David L. Kading, OD, FAAO, has several private specialty practices in the greater Seattle area. Over the years, his practice has evolved into a referral base practice. One of the specialty areas of practice revolve around dry eye disease (DED) and meibomian gland management. In an Optometry Times roundtable discussion, he described how he approaches diagnosing patients.
The discussion with other practitioners showed a few factors indicated a need for increased attention to the ocular surface. The discussion also indicated that most patients do not know that they have dry eye; they report a need for increased blinking to clear vision and burning/stinging but fail to recognize the cause. This raises questions about diagnosing dry eye and differentiating between simple dry eyes and DED.
Kading’s simplified definition of dry eye is that the ocular surface system fails to protect itself from desiccating stress.
The roundtable discussion turned to how often clinicians see dry eyes, especially in patients who are pre-cataract and/or wear contact lenses and glasses. The participants responded that at least 50% of patients have DED. There was disagreement about the difference between DED and MGD; some believe that the 2 are intertwined and others not.
Kading emphasized the importance of administering a questionnaire to patients to ferret out the dry eye cases. The Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire provides a measurable way to track MGD from visit to visit and how well treatments are working. “The SPEED questionnaire highlights patients who have MGD. [Approximately] 86% of patients who have dry eye have MGD, according to the studies,” he said. The bottom line seems to be that detecting DED is far from being an exact science, and clinicians are using several different technologies and treatments to address patient needs.
Ocular surface treatments
Treatments can range from instillation of non-preserved eye drops to nutritional supplementation and use of the LipiFlow Thermal Pulsation System (Johnson & Johnson), which addresses MGD, and intense pulsed light (IPL) therapy (OptiLight; Lumenis). Kading talked about several products that give clinicians a true picture of the ocular status that can steer treatment in the right direction.
However, when trying different treatments, he depends on hard evidence. He has learned to believe his own eyes and not so much what patients are describing. “If I listen to their symptoms, I change my treatment. If my treatment is based on what I see and the improvements that are occurring on the ocular surface, and those improvements continue to happen, I have to believe that eventually their symptoms will improve, and in fact, that is what I have seen over the years” he said.
A practical example is that he knows that patients are improving if the number of oil secretions are increasing from visit to visit, even if they claim that they are not improving. He relies on objective measurements and advises that clinicians place less importance on what patients are saying and rely more on whether the treatments are working and the eyes are functioning better.
Despite a short tear breakup time, and symptoms, the only factor Kading considers in the diagnosis of MGD is the number of functioning glands. He says that the best evidence we have in MGD improvement is seeing that the number of functional glands increases. That is when their MGD is getting better. In his clinic, thermal pulsation has been the most effective treatment. He encouraged attendees to look for treatments that, with time, would increase the number of functional glands.
IPL and heat therapy
The optometrists expressed satisfaction with the effects of IPL for treating DED due to MGD, reporting “phenomenal results.” The clinicians
described performing IPL every 2-4 weeks for 4-5 sessions.
Kading likes to use both thermal pulsation and IPL together because of their different functions. “I realized that IPL was not an alternative treatment to thermal pulsation and that IPL was really targeting inflammation,” he said. Kading mentioned that IPL works in concert with thermal pulsation to create a symphony of treatment.
“If patients have 6 or more glands that are flowing, I know they need a thermal pulsation procedure to improve the flow in the functioning glands. I also know that with IPL, after the glands are flowing due to thermal pulsation, every single IPL I do thereafter is likely going to continue to get those glands flowing better,” he said.
New effective drop
Perfluorohexyloctane ophthalmic solution (Miebo; Bausch + Lomb) is a new drug that helps stabilize the tear film and prevents its evaporation. The effects can last for up to 6 hours. “The drop works by increasing the thickness of the lipid layer of the tear film, which is an effect of functioning meibomian glands,” he said. “I can start my patients on the drop and have them return for their IPL and thermal pulsation, and the lipid layer thickness will start to improve because the meibomian glands are functioning better. This may increase [adherence] with our treatments because there is less of a delay in treatment effects,” Kading said. “This drop is complementary to our in-office procedures. It really is a great option for us to add to our [practice].”