Evidence Based Approach

Dry Eye

Meibomian Gland Dysfunction

Copenhagen 2012

Teifi James

MBBS DO FRCP FRCS FRCOphth

Consultant Ophthalmologist

Calderdale Royal Hospital

MGD — Symptoms

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

Moll secretions

anterior to MGOs

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

Dry Eye

• Lacrimal gland dysfunction, Sjogrens -

rare

• Evaporative dry eye very common

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

Onions

Tears?

MGD

Meibomian seborrhoea

MGD pseudo-

blisters with

capped

orifices

Transient blurred vision — Common in MGD

Blob of lipid in the tear film

Loss of lipid barrier

Loss of lid margin hydrophobicity

Macerated lid margin – water wettable

TFOS MGD Report

• Definition / Classification

• Anatomy, Physiology, Pathophysiology

• Tear Film Lipids & Lipid-Protein interactions

• Epidemiology & Risk Factors

• Diagnosis

• Management and Treatment

• Clinical Trials

MGD — Aetiology

• “Not clear”

• “More research required”

MGD is

The key underlying feature

of…

Dry Eye

Post Laser Ocular Dryness

Contact Lens Associated Dry Eye

Blepharitis

Chalazion

Stye

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.

Temperature Dependent Phase Change

Lipid composition alters melting point

Unsaturated FAs — Increasing Saturation — Wax Esters

Omega 3 •Oily fish +++

•zero butter, red

meats

•or take a

supplement

•Lagad Lacrima

Omega 3

• GLA (Gamma Linolenic Acid)

• Anti-inflammatory Nutrient

• EPA (Eicosapentaenoic Acid)

• Omega 3 Anti-inflammatory Nutrient

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

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.

Jackson Brown — Doctor my Eyes

3 blinks - 2 people

4 blinks - 4 people

118 Opticians

0 - 16

1 - 15

2 - 14

The near response...

• Convergence

• Miosis

• Accommodation

• ? Decreased blink rate

??

The 20-20-20-20 rule

&

Return / blink button

&

Gamers lose a life

or progress to next level

?

Melts at 39º C

Are you a squeezer?

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

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

Blephasteam®

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: bilkhups@aston.ac.uk

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

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Thank You