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Ocular Surface

RGP Lens Wearer with MGD Case Report

Published on Dec 17, 2019
10 Minutes Read

Shilpa Rose, MD & Chevy Chase, MD

KEY POINTS: 

  • Chief Complaint, 3-5-year history of contact lens intolerance.
  • Meibomian gland function and structure changes lead to poor meibum quality.
  • Six months post LipiFlow® treatment, this patient reported continued comfort and ability to wear contact lenses all day without fluctuations in vision.
  • 18 months post LipiFlow® treatment her symptoms returned, although mild in severity lead to a repeat LipiFlow®treatment for her MGD. This resulted in rapid symptom improvement.*

 

Introduction

A 65-year-old Caucasian female presented to the office for consultation in 2016. Her chief complaint was difficulty tolerating her contact lenses for the past 3-5 years. She reported redness, tearing and foreign body sensation. Her most notable complaint was constant deposits of protein on her contact lenses during the day.

She removed and cleaned her lenses approximately 8 to 10 times daily, with lens deposits forming almost immediately, resulting in fluctuations in vision. She also noted these symptoms worsening during the past year. 

She had a 50-year history of wearing rigid gas permeable contact lenses and was currently wearing Boston FP 60 -9.50 OD, -8.50 OS. The patient was not successful with many attempts with soft contact lenses, given her level of astigmatic error. She was deemed not a candidate for laser vision correction given her thin central corneal thickness.

Her symptoms had not improved with Restasis, Xiidra, OTC fish oil supplements or punctal plugs.

 

Examination and Testing

Past medical history included Rheumatoid Arthritis, for which she was taking Plaquenil for 10 years. Recent ERG shows no evidence of toxicity.

Past ocular history included perimacular drusen, for which is taking AREDS2 supplementation.

Examination reveals best corrected visual acuity 20/25 OU.

  • Intraocular pressures 14 OU.
  • External exam reveals mild 
  • ptosis OU.
  • Contact lens examination reveals well positioned RGP contact lenses that move well, with heavy coating of protein deposits.
  • Lid margins showed meibomian gland insippation, capped glands and mild telangiectasia.
  • Meibomian gland expression revealed turbidity in the meibum and mild toothpaste like consistency
  • Slit Lamp Exam was notable for conjunctival perilimbal staining, dense superficial punctate staining and a mild papillary reaction of the palpebral conjunctiva.
  • There was 1+ nuclear sclerosis.
  • Dilated fundus examination revealed rare perimacular drusen with no evidence of macular toxicity.

LipiScan® meibography showed good gland structure, with no evidence of gland drop out or atrophy (Figure 1).

Figure 1: LipiScan® meibography showed good gland structure

Figure 1: LipiScan® meibography showed good gland structure

This patient’s clinical findings indicated meibomian gland functional changes as noted by the relatively poor meibum quality, but no structural changes as noted on the meibography. I find this type of patient responds very well to thermal meibomian gland expression.

The patient was counseled about the risks, benefits and alternatives to LipiFlow® treatment. One week later, the patient returned to the office and underwent LipiFlow® treatment. Post treatment she was prescribed Lotemax gel .05% to both eyes bid for one week, along with Omega 3 supplementation at a daily dose of 2668 mg.

 

Post Treatments

The patient returned for follow up 4 weeks later. She noted that immediately following LipiFlow® treatment she was able to comfortably wear her RGP contact lenses for 10 hours a day without removal*. She did not feel the need to remove and clean her lenses. Her redness and foreign body sensation had resolved*.

Examination revealed well positioned contact lenses with no protein deposits and minimal conjunctival and 
corneal staining*.

  • Six months post LipiFlow® treatment, this patient reported continued comfort and ability to wear contact lenses all day without fluctuations in vision.
  • 18 months post LipiFlow® treatment, she noted a return of her symptoms, although mild in severity*. Based on her MGD status, LipiFlow® was again recommended and she elected to receive the treatment. She chose to then have a repeat LipiFlow® treatment. 

This case report highlights a patient that benefited greatly from LipiFlow® technology in terms of ocular comfort and overall experience of wearing her contact lenses. 

 

*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.

In a randomized controlled clinical trial, LipiFlow® was shown to increase comfortable contact lens wear time by 4 more hours on average, up to 4 months.1

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 a trademark of TearScience, Inc. 

© Johnson & Johnson Surgical Vision, Inc. 2018

All other trademarks are the intellectual property of their respective owners.

PP2019TS415

1. Blackie, CA, et al. A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day. Clin Ophthalmol, 2018; 12:169-183.