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Clinical Research

LASIK Consult with MGD Case Report

Shilpa Rose, MD & Chevy Chase, MD

KEY POINTS:

  • Chief complaint was difficulty tolerating contact lenses for the past 10 years 
  • Clinical findings indicated meibomian gland functional and structure changes. 
  • A single LipiFlow® treatment resulted in a reduction of symptoms and an improvement in clinical signs supporting the patient to elect laser vision correction
  • One year after LipiFlow®, and one year after LASIK this patient is 20/15 with no recurrence of dry eye symptoms and repeat LipiScan® imaging showed no evidence of further meibomian gland atrophy


Introduction

A 33-year-old Caucasian male accountant presented to the office for laser vision correction consultation in 2018. His chief complaint was difficulty tolerating contact lenses for the past 10 years. He reported itching, burning, tearing with fluctuations in vision depending on the time of day. His contact lens intolerance prevented him from wearing contact lenses while at work given his extended use of computers during the day. Glasses during recreational activities were cumbersome, limiting his peripheral vision. He also reported fogging of the glasses while doing sports such as running, tennis and golf. He complained of an increase in “blinking” throughout the day to achieve more comfort.

He was not successful with several brands of contact lenses, developing papillary tissue changes. Given his astigmatic prescription, toric soft lenses did not provide the quality of vision he would prefer. This patient had sought laser vision correction in the past at several other practices and was deemed a “non-candidate” because of his dry eyes.

His symptoms had not improved significantly with preservative free artificial tears, Restasis, Xiidra, punctal occlusion, and a previous trial of Prokera by a local ophthalmologist.

 

Examination and Testing

Past medical history included hypertension, for which he is taking Lisinopril and Verapamil. There is a maternal family history of glaucoma. Examination included best corrected visual acuity of 20/25 OU. Manifest Refraction: OD -2.75 +1.25 X 043; OS -2.25 +1.75 X 130 

  • External exam was unremarkable. Lid margins showed meibomian gland inspissation, mild telangiectasia and capped glands.  Lids upon eversion showed mild bilateral upper and lower lid papillary reaction. 
  • Meibomian gland expression revealed turbidity in the meibum.
  • Slit Lamp Examination showed conjunctival perilimbal staining, dense superficial punctate keratitis and mild conjunctival erythema.
  • Lenses, anterior chamber and dilated fundus exam were all unremarkable.

Corneal Topography showed normal corneal thickness, with no evidence of thinning or irregularities. Scans did show irregularity in the surface which improved with artificial tears and blinking.

LipiScan® showed early evidence of gland atrophy nasally in both lower lids. (Figure 1)

Figure 1: LipiScan® showed beginning evidence of mild meibomian gland narrowing

HD Analyzer showed high Ocular Scatter Index Scores, 1.58 ± 0.52 with evidence of an unhealthy tear film and quick break up time. (Figure 2)

Figure 2: Mean OSI: 0.74 ± 0.07 OSI Evolution With Time

This patient’s clinical findings indicated compromise to gland function and gland structure. His contact lens intolerance and dry eye did not respond as desired, to pharmaceutical treatment or punctal occlusion. His refractive error also limits the options of contact lens to achieve comfort and good vision. Given that this patient had not received treatment for MGD, vectored thermal pulsation for his meibomian glands was discussed as a treatment option. The patient was counseled about the risks, benefits and alternatives to LipiFlow® treatment.

Three days later, the patient returned to the office and underwent LipiFlow® treatment in the office without complications. To supplement his treatment, he was prescribed Lotemax gel .05% to both eyes bid for one week, along with Omega 3 supplementation at a daily dose of 2668mg.

The patient returned to follow up 5 weeks later. He noted an increase in tear production and a decrease in his light sensitivity. His long day of computer use was more tolerable with much less blinking.

Examination revealed a marked decrease in conjunctival and corneal staining and improvement in gland function.

A repeat HD Analyzer was performed with a reduction in OSI, 0.74 ± 0.07 as well as a stable, flat tear film. (Figure 3)

Figure 3: Mean OSI 0.74 ± 0.07 OSI Evolution With Time

Given that the patient had experienced such a remarkable improvement in symptoms, he requested to try contact lenses that weekend for a golf tournament. He was able to wear them for an extended amount of time without the dependency on spectacles. Due to his refractive error, his best correct visual acuity with soft contact lenses was 20/25.

 

Post Treatments

After three months of being relatively symptom free, the patient elected to undergo laser vision correction. His experience of the surgery was positive. One day post op his visual acuity was 20/15 OU. At one-week post op there was no evidence of SPK. Per post-surgical protocol, he used artificial tears qid for the first month to supplement tear production.

This patient continued to maintain excellent vision at the one and three months post-operative visits. One year after LipiFlow®, and one year after LASIK this patient is 20/15 with no recurrence of dry eye signs and symptoms. Repeat LipiScan® showed no evidence of further meibomian gland atrophy.

Figure 4: Repeat LipiScan® showed no evidence of further meibomian gland atrophy

This case report highlights a patient that had limited relief from dry eye until he had his MGD treated. He benefitted from LipiFlow® technology in terms of relief from dry eye signs and symptoms: relief that was previously unattainable. Additionally, once his MGD was treated with LipiFlow®, he was able to enjoy a lifestyle choice that were also previously not available to him, contact lenses and LASIK. Once deemed to be “too dry” for LASIK, he became an excellent candidate for laser vision correction and is now enjoying his contact lens and spectacle independent life.


INDICATIONS AND IMPORTANT SAFETY INFORMATION for LIPIFLOW® Thermal Pulsation System
Rx Only

INDICATIONS
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.

CONTRAINDICATIONS
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)

PRECAUTIONS
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.

ADVERSE EFFECTS
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.

ATTENTION
Reference the LipiFlow Thermal Pulsation System Instructions for Use for a complete listing of indications, warnings, and precautions.

 

INDICATIONS AND IMPORTANT SAFETY INFORMATION for LIPISCAN™ Dynamic Meibomian Imager
Rx Only

INDICATIONS
LipiScan™ Dynamic Meibomian Imager (DMI) is an ophthalmic imaging device intended for use by a physician in adult patients to capture, archive, manipulate and store digital images of the meibomian glands.

CONTRAINDICATIONS
No contraindications have been identified for the LipiScan™.

PRECAUTIONS
Caution: Disinfect the surfaces of the chin rest, forehead rest and Handheld Near Infrared (IR) Lid Everter with isopropyl alcohol immediately prior to use and prior to storage to prevent cross-contamination and patient infection.

WARNINGS
Warnings include any potential hazards for adverse events to the patient or user. Review the warnings in Table 1 of the LipiScan Dynamic Meibomian Imager Instructions for Use prior to using LipiScan™.

ADVERSE EFFECTS
There are no known or anticipated adverse effects associated with use of this device.

ATTENTION
Reference the LipiScan Dynamic Meibomian Imager Instructions for Use for a complete listing of indications, warnings, and precautions.

LIPIFLOW and LIPISCAN are trademarks of TearScience, Inc.  
© Johnson & Johnson Surgical Vision, Inc. 2018
All other trademarks are the intellectual property of their respective owners.
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