meibomian gland disease (mgd): current diagnostic and ... · cynthia matossian, md, facs sebastian...

Cynthia Matossian, MD, FACS

Sebastian Lesniak, MD

Matossian Eye Associates

Meibomian Gland

Disease (MGD):

Current Diagnostic

and

Treatment Options

Continuing Education Event

Monday, September 26th

Disclosures for Cynthia Matossian, MD

• Abbott Medical Optics

• Alcon

• Allergan

• ALPHAEON

• Bausch + Lomb

• Bruder

• Checked-Up

• Imprimis Pharmaceuticals

• i-Optics

• Lenstec

• Marco

• Ocular Therapeutix, Inc.

• OMEROS

• Physician Recommended Nutriceuticals (PRN) – Shareholder

• Progressive Tech Training

• RPS Diagnostics

• Shire

• Strathspey Crown – Shareholder

• Sun Pharmaceuticals

• TearLab

• TearScience

Disclosures for Sebastian Lesniak, MD

• No relevant financial relationships to disclose

MGD Defined

“Meibomian Gland Dysfunction (MGD) is a

chronic, diffuse abnormality of the Meibomian

Glands, commonly characterized by terminal

duct obstruction and/or qualitative/quantitative

changes in the glandular secretion.”1

Function

Structure

Normal Function Normal Structure

Copyright Matossian Eye

Associates 2016

Evaporation Video

MGD Compromises the First

Refractive Surface

9

1. Tutt R, Bradley A, Begley C, Thibos LN. Optical and visual impact of tear break-up in human eyes. IOVS 2000;41:4117

2. Benito A, Perez, GM, Mirabet S, et al. Objective optical assessment of tear-film quality dynamics in normal and mildly symptomatic dry eyes. J Cataract Refract Surg 2011 37:1481.

3. Nemeth J, Erdelyi B, Csakany B. Corneal topography changes after a 15 second pause in blinking. J Cataract Refract Surg 2001 27:589.

4. Goto E, Yagi Y, Masumoto Y, Tsubota K. Impaired functional visual acuity of dry eye patients. Am J Ophthalmol 2002 Feb 133(2): 181-6.

5. Montes-Mico R.. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg 2007 Sep 33(9): 1631-5

An Unstable Tear Film Negatively Impacts

Quality of Vision Leading to:1-5

• Fluctuating Vision

• Ocular Discomfort

• Compromised Barrier to Infection

• Tired eyes

• Need to blink more frequently


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MGD Compromises the First

Refractive Surface

10

1. Trattler WB, Reilly CD, Goldberg DF, et al. ASCRS 2011 [Online:

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB8QFjAAahUKEwiJoPHrhtfHAhWIcz4KHbpKDUU&url=http%3A%2F%2Fascrs2011.abstractsnet.com%2Fhandouts%2F000269_PHACO_eposter_ASC

RS_2011.ppt&usg=AFQjCNFktPHhZQ0-KZzxn0wUXH_bDCqGzg&sig2=xaXETHX4WJDCLw4PCZre5w, 090115]

2. 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.

3. 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.

Who is at increased risk?

• 63%+ of Cataract Patients (PHACO

study results)1

• Contact Lens Patients2

• Glaucoma Patients3

Routinely evaluate patients for MGD and treat

as appropriate to optimize their ocular

surface health


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MGD: The Science

MGD is progressive, obstructive and

prevalent (60-70% of general

population)1,2

• Obstruction can lead to atrophy3

• Early intervention optimizes outcomes4

• For patients whose ocular surface is at risk

for compromise (e.g., pre-surgical patients),

treatment of MGD should be considered a

priority5

• Evaporative stress causes MGD (Modern

lifestyle, Contact lens wear, Chronic use of

topical medications etc.)6,7

1. Foulks GN, Nichols KK, Bron AJ, Holland EJ, et al. Improving awareness, identification, and management of meibomian gland dysfunction. Ophthalmology. 2012 Oct;119(10 Suppl):S1-12.

2. Murakami DK, Blackie CA and Korb DR. The Prevalence of Meibomian Gland Dysfunction in a Caucasian Clinical Population. ARVO abstract 2015

3. Nichols KK et al. ARVO 2014

4. Holland et al. Patient Characteristics Associated with Improved Meibomian Gland Function after Thermal Pulsation Treatment for Meibomian Gland Dysfunction. ASCRS 2015

5. Jackson et al. Evaluation of Thermal Pulsation Treatment for Meibomian Gland Dysfunction in Cataract Surgery Patients ASCRS 2015

6. Suhalim JL, Parfitt GJ, Xie Y, et al. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf. 2014 Jan;12(1):59-68.

7. 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.


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The Cycle of Inflammation

1. Arita R, et al. Increased Tear Fluid Production as a Compensatory Response to Meibomian Gland Loss: A Multicenter Cross-sectional Study.

Ophthalmology. 2015 Jan 24. pii: S0161-6420(14)01195-6. doi: 10.1016/j.ophtha.2014.12.018. [Epub ahead of print]


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Examples of meibum stagnation and

changes that correspond to MGD


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MGD Exposed by the Science

1. MGD is not benign – it is a progressive,

obstructive and prevalent disease.1-3

2. MGD is a major contributor to the majority of

Dry Eye.

(86% of patients with dry eye evidence

MGD)1,4

3. Effective treatment for Dry Eye includes

effective management of MGD and

inflammation. (86% of patients with dry eye

evidence MGD)1,3,4

1. Nichols KK, Foulks GN, Bron AJ. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. IOVS, Special Issue 2011;52 (4)1922-9

2. Foulks GN, et al. Improving awareness, identification, and management of meibomian gland dysfunction. Ophthalmology. 2012 Oct;119(10 Suppl):S1-12.

3. Nichols KK et al. A Murine Model for Characterizing Glandular Changes in Obstructive Meibomian Gland Dysfunction. ARVO Abstract A0002 2014

4. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-

478.


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Diagnostic Work-Up

• Ocular Surface Disease Index (OSDI)

• SPEED Questionnaire

• Tear Osmolarity

• InflammaDry®

• Lissamine Green Staining

• Meibomian Gland Evaluator (MGE)

• Dynamic Meibomian Imaging (DMI)

1. Blackie CA, et al. Nonobvious obstructive meibomian gland dysfunction. Cornea. 2010 Dec;29(12):1333-45. Review.

2. Nichols KK. The MGD Workshop report. Executive summary. IOVS 2011

Meibomian Gland Evaluator (MGE)

Dynamic Meibomian Imaging (DMI)

Early Detection:

Raising the standard of care


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Meibomian Gland Function

• A functional Meibomian Gland is a gland that

releases its liquid contents during a deliberate

blink.1,2

• The number of functional MGs along the lower

eyelid can be counted using the MGETM.1,2

SYMPTOMATIC FOR DRY EYE1 ASYMPTOMATIC2

0 - 4 5 6 7 8 9 10+

NUMBER OF FUNCTIONAL MGs in the Lower Lid

1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-47.

2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297.


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Meibomian Gland Evaluator

(MGE™)

191. 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.

• The first standardized method to assess meibomian gland (MG)

function in-office.

• Easy to incorporate into routine eye care.

• Tracks the MG function with visit-to-visit consistency and

repeatability.

• Approximates the pressure of a deliberate blink, allowing

detection of MG function compromise at a very early stage.1,2


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Meibomian Gland Evaluator™• Intended for use by a clinician to evaluate

Meibomian gland secretions. Used to apply

consistent light pressure to the outer eyelid skin

of a patient while visualizing secretions from

Meibomian gland orifices through a slit lamp

biomicroscope.

MGE Indications for Use


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Meibomian Gland Structure:

LipiView®

II with Dynamic Meibomian Imaging

(DMI)

Dynamic Illumination Adaptive Transillumination Dual-Mode DMI

Normal Gland Structure

Gland Truncation & Drop Out

Gland Duct Dilation & Drop Out

+ =

+ =

+ =

MGD IS PROGRESSIVECopyright Matossian Eye

Associates 2016

1. We are all at risk for MGD

(prevalence is 60-70% in the general population, 86% in the dry eye population)1-4

1. Early Intervention is best5,6

2. Early detection is necessary5,6

23

1. Suhalim JL, Parfitt GJ, Xie Y, et al. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf. 2014 Jan;12(1):59-68.

2. Foulks GN, Nichols KK, Bron AJ, Holland EJ, et al. Improving awareness, identification, and management of meibomian gland dysfunction.

Ophthalmology. 2012 Oct;119(10 Suppl):S1-12.

3. Murakami DK, Blackie CA and Korb DR. The Prevalence of Meibomian Gland Dysfunction in a Caucasian Clinical Population. ARVO abstract

2015

4. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective

study. Cornea. 2012;31(5):472-478.

5. Holland et al. Patient Characteristics Associated with Improved Meibomian Gland Function after Thermal Pulsation Treatment for Meibomian Gland Dysfunction.

ASCRS 2015

6. Jackson et al. Evaluation of Thermal Pulsation Treatment for Meibomian Gland Dysfunction in Cataract Surgery Patients ASCRS 2015

MGD is the Gum Disease of

Eye Care

Detect MGD:

Evaluate MG

function and MG

structure


Associates 2016

Treatments for MGD

Manage Dry Eye Symptoms

• Warm Compresses – Microwaveable Hot Mask

• Lid Massage & Lid Wipes/Scrubs

• Artificial Tear Solutions and/or Ointments

• Humidifier

• Omega-3 Oral Supplements

• Cyclosporine 0.05% or Lifitegrast 0.5%

• Punctal Plugs

• Oral Antibiotics (Doxycycline)

• Ductal Probing

Obtain Baseline MG Evaluation on

all patients - Use metrics

– Tear Osmolarity

– Inflammadry

– Lissamine Green• Uptake lid margin, conjunctiva, and cornea

– MGE (Meibomian Gland Evaluator)

– DMI (Dynamic Meibomian Gland

Imaging)

New Direction:

Proactive, Measurable, Effective


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Level 1 therapy for MGD is to treat

obstruction

– Manual Expression (less effective and

painful)

– Ductal Probing

– IPL

– Vectored Thermal Pulse Therapy

New Direction:



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• Offer supplementary therapy

– Front surface heating (warm compresses, external lid

heating devices)

– Lid margin health (debridement-scaling, at home

scrubs)

– Blink training

– Inflammation control

– Diet (fish oil etc.)

• Educate that MGD is largely a disease of

lifestyle (evaporative stress leads to MGD)

– Empower the patient

New Direction:



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IPL


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• Tanned skin (active tan)

• Pregnancy

• A history of keloid scarring

• Use of medication that may induce

photosensitivity to the skin

• Any inflammatory skin condition at the

treatment site

• A history of skin cancer

• A history of poor wound healing including

Type I Diabetes

• Vitiligo

• Treatment over certain skin areas such as

tattoos, moles, semi-permanent make-up, lip

vermillion or mucous membranes

IPL Contraindications


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Vectored Thermal Pulse Therapy


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What makes Vectored Thermal

Pulse Therapy Unique?

of a single treatment

1. Finis, D. et al. Evaluation of an automated thermodynamic treatment (Vectored Thermal Pulse Therapy) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial.

Ocular Surface 2014 Apr; 12(2); 146-54

2. Greiner, JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Experiment Ophthalmol. 2013

Aug;41(6):524-30

3. Blackie CA, et al. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Current Opinion in Ophthalmology 2015, 26:306–313.

4. Greiner JV. Long-Term (3 Year) Effects of a Single Thermal Pulsation System Treatment on Meibomian Gland Function and Dry Eye Symptoms. Eye Contact Lens. 2015 Oct 27.

FDA CLEARED


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Does Vectored Thermal

Pulse Therapy Work?

A recent review of 31 peer

reviewed articles/abstracts

(including five registered

randomized controlled

clinical trials):1

A single dose, 12-minute

therapy results in:

– Mean gland function

improvement is ~ 3x

baseline

– Mean symptom

improvement is ~ 2x

(symptoms are halved)

1. Blackie CA, et al. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Current Opinion in Ophthalmology 2015, 26:306–313.


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Do not use the Vectored Thermal Pulse Therapy System

in patients with the following conditions:

• Ocular surgery, ocular injury, ocular herpes of eye or

eyelid within prior 3 months

• Active ocular infection or inflammation, or history of

chronic, recurrent ocular inflammation within prior 3

months

• Eyelid abnormalities that affect lid function

• Eyelid abnormalities or ocular surface abnormalities

that may affect/compromise corneal integrity or lid

function

Vectored Thermal Pulse

Therapy Contraindications


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• Severe (Grade 3 or 4) eyelid inflammation (eg, blepharochalasis, staphylococcal blepharitis, or seborrheic blepharitis). Patients with severe eyelid inflammation should be treated medically prior to device use.

• In addition, the treatment procedure may

loosen previously inserted punctal plugs,

which may worsen the patient’s Dry Eye

symptoms.


Therapy Precautions


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Therapy Video


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Vectored Thermal Pulse Therapy Video

Ocular

Surface

Disease

Diagnostic

and

Treatment

Algorithm


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First Visit


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If one or more dry eye symptoms are indicated on SPEED

Questionnaire, technician performs tear osmolarity and MMP-9

test prior to additional workup.

Tear Osmolarity TestMMP-9

Test

Slit Lamp Exam1. Lissamine green and

fluorescein staining

2. Evaluation of

Meibomian glands

Look

for:

MGD,

blepharitis,

SPK, PEK, PEE

NormalIf <300 mOsm/L and symmetric

Look for additional signs of

DED; if none, rule out dry eye

AbnormalIf ≥300 mOsm/L or asymmetric

Determine Severity:

• Mild: -300 - 319 mOsm/L

• Moderate: -320 - 339 mOsm/L

• Severe: >340 mOsm/L

First Visit:

SPEED Dry Eye Symptom Questionnaire


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Baseline treatment protocol recommended

to DED patients:

1.Adequate hydration

2.Preservative free artificial tears

3.Microwaveable Hot Mask

4.High quality Omega-3 supplement

5.Lid hygiene

1-2 month follow-up for DED diagnosis


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DED Patient Education

1.DED is not ‘cured’ with a one-time

treatment

2.DED is chronic and requires on-going

treatment

3.Requires collaboration and

communication between patient and

doctor

4.Environmental changes recommended:

redirect air conditioner/heat vents/fans

away from face, etc.

5.Email DED educational videos to patient

1-2 month follow-up for DED diagnosis

Diagnosed with DED, return visit 1-2 month follow-up:


Tear osmolarity and MMP-9 testing performed to monitor efficacy of prescribed treatment


Test

Slit Lamp Exam1. Lissamine green and fluorescein staining

2. Meibomian gland imaging with LipiView™

3. Evaluation of Meibomian glands

4. Monitor treatment efficacy with results as

compared with previous visit

Look For:MGD, blepharitis, lid abnormalities, conjunctival

chalasis, SPK, PEK, PEE


Determine Severity:

• Mild: -300 - 319 mOsm/L




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Determine Severity:

• Mild: -300 - 319 mOsm/L



Treatment protocol recommended to

DED patients on follow-up:

1. Increase of Omega-3 from 2 to 4

capsules daily, with largest meal

2. Continue heated microwaveable mask,

1 to 2 times daily

3. Continue lid hygiene 1 to 2 times a day

4. Preservative free artificial tears OU

PRN

5. Maintain hydration

Schedule for 4 month

follow-up to repeat testing

and monitor efficacy of

therapy


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Determine Severity:

• Mild: -300 - 319 mOsm/L



Increased treatment protocol

recommended if signs/symptoms

or results do not improve:

1. Start cyclosporine ophthalmic

emulsion 0.05% or lifitegrast

5.0% OU BID

2. Discuss and recommend

thermal pulsation treatment

depending on gland dropout

with Meibomian gland imaging




therapyCopyright Matossian Eye

Associates 2016

4 month follow-up for DED:


Follow-up for DED – Tear osmolarity and MMP-9 testing performed to

monitor efficacy of recommended treatment


Test








Determine Severity:

• Mild: -300 - 319 mOsm/L




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Treatment protocol

recommended to DED

patients on 4 month follow-up:

1. Continue Omega-3 treatment: 4

capsules daily or 1 tsp high

potency liquid, with largest meal

2. Continue heated microwaveable

mask, 1-2 times daily


PRN


5. Continue cyclosporine/lifitegrast

OU BID

6. Increase frequency of lid hygiene

treatments or use two products:

AM and PM


follow-up to repeat

testing and monitor

efficacy of therapy


Determine Severity:

• Mild: -300 - 319 mOsm/L



Treatment progression if

no improvement in clinical signs/

symptoms or TearLab results

1. Add humidifier to bedroom and

start running 1 hour before bed

2. Start a short course of loteprednol

etabonate ophthalmic suspension

0.5% OU BID for 1-3 weeks

3. Perform omega index test to make

sure patient is within the

therapeutic range of 8% or greater

4. Perform allergy testing

5. Recommend thermal pulsation

treatment if not already performed

at previous visit


follow-up to repeat

testing and monitor

efficacy of therapy


Determine Severity:

• Mild: -300 - 319 mOsm/L




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Second 4 month follow-up for DED:


Follow-up for DED – Tear osmolarity and MMP-9 testing performed to

monitor response to therapy and disease progression


Test








Determine Severity:

• Mild: -300 - 319 mOsm/L




Associates 2016

Treatment protocol

recommended to DED

patients on 4 month follow-up:

1. Continue Omega-3 treatment: 4

capsules daily or 1 tsp high potency

liquid, with largest meal

2. Continue heated microwaveable

mask, 1-2 times daily


PRN


5. Continue cyclosporine/lifitegrast BID

6. Continue lid hygiene BID

7. Continue humidifier at night




therapy


Determine Severity:

• Mild: -300 - 319 mOsm/L




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Treatment progression if

no improvement in clinical signs/

symptoms or TearLab results

1. Perform Sjögren’s test

2. Recommend thermal pulsation

treatment if not already

performed at previous visit

3. If thermal pulsation treatment

done in past 6 months,

consider IPL (intense pulsed

light) as adjunctive treatment

4. Insert punctal plugs to both

lower lids

5. Preservative free artificial tear

ointment at bedtime


follow-up to repeat

testing and monitor

efficacy of therapy


Determine Severity:

• Mild: -300 - 319 mOsm/L




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For patient with severe DED,

regimen is as follows:

Treatment protocol recommended to DED patients on 4 month follow-up:

1. Continue Omega-3 treatment: 4 capsules daily or 1 tsp high potency liquid, with

largest meal

2. Continue heated microwaveable mask, 1-2 times daily

3. Preservative free artificial tears OU PRN


5. Continue cyclosporine ophthalmic emulsion 0.05% or lifitegrast 5.0% OU BID

6. Continue lid hygiene

7. Continue humidifier at night

8. IPL: adjunctive treatment to thermal pulsation

9. Consider adding punctal plugs to both upper lids

10. Consider amniotic membrane corneal bandage

11. Testosterone 0.05% Ophthalmic drops compounded off label BID

12. Consider serum tears

13. Consider scleral cover shell

Questions?

Cynthia Matossian, MD FACS

[email protected]

Sebastian Lesniak, MD

[email protected]

www.matossianeye.com

meibomian gland disease (mgd): current diagnostic and ... · cynthia matossian, md, facs sebastian...

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