Image 1 Treatment: LipiFlow heats and expresses the meibomian glands
Jim Kokkinakis, Sydney NSW
Product; LipiView Ocular Surface Interferometer and LipiFlow Thermal Pulsation System
Supplier: Device Technologies
A conservative estimate of the number of patients who have dry eye problems while wearing contact lenses is about 50 per cent. Discomfort and dry eyes are the primary reason that patients give for choosing to discontinue contact lens wear. It stands to reason that aggressive treatment of contact lens induced dry eyes is critical in allowing our patients to take advantage of the many benefits of contact lens wear.
I can say with 30 years of practice that even though we have had many improvements in materials, cleaning systems and replacement modalities, I do not feel that our success rate in contact lens wear has increased. Why?
The answer to this question is complex, but poor or inappropriate management of dry eyes is bound to be a leading factor. In the past couple of years, there have been two important developments that are likely to have turned contact lens induced dry eye management on its head:
- the discovery that meibomian gland dysfunction (evaporative dry eye) is the leading cause of dry eye1
- contact lenses seem to be linked to an increased risk of meibomian gland dysfunction.2
It stands to reason that aggressive (successful) treatment of meibomian gland dysfunction might significantly increase contact lens success.
Think about what most optometrists do when faced with significant symptoms of dryness and irritation reported by their patients. Replacement of the aqueous component three or four times a day would probably be the first option.
We now know that most patients suffer from lipid insufficiency and even though aqueous replacement does help, how many times have you heard that the dryness and irritation come back within five minutes? This is probably because of immediate evaporation due to lack of lipids and drainage through the puncta.
Unfortunately, the next most common piece of advice is: wear your contact lenses less.
It is now clear that we need to think about treating lipid deficiency when managing contact lens discomfort, but treating everyone as lipid deficient is not the answer. How do we know that someone has lipid deficiency in his or her tear film?
This can be determined efficiently only by using the LipiView Ocular Surface Interferometer, a non-invasive instrument that captures live digital images of tear film and measures its lipid content and quality.
Image 2 Assessment: LipiView captures live digital images of tear film and measures the lipid content and quality
Operating on the principle of broad-spectrum white light interferometry, the device provides an interferometric colour assessment of the tear film by specular reflection. The patient’s tear film is seen as an array of colours. Sophisticated software analyses colour refraction patterns on the patient’s tear film while they are blinking. This is not as simple as observing the lid margins for inflammation or applying pressure to the glands to see whether meibum can be expressed. After having examined more than 100 patients with LipiView, it is obvious that I would have been wrong at least 50 per cent of the time using my old and trusted techniques. Some patients also seem to have significant meibomian gland dysfunction greater in one eye than the other, for no apparent reason.
This impressive instrument also monitors incomplete blinking habits. This has stunned me as contributing factor to the possible development of MGD and evaporative dry eye—it is nearly a universal problem. I had not realised this until evaluating my patients using the LipiView.
Even though the LipiView has been a major step forward clinically, sometimes it can be misleading. The following must be ruled out before making a lipid assessment:
- all lipid type drops (for example, Systane Balance or Restasis) must be discontinued for at least two days
- face and eye creams must not be used for two days as spill-over into the eye can look like a healthy lipid layer.
Once a definite diagnosis of lipid deficiency has been made, the next logical step is to try and increase the lipid layer in the tear film.
A number of steps can be attempted, such as warm compresses and lid massage. These methods need to occur daily and are fraught with non-compliance. Ultimately, warm compresses followed by lid massage are not efficient because by the time you have removed the heat, the lipids in the meibomian glands are already cooling. By the time the massage is started, the expression is likely to be inefficient due to the lipids in the meibomian glands solidifying.
Image 3 LipiFlow lid warmer and single use, disposable eye cup
Meibomian gland heating and massage are now best performed using the LipiFlow Thermal Pulsation System. The LipiFlow system uses a single-use disposable eye cup and warmer with an inflatable pulsating bladder to heat and express the meibomian glands at the same time over a 12-minute cycle per eye.
Studies have shown that the LipiFlow Thermal Pulsation System successfully treats patients with lipid deficiencies caused by meibomian gland dysfunction. About 80 per cent of patients remain symptom-free for around nine months, making compliance with any other treatments much less important.
It remains to be seen whether these impressive results will translate to improved contact lens success. To date, we have performed around 20 LipiFlow treatments at the Eye Practice, Sydney, and nearly all the patients had very severe meibomian gland disease. These patients with debilitating symptoms of eye irritation were willing to try every possible treatment.
Ideally, this new meibomian gland treatment will have the most impact in moderate cases, and will either continue to provide contact lens comfort and success, or stop them from slipping into the painful severe category.
1 Nichols KK, Foulks GN, Bron AJ et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci 2011; 52: 4: 1922-1929.
2 Dry Eye Disease Widespread Among Contact Lens Wearers. 19 May 2010 [cited 3 September 2012]. Accessed at http://www.contactlensheadlines.com/713/dry-eyes-and-contact-lens-wear/.
- Jim Kokkinakis