According to the Eyes on Eyecare 2021 Dry Eye Report—the largest report on Dry Eye Disease (DED) ever publicly released—there’s a significant gap between awareness of DED and adequate screening to properly diagnose it. Doctors reported that, although they believe well over half of their patients had some level of DED, only 64% of patients in their practices were screened.
Screening for meibomian gland dysfunction (MGD) was another gap uncovered in the report, with 85% of those surveyed agreeing that MGD screening should be part of a comprehensive eye examination but only 27.8% indicating they incorporate validated dry eye questionnaires, like SPEED or OSDI, into case history or patient intake forms.
Survey results also indicated that many doctors aren’t comfortable performing in-office procedures, such as thermal pulsation and intense pulsed light (IPL) therapy. Although 84.7% of respondents indicated they understand the importance of identifying MGD as a part of every comprehensive exam, only 5.8% offer in-office OSD treatments.
In an interview with Eyes on Eyecare, Dr. Doug Devries of Eye Care Associates of Nevada said the survey results are concerning: “I think those stats should be higher because I do believe it's part of a comprehensive eye exam. You know they have the terminology ‘non-obvious MGD’ and ‘obvious MGD.’ Well, it’s only non-obvious if you don't diagnostically press on the meibomian glands and take a look at the quality of the meibum. That’s actually part of every routine exam I do.”
He said he also incorporates the SPEED questionnaire as part of screening and uses meibography for patients who have a SPEED score higher than 6, along with additional point of care testing. Noting that meibography is valuable for evaluating structure, he stated, “We need to press on those meibomian glands [to evaluate function].”
Dr. Devries described the Meibomian Gland Evaluator™ as a “good tool” to evaluate meibomian function with normal blink pressure. He also suggested that going beyond that by “pressing a little bit harder” makes it possible to evaluate the quality of the meibum: “Is it like baby oil, do we have some turbidity [with discoloration] or is it thickened and paste like?”
He said doing so makes it possible to “grade the meibum accordingly” and “it just takes seconds to do that as part of your exam.” He also incorporates the slit lamp exam when needed. “Clearly, there are levels to this, and the ability to get better and faster with it—knowing what to do and when to do it,” he said.
To underscore the importance of discussing the evaluation process and findings with patients, Dr. Devries said that for patients with abnormal findings, showing them how they compare to a normal exam can be a big help: “I think it's really important when you're doing a comprehensive evaluation on a patient. [For instance], if you have meibography results, you can certainly show them those pictures and [then] show them what normal is. Show them the atrophy and what their glands are actually doing.”
He said he does the same thing when it comes to diagnostic expression of the meibomian glands, comparing the function and appearance of normal oil to those found in the patient. On being able to include meibography results, he said, “Then I [can] correlate the structure with the function. Patients get it when you do that.”
Taking a phased approach to treatment helps too: “I follow up with the patient at some point [and say] ‘During this treatment we're going to address the acute nature of your dry eye, but we're going to [eventually] have to address the eyelid margins and the progression that we're seeing so we can stop it. Because we have a finite number of glands and we don't want to see any more lost.’”
The role of the LipiFlow® system
Dr. Devries attributes a lot of his success in stabilizing the tear film in patients with MGD with his use of the LipiFlow® Thermal Pulsation System, especially in terms of positive outcomes for contact lens comfort. He stated, “A lot of the studies will show an average of four hours increased wearing time, and that's clinically what I've experienced as well. Patients are just more comfortable, able to tolerate their lens, and quite often get through their full day.”
Noting that “success takes many forms” when it comes to treating MGD, there may be a spectrum of positive results, depending upon the severity of a patient’s condition. Although patients may not always report much improvement at the one-month visit post treatment, he can often see a difference in the quality of the meibomian. When he shares this news with them, he said, “They get very enthused at that particular point.”
Dr. Devries was an early adopter of LipiFlow® and has been using it for over eight years: “Honestly, I can’t imagine practicing without being able to offer thermal pulsation to a patient. There are such limited options and nothing really compares. It has completely changed the way I practice. The way I talk to patients. The encouragement I can give them, that we can make a change in what they're feeling.”
Practice implementation of LipiFlow®
When it comes to implementation, Dr. Devries said having effective dialogue with patients about the process is key: “It's so important because you have to let them know the importance of this.” He said comparing normal meibography results with patient findings helps to lay a strong foundation, since patients can actually see the effects of the disease process. According to Dr. Devries, “Patients get the whole concept of ‘this is normal, and this is mine.’ Something I’ve borrowed from Paul Karpecki over the years is when I describe that to the patient, I'll actually move next to him and say, ‘What I'm looking at concerns me.’ And that's the loss of the meibomian glands.”
He stated his concern is genuine, since he’s seen advanced MGD that results in significant loss of meibomian glands, and he doesn’t want to see the same thing happen for that patient. Using specific language during the conversation helps him and the patient get on the same page, including terminology like:
- “I’m concerned”
- “This is normal and these are yours”
- “There's something we can do”
- “We need to be proactive”
Of course, patient flow within the office is important to effective implementation too. Dr. Devries said they start out with a questionnaire to capture “the low-hanging fruit.” If a patient reports a problem and the SPEED score is greater than 6—then meibography, inflammation assessment, and osmolarity are next.
Referring to meibography as “the Snell and visual acuity of dry eye,” he said his clinic feels it’s “very important to do that as part of the workup when they're 6 or above.”
To optimize workflow, he said the use of an automated process to “trigger the scans” is a big help. Once that’s done, the results are provided on a patient-accessible screen and the technician lets the patient know the doctor will review the results with them; this helps to set up the conversation in which patient findings are compared to what’s normal.
“At that point, the patient is waiting to hear information about whether this is normal or not. If they have loss, and I tell them I'm concerned, you physically see them lean forward to listen to you,” he said.
Noting that “patient flow is everything” and is “what makes the difference” in their high procedure rates, Dr. Devries said, “You have to streamline it. If people have this technology and they haven't been utilizing it completely, it's because of patient flow.”
A key part of effective patient flow is having staff on board who can finish your sentences for you: “Everybody must use the same dialogue; everybody has to be on board.”
Discussing treatment costs is part of that as well. Typically, once he determines a patient will benefit from LipiFlow®, Dr. Devries refers them to the front desk for more information about the procedure and costs. However, if a patient “presses” him, he’s happy to discuss it with them too.
Since the procedure can be applied to each eye independently, his staff is trained to offer the option of doing the eyes one at a time, if money is an issue: “That's the beauty of the LipiFlow® procedure. You can do independent eyes and just do one at a time, so I think that's a real advantage as well.”