COMMENTARY

Out With the Old, in With the New: The Best of AAO 2013

American Academy of Ophthalmology 2013

Roger F. Steinert, MD; Eric D. Donnenfeld, MD; Richard A. Lewis, MD

Disclosures

November 25, 2013

In This Article

The Underappreciated Role of Meibomian Glands in Dry Eye

Dr. Steinert: Another medical therapeutic area that we should touch on is the ocular surface (which is a critical part of the refractive picture) and the whole concept of how we treat dry eye. Pure aqueous deficiency is actually quite rare. We have increasing acceptance and awareness of the role of the meibomian glands in so-called "dry eye syndrome." Eric, you have been doing a lot of interesting and very important work in this area. Where are we today, in 2013, on this?

Dr. Donnenfeld: We are making major strides in this area. I agree with you completely: 15 years ago, no one thought about the ocular surface and dry eye. But vision starts with the tear film. All the wonderful technology we have now doesn't work if the tear film is not intact.

In the last decade, we had cyclosporine (Restasis®), which is a wonderful drug; I use it all the time. That is a good treatment for aqueous-deficiency dry eye. But we have come to the realization that meibomian gland dysfunction is 3-4 times more common. As a matter of fact, [84%] of patients in one study[1] and [91%] of patients in another study[2] had meibomian gland dysfunction as a cause of their dry eye.

So now we have some new markers. A company called TearScience makes a machine that provides interferometry and gives us something called the LipiView®, which allows us to look at the tear meniscus, the tear film, and the lipid layer. So we now have a marker that we can follow and see how thick the corneal surface is.

We have osmolarity for measuring dry eye and an evidence-based system where we can look at dry eye and provide real-time information that's reproducible, so that the clinician doesn't have to do archaic tests. We can now rely on evidence-based medicine to make a diagnosis. Once we have that diagnosis, we can treat appropriately.

Dr. Lewis: How much of the surface disease problems are we creating with chronic therapy, such as glaucoma?

Dr. Donnenfeld: It has a lot to do with our problems. Often patients who are at risk for having dry eye are put over the edge by the addition of glaucoma medications with preservatives. Certain surgeries can make dry eye worse as well. These are the patients whom we have to be really cognizant of.

Do you know what the most common problem with ocular surface disease is? It's contact lens wear. Every year, millions of patients stop wearing their contact lenses because of ocular surface problems. If we can improve the quality of their tear film by recognizing and treating meibomian gland disease, we can make these patients more comfortable with contact lenses and also LASIK. Everyday life will be better.

Look at the Lids

Dr. Donnenfeld: A new machine called LipiFlow® is a pulsation device that actually heats the lid and pulses out the inspissated meibomian gland secretions. We have had some very good success in some of these patients who have not had relief with hot compresses, lid hygiene, and oral nutrition. There is a lot of interest in meibomian gland disfunction, and it's good for ophthalmology.

Dr. Steinert: If anything, we have been guilty of neglect. We have not recognized it. We haven't diagnosed it. We haven't treated it soon enough. By the time the meibomian glands are full of pus and plugged, they already have major, irreversible damage. It definitely is a good trend for us to be more aware of this and be more aggressive about early treatment. We just have to convince the patient.

Dr. Donnenfeld: I completely agree. Ophthalmologists have to start looking at the lids before they go in and look at the eye. Spend more time looking at the lids. If I could give one tip to the practicing ophthalmologist, it's lid expression: Press on the lid, and try to express some meibomian gland contents. When you see toothpaste come out, that's telling you that patient needs to be treated.

Dr. Steinert: It should be a nice, clear yellow oil, right?

Dr. Donnenfeld: Exactly. Good olive oil.

Dr. Steinert: You mentioned toxicity from glaucoma drugs. I am just starting to realize that I was creating limbal stem cell deficiency in some cases and goblet cell deficiency. Whether it's the active ingredient or just the preservative, there is no question that all of these medications are stressing the surface.

Dr. Lewis: Another advantage of those drug delivery systems is to avoid the whole exposure to the limbal cells and into the surface, so all that will play a role later.

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