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Meibomian gland dysfunction (MGD) affects a large portion of optometry’s patient population.1 Due to its high prevalence, it is best to proactively screen for it, instead of waiting on the patient to become symptomatic. MGD is chronic and progressive, increasing in severity the longer it goes untreated.2-4 However, once therapy is initiated, physicians can prevent it from causing irreversible changes.5 Although patients may be asymptomatic while damage is occurring, they will eventually start to complain and experience symptoms that can affect their quality of life.4-7 Early detection and intervention are crucial to avoiding these irreversible changes and meibomian gland loss.
Assume MGD, Until Ruling It Out
Mindset is very important when screening for MGD and dry eye disease (DED). Clinicians should approach MGD like they approach glaucoma: Every patient has glaucoma until they prove otherwise. Eye care practitioners screen every patient for glaucoma by checking intraocular pressure (IOP), looking at the optic nerve head (ONH) and performing other diagnostic testing. Optometrists can apply this same methodology to MGD and DED by screening all of their patients using 3 methods.
First, clinicians should consider administering a questionnaire to screen for symptomatic patients. MGD can affect people of all ages, so eye care professionals must screen everyone.8 Next, optometrists should assess meibomian gland morphology through meibography — especially for patients who are asymptomatic. Finally, clinicians should assess expressibility by directly pushing on the glands. Implementing these 3 key procedures as part of the comprehensive exam will be instrumental in successfully identifying and diagnosing patients with MGD.
At-Home MGD Management and Lifestyle Changes
Once MGD is identified, the next step is to educate patients on treatment options. Although in-office procedures may be necessary, optometrists must explain to the patient that they may proactively take certain steps to reduce dry eye symptomatology at home. Members of the clinical team should encourage them to develop good eyelid hygiene habits such as using heat therapy and other hygiene products. Additionally, they can help them identify ingredients in their everyday products that may cause inflammation or exacerbate their condition. This is important in developing treatment protocols since not every patient will want to immediately jump into an in-office procedure.
However, clinicians must remember that noncompliance is one of the reasons patients struggle with home remedies and ultimately fail to help themselves. Proper follow-up is the key to success. Clinicians should have the patient start with home treatment and schedule a 6-week to 3-month follow-up visit to assess how it’s working and determine compliance. Repeat the questionnaire, meibography, expressibility, vital dye testing, and tear breakup time (TBUT) to determine effectiveness. If there is no improvement and they struggle to implement this into their day-to-day lifestyle, the patient may be more comfortable moving to an in-office treatment. The dental model explanation works well in explaining the necessity of in-office procedures, and it really resonates with patients. They understand that even though they floss and brush their teeth daily, they still need a deep cleaning every 6 months. The same analogy works great in eyecare and lid hygiene best practices.
Implementing In-Office Heat and Expression
Consider several points when investing in an in-office heat and expression device (or any diagnostic/therapeutic device for that matter). Take into account the return on investment and consider how many procedures will be needed to pay for the device. Before making this investment, clinicians must ask: Who is going to be operating this instrument? What can be outsourced to another team member? Who is filling out the consent forms, applicable advanced beneficiary notices (ABNs), and so forth? Can other patients be seen while this treatment is happening? What does the footprint look like? Is it portable and how much room does it take up? There are multiple studies showing that these devices all work.9-11
Once an optometrist decides to pursue this investment, they must consider a host of vendor-specific questions as well including the following: What are the terms, conditions, and costs of any applicable warranties? What will the relationship with the vendor look like once the purchase of the equipment is made? Are they interested in ensuring successful outcomes or more interested in simply selling the equipment? Knowing vendor philosophy is vital. Good vendors not only assist with device operation and troubleshooting, but they also share pearls, best practices and strategies, and are vital to clinical success.
Deciding which device to bring into a practice will depend on how the practice owner answers those questions and what works best for clinical flow. Success is determined by 3 things: properly identifying patients that can benefit from this technology, educating patients and team members on its benefits, and exuding confidence when “selling” (i.e. helping the patient) this procedure to the patient.
Ultimately, the instrument that works best is the one that is incorporated into office protocols and actually utilized. It won’t matter how great the technology is if it collects dust in the corner because the MGD foundational protocols were not properly set.
Define Success, Trust the Process
Once diagnostics and heat and expression protocols are implemented, clinicians must routinely assess what is working, and most importantly, what is not working. They can accomplish this by conducting reassessments every 4 to 6 weeks, and then every 3 to 6 months once they become more comfortable with protocols and patient flow. Practice owners must ask themselves several questions to determine whether they have met their ROI. Is the practice meeting its goals? Has patient flow been positively or negatively affected? What kind of feedback are patients and team members providing? What stumbling blocks did the practice encounter? Are media materials (pamphlets, brochures, and so forth) distributed by the practice helpful in educating patients on the benefits of this procedure? Collecting reviews that can be communicated with others through conversations or social media may help to build a stronger patient base.
Incorporating these strategies can help clinicians take better care of their patients, facilitate patient and peer-to-peer referrals, and ultimately grow their practices.
References
1. 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. doi:10.1097/ICO.0b013e318225415a
2. Nichols KK, Hanlon SD, Nichols JJ. A murine model for characterizing glandular changes in obstructive Meibomian gland dysfunction. ARVO. 2014. Abstract #13-A0002.
3. Schaumberg DA, Nichols JJ, Papas EB, Tong L, Uchino M, Nichols KK. The international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci. 2011;52:1994–2005. doi:10.1167/iovs.10-6997e
4. Blackie CA, Korb DR, Knop E, Bedi R, Knop N, Holland EJ. Nonobvious obstructive meibomian gland dysfunction. Cornea. 2010;29(12):1333–1345. doi:10.1097/ICO.0b013e3181d4f366
5. Tomlinson A, Bron AJ, Korb DR, et al. The international workshop on meibomian gland dysfunction: report of the diagnosis subcommittee. Invest Ophthalmol Vis Sci. 2011;52(4):2006-2049. doi:https://doi.org/10.1167/iovs.10-6997f.
6. The definition and classification of dry eye disease: report of the definition and classification subcommittee of the International Dry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92. doi:10.1016/s1542-0124(12)70081-2
7. Geerling G, Baudouin C, Aragona P, et al. Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: proceedings of the OCEAN group meeting. Ocul Surf. 2017;15(2):179-192. doi:10.1016/j.jtos.2017.01.006
8, Gupta PK, Stevens MN, Kashyap N, Priestley Y. Prevalence of meibomian gland atrophy in a pediatric population. Cornea. 2018;37(4):426-430. doi:10.1097/ICO.0000000000001476
9. Wangen Beining M, Schjerven Magnø M, Moschowits E, et al. In-office thermal systems for the treatment of dry eye disease. Surv Ophthalmol. Published online February 10, 2022. doi:10.1016/j.survophthal.2022.02.007
10. Tauber J, Owen J, Bloomenstein M, Hovanesian J, Bullimore MA. Comparison of the iLUX and the LipiFlow for the treatment of meibomian gland dysfunction and symptoms: a randomized clinical trial. Clin Ophthalmol. 2020;14:405-418. doi:10.2147/OPTH.S234008
11. Gupta PK, Holland EJ, Hovanesian J, et al. TearCare for the treatment of meibomian gland dysfunction in adult patients With dry eye disease: a masked randomized controlled trial. Cornea. 2022;41(4):417-426. doi:10.1097/ICO.0000000000002837
