Article

MANAGING LID DISEASE

GATHER INFORMATION TO SUCCESSFULLY BUILD THIS SEGMENT OF YOUR PRACTICE

MEIBOMIAN GLAND dysfunction (MGD) and blepharitis are two related, but distinct, commonly encountered conditions that are frequently associated with ocular surface disease (OSD). MGD is now believed to be the root cause of most dry eye disease (DED). The literature suggests that nearly 90% of DED patients have MGD, either as a primary cause or contributor to their disease. My own experience suggests an even higher percentage.

In this article, I will review the current clinical thinking regarding DED and its relationship to lid disease, specifically in regard to the diagnosis and treatment of MGD and blepharitis, along with strategies for successfully building this segment within an existing practice structure.

DED’S RELATIONSHIP TO LID DISEASE

The term DED describes a constellation of common symptoms rather than the underlying causes of the disorder. Recently, both science and clinical perspective have shifted dramatically to reveal and address the cause rather than just the symptoms, which are most commonly treated with artificial tears. For example, inflammation is well recognized as a major contributor to DED signs and symptoms. However, in a large majority of patients, DED is primarily driven by lid disease, according to the Tear Film & Ocular Surface Society (TFOS). The two primary forms of lid disease:

  1. Blepharitis. This describes inflammation of the anterior lid margin marked by red, swollen eyelids, dandruff-like scurf, erythema, lash loss, crusting and matting with lid debris. Bacterial biofilm formation is also common.

    Blepharitis often contributes to ocular surface inflammation and can be a vexing disease to manage, as it sometimes becomes chronic and recurrent. Staphylococcus species are most commonly associated with blepharitis, although the presence of collarettes, or cylindrical dandruff, are a sign of demodex, a microscopic mite that can cause or contribute to blepharitis.
  2. MGD. Previously described as posterior blepharitis, MGD specifically describes dysfunction, inflammation and often partial and sometimes complete loss of the meibomian glands.

Meibum, the complex lipid normally released from the glands, is critical for creating an evaporative barrier that keeps moisture in. Healthy meibum also contributes to the integrity and stability of the entire tear structure, akin to how a roof adds structure to an entire building.

Overall, MGD is chronic and progressive and, ultimately, leads to ocular surface damage and inflammation.

Note the crusting of the lid and lashes, which is indicative of blepharitis.
PHOTO CREDIT: Art Epstein, O.D. F.A.A.O.

DIAGNOSIS

Diagnosing lid disease requires the slit lamp, gland expression, meibography and staining.

  • Slit lamp. Start with the lids and lashes, looking for signs of blepharitis, especially if the patient’s symptoms or physical appearance are consistent with the diagnosis. Also, inspect the meibomian gland orifices and the line of Marx at the muco-cutaneous junction, as incomplete blinking can result in significant buildup of epithelial and other debris, including bacterial biofilm, which can block the glands. In addition, look at surface elements of the gland structure, including possible atrophy, evidenced by notching, inspissation and lid surface inflammation. These findings suggest MGD and, therefore, require further investigation.

    Finally, inspect the conjunctiva — both bulbar and palpebral, directly and via transillumination, to assess gland structure. If you have one, use a slit lamp camera to transform it from an important diagnostic tool to a communication platform for patients.
  • Gland expression. I assess meibomian gland function by applying light fingertip pressure to the lid margin to simulate the force of a blink. Normal glands produce clear meibum with light pressure. Alternatively, you may use commercially available tools to assist in expression. Abnormal secretions (e.g. turbid, thick meibum) can be noted during this exam segment.
  • Meibography. While transillumination of the meibomian glands can be helpful, I much prefer using meibography, as it allows for much better visualization and, therefore, inspection and analysis of the gland structure and subsequent patient education. The Oculus Keratograph 5M offers meibography. TearScience offers a dedicated meibographer and a unit that measures blink fluency and lipid layer thickness, along with meibomian gland imaging, LipiScan and LipiView, respectively. With the intense focus on this area, a growing number of companies are introducing technology that can help diagnose and stage treatment, such as Box Medical Solutions (Meibox) and Topcon (SL-D701) with an optional meibographer.
  • Staining. Fluorescein and lissamine green stains are key parts of the examination, as they highlight ocular surface damage and provide insight into the severity of the patient’s disease.

Collarettes, or cylindrical dandruff, as seen here, are a sign of demodex, a mite linked with blepharitis.
PHOTO CREDIT: Art Epstein, O.D. F.A.A.O.

TREATMENT

I take the following steps in treating lid disease:

For blepharitis:

  • Lid hygiene. This takes center stage because mechanically removing debris and biofilm buildup from the lashes and lid margins often provides rapid relief. I use Microblepharoexfoliation, (BlephEx, Rysurg), which can be repeated twice annually, as necessary, for maintenance. Depending on severity and cause, I typically prescribe pure hypochlorous acid, which is naturally produced by neutrophils, directly applied to the lids b.i.d. When demodex is evident, I may use a topical tea tree oil preparation. I try to balance effectiveness with comfort and patient compliance.

Staph. overpopulation is a frequently overlooked driver of tear dysfunction, due to saponification, seen here, and degradation of tear lipids.
PHOTO CREDIT: Art Epstein, O.D. F.A.A.O.

Note the dandruff-like scurf, which accompanies blepharitis, or inflammation of the anterior lid margin. Blepharitis also includes red, swollen eyelids, erythema, lash loss crusting and matting with lid debris.
PHOTO CREDIT: Art Epstein, O.D. F.A.A.O.

For MGD:

  • Omega-3 ocular nutritional supplements. Omega-3 supplements reduce inflammation, provide the building blocks for healthy meibum production and offer numerous other ocular surface and general health benefits, including improved tear stability and cardiac and joint health benefits, which I have experienced personally. I have adopted a holistic approach prescribing 2.5 grams of a triglyceride-based omega-3 fish oil using either split dosing or once daily dosing. Most patients will continue this indefinitely because of its effectiveness and broad health benefits.
  • Hypochlorous acid. This effectively reduces staph. overpopulation of the lids and blocks staph. exotoxin, which is inflammatory and inactivates digestive enzymes, such as lipase, that staph. produce to facilitate infection. Staph. overpopulation is a frequently overlooked driver of tear dysfunction, because of saponification and degradation of tear lipids. This is used directly on the lids b.i.d.
  • Direct moist heat. While usually not sufficient to thoroughly melt congealed meibum, this is helpful and makes most patients feel better. I prescribe a microwave-heated mask to be used nightly for 8 to 10 minutes.
  • Artificial tears. Artificial tears can be a helpful adjunct for patients who have mild to moderate disease. They help to maintain ocular surface moisture and tear volume. Lipid-supplement drops are usually my first choice, since several patients suffer from lipid deficiency.
  • Pharmaceutical treatment. With lifitegrast ophthalmic solution (Xiidra, Shire) approved by the FDA for the signs and symptoms of DED and cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) increasing tear production, pharmaceutical treatment is valuable, especially for highly symptomatic patients.
  • Lid debridement/gland expression. Most patients who have advanced disease and significant gland loss need lid debridement and gland expression. I use a vectored thermal lid pulsation system that combines heat applied directly to the meibomian glands on the inner surface of the lids with controlled pulsatile expression of the glands (LipiFlow system, TearScience). A variety of other devices that apply heat indirectly and require manual expression are available.
  • Patient education. One key element of a successful treatment approach is communication. I review my treatment plan with the patient and provide a customized treatment protocol. Specifically, I explain why I am prescribing each item, how it works and how to use it. Every patient leaves with clear, written and verbal directions, which reassures patients that they won’t forget something and dramatically boosts compliance.

STRATEGIES

Aside from the unmet patient need, developing lid disease as a niche practice segment provides a variety of positive practice management and financial benefits. To do so successfully:

  • Identify patients. DED patients suffer silently and often believe it’s a normal part of aging. Use a validated dry eye questionnaire, such as the OSDI or the SPEED surveys. Have a technician administer the questionnaire and, after scoring the results, discuss it with the patient.
  • Decide on offerings. Realize that lid disease management can be time consuming. I recommend that you keep it simple, especially at first. For diagnosis, a slit lamp, fluorescein staining and diagnostic expression will work, but technology can make a huge difference both in identifying and gauging the severity of patients who have MGD. Advanced diagnostic instrumentation helps build the practice segment by educating and engaging patients more effectively and, typically, pays for itself quickly.

    Likewise, when it comes to treatment, develop a simple, but effective, protocol that works for the majority of your patients. As your reputation grows, more challenging patients will require a more extensive armamentarium, but in the beginning, keep it simple.

    Also, while you plan this aspect of your practice, don’t neglect the full-service aspects. For example, I quickly discovered the most common question patients asked was: “Where do I get what you are recommending?” As a result, we now stock and provide all non-pharmaceutical DED products.
  • Code/bill appropriately. Many aspects of DED and lid disease diagnosis and treatment are not covered by health insurance. No procedure codes exist for meibography, lid debridement or meibomian gland expression. Perhaps surprisingly, patients generally have less issue with this than we do. We have become so accustomed to entitlement, that we forget that patients will willingly pay out of pocket for what they perceive will benefit them. Charge appropriately, whether a covered or uncovered service or procedure. I’ve found that bundling services works well in our practice as opposed to charging á la carte for each test or procedure. As the practice evolves, you will gain a better idea of the appropriate fees for services and procedures.

    Also, if you discover lid disease during an exam, explain your findings, and schedule a follow-up patient return for a separate disease-focused visit. This is not only necessary for proper insurance billing, but it provides sufficient time to diagnose and educate the patient.
  • Market the service. In my practice, we planned an independent lid disease service. So, we created a separate web presence focusing on DED and lid margin disease. The result was an almost immediate flow of patients seeking care. The key here is to know what you’re doing and have a plan and effective clinical strategy in place.

Note the tear instability that results from lid disease.
PHOTO CREDIT: Art Epstein, O.D. F.A.A.O.

WHAT ARE YOU WAITING FOR?

Lid disease and associated DED is a rapidly growing and largely unmet medical need for many of our patients. By embracing this important aspect of care, we can not only meet these needs, but also ensure the success of our practices and the continued relevance of our profession. OM