Choosing Treatment for MGD

Detecting and treating dry eye disease (DED) preoperatively is imperative for optimising outcomes of patients undergoing cataract and refractive surgery—but as more treatment modalities emerge, clinicians may find the number of options overwhelming.

Karl Stonecipher MD has devised a simple algorithm for managing meibomian gland dysfunction (MGD), the most common cause of DED. He based the recommendations on a retrospective review of his experience treating a large cohort of patients.

“Dry eye disease, particularly MGD, is common in patients presenting for cataract and refractive surgery. Left untreated, it can limit the accuracy of the measurements used for surgical planning; affect postoperative visual quality, patient comfort, and satisfaction; and even increase risks for infectious complications,” said Dr Stonecipher.

“While there are many effective in-office modalities for treating MGD, having all the devices can be cost-prohibitive for a practice, and it is unnecessary. Our simple algorithm is useful for finding treatment that is both efficacious and cost-effective for physicians and patients.”

The first step in choosing management, he said, is to diagnose MGD and determine whether it represents anterior, posterior, or mixed eyelid margin disease. There is also no need to use expensive tools for performing the diagnostic evaluation.

In his practice, Dr Stonecipher examines patients at the slitlamp to measure tear break-up time and grade MGD severity and conjunctival lissamine green staining. He uses the Ocular Surface Disease Index (OSDI) for symptom assessment.

“Looking for change in the OSDI at follow-up is very helpful for determining if the condition is improving or if the current treatment plan is not working,” Dr Stonecipher said.

TREATMENT RECOMMENDATIONS

To examine the efficacy of various methods for treating MGD, Dr Stonecipher and colleagues conducted an evidence-based review of the literature and the outcomes for a series of 1,721 eyes of 861 of his patients. Most of the patients had been referred for surgery by other clinicians and previously diagnosed with DED but had failed treatment with various topical and systemic pharmacotherapy options.

Dr Stonecipher suggested low-level light therapy (LLLT) can be used to treat anterior, posterior, or mixed disease and offers a good entry point for equipment acquisition based on affordability. A multicentre retrospective study of 230 patients demonstrated its safety and benefit when used in conjunction with intense pulsed light (IPL) therapy. Another study showed the efficacy of LLLT with a standard pharmaceutical regimen for treating recalcitrant chalazia.

“Intense pulsed light is generally used when rosacea is present, but it is somewhat expensive. However, IPL also has cosmetic benefits and so is something that might be considered by clinicians who are interested in offering aesthetic treatments in addition to serving as a dry eye clinic,” Dr Stonecipher said.

For MGD, the LLLT device can be set for blue or red light therapy. Blue light is helpful for anterior lid margin disease and especially for rosacea. Red light causes endothermic heating that melts meibum, enabling expression.

“Meibomian gland obstruction is part of the problem, and addressing it with expression should be part of the treatment,” he said.

The retrospective review found devices providing blinkassisted thermal energy, thermal pulsation, and radiofrequency energy effective as well. However, they carry higher costs for the practice and patients.

Recently, Dr Stonecipher began collaborating with the Canadian group CSI Dry Eye (csidryeye.com) to develop machine-learning, cloud-based software to improve DED diagnosis and patient care. He encouraged others to participate in the project.

“The more data available, the better the recommendations,” he said.

Dr Stonecipher presented at the 40th Congress of the ESCRS in Milan.

Karl Stonecipher MD is a Clinical Professor of Ophthalmology at the University of North Carolina, US, and a Clinical Adjunct Professor of Ophthalmology at Tulane University, Louisiana, US. He is also the Medical Director of Laser Defined Vision Greensboro, North Carolina, US. stonenc@gmail.com

Tags: dry eye disease, MGD Diagnosis