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Evidence Based Approach Dry Eye Meibomian Gland Dysfunction Copenhagen 2012 Teifi James MBBS DO FRCP FRCS FRCOphth Consultant Ophthalmologist Calderdale Royal Hospital

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Page 1: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Evidence Based Approach

Dry Eye

Meibomian Gland Dysfunction

Copenhagen 2012

Teifi James

MBBS DO FRCP FRCS FRCOphth

Consultant Ophthalmologist

Calderdale Royal Hospital

Page 2: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD — Symptoms

Page 3: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Declaration • Fees, Hospitality & expenses from

• Boots

• Allergan

• Specsavers

• EyeCare 3000

• Spectrum Thea

• Bausch & Lomb

• CIBA / Alcon / Novartis

• Rotho / Mentholatum / Sooft

• The EyeBag Company — patent and majority shareholding

Page 4: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 5: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Moll secretions

anterior to MGOs

Page 6: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Sjøgrens

Evaporative

The Dry Eye Pyramid - circa 20 million in UK Intrinsic

Meibomian Gland Dysfunction Lid Aperture disorders – eg GO Low blink rate – eg Parkinson's Drug action Ro-accutane effect on Meibomian Glands

Extrinsic

Vitamin A deficiency

Preservatives in Topical eye treatments

Contact lens wear

Ocular Surface Disease

Post Corneal / laser surgery

HES

Millions with dry eye

Page 7: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 8: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Dry Eye

• Lacrimal gland dysfunction, Sjogrens -

rare

• Evaporative dry eye very common

• MGD is the major cause of ‘Dry Eye’.

Page 9: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 10: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 11: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 12: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 13: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 14: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Onions

Tears?

Page 15: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 16: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 17: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 18: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 19: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 20: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 21: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD

Page 22: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 23: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Meibomian seborrhoea

Page 24: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD pseudo-

blisters with

capped

orifices

Page 25: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 26: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Transient blurred vision — Common in MGD

Blob of lipid in the tear film

Page 27: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Loss of lipid barrier

Loss of lid margin hydrophobicity

Macerated lid margin – water wettable

Page 28: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

TFOS MGD Report

• Definition / Classification

• Anatomy, Physiology, Pathophysiology

• Tear Film Lipids & Lipid-Protein interactions

• Epidemiology & Risk Factors

• Diagnosis

• Management and Treatment

• Clinical Trials

Page 29: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD — Aetiology

• “Not clear”

• “More research required”

Page 30: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD is

The key underlying feature

of…

Dry Eye

Post Laser Ocular Dryness

Contact Lens Associated Dry Eye

Blepharitis

Chalazion

Stye

Page 31: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

MGD

• Tear film has poor quality lipid layer

• Break Up Time is short.

• Strategies to restore it.

• Diagnosis is self-evident.

• Champagne bubbles on lid edge.

• Blepharitis & evaporative dry eye.

Page 32: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 33: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 34: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 35: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 36: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 37: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 38: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 39: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 40: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Temperature Dependent Phase Change

Lipid composition alters melting point

Unsaturated FAs — Increasing Saturation — Wax Esters

Page 41: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Omega 3 •Oily fish +++

•zero butter, red

meats

•or take a

supplement

•Lagad Lacrima

Page 42: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Omega 3

• GLA (Gamma Linolenic Acid)

• Anti-inflammatory Nutrient

• EPA (Eicosapentaenoic Acid)

• Omega 3 Anti-inflammatory Nutrient

Page 43: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 44: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Lipid chemistry

Meibum is a complex soup of variable lipids and lipid

derivatives. The melting point varies according to the exact

composition.

Properties of fatty acids and their derivative lipids depend on

chain length and being unsaturated

Unsaturated FAs have a lower melting point than saturated

FAs of same length

e.g.

C18 – Stearate ( zero double bonds) melts at 69.6ºC

C18 – Oleate ( one cis double bond) melts at 13.4ºC

Page 45: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Meibomian gland dysfunction and ocular

discomfort in video display terminal workers C Fenga1, P Aragona2, A Cacciola1, R Spinella2, C Di Nola1, F Ferreri2

and L Rania2 Eye (2008) 22, 91–95; doi:10.1038/sj.eye.6703025; published online 26 October 2007

• Results

• A total of 52 subjects out of 70 (74.3%) had MGD.

• A statistically significant correlation between the symptoms of ocular

discomfort and hours spent on VDT work was observed in the total

population (r=0.358; P=0.002; 95% CI 0.13–0.54) and in the group of

subjects with MGD (r=0.365; P=0.009; 95% CI 0.103–0.58). Such

correlation was not shown in subjects without MGD.

• Conclusions

• The high prevalence of MGD among the subjects with symptoms of ocular

discomfort suggests that this diagnosis should be considered when

occupational health practitioners encounter ocular complaints among VDT

operators. It appears that MGD can contribute to the development of

ocular discomfort in VDT operators.

http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff1
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff2
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff1
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff2
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff1
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff2
http://www.nature.com/eye/journal/v22/n1/full/6703025a.html%23aff2
Page 46: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Jackson Brown — Doctor my Eyes

Page 47: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 48: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 49: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 50: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

3 blinks - 2 people

4 blinks - 4 people

118 Opticians

0 - 16

1 - 15

2 - 14

Page 51: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

The near response...

• Convergence

• Miosis

• Accommodation

• ? Decreased blink rate

??

Page 52: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

The 20-20-20-20 rule

&

Return / blink button

&

Gamers lose a life

or progress to next level

Page 53: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

?

Melts at 39º C

Page 54: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 55: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 56: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 57: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Are you a squeezer?

Page 58: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 59: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 60: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Clinical Handbooks Moorfields Wills

Heat Wet Flannel

5mins od / bd

Warm

compresses

15 mins qid

Antibiotics Doxy 100mgs

od for 8/52

Tet 250 qid

for 6/52

Lubricants prn 4 to 8 x a day

Page 61: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 62: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 63: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

The ideal warm

compress

• Must raise lid temperture above 39º C

• Stay above 39º C for a while

• Good compliance (nice and easy to

use)

• Affordable (inexpensive)

• No adverse effects

Page 64: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Blephasteam®

Page 65: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 66: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 67: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 68: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 69: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 70: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 71: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 72: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 73: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 74: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

84

Temperature changes of the external and

internal eyelids using the MGDRx EyeBag

Paramdeep S Bilkhu, BSc (Hons) MCOptom. N,

Shehzad A Naroo, BSc (Hons) MSc PhD MCOptom FIACLE FAAO FBCLA

James S Wolffsohn, BSc (Hons) MBA PhD FSB MCOptom FAAO FBCLA

Aston University, Birmingham, UK

Corresponding Author: [email protected]

Page 75: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Conclusions: Paramdeep Bilkhu et al

The MGDRx EyeBag does produce an increase in

external and internal eyelid temperature.

Based on the results, either surface of the MGDRx

EyeBag can be used but 5 minutes application

using the silk surface demonstrates greater

increases of eyelid temperature necessary for

optimal heating

Page 76: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Hot Compress

Survey

125 responses

Page 77: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 78: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 79: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 80: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Tear replacement!

Page 81: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Topical lubricant drops and gels • 4 million UK scripts annually for

Hypromellose

• Hyaluronate

• Polyvinyl alcohol

• Carbomer

• Guar

• Micelle mist / sprays

• Mucin mimetic agents

• Autologous Serum

Page 82: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 83: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of
Page 84: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

£39.10 per 100 mls £30 per 100 mls

Generic Hypromellose 10 mls £ 2.99 from Amazon

Page 85: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

No Recipe for hot spoon treatment!

Page 86: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

Thank You

Page 87: Evidence Based Approach Dry Eye Meibomian Gland ......The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of

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