In this installment of Interventional Mindset, Brandon Ayres, MD, speaks with Preeya K. Gupta, MD, about in-office meibomian gland dysfunction (MGD) treatments. The two discuss which patients do best with which procedure.
There are many different in-office procedures to choose from, such as Lipiflow thermal pulsation, TearCare, iLux, microblepharoexfoliation, and intense pulsed light (IPL) therapy.
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Determining which in-office MGD procedure is the best fit for your patient
With access to so many in-office treatments, there are multiple factors to assess when staging your patients. When starting the diagnosis process, Dr. Ayres says that the best thing to do is sit back, get some diagnostic tests, perform your exam, and then the answers will slowly start to come to you.
Start with tear diagnostic testing, using tools such as the InflammaDry to test MMP-9 levels, osmolarity testing, and a meibography; after doing these tests perform the clinical exam. During this exam, perform a 20-second look, lift, pull, push (LLPP) of the lid, as recommended by the American Society of Cataract and Refractive Surgery (ASCRS). Pay special attention to the lids by looking at their contour and the meibomian glands.
Adding these steps into the exam translates into less than a minute of actual time spent performing the exam, yet it will provide you with so much information you can then use to navigate the diagnosis.
Make sure to check for Demodex mites during the exam
Dr. Ayres described how one of the last things he checks during the exam is to see if there are a lot of collarettes or deposits on the lash margin. To do so, he plucks a few eyelashes and uses the lab scopes at the office to check for Demodex mites. For those without a microscope, simply assessing the lash base for collarettes can help find demodex.
While Demodex doesn’t cause all lid margin and ocular surface disease, a good portion are related, and there have been some remarkable recoveries with Demodex-targeted treatment. Also, buying a lab scope for the office is affordable and as easy as going to your local toy store to invest in a tool worth its money in gold for utility.
Using meibography in the MGD diagnostic process
Meibography is a helpful way to categorize patients with ocular surface disease because it helps to validate and guide the choice of which treatment modality fits the patient best. With meibography, it’s possible to see gland dropout, gland dilation, and asymmetries from the medial to the lateral lid. Dr. Gupta noted that while it takes a little time to comfortably and accurately internally grade how well the meibum flows and to identify its consistency, it really is just a matter of looking at a lot of lids.
Meibography is an excellent tool for disease staging and is particularly helpful for identifying if there is some substrate to work with or if the patient has a burnt-out lid because that affects the recommended treatments. For example, someone with fairly consistent lid disease along the lid margin who has relatively easy-to-express meibomian glands will do well with a thermal pulsation treatment.
On the other hand, with a patient who requires heavy effort to open the meibomian glands and has some gland atrophy on meibography might need multiple treatments to improve symptoms. Further, treatments like TearCare or iLux, in which the user can titrate the amount of compression on the glands at the time of expression, may be better suited.
Staged procedures for MGD patients with severe atrophy
For patients with severe atrophy of the meibomian glands, Dr. Gupta shared that she tends to steer those patients toward intense pulsed light therapy as their first option. In cases where there is more severe atrophy, it is important to look at staged procedures. Some of Dr. Gupta’s MGD patients undergo a series of IPL and then do an iLux, TearCare, or Lipiflow procedure afterward to initially focus on reducing the inflammatory load and which is then followed up with something better at relieving the obstruction.
Similarly, Dr. Ayres mentioned that with IPL, patients will have to come back for three or four procedures as a part of a planned session. He explained that at his office, they aim to create a long-term treatment plan where the patient is seen every 6 months or even once a year to manage the symptoms.
Also, they often combine procedures to get the best result. For example, Dr. Ayres found that both TearCare and Lipiflow work better in tandem with some kind of blepharoexfoliation beforehand, and sometimes a month or two after, to help keep the effect going to the 6- or 9-month mark before coming back for further treatment. For anyone with moderate to severe MGD, it’s helpful to set a plan for recurring treatment and pair procedures that are synergistic instead of repeating the same mechanism every time.
Setting and communicating MGD treatment expectations with patients
Setting patient expectations is vital to the MGD diagnostic and treatment process. It’s important to bring up with patients that this procedure will not cure them of the disease, studies show it will work pretty quickly for most patients (within 2 weeks for some), but these effects and their sustainability vary among patients. They tell all of their patients that these procedures will need to be repeated in the future as there is no cure for MGD, and stating that up front is key for patient communication.
On top of that, finding the procedure that the patient can best tolerate is also important, some patients do not want any occlusion of the eye, and others don’t mind it at all. Sometimes the patient's anatomy will dictate the treatment modality, such as when the lid fissure is so small that it’s difficult to get an applicator in place.
Dr. Gupta reflected that TearCare taught her that the fit and stability of the activators, no matter the device, are essential to getting good patient results. Good heating of the glands requires close contact with the applicator and a tailored expression. For patients who don’t have the traditional lid anatomy, such as anyone with floppy eyelids or tight fissures, TearCare is her first choice.
Incorporating MGD treatment modalities into your practice
Lipiflow, TearCare, and iLux tend to be easy procedures to incorporate into your clinic with minimal difficulty, but with regimented office flows, some may have to be scheduled on a separate day. Training your staff to assist in these procedures greatly facilitates flow and allows a practice to perform more “on-demand” treatments, which prevents patients from having to come back.
Conclusion
There are so many options out there for treating MGD patients. During the diagnostic process, eyecare practitioners should look at meibography, the lid anatomy, and how the oils are flowing in order to assess disease severity and tailor treatment options accurately.
The best piece of advice for clinicians treating MGD patients is to jump in and start treating. So many patients go undiagnosed and under-treated. Intervening with these disease-modifying procedures early in the disease state leads to happier patients and can make a more meaningful impact on early-stage disease compared to late-stage disease. Clinicians should remain nimble and be willing to try alternate procedures as one size does not often fit all in ocular surface disease.
