Heat application device offers another option for MGD treatment

TearCare enables patients to blink while the heat is being applied, which helps facilitate expression of the lids in a natural way.

Understanding of dry eye has improved dramatically, and we have come to appreciate that optimizing the ocular surface and ensuring the health of the tear films are easily the most important unmet needs in improving patient care and surgical outcomes. This applies not only to routine cataract surgery, but to LASIK and a variety of other ophthalmic surgeries as well.

Dry eye was once almost universally thought of in terms of aqueous deficiency, but thanks to pivotal research, we now know that aqueous deficiency is just a part of the dry eye problem and that meibomian gland dysfunction (MGD) is actually the major contributor to dry eye. Unfortunately, MGD remains one of the most difficult diseases we treat primarily because of the challenges inherent in opening the oil glands and keeping them open.

Eric D. Donnenfeld

Management options

With respect to managing MGD, I am a firm believer in harnessing the power of nutrition through the use of oral omega-3s, and I also like using hot compresses. However, it is important to take into consideration that adherence to a hot compress regimen is unlikely to be maintained on a regular basis. As I contemplate the intricacies of an effective warm compress routine, it is easy to see why consistent compliance is unlikely: Warm compresses applied to the outer lid surface must maintain a consistent 45°C (113°F) for the therapeutic heat to reach the meibomian glands, and heat must be applied for a minimum of 4 to 6 minutes for the heat to pass through anatomical barriers that naturally shield the glands, eg, skin, fat, the tarsal plate and vasculature of the eyelids. Perhaps most confounding for our patients is that the only way to maintain the needed heat is to replace the compress with a freshly heated compress every 2 minutes.

Based on these observations, I have come to the realization that it is helpful to circumvent adherence-dependent regimens and instead look to innovative devices. There are a variety of devices available for heating the lid margins to remove gland obstructions and stagnant gland content. The original one was the LipiFlow thermal pulsation system (Johnson & Johnson Vision), which applies a combination of heat and pressure to the inner eyelid by focusing energy on the patient’s closed eyelid. Automatic pulsation is applied throughout the 12-minute procedure, with an aim of expelling meibomian gland blockage. This was followed by the iLUX system (Alcon), in which heat is conducted via an LED light source and then compression is applied by the ophthalmologist via a handpiece to express melted meibum from the obstructed glands over an approximately 10-minute treatment.

The newest device in this category is TearCare (Sight Sciences), which builds on and I believe improves upon the earlier treatments. TearCare, too, applies heat via heating elements — called SmartLids — that are applied directly to the outer eyelids to consistently provide the heat needed to soften blockage of MGD. However, it is the first system to enable treatment while patients’ eyes are open, which allows for patients to blink throughout the heating process, thus priming the meibum pump and allowing natural expression. The ability to blink during the heating process is one of the major advantages of TearCare. Patients say they are comfortable and do not feel vulnerable throughout the process because they can see everything that is happening. What’s more, because the SmartLids are applied to the exterior lids I do not have issues with small or tight lids that make application of more rigid systems difficult.

The TearCare lids maintain a constant temperature of 45°C (113°F) to the external eyelids by communicating with the system’s SmartHub 240 times a second during the procedure.

Since I have been using TearCare in my practice, I have been most surprised by how much blocked oil is expressed. It flows out like water from a faucet. When I have used this device on my patients, I have seen a constant flow of oil that has been transformed from a toothpaste-like material to a soft liquid that is easily expressed. I have had the procedure done on my own eyes and can speak to the fact that when the process was finished, my lids felt much more comfortable and my tear film was markedly improved.

Conclusion

It is gratifying that we now have another treatment that offers a comfortable, physiologically relevant procedure to improve meibomian gland outflow, reduce dry eye and improve patient comfort. This has become an important part of my preoperative surgical plan for patients who are slated for refractive cataract or LASIK surgery. By improving the tear film, I become a better surgeon, and my patients get better outcomes.

Disclosure: Donnenfeld reports relevant financial disclosures for Alcon, Johnson & Johnson, Tear and Sight Sciences.

Understanding of dry eye has improved dramatically, and we have come to appreciate that optimizing the ocular surface and ensuring the health of the tear films are easily the most important unmet needs in improving patient care and surgical outcomes. This applies not only to routine cataract surgery, but to LASIK and a variety of other ophthalmic surgeries as well.

Dry eye was once almost universally thought of in terms of aqueous deficiency, but thanks to pivotal research, we now know that aqueous deficiency is just a part of the dry eye problem and that meibomian gland dysfunction (MGD) is actually the major contributor to dry eye. Unfortunately, MGD remains one of the most difficult diseases we treat primarily because of the challenges inherent in opening the oil glands and keeping them open.

Eric D. Donnenfeld

Management options

With respect to managing MGD, I am a firm believer in harnessing the power of nutrition through the use of oral omega-3s, and I also like using hot compresses. However, it is important to take into consideration that adherence to a hot compress regimen is unlikely to be maintained on a regular basis. As I contemplate the intricacies of an effective warm compress routine, it is easy to see why consistent compliance is unlikely: Warm compresses applied to the outer lid surface must maintain a consistent 45°C (113°F) for the therapeutic heat to reach the meibomian glands, and heat must be applied for a minimum of 4 to 6 minutes for the heat to pass through anatomical barriers that naturally shield the glands, eg, skin, fat, the tarsal plate and vasculature of the eyelids. Perhaps most confounding for our patients is that the only way to maintain the needed heat is to replace the compress with a freshly heated compress every 2 minutes.

Based on these observations, I have come to the realization that it is helpful to circumvent adherence-dependent regimens and instead look to innovative devices. There are a variety of devices available for heating the lid margins to remove gland obstructions and stagnant gland content. The original one was the LipiFlow thermal pulsation system (Johnson & Johnson Vision), which applies a combination of heat and pressure to the inner eyelid by focusing energy on the patient’s closed eyelid. Automatic pulsation is applied throughout the 12-minute procedure, with an aim of expelling meibomian gland blockage. This was followed by the iLUX system (Alcon), in which heat is conducted via an LED light source and then compression is applied by the ophthalmologist via a handpiece to express melted meibum from the obstructed glands over an approximately 10-minute treatment.

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The newest device in this category is TearCare (Sight Sciences), which builds on and I believe improves upon the earlier treatments. TearCare, too, applies heat via heating elements — called SmartLids — that are applied directly to the outer eyelids to consistently provide the heat needed to soften blockage of MGD. However, it is the first system to enable treatment while patients’ eyes are open, which allows for patients to blink throughout the heating process, thus priming the meibum pump and allowing natural expression. The ability to blink during the heating process is one of the major advantages of TearCare. Patients say they are comfortable and do not feel vulnerable throughout the process because they can see everything that is happening. What’s more, because the SmartLids are applied to the exterior lids I do not have issues with small or tight lids that make application of more rigid systems difficult.

The TearCare lids maintain a constant temperature of 45°C (113°F) to the external eyelids by communicating with the system’s SmartHub 240 times a second during the procedure.

Since I have been using TearCare in my practice, I have been most surprised by how much blocked oil is expressed. It flows out like water from a faucet. When I have used this device on my patients, I have seen a constant flow of oil that has been transformed from a toothpaste-like material to a soft liquid that is easily expressed. I have had the procedure done on my own eyes and can speak to the fact that when the process was finished, my lids felt much more comfortable and my tear film was markedly improved.

Conclusion

It is gratifying that we now have another treatment that offers a comfortable, physiologically relevant procedure to improve meibomian gland outflow, reduce dry eye and improve patient comfort. This has become an important part of my preoperative surgical plan for patients who are slated for refractive cataract or LASIK surgery. By improving the tear film, I become a better surgeon, and my patients get better outcomes.

Disclosure: Donnenfeld reports relevant financial disclosures for Alcon, Johnson & Johnson, Tear and Sight Sciences.