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Innovations in MGD:Raising the Standard of Care

Douglas Devries, ODJosh Johnston, OD, FAAO

Tom Kislan, OD, FAAOWalter Whitley, OD, MBA, FAAO

Optometry’s Meeting 2017

Professional Disclosures

• Doug Devries, OD – Abbott Medical Optics , Alcon, Allergan, Akorn, Bio Tissue, Bruder, BVI Medical, B & L, Eyes 4 Lives, TearLab, Tear Science, RPS, RySurg, Science Based Health, Shire, Sun Pharmaceutical, OcuSoft, Ophthalmic Resources

• Josh Johnson, OD - Allergan, Alcon, BioTissue, Shire, J&J

• Tom Kislan, OD - Alcon, Allergan, Biotissue, B+L, Hoya, Katena, MiboMedical, PRN, RPS, Shire, Tear Lab

• Walt Whitley, OD – Alcon, Allergan, Bausch and Lomb, Beaver-Visitec, Biotissue, Diopsys, Glaukos, Ocusoft, Science Based Health, Shire, Sun Pharmaceuticals, TearLab, Tearscience

Presenters have received honorarium, consulting fees or research funding from:

Overview

We want you to think and behave differently about MGD by showing the importance of:

1. Utilizing evidence based medicine2. Implementing POC diagnostics3. Adopting current and future MGD treatments4. Taking your practice to the next level!!

Dry Eye Market Overview

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Opportunity

• $3.8 Billion spent on dry eye symptom relief annually in the U.S. alone

• >29 Million Americans suffer from dry eye disease

• Most frequently encountered disease state by eye care professionals

Better clinical

outcomes for

patients

Patient Retention

& Referrals

Practice

Growth

Market Scope 2013 Comprehensive Report on the Global Dry Eye Products Market

Dry Eye Supplements Fail to Address the Underlying Cause

Beard B. Boston Foundation for Sight Survey. Report Back to the Community. Boston Foundation for Sight. July 15, 2010. www.bostonsight.org.

Why Treat Ocular Surface Disease?• Address signs/symptoms

• Provide relief to patients for which there are limited treatment options

• Improve CL intolerance

• Improve outcomes in surgical procedures

• To grow your practice

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--- 20/20 ---

Better Comfort and Quality of Vision

• Ocular surface disease, even the mildest tear film abnormality, results in a significant reduction in quality of vision and comfort.

• Due to this, proper ocular surface treatment is critical to patient satisfaction.

Dry Eye: Increased Clinical FocusAn Important Opportunity

• Mounting patient awareness• Progresses with age and lack of

effective treatment• Driven by tear instability• Exacerbated by intense,

prolonged visual tasks• Impacts vision as well as comfort

••••

••••

••

DEWS II Released Soon!!!

Updated DEWS II Definition

“Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface

inflammation and damage, and neurosensory abnormalities play etiological roles.”

Growing Awareness of MGD

Dry Eye

MGD is the leading cause of dry eye.1

Core mechanism of MGD: Obstruction.1

Early intervention is best.2

Long-term ocular surface rehabilitation requires functional Meibomian glands.

Treating Dry Eye means Treating Meibomian Gland Obstruction.

Routine MG Function/ Structure evaluation.

1. Nichols KK, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1922-9.2. Knop E, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland.

Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1938-78. 3. Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative

dry eye. Clin Ophthalmol. 2016 Jul 26;10:1385-96.

Healthy Meibomian Gland Function is Foundationalto Ocular Surface Health

MG Assessment requires the evaluation of gland function and/or structure

Early Intervention optimizes outcomesBlackie 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;26:306-313. Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol. 2016 Jul 26;10:1385-96.

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Risk Factors for MGD

Systemic• Age• Autoimmune disease• Rosacea • Medications• Diabetes• And on and on

• Digital devices• Humidity

Ocular• Aqueous deficient• Contact lens wear• Glaucoma• Lid margin disease• Cosmetics

Environmental

Who has MGD?

• Peri-menopausal women study: 91% (n = 471) had DE with 87% having MGD1.

• PCOS study: 73% with PCOS had MGD vs. 62% of the controls2

• Glaucoma and MGD: 96% (using Prostaglandins) had obstructive MGD vs. 58% of those on non Prostaglandin Therapy.3

• Diabetes: 58% had MGD4

• MGD ‘high prevalence and increased’ in smokers5

• VDT users 4+ hrs a day: 85% had MGD vs. 70% of those <4 hrs per day.6

• Cataract Patients: 59% (n-233) had MGD7

• Refractive surgery patients8

• Contact lens wearers: 60% had MGD.9

2014-2017

1. Jin X, et al. Medicine (Baltimore). Hormone replacement therapy benefits meibomian gland dysfunction in perimenopausal women. 2016 Aug;95(31):e4268. 2. Baser G, et al. Evaluation of Meibomian Gland Dysfunction in Polycystic Ovary Syndrome and Obesity. CurrEye Res. 2016 Oct 28:1-5. 3. Mocan MC, et al. The Association of Chronic Topical Prostaglandin Analog Use With Meibomian Gland Dysfunction. J Glaucoma. 2016 Sep;25(9):770-4. 4. Yu T, et al. Changes of meibomian glands in patients with type 2 diabetes mellitus. Int J Ophthalmol. 2016 Dec 18;9(12):1740-1744. 5. Wang S, et al. Impact of Chronic Smoking on Meibomian Gland Dysfunction. PLoS One. 2016 Dec 28;11(12):e0168763. 6. Wu H, the severity of the dry eye conditions in visual display terminal workers. PLoS One. 2014 Aug 21;9(8):e105575.7. Algamadi et al. Epidemiology of Meibomian Gland Dysfunction in an Elderly Population. Cornea. 2016 Jun;35(6):731-5. 8. CochenerB, et al. 9. Machalińska A, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea. 2015 Sep;34(9):1098-104.

Contact Lens Considerations

• Contact lens wearers with unexplainable reduced wearing time had MGD1

• CL wear accelerates MGD2,3

• 60% of CL wearers had MGD4

1. Henriquez AS, Korb DR. Meibomian glands and contact lens wear. Br J Ophthalmol. 1981 Feb;65(2):108-11.2. Ong BL. Relation between contact lens wear and Meibomian gland dysfunction. Optom Vis Sci 1996;73:208-10.3. Arita R, Itoh K, Inoue K, Kuchiba A, Yamaguchi T, Amano S. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology 2009;116:379-84.4. Machalińska A, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea. 2015

Sep;34(9):1098-104.

Surgical Considerations

• Approximately 10–20% of post-LASIK patients may suffer from chronic dry eye disease with more severe discomfort after LASIK1

• Cataract Patients: 59% (n-233) had MGD2

• 62.3% had TBUT < 5 sec3

1. Ambrósio R Jr, Tervo T, Wilson SE. LASIK-associated dry eye and neurotrophic epitheliopathy: pathophysiology and strategies for prevention and treatment. J Refract Surg 2008; 24:396–407.2. Algamadi et al. Epidemiology of Meibomian Gland Dysfunction in an Elderly Population. Cornea. 2016 Jun;35(6):731-5. 3. Trattler WB, Reilly CD, Goldberg DF, et al. Cataract and Dry Eye: Prospective Health Assessment of Cataract Patient Ocular Surface (PHACO)

Study. Paper presented at: ASCRS Symposium and Congress; May 25-29, 2011; San Diego, CA.

Digital Devices

• Approximately 65 percent spend between three to nine hours per day in front of a digital device1

• While asthenopia, glare, and accommodative difficulty are all aspects of CVS, dry eye appears to contribute to a major component of symptoms reported2

• 74.3% of VDT users had MGD3

1. The Vision Council. TVC DigitEYEzed Report 2013. http://www.thevisioncouncil.org/consumers//media/ResearchReports/des2014/TVCDigitEYEzedReport2013.pdf. Accessed 01/01/2014.2. Blehm CS, Vishnu S, Khattak A, et al. Computer vision syndrome: a review. Surv Ophthalmol 2005;50:253-62.3. Fenga C Aragona P Cacciola A . Meibomian gland dysfunction and ocular discomfort in video display terminal workers. Eye. 2008;22:91–95.4. Photo accessed from http://inpublicsafety.com/2012/12/the-era-of-digital-policing-keeping-up-with-a-treasure-trove-of-electronic-evidence/ on 6/2017

Glaucoma Consideration

• Glaucoma medications significantly elevate the risk and progression of MGD1

• Preservative and dry eye2

1. Arita R, Itoh K, Maeda S, et al. Comparison of the long-term effects of various topical antiglaucoma medications on meibomian glands. Cornea. 2012 Nov 31(11): 1229-34.

2. Baudouin, C, Labbe, A, Liang, H, et. Al. Preservatives in eyedrops: The good, the bad and the ugly, Progress in Retinal and Eye Research, Volume 29, Issue 4, July 2010, Pages 312-334

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A. B. C. D.

8%11%

49%

33%

Why Have We Not Seen a Paradigm Shift in the Treatment of MGD?

A. MGD is too complexB. Cost is a barrier to entryC. Lack of efficacy in available

treatment optionsD. I Love MGD – everyone

else is asleep at the wheel

***Data from Audience Response 2016 AOA Panel on MGD

INNOVATIONS IN MGD:IMPLEMENTING POINT-OF-CARE DIAGNOSTICS

Josh Johnston, OD, FAAOClinic Director - Georgia Eye PartnersResidency Program Supervisor

Does this Patient have MGD? Do You Normally Perform?

• Lid expression

• Evaluate for lid seal

QuestionnairesSPEED Questionnaire

Name: __________________________, _______________ Date: ____/____/____ DOB: ____/____/______ Sex: M F (Circle)

How FREQUENTLY do you experience the following dry eye symptoms?

Symptoms

Never (0)

Sometimes (1)

Often (2)

Constant (3)

Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue

How SEVERE are your dry eye symptoms?

Symptoms No

problems (0)

Tolerable – not perfect but not uncomfortable

(1)

Uncomfortable – irritating but does not interfere with my day

(2)

Bothersome – irritating and interferes with

my day (3)

Intolerable – unable to perform

my daily tasks (4)

Dryness, Grittiness or Scratchiness

Soreness or Irritation Burning or Watering Eye Fatigue WHEN have you experienced these symptoms? ( ) Today ( ) Within the past 72 hours ( ) Within the past 3 months

Activities Yes No Do you have difficulty reading? Do you have difficulty using a computer? Do you have difficulty driving? Do you have difficulty watching television? Do you have difficulty wearing contact lenses? Do you have difficulty being outdoors? Do your symptoms worsen throughout the day?

Do you use drops and/or ointment? Yes No (Circle) If yes, which drops and/or ointment do you use? _______________________________________ ______________________________________________________________________________ How frequently do you use the drops and/or ointment? _________________________________ ______________________________________________________________________________ Lid wiper epitheliopathy and dry eye symptoms. Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM, Exford JM, Blackie CA, Douglass T. Eye Contact Lens. 2005 Jan;31(1):2-8.Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Ngo W, Situ P, Keir N, Korb D, Blackie C, Simpson T. Cornea. 2013, Sep;32(9):1204-10.

For office use only Total SPEED score (Frequency + Severity) = ____/28

• SPEED Questionnaire

• OSDI

Alternative Questionnaires

Dry Eye Summit questions (2014)

1. Do your eyes ever feel dry or uncomfortable? 2. Are you bothered by changes in your vision throughout the day? 3. Are you ever bothered by red eyes? 4. Do you ever use or feel the need to use drops?

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Interferometry

• Lipiview® I & II

Lipiview® II

• Uses a light-emitting lid everter• Allows for selection of images from 3

modes• High resolution images utilized in patient

education

Keratograph® 5M

– NIKBUT– Tear meniscus height– Non-contact meibography (meiboscan)– Tear dynamics – Topography

Meibography• Transillumination

• LipiView I, LipiView® II

• Oculus Keratograph® 5M

• LipiScan®

• Meibox

LipiScan™

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LipiSca

10 seconds per eye

High Definition

Under normal

lighting

User-friendly

Small footprint

LipiScan™

REACTIVE CAREPROACTIVE CARE

Duct dilation, atrophy and dropout Severe atrophy and dropout

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Meibox• Anodized silver aluminum chassis• USB 3.0 attachment• 3 MP high resolution imaging

system• Adjustable camera height• Universal pin mount to any slit

lamp• Cloud based software

Meibography

Meibography ResearchPurpose: to determine if meibography could predict meibomian gland function with regard to number of functional MGs and/or estimation of functional MG volume in patients symptomatic for dry eye

• Methods: n=23 symptomatic for dry eye, mean age 48 years, 5 males: 18 females • Scored using the SPEED questionnaire • MG function and estimation of functional MG volume were performed with

meibomian gland evaluator (MGE) • Meibography was performed using the Modi Topographer • Lower lids were examined in three equal sections: nasal (N), central (C) and

temporal • (T) for the number of functional MGs and their functional volume (volume was as

1 for minimal, 2 for moderate and 3 for copious), and for MG dropout.

Meibomian Gland Function Cannot Be Predicted By Meibography In Patients Symptomatic For Dry Eye, David Murakami; Caroline A Blackie; HeikoPult; Donald R Korb Investigative Ophthalmology & Visual Science April 2014, Vol.55, 27.

Meibography Research

• Conclusions: There appears to be no relationship between the level of apparent drop out and the number of functional MGs and/or functional MG volume. These counterintuitive results strongly indicate that standard noncontact infrared meibography cannot be used to predict MG function in terms of number of functional glands and/or functional gland volume except in the case of total gland dropout, when the glands are completely absent.

Transillumination Blink Evaluation

• Blink Rate– Various diagnostics (LipiView I, II)– Manual

• Blink Quality– Partial blinks– Incomplete blinks

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Tear OsmolarityHyperosmolarity

• Central pathophysiologic mechanism for all forms of DED

• Causes inflammation and apoptosis & reduces the ability of mucins to lubricate

• Leads to a breakdown of homeostatic control causing tear film instability

• 308 mOsm/L is a highly sensitive cut-off point that delineates a normal from a mild/moderate dry eye population

• Inter-eye difference = hallmark of DED ( > 8 mOsms/L between eyes)

• Unstable tear film causes inter-eye differences

TearLab• The TearLab Osmolarity System is the first

objective and quantitative test for diagnosing and managing Dry Eye patients

• Fast and accurate results in seconds using only 50 nanoliters (nL) of tear film to diagnose Dry Eye Disease

• Enables discussion with patients around a number improving compliance

• Incorporating osmolarity into the standard of care gives the best indication of early stage disease

Tear Volume Testing Schirmer’s Test• Requires anesthesia• 5 minute testing time • Mildly irritating• Normal results: > 10mm

Phenol Red Thread • No anesthesia required• 15 seconds testing time • Little discomfort• Normal results: > 20mm

Red Phenol Other Tear Tests

• Tear Meniscus Height– Manual– Diagnostics

• Tear Stability: Tear Break Up Time (TBUT, NIBUT)– Less than 8-10 seconds abnormal

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Dry Eye Survey Research• 68 patients • OSDI, Schirmer’s Test, Tear Break-Up Time (TBUT) • Strong inverse correlation was found between

OSDI and TBUT • No correlation between OSDI and Schirmer’s

Testing

Ocular Surface Disease Index for the Diagnosis of Dry Eye Syndrome. Ocular Immunology and Inflammation, Volume 15, Issue 5, 2007.

Dry Eye Disease and MMP-9

Matrix metalloproteinases (MMP) are proteolyticenzymes that are produced by stressed epithelial cells on the ocular surface1

• MMP-9 in Tears– Non-specific inflammatory marker– Normal range between 3-41 ng/ml– More sensitive diagnostic marker than clinical signs1

– Correlates with clinical exam findings1

– Ocular surface disease/dry eye demonstrates elevated levels of MMP-9 in tears1

[1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): 3203-3209.

InflammaDry® Limit of Detection

Normal levels of MMP-9 in human tears ranges from 3-41 ng/ml

NEGATIVE TEST RESULTMMP-9 < 40 ng/ml

POSITIVE TEST RESULTMMP-9 ≥ 40 ng/ml

Type of Dry Eye

• Aqueous and Mucin Deficiency • Lipid Deficiency/MGD

Meibomian Gland Evaluation Microlagophthalmos Lid Seal Exam

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INNOVATIONS IN MGD:ADOPT CURRENT AND FUTURE MGD TREATMENTS

Tom Kislan, OD, FAAOMedical Director - Hazelton Eye Specialists

LipiFlow

LipiFlow® Thermal Pulsation System

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LipiFlow safely and effectively treats Meibomian gland obstruction in both upper and lower eyelids

simultaneously

• In-office procedure

• 12 minutes per eye51

LipiFlow® Offers a Solution for Patients Who Are Difficult to Treat

• Apply heat to the inner eyelids in both upper and lower eyelids simultaneously– LipiFlow® provides heat >40 C

to liquefy obstructed glands

• Liquefy the meibomian gland contents

• Facilitate release of secretion from the meibomian glands

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ActivatorApplies intermittent pressure to the outer eyelid

Inflatable air bladder

Insulated lidwarmer shields eye from heat andvaults above thecornea to preventcorneal contact

Lid warmerApplies directionalheat to inner eyelid

Heat facilitates release of secretion from obstructed meibomian glands

Treat meibomian gland obstruction in an in-office procedure

(12 minutes per eye)

LipiFlow® Provides Heat >40 C to Liquefy Obstructed Glands

Lid warmerComposed of a heater, eye insulation, and vaulted shape

Disposable eyepiece connects to a console used by the physician to control the application of heat and pressure to the eyelids

Heat applied to the palpebral surfaces of the upper and

lower eyelids directly over the

meibomian glands

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Complete Gland Expression: Gland Reset

• Obstructive MGD results in an atrophic process in glandular tissue inside the tarsal plates of the eyelids (histopathologicinvestigations)

• LipiFlow® may provide longer-term relief due to more complete evacuation of lumen contents, “resetting the clock” so that it may take a lot longer for symptoms to recur at the same level as pre-LipiFlow

5555

Effective therapeutic expression of obstructed glands can lead to remodeling of dysfunctional glands

LipiFlow® Provides Pressure to Evacuate Glands

ActivatorComposed of an inflatable air bladder and arigid activator

Disposable eyepiece connects to a control system used by the physician to control the application of heat and pressure to the

eyelids

Graded pulsatile pressure delivered to the outer eyelid

Therapeutic Goal of Pulsation

• Transiently decrease blood flow, thus increasing heat transfer efficiency

• Evacuate liquefied gland contents to alleviate the obstruction

• Apply pressure to the eyelids during the heating phase of the treatment (as opposed to after)

• Enable patient to experience little to no discomfort during treatment

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ActivatorApplies intermittent pressure to the outer eyelid

Inflatable air bladder

Insulated lidwarmer shields eye from heat andvaults above thecornea to preventcorneal contact

Lid warmerApplies directionalheat to inner eyelid

Heat facilitates release of secretion from obstructed meibomian glands

ActivatorActivatorApplies intermittent

the pressure to touter eyelid

Inflatable airbladder

Pressure and Pulsation for MGD

• LipiFlow® expresses upper and lower lids– Traditional focus was on lower lids due to easier

accessibility

• Treatment of all glands is important– ~45% of gland openings are functioning at one

time point1

– ~50% decrease of active glands from age 20 to 80 years1

581. Norn M. Meibomian orifices and Marx’s line: studied by triple vital staining. Acta Ophthalmol (Copenh). 1985;63(6):698-700.

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Pressure and Pulsation for MGD Pressure and Pulsation for MGD

• LipiFlow® inflates and deflates in such a way as to massage the eyelids from the terminal ends of the glands toward orifices

• LipiFlow provides complete, not partial, expression of glands

• In traditional expression, only 7% of patients could tolerate the pressure (range, 10 to 40 PSI) necessary for complete therapeutic expression along entire lower eyelid1

• LipiFlow needs to exert only ~0.6 PSI2

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1. Korb DR, Blackie CA. Meibomian gland therapeutic expression: quantifying the applied pressure and the limitation of resulting pain. Eye Contact Lens. 2011;37(5):298-301.

2. Korb D, Blackie C. Restoration of meibomian gland function post LipiFlow treatment. Poster presented at: ARVO 2011; May 1-5, 2011; Fort Lauderdale, FL. Poster D951.

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Safety

• The globe is insulated/protected from heat during treatment

• Massaging pressure is not transferred directly onto the eyeball1

• Pressure required is significantly less compared with unheated manual expression, which can lead to edema and bruising

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1. Friedland BR, Fleming CP, Blackie CA, Korb DR. A novel thermodynamic treatment for meibomian gland dysfunction. Curr Eye Res. 2011;36(2):79-87.

2. Korb DR, Blackie CA. Diagnostic versus therapeutic meibomian gland expression [abstract]. Presented at AAO Annual Meeting; November 11-13, 2009; Orlando, FL. http://www.aaopt.org/Submission/Search/SubmissionViewer.asp?SID=25745&BR=SP. Program 90745.

MiBo ThermoFLo

• New technology• Class II FDA approved-no 510K required vs• Lipiflow is Class III w a 510K required• No disposables• Cost effective for practice and patient• Easy for staff to perform• Great ROI

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Treatment Protocol-Mild Disease

• 12 minute-one week later-10 minute-2 weeks later-8 minute with office visit and osmolarityand inflammadry

• Mibo Mask (ie $40)• Out of pocket (ie $450)

Treatment Protocol-Moderate Disease

• 12 minute-2 weeks later-12 minute-1 week later-10 minute-1 week later-10 minute-2 week later-8 minute with office visit, osmolarity and inflammadry

• Mibo Mask (ie$40)• Out of pocket (ie$750)

Treatment Protocol-Severe Disease

• 12 minute-1 week later-10 minute-1 week later 8 minute-1 week later office visit with osmolarity and inflammadry and lipiflow

• Mibo Mask (ie$40)• Out of Pocket (ie$1250)

Dry Eye Yearly VIP Program

• For severe and chronic patients (this is a chronic disease, right???)

• Out of pocket (ie$875)• Includes unlimited miboflo treatments• Lipiflow at 50% (ie$450)• One 240 ct bottle of PRN Dry Eye Omega Benefits• 50% off glasses• Doctor cell phone

Treatment Pearls

• Treat early and often• Warm relaxing “SPA” environment• Give patient personal pillow• Relaxing music on with lights dim• Some offices use essential oils for aroma

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Intense Pulse Light

• Intense pulsed light (IPL) is a technology used by cosmetic and medical practitioners to perform various aesthetic and therapeutic skin treatments

• Stimulates the production of collagen, plumping up the skin and giving the patient a younger, fresher look

IPL - Indications

• Facial redness• Acne• Hyperpigmentation• Sun damage• Fine lines or wrinkles• Meibomian gland

dysfunction

True Tear True Tear

• Recently FDA approved• Allergan supported• Neurostimulation of all 3 layers of tear film• Use qid to bid but approved to 10 x a day• End of 6 month trial pts used qd to prn• Painless• Should be owned by ODs

A. B. C. D.

44% 44%

8%

3%

When to Treat MGD?

A. If MGD is present, I always treat MGD first with specific MGD treatment

B. If MGD is present, I sometimes treat MGD first with specific MGD treatment

C. I never treat MGD before treating with all of the other treatments

D. I never specifically treat MGDA. B. C. D.

5%

29%

63%

2%

Do you routinely prescribe warm compresses and for how long?

A. I do not prescribe a specific time

B. 1-5 minutes – as in shower

C. 10 minutesD. I do not prescribe

warm compresses

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INNOVATIONS IN MGD:TAKING YOUR PRACTICE TO THE NEXT LEVEL!!

Doug Devries, ODCo-founder - Eye Care Associates of NevadaAssociate Clinical Professor - Pacific University

Implementation Billing and CodingSuccess With MGD

A. B. C. D.

0%

24%

36%

40%

From the Patient Perspective, MGD Management has?

A. No improvement on my patients

B. Mild improvement for my patients

C. Moderate improvement for my patients

D. Significant improvement for my patients

***Data from Audience Response 2016 AOA Panel on MGD

A. B. C. D.

1%

20%

45%

33%

From the Provider Perspective, MGD Management has?

A. No improvement for my patients

B. Mild improvement for my patients

C. Moderate improvement for my patients

D. Significant improvement for my patients

***Data from Audience Response 2016 AOA Panel on MGD

A. B. C. D.

9%

36%

27%29%

From the Practice Perspective, MGD Management has?

A. No/negative impact on my practice

B. Mild positive impact on my practice

C. Moderate positive impact on my practice

D. Significant positive impact on my practice

***Data from Audience Response 2016 AOA Panel on MGD

Lipiview II

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Lipiview II

Static Illumination

Dynamic Illumination

Lid Transillumination

1. Korb DR, Blackie CA. Meibomian Gland Function Cannot Be Predicted By MeibographyUnless There Is Total Meibomian Gland Drop Out In Patients With MGD. AAO 2013 ABSTRACT

New measurement options of the Keratograph 5M

OCULUS Meibo-Scan

B.Sc. Florian Winzig

Meibomian Gland Evaluator (MGE™)

87

The number of FUNCTIONAL Meibomian Glands correlates with dry eye symptoms

With Symptoms1 (n=133)Asymptomatic healthy eyes2

(n = 24 glands)Severe Symptoms

Moderate Symptoms

Minimal Symptoms

Symptom Score, SPEED (0-28)

≥10(14.4 ± 0.7)

6–9(7.3 ± 0.2)

≤5(2.3 ± 0.2) 0

Number of functional MGs for lower eyelid

4.1 ± 0.6 5.1 ± 0.4 6.3 ± 0.4 10.6 ± 2.6

≤ 4, treatment necessary, (if glands present)5-6, intervention highly advised7-9, preventive treatment (PRN)

Notes: 1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-1147.2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297.

DRY NOT DRY

0 - 4 5 6 7 8 9 10+

FUNCTIONAL MGs in the Lower Lid

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OCULUS TF-Scan - Tear meniscus height measurement

New measurement options of the Keratograph 5M

• Overview of the curvature along the lid

• Digital measuring of the height and automatic documentation

• Automatic calibrated and digital measuring of the TMH

The NIKTMH measurement can be performed under infrared light conditions now → no influences on the tear film conditions!!

B.Sc. Florian Winzig

OCULUS TF-Scan NIKBUT (Non Invasive Keratograph Break-Up Time)

New measurement options of the Keratograph 5M

The NIKBUT measurement can be performed under infrared light conditions now → no influences on the tear film conditions!!

B.Sc. Florian Winzig

OCULUS TF-Scan – Lipid Layer

New measurement options of the Keratograph 5M

T hic k L ipid L ayerT hic k L ipid L ayer

The Lipid Layer:

• coat the underlying aqueous thereby impeding evaporation

• create a hydrophobic barrier to avert the overflow of tears

• act as a lubricant to prevent friction between the eyelid and ocular surface

• facilitate in creating a smooth refractive surface of good optical quality

B.Sc. Florian Winzig

T hin L ipid L ayer

The thickness of the lipid layer is a key indicator of tear film stability and evaporation!

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OCULUS TF-Scan: Tearfilm Dynamic

New measurement options of the Keratograph 5M

The Tearfilm Dynamic:

• Slow movement is associated with a thick lipid layer and a high-viscous tear film

• Rapid movement after a blink is negatively correlated with the tear film thickness and the viscosity

Tear movement correlates significantly with tear film thickness!

B.Sc. Florian Winzig

Lipiview

–C factor– ICU’s/nanometers–Partial/complete blinks–Video display

Micro-blepharoexfolication

Pre-Treatment Post-Treatment

94

BlephEx Treatment

95

Lid Hygiene – Surgical Considerations

• Types of Blepharitis:– Anterior• Staphylococcal• Seborrheic• Demodex• Angular

– Posterior• Meibomian Gland

Dysfunction (MGD)

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Lid Hygiene – Surgical Considerations

• Topical:– Lid wipes/foam– Hypochlorous acid solution– Tea tree oil wipes/foam

• Mechanical:– BlephEx

• Oral: – Ivermectin

The device applies controlled heat to the inner upper and lower palpebral conjunctival surfaces and lid margins, while simultaneously applying pulsating pressure over the upper and lower (outer) eyelids.

THERMODYNAMIC TX TO EXPRESS AND EVACUATE MGs

THE LIPIFLOW (TearScience Inc., Morrisville, NC)

A new thermodynamic treatment to express & evacuate the MGs

Heat applied to both inner lid surfaces

Pulsatile pressure applied to outer lids

FDA approved LipiFlow July 2011

Not the environment for success!

Patients buy what is on sale, end up with

inappropriate combos, may not follow

recommendations.

• Patented, clinically tested oral formula provides continuous relief from the inside out.

• Contains unique omega (GLA) – clinically backed in 7 dry eye trials; not found in diet/flax/fish. Provides other omegas, nutrient cofactors

• Stimulates tear production, eases inflammation

• Effective for almost any dry eye (i.e. contact lens, post-refractive, post-menopausal, allergy-related, Sjögren's, other types)

• Guaranteed relief within 60 days or money back; works for 80-85% of users

HydroEye®

Powerful Dry Eye Relief

Retail: $32.95Wh/sale: $19.50Staff: $13.25

•

•

•

•

TearScience® Solution

101

LipiView® OSI

LipiFlow® Auto

DisposableMeibomian Gland Evaluator

Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in the U.S. Limited by United States law to investigational use.

MGD TREATMENT

• Warm compresses• Meibomian gland scrubs• Home expression• Blinking • Office expression• Secretagogues – Androgens

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Collins Expressor Forceps (Item 98610)For aggressive expression of the Meibomian gland.

Livengood Expressor PaddlesAngled (Item 98620) & Flat (Item 98630)

For mild or gentle expression of the Meibomian gland.

New! Ophthalmic Surgical Instruments

Treatment 108 degreesInitial:12 min/lid1 week:10 min/lid2 weeks: 8 min/lidDual eye pad cuts time in half

Maskin Probe

1)$ 158 box ( 10)

2) 1,2,4,6 MM intraductals

3) Aluminum Handle $104

Wavelength (nm)400 600 700 800 900 1000

Inte

nsity

With a cut-off filter of 560 nm

From ear to ear, including nose

First, IPL:

Then, EXP:

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OSD Procedures• Meibomian Gland Expression– Manual– MeiboFlow

• Thermal Pulsation– LipiFlow

• Punctal Occlusion• Demodex Treatment– In Office Cliradex Swab, OcuSoft Swab

• Micro Blephroexfoliation• Amniotic Membrane

LipiView II with Dynamic Meibomian Imaging (DMI)

Dynamic Illumination Adaptive Transillumination Dual-Mode DMI

Normal Gland Structure

Gland Drop Out

Gland Truncation & Dilation

+ =

+ =

+ =

Demodex Mite In Office Demodex Treatments

• OcuSoft– Contains Tea Tree Oil + Buckthorn seed oil– Ung QHS– OcuSoft Cleansers

• Cliradex In Office Swab– Tea Tree Oil (4 Terpineol)– Preservative Free

112

Merchandising and ComplianceRe-Appointment Level II $45.30Re-Appointment Level III $74.09 to 88.63Re-Appointment Level IV $99.21 to 121.36

Punctal Occlusion OU $231.24 to 264.21Ant Seg Photos $17.35 to 57.78Amniotic Membrane $1489.02 to 2532.51Osmolarity Testing $12.57 to 23.47Inflammadry $10.57 to 19.42LipiView $65.00 to 150.00LipiFlow OU $950.00 to 2000.00Manual Expression $125.00 to 300.00

Bottom Line

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BlephEx $150.00 to 250.00Demodex Tx $125.00 to 200.00Supplements $395.40 ($161.00 Net)

Scrubs,Tears,Masks, Moisture Wear ($196.00 Net)

Bottom Line

4 Visits,Tears, Scrubs, Diagnostics, Net $5774 Visits, Plugs, Tears, Scrubs, Diagnostics, Net $768.004 Visits, Plugs, Tears, Scrubs, Diagnostic, BlephEx Net $9486 Visits, Plugs, Tears, Scrubs, Diagnostic, BlephEx, LipiView,

LipiFlow Net $1556.006 Visits, Plugs, Tears, Scrubs, Diagnostics, BlephEx, LipiView,

LipiFlow, 1 Amniotic Membrane $2464.006 Visits, Plugs, Tears, Scrubs, Diagnostics, BlephEx, LipiView,

Lipiflow, 2 Amniotic Membranes $3272.00

Bottom Line Examples

A. B. C.

2%

40%

58%

If you were going to start a dry eye clinic, which technology would you

look invest first?A. I would not invest in

technologyB. Diagnostic technology

(Anterior Segment Camera, Keratograph 5M, Lipiscan, Lipiview II)

C. Treatment/Management (BlephEx, Lipiflow, MiboThermoflo)

***Data from Audience Response 2016 AOA Panel on MGD

LET’S DISCUSS CASES

“Unable to wear CL’s greater than 2 hours”

• K.H. 54 year old Caucasian female • Symptoms increase with computer use and

prolonged near work• Burning, scratchy eyes OU, foreign body

sensation • OHx: Failed CL’s• Current Tx: AT’s, Tobradex, Lotemax PRN

MGD

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MGD Clinical Data

Baseline DataOsmolarity 308 OD, 296 OSMGE: O OD,OS- >80% gland loss OUPB OD: 7/7, 5/6ICU: 32 OD, 49 OSMMP9 – Neg. OU

Diagnosis

• MGD & KCS• Anterior Blepharitis• Conjunctivochalasis OU • Ocular Rosacea- main issue MGD/Ocular rosacea/Poor blink reflex/blink rate• Mild micro lagophthalmos- S/P Blepharoplasty OU- uppers and lowers

Treatment

• Bruder mask QHS OU, HydroEye PO, ATs PRN, Avenova QHS OU, Lotemax BID OU, start Restasis BID OU, Blink exercises, UNG/Humidifier QHS, removed plugs RLL/LLL, .003 brimonidine QD OU PRN

• Will plan for BBL and Lipiflow staged procedures later- poor potential outcome w/severe gland loss.

Treatment Update

• S/P BBL (4 treatments)• S/P Bilateral Lipiflow• Dispense TrueTear 5/25/17

MGD Treatment Options• Azithromycin• Restasis• Lid hygiene- scrubs, foams, sprays• Warm compresses• Oral Doxycycline, azithromycin PO• Antibiotic/steroid combination drops/ointments• Lid/Gland Expression• IPL/BBL• Omega 3 Supplementation• Gland Ductal Probing• LipiFlow Thermal Pulsation System• TrueTear

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16 yo WF

• Presented for 3rd opinion• CC can’t wear CLs more than 5-6 hours• First OD switched from AV2 to Oasys to Ultra

with no improvements• Second OD switched from Ultra to Oasys one

day to DT1 with slight improvement to 7-8 hours

ITF Guidelines

• ITF 1-lissamine stain of conjunctiva• ITF 2-visual fluctuations and/or peripheral

corneal stain• ITF 3-central stain and/or filaments• ITF 4-RCE/neurotrophic ulcers

Slit Lamp Exam

• Lids: telangiectasia, capped glands, atrophy• Conj: hyperemic, lissamine green stain• Cornea: ITF 2, severe peripheral stain along

lid margins, TBUT 2 seconds• Osmolarity: OD 330 OS 335• Inflammadry: Positive OU• Keratograph: See picture

Treatment

• Limit device time, discussed regular blinking• Lotemax bid• Restasis bid• TG Omega 3 2668 mg/day• Systane balance qid

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10 week follow up

• ITF 2 still• TBUT 2 sec still• Inflammadry: positive to negative• Osmolarity: 330/335 to 315/310• Performed 12 minute Mibo, 1 week later 10

minute Mibo, 1 week later 8 minute Mibo• Mibo Mask 10 minute/day

8 week follow up

• Still on lotemax, restasis, TG Omega 3, systanebalance qid

• Inflammadry: still negative• Osmolarity: 300/301• ITF 1• TBUT 7 seconds• Performed Lipiflow• Lotemax bid x 4 weeks then d/c

8 week follow up

Still on Restasis, TG Omega 3, systane balanceInflammadry: NegativeOsmolarity: 296/301ITF 1Continue present treatments and MiboMask 10 min/dayMom asked about accutane for acne-UGH!!!!

Case Example

• 76YOWF – Present for follow up for Glaucoma and dry eye disease. Compliant with drops OU. Vision has been blurry and eyes irritated more in the past few months– Previous treated with topical azithromycin – Current Ocular Meds: Restasis BID OU,

latanoprost qhs OU– Numerous systemic meds including singulair,

synthroid

• How do you address OSD and Glaucoma?

• Does glaucoma stage make a difference?

• What testing and treatment?

• SPEED Score: 33• Tear Osmolarity 308 / 315• SLE: 2+ MGD OD / 3+ MGD OS / 1+ SPK OU• Cloud secretions OU• MG Structure: See images• IOP: 14/13• HVF: Stable OU

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Early to Moderate Structural Changes to Meibomian Glands

Advanced Gland Atrophy / Dropout

Post Treatment

6 Weeks Post Treatment• Post Tx Osmolarity

– 300/299• Post Lipiflow Management

– Heat masks qhs OU– Hydroeye as directed– Restasis BID OU– Lipid based tear BID OU– Latanoprost qhs OU– F/u 3 months dry eye

• Order tear osmolarity• Order inflammadry• SPEED Questionnaire

Conclusion

Decide on your practice philosophyEducate your entire staffAdd an MGD assessment (function/structure) to all patient encountersInclude and prioritize the treatment of obstructionKnow that this will benefit your patients and your practice

Thank you!

• Doug Devries, OD - drdevries@nveyelaser.com• Josh Johnston, OD - jkjohnston1@yahoo.com• Tom Kislan, OD - foreeyes@ptd.net• Walt Whitley, OD - wwhitley@vec2020.com