts filled with
keratin and epithelial debris- very little calcium
Concretions only n=35
Concretions + MGD n=15
Severe Dry Eye
43%
47%
TBUT < 10 seconds
51%
60%
Concretions Management
•  Asymptomatic- neglect (@ 6% become
symptomatic
•  Symptomatic
–  Fine tipped forceps delivery
–  25 ga needle
–  Education R.E. recurrence
Haici P et al Dry eye syndrome in patients with conjunctival concretions.
Cesk Slov Oftalmol. 2006
6
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Filamentary Keratitis
Filamentary Keratitis
62 yo female
n  VA 20/200
n  Pain OU 2 years
n  Third doctor in 2 years
n  AT prn
n 
Filaments adhere to the
cornea, causing discomfort
Epithelial cells
and mucin
bind to form
filaments
Filamentary Keratitis
n 
Debridement of filaments
n  Iris
forceps
office visits
n  Weekly
Blinking
stimulates
filamentary
traction and
corneal
microtrauma
n  5
Compromised
epithelial cells
become
desquamated
Inflammatory
stimuli induce
excess mucus
production
Corneal
inflammation
induces
epithelial
damage
Filamentary Keratitis
Medications : week 1
Filamentary Keratitis
n 
Month 2
n  Restasis
n 
Lotemax
n  Qid
n 
Refresh Ung
n 
PF AT
tid
AT q 1 hour
n  PF UNG pm
n  PF
n  Pm
n  Q
I hour
7
11/8/15
filaments to none
Month 3
n  Lacriserts am /pm
n  Restasis
n  ( consider Bandage Contact lens)
What is Missing
MGD
Meibomian Gland Dysfunction
Meibomian Gland
Dysfunction
n 
Level one Treatment: Available to all
Doctors
Meibomian Gland
Dysfunction
n 
1 Manual Expression
office and home Procedures
n 
2 Miboflow
Level two Treatment: Specialized
equipment needed
n 
3 Lipiflow
n  Medical:
n  In
n 
8
11/8/15
THERMODYNAMIC TX TO EXPRESS AND EVACUATE MGs
MGD
A new thermodynamic treatment to express & evacuate the MGs
Heat applied to both inner lid surfaces
Pulsatile pressure applied to outer lids
THE LIPIFLOW
Meibomian Gland Disease
(TearScience Inc., Morrisville, NC)
The device applies controlled heat to
the inner upper and lower palpebral
conjunctival surfaces and lid margins,
while simultaneously applying pulsating
pressure over the upper and lower
(outer) eyelids.
FDA approved LipiFlow July 2011
Meibomian Gland Dysfunction
Meibomian Gland Dysfunction
and Management
Kelly K. Nichols, OD, MPH, PhD
FERV Professor
University of Houston College of Optometry
Chair, TFOS International Meibomian Gland Workshop
•  The TFOS Report of the International
Meibomian Gland Dysfunction Workshop
–  Etiologies
–  Definition / Classification
–  Epidemiology
–  Clinical characteristics
–  Diagnosis / Management
–  Contact lenses, surgical implications
©KNichols 2012
Current Dry Eye Definition
DEWS—Classification of Dry Eye
“Dry eye is a multifactorial
disease of the tears and
ocular surface that results in
symptoms of discomfort,
visual disturbance, and tear
instability with potential
damage to the ocular
surface. It is accompanied by
increased osmolarity of the
tear film and inflammation of
the ocular surface.”
©KNichols 2012
20% 5%
65%
35%80%
©KNichols 2012
9
11/8/15
TFOS International MGD Workshop
www.tearfilm.org
Lecture Description
Special Issue
The International Workshop on Meibomian Gland
Dysfunction: Executive Summary
Kelly K. Nichols,1 Gary N. Foulks,2 Anthony J. Bron,3 Ben J. Glasgow,4,5 Murat Dogru,6
Kazuo Tsubota,6 Michael A. Lemp,7 and David A. Sullivan8,9
The 65 Most-Frequently Read Articles
M
eibomian gland dysfunction (MGD) may well be the leading cause of dry eye disease throughout the world. Although this condition affects the health and well-being of
millions of people, there is no global consensus on the definition, classification, diagnosis, or therapy for MGD. To achieve
such a consensus, the Tear Film and Ocular Surface Society
(TFOS; http://www.tearfilm.org), a nonprofit organization,
launched the International Workshop on Meibomian Gland
Dysfunction (www.tearfilm.org/mgdworkshop/index.html).
The objectives of the workshop were to:
in Invest. Ophthalmol. Vis. Sci. during October 2010 thru September 2011 -- updated
The entire workshop
monthly report is published in English in this
issue of IOVS. The report has also been translated, at least in
part, into Chinese,
Dutch,
French,
German,at Greek,
Italian,
Most-read
rankings
are recalculated
the beginning
of the month and are based on full-text and pdf views.
Japanese, Polish, Portuguese, Spanish, Russian and Turkish;
Kellyavailable
K. Nichols, Gary
Foulks,
Anthony
J. Bron, Ben J. Glasgow, Murat Dogru, Kazuo Tsubota, Michael A. Lemp, David A. Sullivan
these translations 1.are
onN.the
TFOS
website.
The International Workshop on Meibomian Gland Dysfunction: Executive Summary
An executive summary
of the conclusions
and
recommenInvest Ophthalmol
Vis Sci Mar 30, 2011;
52: 1922-1929.
(In "Special Issue") [Full Text] [PDF]
dations of the TFOS Workshop
on MGD is presented in this
(Read 5554 times)
article. The material is abstracted from the full report, and thus,
2. Kelly K. Nichols
additional details and references
can
be obtained
inGland
the Dysfunction:
open- Introduction
The International
Workshop
on Meibomian
Ophthalmol Vis Sci Mar 30, 2011; 52: 1917-1921.
access, online version.Invest
(In "Special Issue") [Full Text] [PDF]
•  Over 65 International clinicians,
scientists, and industry participants
D
•  2+ year process
•  Published in March 2011, IOVS
•  #1 Most downloaded IOVS article for
the last 12 months
•  Downloaded over 5500 times
•  All MGD workshop reports are in the
“top 10”
•  Translation into 12 languages
•  www.tearfilm.org
©KNichols 2012
● conduct an evidence-based evaluation of meibomian
gland structure and function in health and disease;
● develop a contemporary understanding of the definition
and classification of MGD;
● assess methods of diagnosis, evaluation, and grading of
the severity of MGD;
● develop recommendations for the management and therapy of MGD;
● develop appropriate norms of clinical trial design to evaluate pharmaceutical interventions for the treatment of MGD;
and
● create a summary of recommendations for future research in MGD.
The report of the Workshop on MGD, which required more
than 2 years to complete, was finalized in 2010. This effort
involved more than 50 leading clinical and basic research
experts from around the world. These participants, who were
assigned to subcommittees, reviewed published data and examined the levels of supporting evidence. Subcommittee reports were circulated among all workshop participants, presented in open forum, and discussed in an interactive manner.
From the 1College of Optometry, Ohio State University, Columbus, Ohio; the 2Department of Ophthalmology and Visual Sciences,
Kentucky Lions Eye Center, Louisville, Kentucky; the 3Nuffield Laboratory of Ophthalmology, Oxford University, Oxford, United Kingdom;
the Departments of 4Ophthalmology and 5Pathology and Laboratory
Science, Jules Stein Eye Institute, University of California Los Angeles,
Los Angeles, California; the 6Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan; 7Georgetown University,
Washington, DC; 8Schepens Eye Research Institute and the 9Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
Supported by the Tear Film and Ocular Surface Society (TFOS;
http://www.tearfilm.org); individual author support is listed in the
Appendix of the Introduction.
Submitted for publication December 8, 2010; accepted March 23,
2011.
Disclosure: Each Workshop Participant’s disclosure data can be
found in the Appendix of the Introduction.
Corresponding author: Kelly K. Nichols, College of Optometry,
338 West 10th Avenue, Ohio State University, Columbus, OH 432101280; [email protected].
1922
(Read 5318 times)
3. Erich
Knop, Nadja Knop, Thomas
Millar,
Hiroto Obata, David A. Sullivan
EFINITION AND
CLASSIFICATION
OF
MGD
The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Anatomy, Physiology, and
Pathophysiology of the Meibomian Gland
Invest Ophthalmol
Vis Sci Maris
30,a2011;
52: 1938-1978.
Meibomian gland dysfunction
(MGD)
chronic,
diffuse
(In "Special Issue") [Full Text] [PDF]
abnormality of the meibomian
(Read 4663 times)glands, commonly characterized by terminal
duct obstruction and/or qualitative/
4. Alan Tomlinson, Anthony J. Bron, Donald R. Korb, Shiro Amano, Jerry R. Paugh, E. Ian Pearce, Richard Yee, Norihiko Yokoi, Reiko Arita,
quantitative changes
in the glandular secretion. It may
Murat Dogru
The International Workshop on Meibomian Gland Dysfunction: Report of the Diagnosis Subcommittee
result in alteration Invest
of Ophthalmol
the tear
film, symptoms of eye
Vis Sci Mar 30, 2011; 52: 2006-2049.
"Special Issue")
[Full Text] [PDF]
irritation, clinically (In
apparent
inflammation,
and ocular
(Read 4074 times)
surface disease.
5. Gerd
Geerling, Joseph Tauber,
Christophe Baudouin,
Goto,
Yukihiro Matsumoto, Terrence O''Brien, Maurizio Rolando, Kazuo Tsubota,
There are several
evidence-based
explanations
forEikithe
terKelly K. Nichols
minology used in this definition.
The
termondysfunction
used Report of the Subcommittee on Management and Treatment of
The International
Workshop
Meibomian Glandis
Dysfunction:
Meibomian
Gland Dysfunctionglands is disturbed.
because the function Invest
of the
meibomian
Ophthalmol Vis Sci Mar 30, 2011; 52: 2050-2064.
The term diffuse is used
because
the[Full
disorder
involves most of
(In "Special
Issue")
Text] [PDF]
4027 times)
the meibomian glands.(Read
Localized
involvement of meibomian
6. J. Daniel Nelson,
Jun Shimazaki,
Jose M. Benitez-del-Castillo,
glands, such as in chalazion,
tends
not to cause
abnormalitiesJennifer
in P. Craig, James P. McCulley, Seika Den, Gary N. Foulks
The International Workshop on Meibomian Gland Dysfunction: Report of the Definition and Classification Subcommittee
the tear film or ocularInvest
surface
epithelia
therefore
is not
Ophthalmol
Vis Sci Mar and
30, 2011;
52: 1930-1937.
(In "Special
Issue")
[Full Text]
[PDF]
considered to belong within
the
context
of MGD.
Obstruction
(Read 3221 times)
of the meibomian gland orifices and terminal ducts and quali7. Penny A. Asbell,
Fiona J.in
Stapleton,
Kerstin Wickström,
K. Akpek, Pasquale Aragona, Reza Dana, Michael A. Lemp, Kelly K. Nichols
tative and/or quantitative
changes
meibomian
glandEsen
secreThe International Workshop on Meibomian Gland Dysfunction: Report of the Clinical Trials Subcommittee
Investmost
Ophthalmol
Vis Sci Mar 30,
2011; 52: 2065-2085.
tions are identified as the
prominent
aspects
of MGD. In
(In "Special Issue") [Full Text] [PDF]
addition, subjective symptoms
of eye irritation are included in
(Read 2580 times)
the definition, as it is the symptoms that are of greatest concern
8. Kari B. Green-Church, Igor Butovich, Mark Willcox, Douglas Borchman, Friedrich Paulsen, Stefano Barabino, Ben J. Glasgow
to the patient and often
the clinician.
Improvement
in the Report of the Subcommittee on Tear Film Lipids and Lipid–
The to
International
Workshop on
Meibomian Gland Dysfunction:
Protein
Interactions
Disease
patient’s symptoms is the
major
goalininHealth
theand
treatment
of MGD.
Invest Ophthalmol Vis Sci Mar 30, 2011; 52: 1979-1993.
The role of inflammation
in the
etiology
of MGD
is controver(In "Special
Issue")
[Full Text]
[PDF]
(Read 2546 times)
sial and uncertain.
9. Debra
Schaumberg,
J. Nichols,
Eric B. Papas,
Louis Tong, Miki Uchino, Kelly K. Nichols
Recent literature
hasA. used
the Jason
terms
posterior
blepharitis
The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on the Epidemiology of, and
and MGD as if they were
synonymous,
these terms are not
Associated
Risk Factors but
for, MGD
Invest Ophthalmol
Vis Sci describes
Mar 30, 2011; 52:
1994-2005.
interchangeable. Posterior
blepharitis
inflammatory
(In "Special Issue") [Full Text] [PDF]
conditions of the posterior
lidtimes)
margin, of which MGD is only
(Read 2437
one possible cause. In its earliest stages, MGD may not be
!
associated with clinical
signs characteristic of posterior blepharitis. At this stage, affected individuals may be symptomatic,
but alternatively, they may be asymptomatic and the condition
regarded as subclinical. As MGD progresses, symptoms develop and lid margin signs, such as changes in meibum expressibility and quality and lid margin redness, may become
more visible. At this point, an MGD-related posterior blepharitis is said to be present.
The term MGD is regarded as appropriate for describing the
functional abnormalities of the meibomian glands. Meibomian
gland disease is used to describe a broader range of meibomian gland disorders, including neoplasia and congenital dis-
©KNichols 2012
DOI:10.1167/iovs.10-6997a
Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4
Copyright 2011 The Association for Research in Vision and Ophthalmology, Inc.
Anatomy,Physiologyand
Pathophysiologyofthe
MeibomianGland
ErichKnop,M.D.,Ph.D.(Chair)
NadjaKnop,M.D.,Ph.D.
ThomasJ.Millar,Ph.D.
HirotoObata,M.D.
DavidA.Sullivan,Ph.D.
MeibomianGland-ANATOMY
•  Largesebaceousglands
•  Nodirectcontactto
hairfollicles
•  Locatedinthetarsal
plates
•  Upperandlower
eyelids
Modified and colored from Krstic H. Human
microscopic anatomy. Springer Medizin Verlag
1991, (reproduced from Knop N & Knop E
Ophthalmologe 2009; 106:872–883)
©KNichols 2012
MeibomianGland-ANATOMY
•  Length
•  Followsthetarsus
•  Number
•  Moreinupperlid(30-40)
•  Lessinlowerlid(20-30)
•  Volume
•  Higherinupperlid(26µlvs.13µl)
•  Rela4vefunc4onalcontribu4on(uppervs.
lower)tothetearfilmlipidlayerisunknown
©KNichols 2012
MeibomianGland–PATHOLOGY
•  Obstruc4veMGDleadstoaprogressiveductal
DILATATIONandacinarATROPHY
Modified from Sobotta Atlas der Anatomie des Menschen.
Urban & Schwarzenberg Verlag 1982, (reproduced from
Knop N & Knop E. Ophthalmologe 2009; 106:872–883)
©KNichols 2012
Fom Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen in der
Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987
©KNichols 2012
10
11/8/15
MeibomianGlandDysfunc2on
Defini2on&Classifica2on
J.DanielNelson,M.D.(Co-Chair)
JunShimazaki,M.D.,Ph.D.(Co-Chair)
JoseM.Benitez-del-Cas4llo,M.D.,Ph.D.
JenniferCraig,Ph.D.,MCOptom
JamesP.McCulley,M.D.
SeikaDen,M.D.,Ph.D.
GaryN.Foulks,M.D.
©KNichols 2012
Evalua2on,Diagnosisand
GradingofSeverityof
MeibomianGlandDysfunc2on
AlanTomlinson,MCOpt,Ph.D.(Chair)
AnthonyJ.Bron,F.R.C.S.
DonaldR.Korb,O.D.
ShiroAmano,M.D.,Ph.D.
JerryR.Paugh,O.D.
©KNichols 2012
Tes2ngSummary
•  Symptoms(novalidatedsurvey)
•  Expression(notwidelyaccepted)
–  Quality/Quan4ty
•  Lidassessment
–  Redness(difficulttograde)
–  Irregularity
–  MGloca4on
•  Staining(fluorescein)
–  Photography
•  Aq.Produc4on(©1903)
E.IanPearce,Ph.D.
RichardYee,M.D.
NorihikoYokoi,M.D.,Ph.D.
ReikoArita,M.D.,Ph.D.
MuratDogru,M.D.
StagesofMGD
ManagementandTherapy
ofMeibomianGland
Dysfunc2on
GerdGeerling,M.D.(Chair)
JosephTauber,M.D.
ChristopheBaudouin,M.D.,Ph.D.
EikiGoto,M.D.
YukihiroMatsumoto,M.D.
©KNichols 2012
TerrenceO’Brien,M.D.
MaurizioRolando,M.D.
KazuoTsubota,M.D.
KellyK.Nichols,O.D.,M.P.H.,Ph.D.
©KNichols 2012
11
11/8/15
CurrentPrac2cePaSerns
CurrentPrac2cePaSerns*
•  World-widevaria4on
•  Lidhygiene,warmcompressesandlidmassage
•  Underrepor4ngàdifficulttoassesspamerns
•  Underdiagnosiscommon,clinicalfollow-upirregular
•  Cleaningofthelidmarginwithbabyshampoo,
comonbudsorwettowels,dailyfor5-15minutes
• 
• 
• 
• 
Lubricantsincaseswithaddi4onaldryeye
Topicalan4bio4coint(moderatetosevere)
Systemictetracyclines/deriva4vesinrecurrence
Incisionandcuremagewithop4onalsteroid
injec4oninchalazion
•  Lidwarmingandhygienecommon
•  Manyusear4ficiallubricants
•  MostCommonRx:Systemictetracyclineor
deriva4ves(lessfrequentinEU/Japan)
–  2ndmostcommonRx:topicalan4bio4coran4bio4csteroidcombina4on
*ExcerptedfromMoorfieldsManual,WillsEyeManual
(Guidelinesforposteriorblephari4sandmeibomi4s)
©KNichols 2012
©KNichols 2012
Structure of a Stable Tear
Film
Structure of the Lipid Layer
Nonpolar Lipid layer
- complex - over 100
Amphiphilic Lipid Layer different species of lipid
Two-Phase
Lipid Layer
Model
Aqueous/Mucin complex -mucins are distributed
throughout this layer,
rather than in distinct
aqueous and mucin layers
HC-Hydrocarbon
WE- Wax Ester
CE-Cholesterol Ester
TG- Triglyceride
F-Free Fatty Acid
C-Cerebroside
P-Phospholipid
Glycocalyx -mucin bound complex
responsible for the
integration of aqueous layer
Corneal
with corneal epithelium
Epithelium
McCulley et al. A Compositional Based Model for the
Tear Film Lipid Layer. Tr Am Ophthal. Sci., 1997
69
Meibomian Glands
30-40 glands exist in upper tarsus
20-40 glands exist in the lower tarsus
n  Secretion stimulus not fully
understood
n 
n 
n  Secretion
of meibomian oil increases with
testosterone; decreases with estrogen
n  Oil expelled by mechanical force on gland
during blinking
n  Not all glands secreting simultaneously
71
Non-Obvious MGD
(NOMGD)
MGD may be non-obvious without
inflammation and without other
obvious signs (NOMGD)
n  NOMGD may be precursor to obvious
MGD
n  Highly prevalent and under-diagnosed
– may be most common cause of
evaporative eye disease
n  In a recent dry eye study of the 52
subjects that had MGD, 48% of them
had NOMGD.
n 
Modified sebaceous gland
70
72
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TearScience® Solution
Treatment of MGD/NOMGD
At Home Therapy
–  Warm compresses
–  Eyelid Scrubs
–  Self expression
In-Office Therapy
n 
n 
Manual Expression
Off-Label Pharmacotherapy
n 
n 
n 
Oral tetracycline/doxycycline
Topical Antibiotics – erythromycin, tobramycin
Topical Steroids – dexamethasone
LipiView® OSI
LipiFlow® Auto
Disposable
Meibomian Gland Evaluator
73
Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in
the U.S. Limited by United States law to investigational use.
74
MGD TREATMENT
Warm compresses
Meibomian gland scrubs
n  Home expression
n  Blinking
n  Office expression
n  Secretagogues – Androgens
n 
n 
Additional Manual
Expression
Mastrota Paddle
Jaegar Platemodified by M.
Gutierrez, OD
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New! Ophthalmic Surgical Instruments
Collins Expressor Forceps (Item 98610)
For aggressive expression of the Meibomian gland.
Livengood Expressor Paddles
Angled (Item 98620) & Flat (Item 98630)
For mild or gentle expression of the Meibomian gland.
You can use the BIO to get a lighted slightly magnified view
of the lids
Maskin Expressor
n 
n 
BRUDER EYE COMPRESSES
WARNING
Microwave Activated
Bruder Eye Hydrating Compress and Stye Compress conveniently provide an
effective yet natural and drug-free way to help provide and maintain proper
eye moisture.
BENEFITS
FEATURES
•  Replenishes Moisture Naturally
•  Relieves Dryness
•  Refreshes Tired Eyes
•  Provides Drug Free Relief
•  Ready in Minutes from the Microwave
•  Naturally Hydrating
•  Washable & Reusable
•  Clean Moist Heat
•  Soft Conforming Design
•  Non-Allergenic
•  Dust-Free
$ 575
Rhein Medical n 
BRUDERSTYECOMPRESS
Item#34170
Hot compresses can change the corneal
tissues and structure
n 
Possible Link to Keratoconus
n 
Evidence Based Medicine
BRUDEREYEHYDRATINGCOMPRESS
Item#34160
08.10
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Meibomian Gland Expression
MGD EXPRESSION
Schaeffer Eye Protocol
1)  OSD Evaluation
Fees:
$289 / $25
Out of pocket
Covers 3 Office visits
$68.00 Per visit after initial three visits 99213 / 99212
Dry eye progress check before expression
1) 
2) 
2) 
Includes test expression
All staining
RTC expression
At home heat with eye medibeads
2) 15-20 minutes in waiting room with Bruder’s
heat pack (or rear wait)
3) Expression 1 of 3
4) RTC 2 weeks
1) 
Advanced Beneficiary Notice: ABN MGD
Maskin Expressor
Maskin Probe
1)$ 158 box ( 10)
2) 1,2,4,6 MM intraductals
3) Aluminum Handle $104
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Maskin Tube
Meibomian gland Drug delivery
system
Maskin Probe
Leiter Pharmacy
8% lidocaine with 25% Jojoba in
ung base
16
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OBSTRUCTIVE MGD
Warm Compress Treatment
Increase in LLT Following Treatment with
Warm Compresses in Patients with MGD
Olson, Korb, Greiner, Eye & CL, 2003
Baseline LLT
5 minutes
15 minutes
30 minutes
Tear Conservation
= 60 nm
= 105 nm
= 117 nm
= 122 nm
Not published: 1 to 2 mins – minimal or no improvement
Warm Compresses: Olson et al., 2003: Matsumoto et al., 2006
Warming devices : Goto et al., 2002; Mori et al., 2003; Nagymihalyi et al., 2004;
Mitra et al., 2005; Di Pascuale et al., 2005; Spiteri et al., 2007
Therapeutic Approaches
n 
n 
n 
n 
n 
Stabilize the tear film
(subjective)
Increase lubricity decrease coefficient
of friction
Increase aqueous
production
Decrease
inflammation
Create a more normal
tear film environment
for epithelial healing
Categories of Lubricant Eye Drops
Cellulose Derivative Products
Tear Conservation- Therapeutics
Artificial tears
Ointments
n  Steroids
n  Cyclosporine
n  Doxycycline
n  Lacriserts
n  Lid disease therapy
n  Glasses
n  Sunglasses
n 
n 
Glycerin Containing Products
Lipid Based Emulsion Products
Polyethylene Glycol and
Propylene Glycol Products
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Tear Conservation: Surgical
Intervention
Lifestyle Adaptations:
Increase humidity
Wear eye shield or goggles
n  Avoid:
n 
n 
Punctal occlusion
Lateral tarsorrhaphy
n  Other procedures
n 
n 
n  Ectropion
n  wind,
air conditioning, dry heat, high altitudes
exhaust, smoke
n  prolonged computer use
n  contact lens wear
n  medications that contribute to KCS
n  Sunglasses
n  smog,
correction
Restasis™ Dosing: BID
Restasis™
n  Ophthalmic
n 
emulsion of cyclosporine 0.05%
Restasis™ regimen: 1 drop in
each eye every 12 hours
n  Recommended
Unique emulsion technology provides effective drug
delivery to ocular tissue at low cyclosporine
concentrations
n 
n  Cyclosporine
is a complex molecule with
antiinflammatory and immunomodulatory
properties.
n 
n  In
n  Concomitant
therapy
Clinical study showed Artificial tears excellent
adjunct
n  Additional emulsion may be poorly tolerated
n 
Inhibits T-cell mediated inflammation and cytokine
driven inflammatory cell chemotaxis
n  Contact
the eye:
n 
n  Restasis™
increases production of natural tears
increases goblet cell density
lens users
Remove lenses, administer Restasis™, replace
lenses after 15 minutes
Restasis and MGD
How Does Restasis™ Work?
n 
Inform patients: do not use “as needed” like
traditional drops
Restasis™ prevents T-cell activation
n 
(Kunert et al, Arch Ophthalmol. 2000;118:1489)
n 
n 
n  Activated
T cells produce inflammatory
cytokines that result in:
n  Recruitment
n 
n  More
of more T cells (Stern et al, IOVS. 2002;43:2609)
cytokine production (Pflugfelder et al, Curr Eye Res.
n 
1999;19:201)
Two studies
Cornea 2012
Study goal – compare efficacy of topical cyclosporine
0.05% and preservative-free artificial tears in the treatment
MGD.
70 patients with MGD and TBUT less than 8 seconds
After 3 months significant improvement in mean OSDI, TBUT,
lid margin inflammation, meibomian gland expressibility, and
tarsal injection cyclosporine 0.05% group.
1
0
7
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Restasis and MGD
n 
n 
n 
n 
n 
n 
Steroids and Dry Eye
Cornea 2006
Study goal – evaluate efficacy of topical cyclosporine 0.05%
in the treatment MGD.
33 patients with MGD
Randomized in a prospective study to either cyclosporine
0.05% or placebo (Refresh Plus preservative-free artificial
tears), 2 times daily for 3 months.
At 3 month visit, statistically significantly improvement in the
cyclosporine 0.05% group.
Lid margin vascular injection, tarsal telangiectasis, NaF
staining. Most significant finding - greater decrease in the
number of meibomian gland inclusions in the cyclosporine
group compared with the placebo group.
Symptomatic improvement in irritation
symptoms in 83% and objective
improvement (ê redness, dye staining
and tarsal papillae, é FTC) in 80%
of 70 patients treated for 2 weeks with
non-preserved methylprednisolone
Prabhasawat & Tseng BJO 1998
DOXYCYCLINE THERAPY
to Reduce Inflammation in
MGD
n 
n 
n 
n 
DOXYCYCLINE
n 
An abnormal production of
esters &/or bacterial colonies
cause the oils to become
acidic leading to burning
The AB inhibits staph lipase
from converting lipids to fatty
acids thereby reducing
inflammation
Dose: 50 mg BID x 1-2 mos
Maintenance: 20-50mg qd- bid
Alodox
n 
n 
20 mg Doxycyline Hyclate
Sub-antimicrobial dosage
n 
n 
n 
n 
n 
n 
n 
WARNINGS
n 
Drink fluids to prevent
esophagitis, use sun block,
simultaneous ingestion of
food OK.
Link to Breast CA?
n 
ALTERNATIVES
n 
n 
n 
Tetracycline qid
Minocycline $$
ALODOX
ONCE DAILY DOXYCYCLINE
n 
n 
n 
(<50mg)
Enzyme modulation of inflammation
By OCuSOFT
Kit comes with lid scrub foam
Claims to be a more potent
collagenase inhibitor than
minocycline and therefore less SE
Long term use
SIDE EFFECTS
NVD, anorexia,
dysphagia, severe
photosensitivity,
superinfection
(fungus, vaginal
candidiasis) benign
IC-HTN, hepatoxicity,
pancreatitis
Great for long term usage once controlled
Blepharitis, dry eye, rosacea
Brand Name Oracea® 40mg
n 
n 
n 
ORACEA helps break cycle of inflammation associated with
rosacea.
Results seen as early as week 3 and continued through week
16.
Long term –cycline therapy associated with pseudotumor
cerebri
n  TCN, Doxycycline, Minocycline
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Contraindications
n  Pregnant
Cautions
n  Photosensitivity
or child bearing age
n  Chelates
with dairy products,
antacids etc.
n  Minocycline may cause
vestibular toxicity
n  Children
How to Minimize Stomach
Problems with Tetracycline
Omega-3s and Omega-6s:
Essential Fatty Acids
n 
1. 
2. 
3. 
4. 
Do not take the second pill (bid) before
going to bed
Do not take pills with acidic beverages
Take pills with food (except a high
dairy meal)
Prescribe the lowest dose available
Omega-3 Essential Fatty Acids
n 
n 
n 
n 
Essential fatty acids
Optimum Omega-6:Omega-3 ratio for good health
varies from 3:1 up to 1:1:
Ratio in current American Diet is about 1:10
American diet too high in Omega-6s from dairy
products, beef, vegetable oils, shortening
American diet too low in Omega-3’s from salmon,
cold-water fish, krill oil, flaxseed, walnuts, dark
green leafy vegetable, beans
LWE
Omega-3s
American diet has undergone a 6-fold reduction in
Omega-3s since 1850
n  Increases “good” prostaglandins
n  Inhibits “bad” prostaglandins
n 
n 
n 
Lid Wiper Epitheliopathy
Omega 6s
US consumption of this fatty acid has doubled
from what it was in 1940.
n  Excess intake can increase water retention, raise
blood pressure and increase blood clotting.
n 
20
11/8/15
THE LID WIPER DEFINED
Ocular surface
That aspect of
the marginal
conjunctiva of
the upper eyelid
that wipes the
ocular surfaces
during blinking
©
16 M
LID WIPER &
AUTOMOBILE WINDSHIELD WIPER
Width = .4 to .6 mm
Ocular
Surface
LID WIPER
Korb et al., 2002-2005
Windshield
Wiper
Windshield Wiper
Clearance Space
Kessing’s
Space
21