Novel Procedure for Blepharitis

The approach to this condition is about to be turned on its head.

By PARAG A. MAJMUDAR, MD

Most eye care specialists have long glossed over the subject of meibomian gland dysfunction (MGD), despite the fact that its symptoms are directly correlated to some of the most common ocular complaints. In fact, MGD is now recognized as one of the most important causes of dry eye syndrome or ocular surface dysfunction. In my opinion, the latter term better encompasses the multiple interrelated entities such as dry eye syndrome and blepharitis. A new subclass of MGD might be identified as “nonobvious MGD”; there is no overt inflammation or pathology, yet the glands may not function (Figure 1). Nonobvious MGD may delay accurate diagnosis.

This article reviews the current options for treating blepharitis, which include a new modality.

THE LONG-STANDING APPROACH

Historically, the treatment of MGD has facilitated the outflow of meibum or secretions from the ducts of the meibomian gland. Research has shown that, in these dysfunctional states, the physicochemical makeup of the secretions is altered, leading to changes in viscosity and a predisposition to obstruction.1 Chronic blockage often results in histological changes to the ducts such as narrowed lumens, further enhancing the likelihood of obstruction.

Despite the recent availability of pharmacological advances to help resolve the symptoms of MGD, the only invasive option was to probe the meibomian gland. Typically, this procedure involves anesthesia topically applied to or injected into the eyelids, followed by manual probing of individual glands’ orifices using specialized instruments. Steven Maskin, MD, has developed a specialized intraductal probe (Rhein Medical, Inc., Tampa, FL), which will alleviate the obstruction as well as clear any fibrovascular proliferation affecting ductal patency. One disadvantage of this approach is that it can be time intensive for the practitioner, because each individual gland must be probed. In addition, this technique causes some degree of discomfort for patients.

INTENSE PULSED LIGHT

The use of intense pulsed light is new option for treating blepharitis.2 Popularized by Rolando Toyos, MD, this technique uses a source of pulsed light initially developed for dermatologic indications. The patient undergoes multiple, monthly light treatments of the periocular region. The increased stimulation of the meibomian gland or reduction of telangiectasia may account for the improvement in symptoms that some patients experience.

LIPIFLOW THERMAL PULSATION SYSTEM

Background
In July 2011, the FDA cleared the LipiFlow Thermal Pulsation System (TearScience, Inc., Morrisville, NC). My experience with this device began during its initial clinical trials. The concept is simple yet brilliant. Developed by Donald Korb, OD, the premise behind LipiFlow is this: no matter how well eye care specialists instruct patients in using warm compresses and lid scrubs, even those who are compliant find it nearly impossible to achieve a sufficient temperature and pressure at the base of the meibomian gland to effect any long-term change.

LipiFlow is a 12-minute, bilateral treatment that uses a specially designed eyelid warmer and eyecup (Figure 2). It achieves a temperature high enough to liquefy the contents of the meibomian gland, facilitate secretions from that gland, and increase the likelihood that it can resume normal function. The eyecup is designed to vault over the cornea, and the heating element is confined to deliver heat only to the tarsal conjunctiva. As heat reaches the base of the glands, pulsation is achieved by means of a bladder that compresses the eyelids. This action has several purposes. First, it transiently increases blood flow to the tissue surrounding the glands, thus increasing the efficiency of heat transfer. Second, the pulsatile action mechanically evacuates the gland’s heated and liquefied contents, thus alleviating the obstruction. Based on my personal experience with more than 35 patients, the procedure produces considerably less eyelid pain/discomfort compared with manual expression techniques.

Results
In an open-label, randomized, controlled, multicenter trial, the LipiFlow system was compared to the iHeat warm compress system (Advanced Vision Research, Woburn, MA) for the treatment of MGD. Nine centers participated in this study and enrolled 278 eyes (139 subjects). These patients were randomized to receive either the LipiFlow treatment (n = 138 eyes in 69 subjects) or the iHeat warm compresses (n = 140 eyes in 70 control subjects).

At 2 weeks, the control group stopped warm compress therapy and received LipiFlow treatment. For all parameters measured (ie, meibomian gland obstruction scores, tear breakup time, Standard Patient Evaluation for Eye Dryness, and Ocular Surface Disease Index), the treated group showed significant improvements compared with the control group. Moreover, after the control group crossed over to the treatment arm of the study, all of their measured parameters increased significantly.

Aside from three eyes (out of 278) that experienced mild pain and one eye that had conjunctival injection, there were no adverse events, including no changes in vision or IOP. In addition, although this was a 4-week study, other ongoing research with the LipiFlow system indicates that its effects may persist for more than 1 year. The final results of these long-term studies, however, will not be available for some time.

CONCLUSION

Blepharitis and dry eye syndrome have been among the most mundane conditions to greatly trouble patients yet be largely ignored by eye care specialists. Innovative new treatments are changing this situation. As clinicians’ understanding of ocular surface dysfunction increases, these new technologies will help practitioners increase their patients’ quality of life.

Parag A. Majmudar, MD, is an associate professor, Cornea Service, Rush University Medical Center, Chicago Cornea Consultants, Ltd. He is a consultant for and has received research funding from TearScience, Inc. Dr. Majmudar may be reached at (847) 822-5900; pamajmudar@chicagocornea.com.