Vectored Thermal Pulsation as a Treatment for Meibomian Gland Dysfunction: A Review Spanning 15 Years.

The LipiFlow Thermal Pulsation System received its first marketing clearance for the treatment of meibomian gland dysfunction (MGD) 13 years ago. Since then, the evidence evaluating the effectiveness and safety of LipiFlow as a treatment for MGD has grown significantly. The objective of this comprehensive review was to summarize all clinical reports evaluating the effectiveness and safety of LipiFlow over the past 15 years. The literature was systematically reviewed, and 55 unique articles had subjective (patient-reported outcomes) and objective (meibomian gland function, tear production, and ocular staining) outcomes for extraction. Data were collected from 2101 patients and 3521 eyes treated with LipiFlow. Of these, effectiveness was evaluated in 2041 patients and 3401 eyes, and safety was evaluated in 1448 patients and 2443 eyes. Taken together, the studies demonstrate that a single 12-min treatment with LipiFlow safely improves signs and symptoms of MGD and associated evaporative dry eye disease (DED), and the benefits persist up to 3 years in some cases. The findings are corroborated by multiple meta-analyses and consensus guidelines. While some studies showed that daily eyelid hygiene, warm compress, and/or massage had a similar benefit to a single LipiFlow, these treatments were limited by inconvenience, discomfort, and non-compliance. The majority of studies evaluating safety reported no discomfort or pain associated with LipiFlow treatment, which supports the patient acceptability of LipiFlow therapy. All adverse events (AEs) related to LipiFlow were transient, non-vision-threatening, and did not require treatment. No studies reported serious AEs. The data obtained from 55 studies conducted globally overwhelmingly show that LipiFlow is effective and safe for the treatment of MGD and associated evaporative DED. The conclusions are supported by the diversity of the patient populations (geography, race, disease severity, and diagnosis), the large population treated with LipiFlow, the meta-analyses, and that this review analyzed all published clinical studies to date.

Temporal variations in meibomian gland structure-A pilot study.

PURPOSE: To investigate whether there is a measurable change in meibomian gland morphological characteristics over the course of a day (12 h) and over a month. METHODS: The study enrolled 15 participants who attended a total of 11 study visits spanning a 5-week period. To assess diurnal changes in meibomian glands, seven visits were conducted on a single day, each 2 h apart. For monthly assessment, participants attended an additional visit at the same time of the day every week for three consecutive weeks. Meibography using the LipiView® II system was performed at each visit, and meibomian gland morphological parameters were calculated using custom semi-automated software. Specifically, six central glands were analysed for gland length ratio, gland width, gland area, gland intensity and gland tortuosity. RESULTS: The average meibomian gland morphological metrics did not exhibit significant changes during the course of a day or over a month. Nonetheless, certain individual gland metrics demonstrated notable variation over time, both diurnally and monthly. Specifically, meibomian gland length ratio, area, width and tortuosity exhibited significant changes both diurnally and monthly when assessed on a gland-by-gland basis. CONCLUSIONS: Meibomian glands demonstrated measurable structural change over short periods of time (hours and days). These results have implications for innovation in gland imaging and for developing precision monitoring of gland structure to assess meibomian gland health more accurately.

A Deep Learning Approach for Meibomian Gland Appearance Evaluation.

Purpose: To develop and evaluate a deep learning algorithm for Meibomian gland characteristics calculation. Design: Evaluation of diagnostic technology. Subjects: A total of 1616 meibography images of both the upper (697) and lower (919) eyelids from a total of 282 individuals. Methods: Images were collected using the LipiView II device. All the provided data were split into 3 sets: the training, validation, and test sets. Data partitions used proportions of 70/10/20% and included data from 2 optometry settings. Each set was separately partitioned with these proportions, resulting in a balanced distribution of data from both settings. The images were divided based on patient identifiers, such that all images collected for one participant could end up only in one set. The labeled images were used to train a deep learning model, which was subsequently used for Meibomian gland segmentation. The model was then applied to calculate individual Meibomian gland metrics. Interreader agreement and agreement between manual and automated methods for Meibomian gland segmentation were also carried out to assess the accuracy of the automated approach. Main Outcome Measures: Meibomian gland metrics, including length ratio, area, tortuosity, intensity, and width, were measured. Additionally, the performance of the automated algorithms was evaluated using the aggregated Jaccard index. Results: The proposed semantic segmentation-based approach achieved average aggregated Jaccard index of mean 0.4718 (95% confidence interval [CI], 0.4680-0.4771) for the 'gland' class and a mean of 0.8470 (95% CI, 0.8432-0.8508) for the 'eyelid' class. The result for object detection-based approach was a mean of 0.4476 (95% CI, 0.4426-0.4533). Both artificial intelligence-based algorithms underestimated area, length ratio, tortuosity, widthmean, widthmedian, width10th, and width90th. Meibomian gland intensity was overestimated by both algorithms compared with the manual approach. The object detection-based algorithm seems to be as reliable as the manual approach only for Meibomian gland width10th calculation. Conclusions: The proposed approach can successfully segment Meibomian glands; however, to overcome problems with gland overlap and lack of image sharpness, the proposed method requires further development. The study presents another approach to utilizing automated, artificial intelligence-based methods in Meibomian gland health assessment that may assist clinicians in the diagnosis, treatment, and management of Meibomian gland dysfunction. Financial Disclosures: The authors have no proprietary or commercial interest in any materials discussed in this article.

Evaluation of Meibomian gland structure and appearance after therapeutic Meibomian gland expression.

CLINICAL RELEVANCE: Evaluating how Meibomian glands can change in appearance has the potential to advance the understanding of Meibomian gland health and may lead to enhanced diagnosis and therapy. BACKGROUND: This work aimed to investigate Meibomian gland appearance after therapeutic Meibomian gland expression. METHODS: Fifteen subjects attended three study visits over a two-week period. Meibography was performed before and after therapeutic Meibomian gland expression, the following day, and 2 weeks after expression. Six central glands were used to calculate Meibomian gland morphological parameters such as gland length ratio, gland width, gland area, gland tortuosity, and gland contrast. A custom semi-automated image analysis software was used to calculate Meibomian gland metrics. Furthermore, a high-resolution imaging system was developed to capture clear images of the Meibomian glands, free of any artefacts, which were used for precise calculations of Meibomian gland contrast. RESULTS: The expression procedure had a significant impact on Meibomian gland contrast and length ratio immediately afterwards. The least square mean difference (95% CI) from baseline for Michelson contrast was -0.006 (-0.010, -0.001) and -1.048 (-2.063, -0.033) for simple contrast. The least square mean ratio of the gland length ratio immediately after the expression to baseline was 0.758 (0.618, 0.931). CONCLUSIONS: Following therapeutic expression, Meibomian glands exhibit reduced brightness and length. However, within 24 h, they appear to recover and return to their baseline state, indicating a relatively short recovery time. This sheds light on whether meibography is solely focused on capturing gland structure or if it also captures acinar activity. The hyperreflective properties of lipids suggest that the decrease in contrast observed after expression could be attributed to a reduction in the visualisation of acini activity. A decrease in Meibomian gland length ratio implies that the loss of gland structure following treatment may be indicative of a temporary structural alteration.

Preoperative Treatment of Meibomian Gland Dysfunction with a Vectored Thermal Pulsation System Prior to Extended Depth of Focus IOL Implantation.

INTRODUCTION: Patients implanted with a range-of-vision intraocular lens (IOL) (multifocal or extended depth of focus, EDOF) may be more susceptible to visual disturbances from poor tear film quality, and prophylactic treatment of meibomian gland dysfunction (MGD) has been recommended. The purpose was to evaluate whether vectored thermal pulsation (LipiFlow™) treatment prior to cataract surgery with a range-of-vision IOL safely improves postoperative outcomes. METHODS: This is a prospective, randomized, open-label, crossover, multicenter study of patients with mild-to-moderate MGD and cataract. The test group underwent LipiFlow treatment prior to cataract surgery and implantation of an EDOF IOL, while the control group did not. Both groups were evaluated 3 months postoperatively, after which the control group received LipiFlow treatment (crossover). The control group was re-evaluated 4 months postoperatively. RESULTS: A total of 121 subjects were randomized, with 117 eyes in the test group and 115 eyes in the control group. At 3 months after surgery, the test group had a significantly greater improvement from baseline in total meibomian gland score compared with the control group (P = 0.046). At 1 month after surgery, the test group had a significant decrease in corneal (P = 0.04) and conjunctival (P = 0.002) staining compared to the control group. At 3 months after surgery, the test group had significantly lower incidence of being bothered by halos compared with the control group (P = 0.019). The control group had a significantly lower incidence of being bothered by multiple or double vision compared with the test group (P = 0.016). After crossover, patients had significant improvement in vision (P = 0.03) and total meibomian gland score (P < 0.0001). No safety concerns or relevant safety findings were uncovered. CONCLUSION: Presurgical LipiFlow treatment of patients implanted with range-of-vision IOLs improved meibomian gland function and postoperative ocular surface health. This supports guidelines recommending proactive diagnosis and management of MGD in patients with cataracts to improve patient experience. TRIAL REGISTRATION: The study was registered on www. CLINICALTRIALS: gov (NCT03708367).

Listening to Patients With Lupus: Why Not Proactively Integrate the Internet as a Resource to Drive Improved Care?

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease. It is characterized by a broad spectrum of manifestations, depending on the affected organs and the severity of the inflammation at the time of presentation. Despite improvements in management, treatments are required on a chronic, cyclical basis; have high potential for unpleasant side effects; and deliver variable efficacy. Patients require care from multiple specialists, which can be delivered simultaneously and sporadically. Our fragmented health care system further exacerbates the disconnect between intermittent medical care and the lived experiences of patients with SLE. The goals of this research are to (1) assess the current standard of care for patients with SLE through the review of medical literature, including clinical consensus guidelines and systematic reviews; (2) assess the lived experiences of patients with lupus through the review of peer-reviewed literature on social listening, structured interviews, and data available from the open-access digital health platform PatientsLikeMe; and (3) present the perspective that the medical community has an opportunity to acknowledge and review the use of digital health interventions (DHIs) with their patients. The results of this research indicate that patients are incorporating DHIs, such as the internet and social media platforms, as critical components of their care for even the most basic of support. Although patients with SLE are depending on this support to shape their care, it is not considered a primary source of care by clinicians. Integrating the voices of patients brings valuable dimension to understanding the lived experiences of patients with SLE and the impacts of mutually dependent patient needs as patients navigate the disease in daily life. The medical community has a meaningful opportunity to leverage and recommend existing DHIs, such as web-based community platforms and web-based patient registries, at every stage of the patient journey to help patients better manage their condition. This has the potential to proactively build patient trust and well-being, reduce the underreporting of symptoms, increase shared decision-making, inform and shape clinical guidelines and future research, and improve patient outcomes.

Development of Artefact-Free Imaging System for Accurate Meibomian Gland Reflectivity Assessment.

Purpose: To develop and evaluate a custom imaging system to provide high-resolution, wide depth-of-field, reflection-free, multispectral infrared (IR) imaging of the Meibomian glands. Methods: Lower eyelids of 15 volunteers were everted to obtain multispectral images of the Meibomian glands with custom imaging setup. Photographs were captured at 10 different ISO settings (from underexposure to overexposure) and using nine IR imaging filters (ranging from 600 nm to 1000 nm in 50-nm steps). Meibomian gland contrast (simple and Michelson) was calculated for the images to choose an optimal wavelength for Meibomian gland imaging and to determine differences in contrast across individuals. Results: The overall linear regression model showed a significant effect of wavelength on Meibomian gland contrast (Simple contrast: F = 7.24, P < 0.0001; Michelson contrast: F = 7.19, P < 0.0001). There was a significant negative correlation between Meibomian gland contrast and Meibomian gland depth for 750-nm IR filter (ρs= -0.579; P = 0.026). Conclusions: Meibomian gland contrast varies across individuals and depends on Meibomian gland depth. IR filter of 750 nm is the optimal choice for Meibomian gland imaging because it provides images of greatest contrast. Translational Relevance: This study adds to our understanding of Meibomian gland imaging. It has successfully demonstrated that Meibomian glands that are deeper in the tarsal plate require longer wavelengths for imaging.

Latest developments in meibography: A review.

Meibography is a visualisation technique that has been used for over 40 years. There have been significant improvements in image quality, examination technique and image interpretation over this period. Although meibography has received sporadic reviews in the past, an updated review is timely due to the rapid recent rise of relevant technology and advances in both image processing and artificial intelligence. The primary aim of this paper is to review recent research into Meibomian gland imaging and update the community about the most relevant technologies and approaches used in the field.

Comparison of a single-dose vectored thermal pulsation procedure with a 3-month course of daily oral doxycycline for moderate-to-severe meibomian gland dysfunction.

PURPOSE: The aim of this study was to compare the efficacy of a single bilateral 12-minute vectored thermal pulsation (VTP) procedure versus daily oral doxycycline for 3 months for moderate-to-severe meibomian gland dysfunction (MGD). METHODS: This prospective, randomized, parallel-group, single-masked study included 28 subjects who received either a single-dose VTP or 3 months of doxycycline treatment. At baseline and 3 months post treatment, all subjects were evaluated for the following: dry eye symptoms with a standard dry eye questionnaire (the Standard Patient Evaluation for Eye Dryness [SPEED]), meibomian gland (MG) function by counting the number of glands yielding liquid secretion with the MG evaluator (MGE), tear breakup time (TBUT) and corneal and conjunctival staining. RESULTS: In the VTP group, at 3 months, there was a significant improvement in MG function (4.00±1.47 to 7.73±5.53), SPEED score (11.00±3.30 to 5.42±2.15), TBUT (6.26±2.01 to 8.44±1.81), corneal staining (0.38±0.50 to 0.12±0.33) and conjunctival staining (1.69±1.93 to 0.62±0.85). In the doxycycline group, there was a significant improvement in MG function (4.63±1.41 to 10.63±5.91), SPEED score (13.42±4.17 to 9.42±5.47) and conjunctival staining (2.38±1.88 to 1.13±1.51), but the improvement in TBUT (6.90±2.56 to 7.59±2.03) and corneal staining (0.21±0.41 to 0.13±0.34) was not statistically significant (p=0.262 and p=0.414, respectively). At 3 months, SPEED score was significantly better in the VTP group (p<0.05); other parameters were comparable between the two groups. CONCLUSION: A single 12-minute bilateral VTP procedure was significantly more effective than the 3-month daily course of oral doxycycline at improving the dry eye symptoms secondary to MGD. A single 12-minute VTP treatment was at least as effective as a dose of doxycycline for 3 months, in improving MG function and all measured signs of MGD. Given the minimal risk profile of the single VTP procedure over long-term doxycycline use, a single VTP presents a favorable alternative to long-term antibiotic use.

A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day.

PURPOSE: To evaluate the effect of a single vectored thermal pulsation (VTP) treatment in contact lens wearers with meibomian gland dysfunction (MGD) and dry eye symptoms. METHODS: The prospective, nonsignificant risk, open-label, randomized, multi-center clinical trial included 55 soft contact lens (SCL) wearers with MGD and evaporative dry eye. Subjects were randomized to the single VTP treatment group or an untreated control. The controls received a crossover VTP treatment at 3 months (crossover treatment group). Primary effectiveness measures were meibomian gland secretion (MGS) score and Standard Patient Evaluation of Eye Dryness (SPEED) that were evaluated at baseline, at 1 and 3 months post-VTP treatment, and at 1 month post-VTP treatment in the crossover treatment group. Exploratory variables included fluorescein tear break-up time (TBUT), lid wiper epitheliopathy (LWE), lid parallel conjunctival folds (LIPCOF), ocular surface staining, frequency of over-the-counter (OTC) drop use, and hours of comfortable contact lens wear. RESULTS: At 3 months, the treatment group showed significantly greater mean change from baseline in MGS (12.4±9.1 vs 1.4±6.4, p<0.0001), SPEED (-8.4±4.7 vs -0.7±4.4, p<0.0001) and significantly greater improvement in exploratory variables (TBUT, LWE, and frequency of OTC drop use) relative to the controls. Mean comfortable contact lens wearing time increased by 4.0±3.9 hours at 1 month. This was sustained for 3 months with no change in the control group. The crossover treatment group demonstrated similar results to the treatment group at 1 month post-VTP. CONCLUSION: In SCL wearers with MGD, a single VTP treatment significantly improved mean meibomian gland function and significantly reduced dry eye signs and symptoms compared to an untreated control. The treatment increased mean comfortable lens wearing time by 4 hours (approximately doubling the pretreatment findings). This was sustained for up to 3 months post-treatment on average.

Meibomian gland dysfunction patients with novel Sjögren's syndrome biomarkers benefit significantly from a single vectored thermal pulsation procedure: a retrospective analysis.

PURPOSE: To measure the effects from a single vectored thermal pulsation treatment of the meibomian glands on dry eye signs and symptoms in patients who tested positively versus negatively for novel Sjögren's syndrome (SS) biomarkers. METHODS: The retrospective study included the deidentified data of 102 eyes of 59 patients with dry eye and meibomian gland dysfunction (MGD), who were also tested for novel biomarkers for SS and underwent a single 12-minute LipiFlow thermal pulsation procedure. All patients were already being treated with individualized dry eye therapy but remained symptomatic. Meibomian gland secretion (MGS) scores, Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire scores and tear breakup times (TBUTs) before and 8 weeks after thermal pulsation treatment were analyzed. RESULTS: Twenty-three patients tested positive for novel biomarkers of SS and 36 patients tested negative. At baseline, MGS, SPEED and TBUT of both SS-positive and SS-negative patients were equivalent. At 8 weeks' post-treatment, mean MGS score, SPEED and TBUT were 13.0±7.8, 12.5±6.8 and 9.6±4.6, respectively, in SS-positive patients and 15.9±7.9, 10.0±6.3 and 8.3±4.6, respectively, in SS-negative patients (P<0.001). While the post-treatment MGS was significantly better in SS-negative patients than SS-positive (P=0.021), no significant difference between post-treatment SPEED and TBUT was observed between the two groups (P>0.05). CONCLUSION: LipiFlow treatment in MGD patients who were SS-positive for novel biomarkers of SS demonstrated improvement in signs and symptoms of dry eye. While improvement in MGS scores in SS-negative patients was higher than that observed in SS-positive patients, SPEED and TBUT were equivalent between these two groups.

The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye.

PURPOSE: To evaluate the sustained effect (up to 1 year) of a single, 12-minute vectored thermal pulsation (VTP) treatment in improving meibomian gland function and dry eye symptoms in patients with meibomian gland dysfunction and evaporative dry eye. METHODS: The prospective, multicenter, open-label clinical trial included 200 subjects (400 eyes) who were randomized to a single VTP treatment (treatment group) or twice-daily, 3-month, conventional warm compress and eyelid hygiene therapy (control group). Control group subjects received crossover VTP treatment at 3 months (crossover group). Effectiveness measures of meibomian gland secretion (MGS) and dry eye symptoms were evaluated at baseline and 1, 3, 6, 9, and 12 months. Subjects with inadequate symptom relief could receive additional meibomian gland dysfunction therapy after 3 (treatment group) and 6 months (crossover group). RESULTS: At 3 months, the treatment group had greater mean improvement in MGS (P<0.0001) and dry eye symptoms (P=0.0068), compared to controls. At 12 months, 86% of the treatment group had received only one VTP treatment, and sustained a mean improvement in MGS from 6.4±3.7 (baseline) to 17.3±9.1 (P<0.0001) and dry eye symptoms from 44.1±20.4 to 21.6±21.3 (P<0.0001); 89% of the crossover group had received only one VTP treatment with sustained mean improvement in MGS from 6.3±3.6 to 18.4±11.1 (P<0.0001) and dry eye symptoms from 49.1±21.0 to 24.0±23.2 (P<0.0001). Greater mean improvement in MGS was associated with less severe baseline MGS (P=0.0017) and shorter duration of time between diagnosis and treatment (P=0.0378). CONCLUSION: A single VTP treatment can deliver a sustained mean improvement in meibomian gland function and mean reduction in dry eye symptoms, over 12 months. A single VTP treatment provides significantly greater mean improvement in meibomian gland function and dry eye symptoms as compared to a conventional, twice-daily, 3-month regimen. Early VTP intervention for meibomian gland dysfunction is associated with improved treatment outcomes.

A Comparative Study Between an Oil-in-Water Emulsion and Nonlipid Eye Drops Used for Rewetting Contact Lenses.

OBJECTIVES: The purpose of this study was to determine the clinical impact of using SYSTANE BALANCE Lubricant Eye Drops (Alcon, Fort Worth, TX), an oil-in-water emulsion, as a rewetting eye drop in symptomatic contact lens wearers. METHODS: Subjects who had previously experienced contact lens discomfort (CLD), with a mean lens wearing history of 18.6±12.8 years, were randomly assigned to use a Test (SYSTANE BALANCE Lubricant Eye Drops; n=76) or control (habitual nonlipid contact lens rewetting eye drop; n=30) drop over their contact lenses within 5 min of lens insertion and then subsequently at 2 hr intervals up to a maximum of 4 drops per eye daily for a 1-month period. Assessments of subjective comfort, comfortable wearing time, lid wiper epitheliopathy (LWE), and corneal staining were conducted at baseline and after 1 month, after 6 hr of lens wear. RESULTS: Comfort, wearing time, LWE, and corneal staining all showed statistically significant improvements in the test group using SYSTANE BALANCE Lubricant Eye Drops at the 1-month visit compared with baseline data (all P<0.01) and compared with the control group at the 1-month visit (P<0.01, P=0.01, P<0.01, and P=0.03, respectively). CONCLUSIONS: The use of SYSTANE BALANCE Lubricant Eye Drops as a rewetting drop in a group of wearers who experienced symptoms of CLD improved subjective comfort scores, increased comfortable wearing time, and reduced signs of LWE and corneal staining, when compared with the use of non-lipid-containing contact lens rewetting eye drops.

All Warm Compresses Are Not Equally Efficacious.

PURPOSE: To investigate which warm compress (WC) methods used in a small case series are the most effective in providing heat to the inner eyelids for the supplemental treatment of meibomian gland dysfunction. METHODS: Inclusion criteria included the following: 18 years or older and willingness to participate in the study, no current ocular inflammation/disease, and no ocular surgery within the last 6 months. Five patients were fully consented and enrolled. Various forms of contact and noncontact WC heating methods (dry, wet/moist, and chemically activated dry heat) were tested. A paired contralateral design was used; each subject had a heated test eye and an unheated control eye. For both test and control eyes, the temperature of the external upper, external lower, and internal lower lids was measured at baseline and every 2 minutes for 10 minutes during application. Each participant underwent each of the eight treatments under study. Microwaved compresses were heated to 47 ± 1.0°C; two compresses were self-heating and thus not under investigator control. RESULTS: The mean (± SD) age of the patients was 42.2 (± 20.3) years. Out of the eight methods tested, the bundled wet/moist towel method was the only compress that elevated the temperature of all three lid surfaces (external upper, external lower, and internal lower lids) to 40°C or higher. The chemically activated EyeGiene, MGDRx EyeBag, and MediBeads compresses resulted in the lowest temperature increase at the inner palpebral surface. CONCLUSIONS: The Bundle method, although the most labor intensive, increased lid temperatures above therapeutic levels, as reported in the literature, for all measured sections during the WC application. As such, this method of WC application can be recommended for supplemental at-home therapy for meibomian gland dysfunction and any condition requiring that therapeutic heat of 40°C be administered to the meibomian glands.

"Dry Eye" Is the Wrong Diagnosis for Millions.

The clinical perspective that dry eye is, at best, an incomplete diagnosis and the benefit of an etiology-based approach to dry eye are presented. To provide context for this perspective, the historical and current definition of dry eye is reviewed. The paradigm shift introduced by the Meibomian Gland Dysfunction (MGD) Workshop, that MGD is likely the leading cause of dry eye, is discussed in combination with the advancements in the diagnosis and treatment of MGD. To facilitate discussion on the benefit of an etiology-based approach, a retrospective observational analysis was performed on deidentified data from eligible, fully consented, refractory dry eye patients, where conventional sequelae-based dry eye treatment had failed. In this refractory population, the diagnosis of MGD, which directed treatment to evacuating gland obstructions and rehabilitating gland function, was successful. The clinical perspective that "dry eye" is the wrong diagnosis for millions is provocative. However, the MGD-first approach has the potential to revolutionize the timing of diagnosis and the choice of frontline therapy in most patients with dry eye. Additionally, the ability to screen for MGD in its earliest stages, during routine care, expands the scope of clinical practice to include early intervention. For most patients, we are no longer constrained to delay diagnosis until the tear film has decompensated and the cascade of inflammation has ensued. We do not have to wait for our patients to tell us there is a problem.

Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review.

PURPOSE OF REVIEW: Meibomian gland dysfunction (MGD) is understood to be a highly prevalent, chronic progressive disease and the leading cause of dry eye. All available published peer-reviewed results of the novel vectored thermal pulsation therapy for patients with MGD are investigated. RECENT FINDINGS: The PubMed and meeting abstract search revealed a total of 31 peer-reviewed reports on vectored thermal pulsation therapy at the time of the search (eight manuscripts and 23 meeting abstracts). All manuscripts evidence a significant increase in meibomian gland function (∼3×) and symptom improvement post a single 12-min treatment. Additional reported objective measures such as osmolarity, tear break-up time, or lipid layer thickness also increased as a result of the therapy; however, not all findings were statistically significant. The randomized controlled studies evidence sustained gland function and symptom relief lasting out to 12 months. The uncontrolled case series evidence significantly longer duration of effect. SUMMARY: A single 12 minute vectored thermal pulsation treatment allows for reducing dry eye symptoms, improving meibomian gland function and other correlates of the ocular surface health.

Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on meibomian gland functionality in patients with lipid deficient/evaporative dry eye.

PURPOSE: The aim of this study was to assess the efficacy of using a combination treatment approach consisting of lipid emulsion eye drops, eyelid cleansing wipes, and omega-3 vitamin supplements compared with warm compresses in improving meibomian gland functionality in patients with lipid-deficient/evaporative dry eye disease (LDDE). METHODS: This single-center, open-label, investigator-masked, randomized study enrolled patients aged ≥18 years, clinically diagnosed with LDDE defined as having ≤6 functional meibomian glands [meibomian gland yielding liquid secretion (MGYLS)] and positive for dry eye symptoms at screening. Patients were randomized to receive either the combination treatment (lipid emulsion eye drops, omega-3 supplements, and lid hygiene with eyelid wipes) or to apply warm, wet compresses once daily, 8 minutes per day, for 3 months. Meibomian gland functionality (number of MGYLS; primary outcome) and patient-reported subjective assessments (SPEED and OSDI questionnaires; secondary outcomes) were evaluated. Adverse events (AEs) and visual acuity were assessed as safety endpoints. RESULTS: Mean patient age was 41.7 years (n = 26; n = 13 per group). Mean ± SD number of MGYLS was not statistically significantly different between groups at baseline (combination treatment, 3.5 ± 1.5; warm compresses, 4.2 ± 1.4, P > 0.5), and was significantly greater with combination treatment versus warm compresses after 3 months of treatment (9.3 ± 2.7 vs. 4.7 ± 2.3; P = 0.006). Dry eye symptoms were significantly improved in both groups at all follow-up visits. Two AEs unrelated to treatment were reported; the BCVA was unchanged from baseline in both groups. CONCLUSIONS: The combination treatment regimen resulted in significant improvement in meibomian gland functionality and dry eye symptoms. No safety issues were observed.

A novel lid seal evaluation: the Korb-Blackie light test.

PURPOSE: To develop a clinical method to qualitatively evaluate whether a compromised moisture seal is possible even when the lids are apparently closed and to compare these findings with symptoms of ocular discomfort on awakening. METHODS: Patients (n=116) were fully consented and enrolled. The Korb-Blackie lid-light evaluation was performed by placing a transilluminator against the relaxed, closed, outer upper eyelids of semi-reclined patients. The amount of visible light emanating from the lid area between the lashes was quantified on a scale of 0 to 3, where 0=no light, 1=minimal, 2=moderate, and 3=severe for temporal, central, and nasal sections of the eyelids. Eye discomfort on awakening was quantified on a scale of 0 to 2 (0=no discomfort, 1=mild, and 2=significant discomfort). RESULTS: Data are presented for right eyes only. The mean age of the patients was 52.6±16.8 years. The central lid section had a positive lid-light score (54.3%), significantly more frequently than the nasal (37.9%) or temporal (21.6%) lid sections (P<0.0001). Patients with a positive lid-light evaluation were significantly more likely to have symptoms of discomfort on awakening (P<0.0001). CONCLUSION: Light emanating from between "closed" lids during the Korb-Blackie lid-light evaluation is associated with symptoms of ocular discomfort on awakening. These symptoms of discomfort may be linked to the inability of the lids to achieve an adequate seal to prevent subtle ocular surface desiccation during sleeping.

Debridement-scaling: a new procedure that increases Meibomian gland function and reduces dry eye symptoms.

PURPOSE: To evaluate whether a new in-office procedure, the mechanical debridement-scaling of the line of Marx (LOM) and keratinized lid margin, improves meibomian gland (MG) function and reduces dry eye symptoms. METHODS: Twenty-eight patients symptomatic for and diagnosed with evaporative dry eye (16 test patients and 12 controls), who also evidenced anteroplacement and a thickened LOM, were enrolled and consented. SYMPTOMS were evaluated with the Standard Patient Evaluation of Eye Dryness questionnaire. The MG function was evaluated with the standardized MG function evaluator. The LOM was stained with lissamine green (Odyssey Medical, TN) for evaluation. For the test group only, the stained LOM and the entire width of the keratinized lower lid margin were debrided-scaled using a stainless steel, foreign body, golf club spud (Hilco Wilson Ophthalmics, Plainville, MA). All the patients were monitored for change in symptoms and MG function approximately 1 month later. RESULTS: The mean ages of the patients were 55.9 ± 15.0 years (test) versus 53.7 ± 15.3 years (control). There was a significant improvement in the symptoms and MG function 1 month post-debridement-scaling in the test group. The controls evidenced no significant change in either parameter. SYMPTOMS: baseline mean pre-debridement-scaling: 13.4 ± 4.6 (test) versus 13.9 ± 5.5 (control); 1 month post-debridement-scaling: 10.5 ± 3.8 (test, population level statistic < 0.0001) versus 14.3 ± 7.5 (control, population level statistic > 0.05). Number of functional MGs: baseline mean pre-debridement-scaling: 2.6 ± 1.3 (test) versus 2.7 ± 1.5 (control); 1 month post-debridement-scaling: 3.8 ± 1.4 (test, P = 0.0007) versus 2.4 ± 1.1 (control, P > 0.05). Only data for the right eye are reported. CONCLUSIONS: The debridement-scaling of the LOM and lower lid margin provides statistically significant symptom relief and improvement in the MG function. The novel procedure should be considered in the management of MGD and evaporative dry eye.