In this episode of Interventional Mindset, host Preeya Gupta, MD, a cornea and refractive surgeon, interviews Damon Dierker, OD, FAAO, to discuss an evolving approach for dry eye management that extends beyond prescription eye drops.
“There is no one-size-fits-all therapy.”
The discussion centers on a systematic approach to dry eye care: identifying the underlying cause, intervening earlier with advanced therapies when appropriate, and tailoring treatment to each patient's needs.
Dr. Dierker is an Indiana-based optometrist specializing in ocular surface disease and dry eye management.
Meibomian gland dysfunction fast facts
- Meibomian gland dysfunction (MGD) is the leading cause of evaporative dry eye, but many patients also have aqueous deficiency, inflammation, Demodex blepharitis, rosacea, or other contributing factors.1
- Dry eye management is most effective when treatment targets the underlying disease drivers rather than following the same treatment pathway for every patient.2
- Earlier intervention for MGD may improve gland function before disease becomes more advanced and treatment becomes more complex.3
- For appropriately selected patients, in-office interventional therapies, such as thermal pulsation or intense pulsed light (IPL), may reduce reliance on long-term prescription medications or extensive at-home regimens.4
An interventional approach to dry eye management
A central theme is the shift away from a rigid, stepwise approach that reserves procedural therapies for more severe dry eye cases. Instead of progressing from artificial tears to prescription medications before considering in-office procedures, Dr. Dierker advocates for an individualized, etiology-driven approach—identifying and addressing the primary contributors to each patient's disease from the outset.
“I'm going to be addressing the root cause and not just chasing symptoms.”
For patients with MGD, earlier in-office intervention may address gland obstruction before disease becomes more difficult to manage. Dr. Dierker emphasizes that treatment should be individualized based on disease severity and each patient's underlying disease drivers.
A deeper dive into thermal pulsation
Throughout the discussion, Dr. Dierker presents thermal pulsation as an example of earlier intervention for appropriately selected patients with obstructive MGD. Rather than waiting until conservative therapies fail, the goal is to restore meibomian gland function before chronic obstruction contributes to more advanced disease.
Multiple studies have demonstrated that thermal pulsation improves objective clinical markers and patient-reported outcomes in MGD. This growing body of evidence was comprehensively evaluated in a 2023 report from the American Academy of Ophthalmology, which reviewed the available literature on thermal pulsation for MGD and dry eye.5
The report included 11 clinical studies—eight Level I and three Level II investigations —evaluating LipiFlow compared with conservative therapies or no treatment.
Across these studies, thermal pulsation consistently improved both clinical signs and symptoms of MGD, including:6
- Meibomian gland function
- Tear breakup time (TBUT)
- Dry eye symptom scores
Improvements persisted for up to 12 months after treatment, leading the authors to conclude that thermal pulsation provides clinically meaningful benefits for appropriately-selected patients with MGD.
Additional research on the efficacy of thermal pulsation for MGD
A 2025 systematic review and meta-analysis of randomized controlled trials further reinforced these findings.7 The analysis found that thermal pulsation significantly improved meibomian gland secretion scores and corneal fluorescein staining compared with control treatments, with the greatest benefit observed in patients with more severe baseline MGD.
Improvements in TBUT and patient-reported symptom scores were less consistent across pooled analyses, highlighting the need for additional high-quality studies to better define long-term outcomes and patient selection.
Collectively, these findings support Dr. Dierker's emphasis on considering thermal pulsation earlier in the treatment paradigm for appropriately selected patients with obstructive MGD. Rather than replacing at-home therapies or pharmacologic treatment, thermal pulsation may help establish a healthier baseline from which individualized maintenance strategies can be tailored to each patient's underlying disease drivers.
Setting realistic expectations
Because dry eye disease requires ongoing management, Drs. Gupta and Dierker emphasize the importance of setting realistic expectations. The goal of thermal pulsation is to improve meibomian gland function—not necessarily eliminate all symptoms. Persistent symptoms following treatment may reflect coexisting disease processes, including aqueous deficiency, ocular inflammation, Demodex blepharitis, or rosacea.1,8
Dr. Dierker also stresses the importance of monitoring objective findings—including gland expressibility, meibomian secretion quality, TBUT, and ocular surface staining—alongside patient-reported outcomes to assess treatment response and guide additional therapy.
A shift toward earlier intervention
As interventional therapies become more integrated into dry eye care, the emphasis is shifting from a rigid stepwise algorithm to earlier, etiology-driven intervention.
“I don't wait to introduce interventional care if I think that's going to give them the best outcome.”
For appropriately selected patients, addressing gland obstruction before irreversible dysfunction develops may improve outcomes while reducing the long-term treatment burden.
This article was written by Lindsay Curtis based on the recorded conversation between Drs. Gupta and Dierker.
