Michael A. Lemp, MD, FACS: According to the American Academy of
Ophthalmology, between 30% and 35% of patients present with symptoms consistent
with dry eye disease.1 Although ophthalmologists frequently treat
patients with meibomian gland dysfunction (MGD), the most prevalent form of dry
eye disease,2 there is still much that physicians need to learn
about its causes, diagnosis and management to better relieve symptoms and
improve quality of life for patients. When Stern and colleagues3
first described the lacrimal functional unit as comprising the meibomian
glands, MGD’s principal role in dry eye disease could no longer be
With MGD being the most common form of dry eye disease,4 do
you find that MGD significantly affects your patients?
John A. Hovanesian, MD, FACS: My colleagues and I perform a range
of general procedures, LASIK and cataract surgeries. MGD has a profound effect
on my patients’ vision, and it must first be controlled to acquire
accurate keratometry (K) measurements. Significant MGD alters the stability of
the tear film, which is measured by interferometry.5 A stable lipid
film is essential for cataract surgery because an error of 1 D in K measurement
results in a refractive error of 1 D. This one-to-one ratio indicates the need
for consistent measurements at the front of the cornea.
William B. Trattler, MD: I find that, although MGD profoundly
affects patients as they age, older patients are less symptomatic than younger
patients. My colleagues and I performed a screening study of patients scheduled
for cataract surgery and found that 59% had MGD.6 Furthermore, a
high percentage of patients with active MGD and rapid tear breakup time were
asymptomatic or minimally symptomatic. Although these patients were coming in
for routine cataract surgery, we first had to address their MGD to obtain
accurate K readings.
I have also found that a poor tear film resulting from MGD could be a
reason why younger patients become intolerant to contact lenses.
Stephen S. Lane, MD: In my practice, MGD is the most prevalent
diagnosis – 85% of my patients have MGD. When a patient presents with the
typical symptoms of dryness, bogginess, lid redness and especially fluctuations
in vision, the diagnosis is most likely MGD, even in postoperative refractive
and LASIK patients.
J.E. “Jay” McDonald II, MD: The meibomian gland is the
sentinel place around which dry eye revolves. My colleagues and I discuss MGD
with approximately 30% to 40% of our patients. We examine the meibomian
expressions routinely and stain with Fluramene (fluorescein sodium/lissamine
green; Noble Vision Group) to evaluate the tear film, corneal surface and lid
Dry eye disease and MGD: Demographic breakdown
Lemp: Demographic studies suggest that the prevalence of dry eye
disease is much higher than previously thought. A Harvard study7,8
suggests that 5.9 million people have moderate to severe dry eye in the United
States and that, for every one of those moderate to severe cases, there are
probably three or four patients with a less significant form of the disease. In
total, an estimated 20% of the population has either chronic dry eye problems
or episodic dry eye in response to environmental stress. How has dry eye
disease affected your patients?
Hovanesian: My practice has a high incidence of both dry eye
disease and MGD because more than half of my patients are age 60 or older.
McDonald: I practice in an area that has four distinct
seasons, and in the fall, when humidity drops and people start heating their
homes, I see an upswing of patients with asymptomatic dry eye. Patients also
present with, as TearScience cofounder and researcher Donald R. Korb, OD
describes, non-symptomatic MGD – patients have decreased meibomian gland
secretions, yet, have not developed symptoms.
Trattler: About 20% of my patient population has dry eye disease
and MGD. I treat a large number of young patients who spend a significant
portion of the day using a computer. Selection is a factor as well.
Ophthalmologists treat patients who present with vision fluctuations and mild
cataracts. However, if the ophthalmologist treats the patient’s dry eye or
MGD, then the patient’s vision is corrected sufficiently and surgery may
not be necessary.
Parag A. Majmudar, MD: I believe that dry eye in general, and MGD
specifically, are under-diagnosed, yet they account for a high percentage of
patients’ symptoms. As we know, the majority of patients do not present
with a chief complaint of, “I have MGD.” Rather, they may have a
constellation of signs and symptoms that the practitioner must analyze to make
a connection. The main complaint that patients likely have is poor vision, yet
many eye care providers may not correlate a poor quality tear film as having
any significant impact on visual acuity.
Lemp: Traditionally, most ophthalmologists do not think dry eye
affects vision, except in patients who have advanced dry eye disease. What
happens mechanistically that affects patients’ vision?
Trattler: Most commonly, central corneal staining could be the
cause for a patient’s declining vision, due to an irregular corneal
surface. Using fluorescein, I often will see subtle, more advanced corneal
changes in the center, in addition to seeing a rapid tear breakup time.
Patients with a rapid tear breakup time who keep their eyes open longer while
staring at something will experience fluctuations in vision because of a poor
tear film after blinking.
Lemp: One study from Japan by Ridder and colleagues9
has shown that visual acuity declines 3 to 5 seconds after blinking, causing
many patients to fail a driver’s test. Until recently, ophthalmologists
have not been able to report this phenomenon because few patients present with
vision loss due to dry eye. Rather, they complain of tired eyes and excessive
blinking. Another study by Sullivan10 confirms that hormonal changes
associated with menopause are another factor that increases the risk for dry
Several population-based studies show a significant number of patients
have MGD. Schaumberg and colleagues11 showed a high distribution of
the disease in the elderly Japanese population. Another study by Tong and
colleagues12 evaluated a referral practice in Singapore and found a
high prevalence of MGD in patients who have severe dry eye, and a more recent
study out of Spain by Viso and colleagues13 showed similar results
when examining the general population.
It has been suggested that there is a higher prevalence of MGD in Asian
populations, but I am not sure that is true. However, my colleagues and I
conducted a large study in Europe and the United States evaluating the
frequency of aqueous tear deficiency and/or MGD in patients and we found that
86% of patients had MGD (Figure 1).14 Our study outcomes also
suggest that the mixed form of the disease is more prevalent as the disease
becomes more severe, and that MGD and dry eye disease are interrelated.
Trattler: Upon completing my residency, I believed that patients
with MGD would have a rapid tear breakup time while patients with aqueous
deficient dry eye would demonstrate a more normal tear breakup. Now we have
learned that both aqueous deficient and MGD groups experience the same
problems, including rapid tear breakup time, corneal staining and conjunctival
staining, which lead to similar effects on the ocular surface.
McDonald: I think of MGD as being at the base of a pyramid. In my
opinion, the first sign ophthalmologists should look for in 90% of patients
with dry eye is decreased meibomian gland secretions, because it is generally
the primary factor in the development of all dry eye disease. Learning to
express and grade gland secretions is very helpful.
Evaporative dry eye is a highly prevalent condition, with 86% of patients
suffering from meibomian gland dysfunction. Graphic source:
Adapted from data published in: Lemp MA, Crews LA, Bron
AJ, Foulks GN, Sullivan BD. Distribution of aqueous deficient and evaporative
dry eye in a clinic-based patient population. Cornea
. In press.
Terminology and education
Lemp: What are your recommendations for educating patients and
general practitioners about MGD and dry eye?
Majmudar: I believe we have to restructure the way we think about
dry eye, perhaps referring to it as ocular surface dysfunction. Some patients
have aqueous deficiency, but I think much of the impetus for developing
symptoms that we associate with dry eye are unrelated to the fact that the eye
is dry. If ophthalmologists start talking in terms of ocular surface or lid
dysfunction, then we can fully understand the importance of meibomian glands
and the role they play in this dysfunctional state.
Lemp: The terminology that ophthalmologists use has been debated
over the last 5 years. For example, dysfunctional tear syndrome is certainly
more descriptive of the symptoms, but it is more universally referred to as dry
eye. If we examine the causes of dry eye disease and whether it begins with
increased evaporation or decreased lipid secretion, I believe most
ophthalmologists agree that the tear film is unstable, as reflected in visual
problems between blinks and a hyper concentration of the tear film. How can we
help practitioners and patients better understand the terminology?
Hovanesian: A general practitioner may have a better
understanding of the pathophysiology that ophthalmologists refer to as dry eye
if we describe it in a different way and encourage, for example, an examination
of the meibomian glands to determine the root cause of the problem.
McDonald: Instead of using the term “dry eye” as a
single entity, since it is usually present in most patients, I also include
Korb’s description of lid wiper epitheliopathy15 to better
explain the problem to my patients. Since this change in terminology, I find
that my patients are more compliant to therapy.
Trattler: I educate my patients about evaporative dry eye disease
versus aqueous deficient dry eye syndrome. I find that my patients understand
that if there is not enough of a lipid layer to lock in the tears, then
evaporation results. If the condition is aqueous deficient dry eye, then the
physician should increase tear film thickness with a topical treatment such as
Hovanesian: I focus more on treatment than pathogenesis because,
although it is worthwhile to explain, I have limited time in the exam room with
patients. Instead, in addition to providing patients with a handout with
tailored treatment options, I direct patients to a 30-minute YouTube
presentation about all forms of dry eye. The video includes details about warm
compresses, lid hygiene and treatment options.
Standardized terminology may facilitate improved diagnosis
Confusion exists in the ophthalmologic community regarding the
various forms of dry eye disease, which commonly leads to misdiagnosis and
underdiagnosis. Using consistent terminology, classification and clinical
examination methods can help clinicians differentially diagnose dry eye disease
and select the most appropriate and effective treatment for their patients.
A proper exam for dry eye disease includes gland expression, lid
inversion and examination of the tear film. When a patient presents with dry
eye disease, ophthalmologists should examine the lids as well as the cornea,
and check the consistency of the expressed contents of the glands. Gland
expression is performed not only for meibomian gland dysfunction (MGD), but
also to prevent patients from progressing to an obstructive form of the
disease. Because the average clinician may not be familiar with the gland
expression technique, developing a standard, step-by-step examination procedure
Clinicians must be challenged to become better and more thorough
in their diagnosis and treatment. With so many forms of dry eye disease,
including mixed dry eye, aqueous tear deficiency and MGD, such a diagnostic
spectrum calls for a more specific classification that details symptoms
associated with each form.
By “speaking the same language,” ophthalmologists can
eliminate confusion, increase awareness of dry eye disease and properly educate
Edward J. Holland, MD, is director of Cornea Services at
Cincinnati Eye Institute and professor of Ophthalmology at the University of
Lemp: How do you evaluate a patient for MGD?
Hovanesian: Because proximity to the eye can cause reflex
tearing, I prefer to examine a patient using the overhead lights with the slit
lamp light turned off when I examine the tear lake. I look at the overall
wetting of the eye. Tear film debris indicates some form of dry eye, but it is
fairly nonspecific for MGD versus aqueous deficiency. In addition, a Schirmer
tear test is useful for examining aqueous production. Most importantly, I
conduct a thorough visual inspection by pressing on the glands to see the
secretion consistency and magnitude of the blockage to determine how much MGD
Lane: I perform an external exam first, looking at the overall
appearance of the eyelids and the symmetry of the two eyes in terms of swelling
and redness. Then, at the slit lamp, I look at telangiectasia of the lid
margins, inspissation of the glands, and the tarsal and bulbar conjunctiva for
inflammation (Figure 2). At this point, I will also use a cotton swab to
attempt to express the meibomian glands to determine the nature and quality of
the expressed secretions. I also look for foaminess at the canthi of the eyes,
which usually indicates the presence of MGD. I prefer lissamine green over
fluorescein to aid in diagnosis, but I do not use a Schirmer tear test unless
the patient has severe Sjögren syndrome.
Meibomian gland dysfunction with conjunctival reaction. Lid expression
reveals inspissated dysfunctional glands. Source: McDonald JE.
Lemp: When evaluating the lid margin, what emphasis do you put on
vascular changes versus secretory changes?
Lane: Although they most often go hand in hand, I believe that
the secretory changes are more important than the vascular changes. In my
experience, patients with secretory changes are more symptomatic, whereas
vascularization may be an early sign of MGD.
Majmudar: Since MGD is now recognized as one of, if not the,
leading cause of dry eye, the first thing a clinician should do when diagnosing
MGD is incorporate the signs and symptoms into the thought process prior to any
patient encounter. It is also important to take the time to listen to a patient
discuss his or her symptoms and let that be the guide during examination and
McDonald: I always use Fluramene and evert the lid to look at the
lid wiper. I then perform a lower lid meibomian gland expression.
Trattler: Many physicians may not realize that, when assessing
severity with fluorescein, they should wait at least 1 to 3 minutes to observe
maximum corneal staining.
Grading MGD severity
Lemp: Do you use a grading scale to develop a treatment plan?
Majmudar: If the patient has no secretion, then conventional
therapies will not work. However, I grade patients on the following scale: a
secretion of clear liquid is considered grade 1; a secretion that is slightly
more turbid is considered grade 2; and a secretion that is thicker, like
toothpaste, is grade 3. For MGD grades 2 and 3, advising patients about
grade-specific treatments will be more impactful and will lead to better
McDonald: My colleagues and I quantitate symptoms in two ways and
enter these values into our electronic medical records for use practice-wide.
First, we changed the algorithm in our medical record so that we grade how many
glands are open during expression. The three categories are four or fewer, four
to seven, and more than seven. We also grade lid wiper epitheliopathy using
Fluramene. The grading is based on the thickness and length of the lid wiper,
as well as the absence or presence of furrows.
Hovanesian: In my opinion, the severity of symptoms does not
correlate with the objective signs of turbidity or inspissation of the glands.
Particularly, there is a loss of correlation in patients who have MGD with
minimal to no aqueous secretions because most of those patients are fairly
Majmudar: This lack of correlation indicates a need for patient
education because, although patients may not show symptoms of MGD, they have
been diagnosed and must start treatment.
Lemp: Blackie and colleagues16 recently wrote about
nonobvious MGD (Figure 3). How frequently do you see patients who do not have
obvious signs of MGD yet are symptomatic?
Lane: Although a patient may not exhibit symptoms, the meibomian
glands may be abnormal. The question becomes whether to intervene and treat
this patient who is not symptomatic or wait until the patient returns in 3 to 6
months. In my practice, I would intervene and treat nonobvious MGD. Although
patients may be hesitant to treat the problem due to lack of symptoms, there
are simple things that I suggest to help prevent them from becoming
symptomatic, including lid scrubs or artificial tears. I have found Systane
Balance (Alcon Laboratories, Inc.) to be particularly useful in these
Furthermore, I never diagnose a patient with dry eye syndrome. Instead,
I will indicate signs of anterior and posterior blepharitis or MGD in my chart
notes. A patient who presents with classic dry eye symptoms, such as itching
and burning sensation, and who does not have full meibomian gland dysfunction,
should be diagnosed with nonobvious MGD, not dry eye syndrome.
Lemp: Traditionally, ophthalmologists have been taught to
differentiate between aqueous tear deficiency, MGD and posterior blepharitis by
asking patients to describe the time of day they experience the worst symptoms.
Although we have been taught to differentiate between dry eye conditions by
taking into account the time of day, this may not be a helpful indicator, based
on demographic data about the high prevalence of patients with a mixed form of
the disease. Do you feel it is a useful tool in diagnosis?
Hovanesian: I am not aware of any data that support using time of
day to determine what kind of dry eye is present.
McDonald: Although rare, patients may say that their eyes hurt
worse in the morning or upon waking up during the night. For those patients, I
recommend nighttime ointments and lubrications, but noting time of day is
typically not a useful way to diagnose my patients. Instead, my treatment is
based on my findings as well as symptoms.
Figure 3: Patients with obvious (A) and nonobvious (B)
meibomian gland dysfunction. The cross-section (C) shows an occluded meibomian
Source: TearScience, Inc.
MGD and rosacea
Lemp: One of the most common associations with MGD reported in
literature is rosacea.17 How frequently do you see the association
with rosacea in patients with MGD?
Hovanesian: In my practice, roughly 20% of patients with MGD also
Trattler: In my practice, a patient with rosacea will typically
have a more severe form of MGD, although this represents a small subset of my
patients with MGD.
Lane: After seeing several physicians who fail to diagnose their
symptoms as rosacea, I find that these patients often present when their MGD is
more advanced, showing fairly significant corneal changes with vascularization
and irregular or frank scarring. I have treated some children who have severe
lid changes and vascularization of the eyelid margins, yet do not show other
signs of rosacea, such as flushing and telangiectasia of the face and the nose.
Lemp: In general, I believe rosacea develops with age in people
who have a predisposition to develop it. I do not think they have the facial
features in childhood.
Do you think that the prevalence of rosacea is higher in certain ethnic
Lane: I find patients of Mediterranean, Irish and English descent
to be more prone to rosacea. I believe the incidence of rosacea in patients
with MGD may be higher than clinicians think. Rosacea presents with a spectrum
of severity, just like MGD, causing physicians to underrecognize it. There are
several reasons to believe that rosacea and MGD are part of the same disease
spectrum, in that they are both vasodilatory malfunction.
When to treat MGD
Lemp: What is the natural history of MGD if left untreated?
Majmudar: Whether patients present with nonobvious MGD or
minimal-to-moderate symptoms, they will become worse as they age. Physicians
should start treatment early in an effort to improve symptoms and delay further
Lane: Pediatric ophthalmology partners in my practice sometimes
refer to me children who have moderate to severe MGD. If not treated
chronically to maintain stability, the patients are at risk for future lid
changes and severe corneal problems.
Lemp: When is the proper time to treat MGD? Do you treat
asymptomatic and symptomatic patients alike?
Lane: With new treatment options now available, clinicians should
always examine a patient’s lids to find a potential problem at an early
stage, whether the patient comes in for a routine exam, a LASIK consultation,
cataract consultation, or surgical follow-up exam.
Hovanesian: I believe it is important to treat a patient if I
suspect that symptoms will become worse at other times of the year, or during
the perioperative stage.
Lemp: What is your recommended treatment protocol?
McDonald: I prescribe a nighttime ointment, lubrication such as
Soothe eye drops (Bausch + Lomb, Inc.) for daytime administration, and I teach
patients how to express the glands. In addition to these three treatments, I
prescribe a steroid for the first 4 to 6 weeks. If a patient has active
posterior blepharitis or active infection, I prescribe a steroidal antibiotic
combination, or more commonly, AzaSite (azithromycin ophthalmic solution 1%;
Merck & Co., Inc.).
Trattler: In some of my patients, the MGD pathogenesis begins
with the presence of bacteria, which secrete lipases that metabolize good oils
into bad oils. I treat these patients with an antibiotic, such as topical
azithromycin, for 1 month. Studies show that azithromycin can be effective in
treating MGD and blepharitis, from improving signs and symptoms to improving
the quantity of the meibomian gland lipids.2 I may also prescribe a
steroid, such as Pred Forte (prednisolone acetate 1%; Allergan, Inc.), for 1 to
Hovanesian: My decision to use steroids depends on the level of
discomfort and inflammation the patient experiences. I prescribe antibiotics in
more severe cases. However, warm compresses are the mainstay of therapy that I
recommend because I find that lid hygiene with soap or baby shampoo is
difficult for patients to carry out.
Lane: Lid hygiene is extremely important, however, in my
experience, most patients are not compliant or do it improperly. To more
thoroughly relieve symptoms, I recommend expression therapy. Regarding
antibiotics, I prescribe TobraDex ST (tobramycin/dexamethasone ophthalmic
suspension 0.3/0.05%; Alcon Laboratories, Inc.) because it is more viscous than
other antibiotic therapies. For patients with moderate MGD symptoms, I will
first prescribe a steroid and then azithromycin twice a day. If symptoms are
chronic, then I will prescribe the antibiotic every other month to fully
benefit from its anti-inflammatory properties.
I also routinely recommend Omega 3 fatty acid supplements, yet many
patients already take them for other health reasons.
Majmudar: Patients must understand that there is no cure for MGD,
so treatment compliance is imperative. Because MGD is a multifactorial disease,
a multifactorial treatment process is necessary, and includes lubrication, tear
replacement, and physical measures, such as mechanical expression, thermal
application or a combination of both.
Lemp: How should ophthalmologists manage patients whose glands
are completely plugged, and who may not respond to standard treatment?
Trattler: I believe adequate therapies for patients with
completely clogged meibomian glands are lacking.
McDonald: Until a therapy that restores natural meibomian gland
expression is developed, ophthalmologists must turn to traditional
Majmudar: If a patient presents with physical obstruction of the
meibomian glands or damage to the acinar structure, then he or she may have no
secretion or abnormal secretion as a consequence. Also, there may be an
inhibitory feedback mechanism, or down-regulation, that would potentiate this
vicious cycle because further production of abnormal secretions may further
damage the acinar structure, and so on.
Lane: For patients with severe complications, I recommend more
frequent office visits, perhaps three to four a year. These more frequent
visits allow me to perform expression during the appointments and monitor
patient compliance and improvements. If inflammation is apparent, then I
prescribe TobraDex ST. Until Lotemax (loteprednol etabonate ophthalmic
suspension 0.5%, Bausch + Lomb, Inc.) becomes available as an ointment, I
prefer TobraDex ST, which features higher viscosity and a long contact time.
McDonald: I prescribe Lotemax for 4 to 6 weeks in patients with
severe MGD. Once their symptoms subside, I then prescribe four refills of a
mild steroid, such as fluoromethalone, for 1 year.
An alternative to traditional treatment options
Meibomian gland dysfunction (MGD) associated with dry eye disease
is a common diagnosis in my clinical practice. MGD causes significant eye
discomfort and blurred vision, often leading to dissatisfaction not only with
glasses and contacts, but after refractive and cataract surgery as well.
Because of the chronic nature of the disease, treatment is frustrating for
patients, consisting of frequent drops, oral medications and mechanical therapy
to the lids.
Recently, TearScience, Inc. received U.S. Food and Drug
Administration clearance for the LipiFlow® Thermal Pulsation
System. Our practice took part in the clinical study1 used to
support the premarket notification of LipiFlow®. In our
experience, patients treated with the device reported positive results.
In my opinion, this new technology provides ophthalmologists with
an improved treatment modality for patients with MGD and associated dry
David R. Hardten, MD, is a founding partner of Minnesota Eye
Consultants and director of its Clinical Research Department.
- Lane SS, LipiFlow® Study Group. A new system,
the LipiFlow®, for the treatment of meibomian gland dysfunction.
Cornea. In press.
Lemp: Although more treatment options are available now than in
previous years, ophthalmologists are still looking for better tools to manage
obstructive MGD, the most common form. What do you see in the future of MGD
care, especially for patients with chronic conditions?
McDonald: Ophthalmologists need a treatment that lasts longer
than those currently available and is easier for patients to use.
Lane: It is important to clean out the meibomian glands in an
effort to relieve the blockage so that new secretions escape without
stagnation. The treatment of MGD in the future, in my opinion, may be to first
liquefy the obstructed material, which is complicated by keratinized,
desquamated cells, followed by a mechanical means of expressing the glands and
relieving the blockages that occur behind the plugs. If ophthalmologists are
able to evacuate the glands, I believe patients have a good chance of avoiding
McDonald: In my opinion, giving the meibomian glands a chance to
reset themselves using a thermal mechanical means of expression, while also
administering pharmaceutical agents, would be the best treatment. Since the
meibomian glands are obstructed, the first step would be to remove the
obstruction without damaging the glands, giving them a chance to up-regulate.
Although secretions may not be perfectly normal, the lipids will aid in
symptomatic and curative relief.
Lane: This type of mechanical expression has a dual effect, in
that it would also prevent corneal changes.
Trattler: With traditional treatments, ophthalmologists
continually encounter problems with patient compliance, long-term steroid use
and overall patient satisfaction. MGD is a common condition, and I am eager to
implement a single thermodynamic treatment, such as the
LipiFlow® Thermal Pulsation System (TearScience, Inc.; Figure
4), because I think it will greatly impact our patient outcomes.
Figure 4: Cross-section of an
eye with the LipiFlow® Thermal Pulsation System applied to the eyelid.
Source: TearScience, Inc.
Majmudar: I have treated more than 40 patients with the
LipiFlow® system in clinical trials, and many of my patients
with dry eye resulting from MGD and/or blepharitis report symptomatic
Lane: Tools that examine osmolarlity in an easy, noninvasive way,
will significantly improve diagnostic abilities, as well as the ways of
potentially evaluating the success of treatments. As improved tools become
available in the near future, frustrated and noncompliant patients will see
evidence of success and begin to be proactive in their therapies.
Lemp: Patients may experience expectation fatigue, seeking help
from several ophthalmologists without experiencing relief, because physicians
do not fully understand dry eye disease. Some diagnostic modalities do not
allow physicians to examine the glands; rather, they only provide an
opportunity to look at the effects of this condition in terms of the lacrimal
functional unit. The promise of not only identifying patients, but also having
an objective number from which the ophthalmologist can gather data in response
to treatment, is an important component of determining a treatment plan.
McDonald: As occurs with patients who have diabetes and use a
meter to test blood sugar levels, compliance in patients who have MGD will
improve with the use of a metric. In research, interferometry has been used to
provide a quantitative measurement of the lipid layer thickness in the tears.
Studies18-20 show a correlation between treatment success or symptom
relief and restoration of the ocular lipid layer thickness as measured by the
interferometry devices used in research.
Trattler: Interferometry may prove to play a significant role in
evaluating patients prior to cataract surgery. An unstable tear film can
negatively impact the accuracy of our preoperative corneal
measurements.21 In my practice, we were part of a multicenter study
and found that 62% of patients scheduled for cataract surgery had an abnormal
tear breakup time of 5 seconds or less.22 Patients with a rapid tear
breakup time are more likely to have inaccurate K and topography readings, so
identifying and treating patients with an abnormal tear film may help improve
the accuracy of the preoperative tests and potentially cataract surgery
If my practice implements the LipiFlow® system, my
colleagues and I could pretreat patients for MGD with the objective of
improving surgical planning.
Hovanesian: Patients dislike lid hygiene and warm compresses, and
medications prove difficult in terms of tolerability, administration and cost.
Patient satisfaction is important, but duration of benefit is essential as
well. It is really the area under the curve where ophthalmologists must focus.
A treatment that provides prolonged,23,24 significant benefit
relative to a warm compress regimen, as data suggests is the case with the
LipiFlow® system, is something to which patients will respond.
Lemp: To summarize, MGD is a widespread condition and exists as
part of a larger condition called dry eye disease. In response to this
phenomenon, ophthalmologists are better understanding the pathogenetic
mechanisms that lead to problems, such as fluctuating vision, that were not
truly understood just a few years ago. Although better technology is available,
there is still room for improvement in relieving symptoms and achieving better
I would like to thank the faculty for their time and expertise, as well
as TearScience, Inc. for sponsoring this supplement.
- AAO Cornea/External Disease PPP Panel. Preferred Practice Pattern:
Dry Eye Syndrome. American Academy of Ophthalmology; 2003.
- Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on
meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis
- Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC.
The pathology of dry eye: the interaction between the ocular surface and
lacrimal glands. Cornea. 1998;17(6):584-589.
- Lemp MA, Nichols KK. Blepharitis in the United States 2009: a
survey-based perspective on prevalence and treatment. Ocul Surf.
- King-Smith PE, Fink BA, Fogt N. Three interferometric methods for
measuring the thickness of layers of the tear film. Optom Vis Sci.
- Luchs J, Buznego C, Trattler W. Asymptomatic or minimally symptomatic
blepharitis in patients having cataract surgery. Poster presented at: American
Society of Cataract and Refractive Surgery 2011 Symposium and Congress; March
25-29, 2011; San Diego.
- Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye
syndrome among US women. Am J Ophthalmol. 2003;136(2):318-326.
- Schaumberg DA, Dana R, Buring JE, Sullivan DA. Prevalence of dry eye
disease among US men: estimates from the Physicians’ Health Studies.
Arch Ophthalmol. 2009;127(6):763-768.
- Ridder WH 3rd, Tomlinson A, Huang JF, Li J. Impaired visual
performance in patients with dry eye. Ocul Surf. 2011;9(1):42-55.
- Sullivan DA. Tearful relationships? Sex, hormones, the lacrimal
gland, and aqueous-deficient dry eye. Ocul Surf.
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