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SPECIAL FEATURE: DRY EYE Meibomian gland dysfunction and contact lenses: our challenge BY GRANT WATTERS* Awareness of meibomian gland dysfunction (MGD)—and its role in ocular surface discomfort and contact lens intolerance—has been raised by the Tear Film and Ocular Surface Society (TFOS) workshop. Working towards understanding the mechanisms contributing to MGD and the implications of MGD on ocular surface health, the TFOS came up with a definition of MGD: MGD is a chronic, diffuse abnormality of the meibomian glands, commonly characterised by terminal duct obstruction and/or qualitative/ quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease. Because it is well established that all types of contact lenses (CL) can disrupt the lipid layer of the tears, it stands to reason that any MGD will exacerbate the situation, and cause an increase in evaporative dry eye and contact lens intolerance. Add to this the “hostile” environment of airconditioned offices, heating in cars and at home, and a lowered blink rate during long hours of computer work and you end up with a surprising number of patients struggling, especially with the added “double whammy” of impending presbyopia. These “Peter Pan Presbyopes” want solutions. Their eyes are drying out, causing blurred vision, and their near focus is also deteriorating. CL technologies for presbyopia can still be limiting, especially as we absolutely require wettable CL materials with good stable optics. A bridge too far? To provide some sort of a solution in our practice, we have become more assertive in offering in-house MGD therapy. We recommend the purchase of an eye wheat bag to replace the use of facecloths at home for more sustained heat release and for longer heat exposure periods of four to five minutes. We perform regular in-house expression programmes: first with eye wheat bags to warm up the MG’s; then, a golf club spud for lid margin debridement of any keratin over the MG’s; and finally with MG expression using mastrota paddle tweezers. We are also considering buying an E>EYE IPL machine, which has shown great promise (see separate story). The problem is that MGD, like blepharitis, can be chronic and recurrent—two ominous words—and patients are time-poor and even lazy when it comes to doing their own home therapy. Usually when things are going better, patients tend to stop doing their home treatments and then of course things take a turn for the worse. Educating them is therefore key so they know how to get back on track. In-house MGD therapy actually achieves two things: you motivate the patient into keeping it up and you give them a “head start” for their home sessions; plus it allows you to diagnose far more accurately the degree or grade of blockage. Are the ducts completely plugged? Or, if expressible, what is the texture and colour like? Is it cloudy or creamy like tooth-paste or fairly clear? Does the patient show improvement with time? Are the lid margins looking less red and inflamed? Is there any improvement in corneal staining? I tell patients that one session in-house is the equivalent of them doing it for about two weeks at home to help motivate them. If after a month of weekly in-house and home sessions there is little or no improvement, I write to the patient’s GP to ask for additional oral doxycycline or azithromycin supply, explaining why. Most GP’s will send out a script without insisting on a consultation and the mucolytic effect of tetracyclines can often soften up the blockages, improving treatment outcomes. With a bit of effort and teamwork from us and the (motivated) patient, we can usually make good progress. Keeping them on an on-going home maintenance programme of eye wheat bag warm compresses and digital massage for 2-3 sessions a week also seems to help avoid regression. Finally, there are two other groups of CL wearers who have to have a good stable tear film: orthokeratology (OK) wearers and keratoconics. The hydraulic engineering the tear film must achieve in OK lens wearers is massively affected by marginally dry eyes. While a lot of keratoconics have little choice other than to tolerate CLs for at least 16 hours a day in all sorts of crazy conditions. I have had to “pre-treat” OK children for MGD before proceeding, as it’s much easier to do first than having to backtrack! It is also not unusual for OK kids and keratoconics to have rosacea Factors and associations thought to adversely affect MG performance • Lid hyperkeratinisation • Age • Androgen deficiency with menopause • Contact lens wear • Asian ethnicity • Rosacea • Sjögren’s syndrome • Blepharitis • Atopy • Demodex folliculorum • Antihistamines • Antidepressants which has been overlooked. Also do a little bit of investigative work to see if any of your teenage OK wearers are on Roaccutane? Plus, MGD is known to be more prevalent in the Asian population. In general we need to be more attentive to MGD therapy to help our CL patients maintain asymptomatic wear for reasonable periods. Our patients certainly enjoy their in-house “day spa” sessions and get on board with some positive education, after all “a problem shared is a problem halved!” O * Grant Watters is a qualified TPA optometrist and co-owner of Mortimer Hirst in Auckland. He specialises in keratoconus, DRY EYE TREATMENT E>Eye gets the thumbs up in latest NZ patient research More than 80 per cent of patients who received E>Eye intense pulsed light (IPL) treatments at Merivale Optical in Christchurch reported their dry eye symptoms had improved, while 95.7 per cent said they would recommend the treatment to others. The results come as part of a survey of E>Eye patients at Merivale treated over a 10-month period. Of the 86 respondents, 74.4 per cent were over 60 years old, 23.3 per cent were between 20 and 40 years old and 2.3 per cent were between 20 and 40. The research was conducted by John Veale, optometrist at Merivale and New Zealand distributor for France Medical’s E>Eye machine. The E>Eye machine has been specifically designed for treating dry eye due to meibomian gland dysfunction (MGD). The device works by producing a calibrated series of IPL. These light pulses are precisely set at a specific energy and frequency to stimulate the meibomian glands and help them to recover their function. Other results from Merivale’s research include 98.5 per cent saying the treatment was “no problem” or “okay”, and 55 per cent reporting they no longer needed to use eye drops following treatment. A double-blind, placebo-controlled clinical trial of 28 patients with MGD by Associate Professor Jennifer Craig from the Ocular Normal meibomian glands Ortho-K (orthokeratology), complex contact lens fitting and management and contact lens troubleshooting. He’s also a lecturer and researcher with the Departments of Optometry and Vision Science and Ophthalmology, University of Auckland. REFERENCES: • Craig JP, Chen Y-H, Turnbull PRK. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthal Vis Sci 2015; 56(3):1965-1970. • Nichols KK et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. Invest Ophthal Vis Sci 2011; 52(4):1922-1929. • Pult H, Riede-Pult BH, Nichols JJ. Relation Between Upper and Lower Lids’ Meibomian Gland Morphology, Tear Film, and Dry Eye. Optom Vis Sci 2012; 89(3):310-315. • Kunnen C, Nichols JJ. Meibomian Gland Dysfunction: An Update. CL Spectrum 2015; 30:22-27. • Efron N. Contact Lens Complications (3rd.Ed) 2012 Elsevier. Surface Laboratory in Auckland University’s Department of Ophthalmology found 82 per cent of patients showed improvement after three treatments with the E>Eye device of at least one lipid layer grade on day one with 86 per cent noting reduced symptoms by day 45. There was also significant improvement in non-invasive tear breakup time (NIBUT) vs controls*. For more information on the E>Eye visit: www.dryeyetreatment.co.nz. O *Source: Craig, Jennifer P., Yen-Heng Chen, and Philip RK Turnbull. “Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction.” Investigative ophthalmology & visual science 56, no. 3 (2015): 1965-1970. Current price available until October 1 For more information visit our website www.dryeyesyndrome.co.nz or email us info@dryeyetreatment.co.nz Achieving great results throughout NZ I started using E►Eye in January 2014. It quickly became evident that patients were extremely happy with the results. In particular, the patients with obvious rosacea were describing huge improvements in their ocular comfort and an improvement in their conjunctival injection. For a condition that previously had limited therapeutic options, IPL is an exciting and highly eff ective new treatment modality for patients with dry eye from MGD. Dr Brendan Cronin, Ophthalmologist I invested in E►Eye with peace of mind as I would have got my money back in the fi rst three months if it was not successful. Not only my dry eye patients were happy with their IPL treatments but they also recommended their friends and relatives to get treated too and this has become a very profi table service for my business. In fact, in less than four months, I had already got the return on my investment! There is no other optometry equipment on the market with such a quick return and it defi nitely makes my practice stand out from the crowd. E►Eye is defi nitely the best piece of equipment that I have invested in. It is attracting on average three to fi ve new customers per week and these customers are now coming to buy our frames and have their eyes examined. John Veale, Optometrist My eyes felt great after three treatments and continue to improve in regards to tolerance of air conditioning and computer use, especially after a long day. Thank you for being so kind and allowing me to have the treatment. My eyes felt so much better I was fi nally encouraged to apply for a job and was successful. Sofia, dry eye sufferer from Sydney IPL research call for patients BY ALLY XUE* Artificial tears, warm compresses, manual expression, lid scrubs - the majority of current treatments for meibomian gland dysfunction (MGD) are deemed largely palliative, providing at best transient relief from dry eye symptoms. Both clinicians and affected patients frequently describe MGD therapies as disappointing and continually seek alternative management options. One alternative which has emerged in recent years is intense pulsed light (IPL) therapy, conventionally applied to reduce facial melasma, but within the last decade recognised to have positive ocular effects in MGD. Following the arrival of the E>Eye IPL device (France Medical) in New Zealand in 2013, Associate Professor Jennifer Craig and her team at the Ocular Surface Lab (OSL) conducted a Prospective Trial of Intense Pulsed Light for the Treatment of Meibomian Gland Dysfunction. Results from this randomised, doublemasked, placebo-controlled study (published in IOVS this year) demonstrated significant improvements in tear film quality and patient symptoms. Effects were cumulative, prompting Dr Craig and I to design a second IPL trial on a larger participant group, and over a longer treatment period. In addition to assessing efficacy, we will explore a range of potential therapeutic mechanisms involved in IPL therapy. We hope to better understand the applicability of IPL in different patient sub-groups in order to improve prognostic value and enable further therapeutic refinements. We will be offering IPL treatment to patients interested in participating in the research project in exchange for a few hours of their time. Recruitment of suitable dry eye patients with symptomatic MGD is due to begin shortly, with plans to commence the IPL study later this year. Practitioners are invited to mention the study to patients they think might be suitable. O *Ally Xue is a PhD student with the OSL. Practitioners and patients interested in the study can contact Ally at a.xue@auckland.ac.nz to obtain more information about the study. 10 NEW ZEALAND OPTICS September 2015
Topography and advanced external imaging Complete Dry Eye Assessment TF-Scan, R-scan Meibo-scan Imaging TF-Scan The Dry Eye Relief Mask, D.E.R.M., contains Silica beads which naturally attract moisture from the air and release it when microwaved. Heating the mask for 20 seconds will provide soothing moist-heat relief for 4-6 minutes. Applying a moistened cotton liner to the mask prior to heating will extend the treatment to 7-9 minutes. D.E.R.M.. is hypoallergenic and can also be used to create cold therapies for allergy relief. The Tranquileyes system incorporates two re-usable gel pack technologies to create moist-heat therapies, proven to effectively improve tear quality by providing the intensity and duration of heat required while hydrating the sensitive eyelid and surrounding skin. Tranquileyes allows patients to create soothing moist-heat compresses, ranging in temperature from 101–110°F/38.33-43.33°C and lasting up to 25 minutes. May also be used for cold therapies. Meibomium Gland Expression Paddle Long Term Temporary Canalicular Inserts. Effective 60 – 180 days The most advanced silicone punctum plug available InflammaDry is a rapid, immunoassay test for the detection of elevated levels of the MMP-9 protein in human tears, to aid in the diagnosis of dry eye, in conjunction with other methods of clinical evaluation. This test is intended for professional use at point-of-care sites. 0800 338 800 www.designsforvision.co.nz September 2015 NEW ZEALAND OPTICS 11 DV765-0715
Page 1 and 2: THE MAGAZINE FOR NEW ZEALAND’S OP
Page 3 and 4: Time to move over....... It’s tim
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