Treating Meibomian Gland Dysfunction With Collaborative Care

Nov 30, 2020
37 min read

When it comes to ensuring good surgical outcomes, one of the first things an eyecare provider looks for is Meibomian Gland Dysfunction (MGD). Equipping your practice with tools and treatment options to address MGD before surgery is a way to not only set your practice apart, but ensure your patients are happy and healthy for years to come.

At Empire Eye—an ophthalmic practice in Spokane, WA—we use the Johnson & Johnson TearScience® suite of products to evaluate gland function and treat MGD. With these products and the workflow we’ve installed in the practice, we’ve seen an increase in happy patients, better collaborative care, and good surgical outcomes.6,10

Dr. Claypool and Dr. Kontos are paid consultants for Johnson & Johnson Vision.

Hear from Dr. Claypool and Dr. Kontos on how they practice collaborative care at Empire Eye!

MGD and your patient population

Meibomian gland dysfunction can present in various levels and eye care professionals (ECPs) will likely only continue to see more of it as our environments both at home and work become increasingly dependent upon immersion in technology and screen-use.1 Single studies have shown the prevalence of meibomian gland dysfunction in:

  • Up to 86% of patients with dry eye2
  • Up to 39% of asymptomatic patients3
  • 80% of glaucoma patients taking long-term anti-glaucoma medications4
  • 63% of pre-cataract surgical patients5

Although MGD may be increasingly prevalent in our patient populations, it can be challenging to identify. Too often, ECPs may wait for patients to complain of symptoms rather than proactively testing and searching for it.

MGD can be difficult to identify due to its co-mingled nature with other forms of Ocular Surface and Dry Eye Disease.2 Separating MGD from these diseases is paramount for treating it properly. The two critical characteristics that ECPs should look for when determining if MGD is present are gland structure and function—not symptoms.

Gland function: checking for meibomian gland dysfunction

Left: Transillumination show no signification structural change; Right: Testing gland function to see clear oil. Images for illustrative purposes only.

Everyone who presents in our practice is imaged with meibography, especially those cataract surgical patients who are presenting for premium IOLs. This gives us an inside look into structure and whether there is any visible structural absence. If you can identify this ahead of time, you can plan properly for treatment, particularly in patients presenting for surgical care.4 When it comes to assessing gland function, the device we rely on is the TearScience® Meibomian Gland Evaluator (TearScience® MGE). By using this device and applying a consistent pressure to the glands, it can assist in identifying if the patient’s glands are functioning properly. Using meibography to assess structure and the TearScience® MGE to assess function, you can quickly identify gland issues.

MGE Horizontal.jpg

TearScience® Meibomian Gland Evaluator (MGE)

In more advanced cases of MGD, we also investigate the presence of inflammation in the tears. In these instances, we like to leverage InflammaDry (Quidel). Based upon our findings, it will clue us in as to whether or not we need to consider additional topical therapies.

Collaborative care for cataract patients between an MD and OD

When it comes to offering collaborative care for cataract patients between an MD and an OD, there are a few things that ODs can do in order to ensure a smooth process.

In our practice, the language we use most often is “preparing the eyes for surgery.” In many cases, a little bit of therapy goes a long way, and we educate patients on proper eye hygiene, hot compresses, and other therapies they can perform at home. For patients presenting with MGD, we recommend TearScience® LipiFlow® before surgery.

As an independent optometrist, preparing patients for surgery and spending the time on patient education is of tremendous value to the surgeon, but also to the patient. If a patient presents for a surgical evaluation only to hear for the first time they have another condition that needs treatment, it can create an uncomfortable situation for all parties involved.

If the independent optometrist doesn’t have the technology or resources to fully evaluate and manage a patient’s MGD, it can still be immensely helpful to educate their patients on the common treatments that could occur prior to surgery or afterwards. It makes patients happier and more willing to continue treatment when they know that the problem was already there.

When the patient has had their conditions explained to them before treatment, patient compliance and satisfaction are improved. Educating the patient on the condition and informing them that they might need treatment for it ahead of time can go a long way in building that trust and relationship between the referrer, the patient and the surgeon.

Hear from Dr. Claypool and Dr. Kontos about how they manage dry eye patients through collaborative care

Addressing dry eye and treating MGD before cataract surgery

In 2019, the ASCRS Cornea Clinical Committee introduced consensus-based clinical practice guidelines, which acknowledged the importance of screening for and addressing visually significant ocular surface disease due to its potential direct adverse effect on visual quality and acuity both pre- and post-operatively.6 We see this in the literature and in our practice every day. Today, leading eye care providers are increasingly recognizing the importance of healthy meibomian glands in managing the integrity of the ocular surface.

This is especially important for those patients preparing for eye surgery. Without treatment or intervention, tear film and gland dysfunction can advance and increase causing poor visual outcomes and consequently reduced patient satisfaction. Often, a patient’s MGD will have gone undiagnosed, and will only be discovered when they come in with a complaint of degrading vision that they assume is due to a cataract. Often, they will not be aware that their MGD is impacting their vision—or that, untreated, it will have deleterious effects on their surgical outcomes. Untreated MGD can lead to recurrent corneal erosion, corneal scarring, and other ongoing problems.6,13

Treating MGD before cataract surgery is a great way to support better surgical outcomes. We know that when the tear film is disrupted, which we can understand through corneal staining and other means, IOL calculations can be inaccurate. An unstable tear film impacts surgical planning—whether that means the choice of IOL, the IOL power, or any aspect of the surgery itself. This is why it’s so crucial to address MGD before surgery. Similarly, in those patients who present for laser refractive surgery, healthy glands and a stable tear film are vital for optimal outcomes.

In addition, failing to treat MGD before surgery can result in new and more difficult problems—not least an erosion of patient trust. Patients often don’t have context for accepting ongoing care as their new normal, and if MGD is left untreated, you might be denying the patient the full benefit they could be receiving from the surgery. Better outcomes mean more satisfied patients, which can also have a positive impact on your practice. Recognizing issues with glands and tear film can also help you manage patient expectations ahead of time, so you and they are not caught by surprise.

Finally, identifying MGD as early as possible in the disease state will enable early intervention. Early intervention for any disease typically offers a less complex treatment approach.

Identifying MGD before surgery or afterwards: Patient case studies

*The information contained in a case report is anecdotal and may not be assumed to be generalizable to the larger clinical population. Anecdotal findings may or may not have been verified in randomized controlled clinical trials. The findings should be considered particular to the individual case reported here.*

Patient #1: Pre-surgery

In March 2020, a patient was referred to us for cataract surgery. During the slit lamp examination, we also tested for gland function and determined she had an advanced stage of MGD. Her chief complaint was problems with blurry and unclear vision; the patient reported avoiding driving at night in unfamiliar territory and noted that the bad vision had been going on for at least a year. She was a -7.00 myope currently wearing Acuvue® Oasys contact lenses, who showed interest in receiving an advanced technology lens.

Though she made no complaints of dry eye symptoms to either her referring optometrist, or in our ophthalmic exam, her completed SPEED questionnaire score was 18/28, even while wearing a contact lens designed for moisture. Because of her interest in an advanced technology lens, meibography was performed as part of the pre-cataract surgery workflow so we could have a better understanding of her overall ocular surface health. Her images showed severe gland drop out OU. During the slit lamp exam, we also tested for gland function and determined she had an advanced stage of MGD.

Patient 1 with severe gland atrophy - treated prior to cat sx

Severe gland dropout OU shown in meibography

Aggressive therapy, including TearScience® LipiFlow®, was recommended so we could quickly address her MGD prior to surgery. We provided education about her disease and the need for long-term care even after surgery. The patient was relieved to hear she had treatment options like TearScience® LipiFlow®, and had assumed her dry eye symptoms were normal. On the same day as the consult, she received the TearScience® LipiFlow® treatment, and her surgery with a premium lens was scheduled.

After her 1-day post-cataract surgery follow-up appointment, she had a new SPEED score of 8 (improvement from the original 18). Her original TearScience® MGE measurements for gland function revealed 2 functioning glands OU with inspissated meibum. After her TearScience® LipiFlow treatment®, gland functioning had improved to 4 functional glands OU. Her visual acuity was 20/20 OD/OS, with great near and distance vision. She was pleased with both her visual outcome and overall eye comfort.

Though we were able to address her MGD before surgery, the patient presented with advanced disease state that will require long-term management to maintain ocular surface health & comfort.

Patient #2: Post-surgery

Contrast this patient's experience with another case: in October 2019, a 93 year old female patient presented to our clinic with chief complaints of glare and difficulty reading, and mild complaints of watering and irritation of the eyes. She had best corrected vision of 20/50 due to grade 3 nuclear sclerosis.

Patient MG with severe gland atrophy.bmp

Meibography performed October 2019 during initial cataract consult.

Cataract surgery was performed in November 2019. The surgery was uncomplicated, and the patient was initially happy with her comfort and vision following surgery. However, over the next two weeks, the patient reported constant severe foreign body sensation OU with limited relief from artificial tears. The patient had grade 2 corneal staining OU. She regretted the surgery, and reported feeling like it had made her life miserable as her discomfort was now severe, and her depression increased as her dry eyes were now keeping her from functioning. Ointments, warm compresses, topical steroids, oral doxycycline, prescription dry eye drops and more aggressive lubrication were prescribed with limited relief over 6 months with several visits mixed in.

The patient had grade 3 to 4 MGD with two functioning glands on each lower eyelid (two cloudy OD and one inspissated, one cloudy OS). Meibography demonstrated 75% visible gland atrophy OU. I showed the patient the difference in gland atrophy, offered TearScience® LipiFlow®, and the patient considered it for several months before agreeing to the treatment in June 2020.

Six weeks following treatment, the patient noted better comfort after TearScience® LipiFlow®. She was still struggling to read for long periods of time, but was happy to finally notice some improvement after six months.8 Corneal staining had dramatically improved from grade 2 SPK to trace OD and trace to +1 OS.  Glands doubled in expression (now had four open OU - 4 cloudy OD and 3 cloudy and 1 inspissated OS) and SPEED score improved from 27 to 22.

This was the happiest I had seen the patient in 6 months and was excited for the improvement as well.  With continued therapy and ongoing management, I expect her to continue to improve.

Key Takeaways:

  • SPEED questionnaires can help pull out symptoms of dryness that patients may assume is normal
  • Check patients gland function during your slit lamp exams for a quick insight into their ocular surface health
  • Meibography can be a great tool to better understand health and educate the patient

The impact that treating MGD can have on your surgical patients

One of the most common complaints I’ve seen from cataract patients whose MGD was left untreated before their surgery is that they are still experiencing vision loss post-surgery. They find they are unable to read for long periods of time. While we know that it’s because their tear system is degraded, for them, it’s the same issue but a different cause.

So even if—for whatever reason—we can’t treat MGD prior to surgery, it’s absolutely crucial to discuss the potential impact of not treating it with patients before surgery. That way, if they don’t receive the outcomes and success they expect, the next level of treatment does not come as a surprise.

One could argue that MGD is a very overlooked problem. It is easy to see dryness and note it, but not really do anything about it. Sometimes, patients don’t suffer immediately from it, and therefore, you can fall into the trap of convincing yourself that it doesn’t need to be addressed. This is why assessing even our asymptomatic patients’ glands structure and function is so critically important. Addressing MGD, and doing so in a serious way, makes the patient feel that they're being listened to, that they're being paid attention to as far as what the issues that are bothering them are. This results in a more satisfied patient when they come through the other side.

These are the patients who become very loyal to our practice, the ones we continue to see, and the ones who refer a lot of people in. Having advanced tools and therapeutic instruments really helps differentiate our practice as well.

Since we started treating MGD at our practice, our surgical patients have experienced far fewer residual refractive errors. Overall, the number of refractive touch ups or surgical retreatments have dropped by 50% since we have begun treating MGD before surgery.

Furthermore, it makes surgery and surgical planning much smoother. With all of the ocular imaging equipment we use to assist us, our planning can still be stymied by the way tear film degradation and severe MGD disrupts accurate measurements. It doesn’t matter whether your equipment is top-of-the-line or the least expensive on the market: the accuracy you’re getting when a patient’s MGD is generating bad information is going to be poor.

Patient expectations for cataract surgery are extremely high—as ophthalmologists, we’ve created high expectations for ourselves, and usually we meet them! However, in order to live up to them, we need to think about all of the factors that affect surgery outside of the operating room.

Why invest in technology like TearScience® LipiFlow®, TearScience® LipiView® II, and TearScience® LipiScan®

There are many ways to treat MGD and a variety of reasons as to why investing in technology is important and worthwhile. Conservative therapies are often the first line of treatment. Hot compresses, lid hygiene, and various topical treatments are all highly regarded as the first line of therapy. The issue is, as we all know, that patient compliance with home therapy can be suspect.

That’s where robust technologies like TearScience® LipiFlow® come in. When it comes to surgical intervention, we typically want an efficient approach to treating MGD for optimized surgical outcomes. In these cases, TearScience® LipiFlow® is invaluable.