Gina Wesley, OD, MS, FAAO; Medina Minnesota
- Decreased comfortable wear time and ocular redness can be signs of Meibomian Gland Dysfunction (MGD).
- This case highlights a patient with marked reduction of gland function and structure.
- Blink rate and subjective assessment via SPEED were reported.
- A single LipiFlow® treatment improved gland function and subjective improvements were noted.
A 46-year old Caucasian male presented for his annual exam. Primary concerns were the minimal amount of time he could comfortably wear his contact lenses, as well asthe chronic redness of his eyes. He reported using a common redness reliever drop every day to the point of feeling “addicted” to using the drop. Health history was positive for rosacea and occasional migraines, for which he was taking Maxalt prn.
Examination and Testing
Comprehensive exam revealed unremarkable internal ocular health. Best corrected VA’s were 20/20 OD and 20/20 OS. Anterior segment exam noted moderate Meibomian Gland Dysfunction (MGD), with 2 glands OD and 2 glands OS yielding fluid upon meibomian gland evaluation of the lower lids. Bulbar conjunctival injection was graded at 1 OU. We discussed the clinical indications of dry eye and need for further evaluation; the patient was scheduled to return for further testing.
At his subsequent appointment, meibography showed degree 3 loss OD and degree 2 loss OS (figures 1 & 2).
Figure 1: OD Meibography
Figure 2: OS Meibography
There was moderate exposure when testing for microlagophthalmos. Tear Lab osmolarity testing yielded 298 OD, 296 OS, although MMP9 testing was negative OD and weak positive OS. Lissamine green staining was Gr 2+ nasally with trace temporal staining OU of the bulbar conjunctiva; Line of Marx staining was Gr 2 OU. Partial blinks were 50% of the time evaluated. SPEED survey was 16/28.
In review this patient has marked reduction of gland function with noted gland loss. Tear osmolarity was normal with no real difference between eyes. Conjunctival staining was notable, he had a high rate of incomplete blinking and was symptomatic per SPEED.
The patient was educated about LipiFlow® treatment, his ability to benefit and hopefully experience relief and improved contact lens wear. He elected to proceed and underwent an uncomplicated procedure on the day of his evaluation. He was instructed to begin a daily regimen OU of warm compresses with massage for 10 min bid, use lid foam cleanser bid, preservative-free artificial tears at least bid, and daily omega-3 supplementation of 2000 mg with at least half of that supplement being of a high-quality DHA/EPA component.
Patient returned for his 8-week follow-up reporting taking the omega supplement, doing warm compresses/massage bid OU, using the lid foam and preservative-free artificial tears prn. His new SPEED score was 6/28. Meibomian gland evaluation score was now 8 glands OD, and 11 OS yielding fluid. He was thrilled with the outcome, and his eyes not only felt better, but he noted they were “whiter and brighter” per his comments. Family and friends had similarly noticed this as well, thus the patient had discontinued all use of red-eye products. Contact lens comfortable wear time had increased by about 4 hours each day similar to what has been documented by Caroline Blackie, OD’s paper.1
This patient is an example of the mild to moderate start of dry eye symptoms, but no direct conscious link of redness of the eyes being a manifestation of his dry eye disease/MGD. As the patient experienced and was educated, addressing the root of the dry eye issue is what helped resolve his injected eyes. Instead of masking the problem, being able to address it directly was of great value to him. The added benefit of contact lens comfort improvement was appreciated. He has already returned for an annual LipiFlow® treatment and plans to continue annual treatments to maintain his excellent outcome.
INDICATIONS AND IMPORTANT SAFETY INFORMATION for LIPIFLOW® Thermal Pulsation System
The LipiFlow® Thermal Pulsation System is intended for the application of localized heat and pressure therapy in adult patients with chronic cystic conditions of the eyelids, including meibomian gland dysfunction (MGD), also known as evaporative dry eye or lipid deficiency dry eye.
Do not use the LipiFlow® System in patients with the following conditions. Use of the device in patients with these conditions may cause injury. Safety and effectiveness of the device have not been studied in patients with these conditions.
- Ocular surgery within prior 3 months, including intraocular, oculo-plastic, corneal or refractive surgery procedure
- Ocular injury within prior 3 months
- Ocular herpes of eye or eyelid within prior 3 months
- Active ocular infection (e.g., viral, bacterial, mycobacterial, protozoan, or fungal infection of the cornea, conjunctiva, lacrimal gland, lacrimal sac, or eyelids including a hordeolum or stye)
- Active ocular inflammation or history of chronic, recurrent ocular inflammation within prior 3 months (e.g., retinitis, macular inflammation, choroiditis, uveitis, iritis, scleritis, episcleritis, keratitis)
- Eyelid abnormalities that affect lid function (e.g., entropion, ectropion, tumor, edema, blepharospasm, lagophthalmos, severe trichiasis, severe ptosis)
- Ocular surface abnormality that may compromise corneal integrity (e.g., prior chemical burn, recurrent corneal erosion, corneal epithelial defect, Grade 3 corneal fluorescein staining, or map dot fingerprint dystrophy)
The Activator or Activator II (Disposable) may not fit all eyes, such as eyes with small palpebral fornices.
Use of the LipiFlow® System in patients with the following conditions may result in reduced treatment effectiveness because these conditions may cause ocular symptoms unrelated to cystic meibomian glands and require other medical management. Safety and effectiveness of the device have not been studied in patients with these conditions.
- Moderate to severe (Grade 2-4) allergic, vernal or giant papillary conjunctivitis
- Severe (Grade 3 or 4) eyelid inflammation (e.g., blepharochalasis, staphylococcal blepharitis or seborrheic blepharitis). Patients with severe eyelid inflammation should be treated medically prior to device use.
- Systemic disease conditions that cause dry eye (e.g., Stevens-Johnson syndrome, vitamin A deficiency, rheumatoid arthritis, Wegener’s granulomatosis, sarcoidosis, leukemia, Riley-Day syndrome, systemic lupus erythematosus, Sjögren's syndrome)
- Taking medications known to cause dryness (e.g., isotretinoin (Accutane®) and systemic antihistamines)
- Esthetic eyelid and eyelash procedures (e.g., blepharoplasty, lash extensions, eyelid tattooing)
In addition, the treatment procedure may loosen previously inserted punctal plugs, which may worsen the patient’s dry eye symptoms.
Potential adverse effects that may occur as a result of the procedure include, but are not limited to, the onset or increase in:
- Eyelid/eye pain requiring discontinuation of the treatment procedure;
- Eyelid irritation or inflammation (e.g., edema, bruising, blood blister, dermatitis, hordeolum or chalazion);
- Ocular surface irritation or inflammation (e.g., corneal abrasion, conjunctival edema or conjunctival injection (hyperemia)); and
- Ocular symptoms (e.g., burning, stinging, tearing, itching, discharge, redness, foreign body sensation, visual disturbance, sensitivity to light).
Potential serious adverse events (defined as permanent impairment or damage to a body structure or function or necessitates medical or surgical intervention to preclude permanent impairment or damage to a body structure or function) that are not anticipated because of the device mitigations to prevent occurrence include:
- Thermal injury to the eyelid or eye, including conjunctiva, cornea or lens;
- Physical pressure-induced injury to the eyelid; and
- Ocular surface (corneal) infection.
Reference the LipiFlow® Thermal Pulsation System Instructions for Use for a complete listing of indications, warnings, and precautions.
LIPIFLOW is a trademark of TearScience, Inc.
© Johnson & Johnson Surgical Vision, Inc. 2018
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