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I am continually impressed by the caliber of the graduates coming out of optometry school each year. I spent several months with Ms. Sarah Henderson in my office and watched as her dry eye knowledge blossomed. This case is a prime example of how we as clinicians can get caught up in seeing only the short-term benefits for patients. This patient—as most with dry eye symptoms are—was extremely skeptical about our ability to help her. Sarah and I provided education and a lot of assurance to this patient, and we were able to keep her in our practice while her treatment ran its course. Through this case, we saw first hand how we can change patients lives with the proper therapy and patience.
—Section Editor David L. Kading, OD, FAAO
Meibomian gland dysfunction (MGD), one of the leading causes of dry eye disease (DED), is characterized by decreased and thickened secretion from the oil-producing glands of the tear film.1 MGD decreases not only the quality of the oil secretions, but also the number of working glands. These oil glands help to produce the lipid layer of the tear film, and compromise to this layer can cause severe discomfort for a patient.
One of the best approaches to relieving meibomian gland obstruction is applying heat to the eyelids. Although use of warm compresses and physical massage to the external eyelids has been the traditional approach to improving oil flow, it is not the most effective, and it requires reheating for optimal results.1 Application of warm compresses and physical eyelid massage has been shown to change the shape of the cornea, which could cause secondary keratoconus or other corneal irregularities that may decrease a patient’s overall visual acuity.2 Another method of applying heat is the LipiFlow system (TearScience), which both heats and pulsates the meibomian glands from the internal eyelid surface without compromising the cornea. Patient symptoms and oil gland function have been shown to improve for up to 9 months after LipiFlow treatment.3
A 42-year-old white woman presented for an annual eye examination with a chief complaint of blurred near vision. She had a history of dryness in both eyes over the past several years. Omega-3 fatty acid supplementation and Restasis (cyclosporine ophthalmic emulsion 0.05%; Allergan) had been previously recommended, but the patient reported poor compliance.
Slit-lamp examination revealed thickened oil expression in both eyes, with some glands expressing no oil at all. It was recommended that the patient return at earliest convenience for a DED evaluation and that she restart 1,000 mg eicosapentaenoic acid and docosahexaenoic acid omega-3 fatty acid supplementation per day.
At the DED evaluation, the patient scored 19 on the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire (normal score is <10) and 18 on the Ocular Surface Disease Index (OSDI) questionnaire (normal score is <20). The LipiView II (TearScience) device was used to measure lipid layer thickness of the tear film via the Interference Color Unit (ICU) score and to count partial blinks. A normal ICU score is greater than 75 µm. The lipid layer thickness was 49 µm and 48 µm in the right and left eyes, respectively, and the partial blink rate was 5/7 in the right eye and 3/7 in the left.
The patient’s score on the five-grade pictorial meiboscale of the lower and upper eyelids was 3.5 in both eyes (Figures 1 and 2), indicating 75% meibomian gland atrophy. The line of Marx was mild in both eyes superiorly and moderate in both eyes inferiorly. Lid wiper epitheliopathy was 3x2 in each eye.
The number of meibomian glands yielding liquid secretion (MGYLS) was also evaluated, performed on the lower eyelids with a meibomian gland expresser (applying constant pressure of 1.25 mm/g2). The total MGYLS score was 5 in the right eye and 5 in the left.
LipiFlow treatment was strongly recommended to the patient, and after consent it was performed in the office. The patient was instructed to return in 6 weeks for a follow-up of the LipiFlow treatment.
At her follow-up appointment 4 weeks after LipiFlow, the patient reported very little relief of her DED symptoms. However, her SPEED and OSDI scores were 14 and 10, respectively, indicating improvement from previous scores. Total MGYLS scores were 18 in the right eye and 14 in the left. Although MGYLS had improved drastically since the initial evaluation, the patient was concerned that the LipiFlow had not completely cured her DED symptoms. It was recommended that the patient continue blinking exercises, warm compresses, and artificial tear application as needed.
At the next follow-up appointment at 6 weeks after LipiFlow, the patient’s symptoms had improved dramatically since her previous visit. SPEED and OSDI scores were 8 and 7, respectively. Her lipid layer thickness as measured with LipiView II showed an average ICU of 80 µm in the right eye and 76 µm in the left and a partial blink of 4/9 in the right eye and 7/9 in the left; both of these scores had improved from the initial visit. Further, MGYLS was 20 in the right eye and 22 in the left.
It was recommended that the patient continue the omega-3 fatty acid supplement and warm compresses for 5 minutes per day. The patient returned to the clinic for her final follow-up appointment at 4 months after LipiFlow, which revealed SPEED and OSDI scores of 4 and 3, respectively, and MGYLS of 30 in the right eye and 21 in the left.
This patient had been experiencing DED for several years, but it was only after the LipiFlow treatment that her symptoms and signs began to improve dramatically, indicating the strong potential benefit of LipiFlow treatment for DED. Although the atrophy of her meibomian glands is not reversible, her symptoms and meibomian gland evaluation scores greatly improved, and the glands she still has are functioning much better (Figures 3 and 4).
LipiFlow treatment has been shown to improve the quality and quantity of oil gland secretion. Although patients may see improvement in their DED for up to 9 months after LipiFlow treatment,4 it is unusual to see an improvement of oil flow by as early as a few weeks after treatment. This patient showed great improvement in her signs in a short period of time (Figure 4).
It is imperative to discuss the benefits and potential time line with patients undergoing the treatment so that their expectations are in line with reality. A single treatment with LipiFlow can provide long-term results, which eliminates physician concerns regarding patient compliance and other variables with at-home treatments.4 Results of this method of treatment have been shown to improve quality of life for patients experiencing DED by getting their glands to secrete the healthy oil that is necessary for a properly functioning tear film and, ultimately, for the patients’ comfort. n
1. Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol. 2015;26(4):306-313.
2. McMonnies CW, Korb DR, Blackie CA. The role of heat in rubbing and massage-related corneal deformation. Cont Lens Anterior Eye. 2012;35(4):148-154.
3. Blackie CA, Solomon JD, Greiner JV, et al. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008;85(8):675-683.
4. Greiner JV. A single LipiFlow Thermal Pulsation System treatment improves meibomian gland function and reduces dry eye symptoms for 9 months. Curr Eye Res. 2012;37(4):272-278.
Section Editor Mile Brujic, OD, FAAO
• Partner, Premier Vision Group, Bowling Green, Ohio
• (419) 352-2502; firstname.lastname@example.org
Section Editor David L. Kading, OD, FAAO
• Partner, Specialty Eye Group, Seattle, Washington
• (425) 821-8900; email@example.com
Sarah Henderson, BS
• Doctor of Optometry candidate, 2017, Southern College of Optometry, Memphis, Tennessee