Article Date: 3/1/2012

Let’s Ask Siri a Dry Eye Question
dry eye

Let’s Ask Siri a Dry Eye Question

Online searches can yield both confusing and complicated answers.

Kelly Nichols, O.D., M.P.H., Ph.D.

Imagine you have diagnosed a patient with meibomian gland dysfunction (MGD) or evaporative dry eye, and your next step is to prescribe and describe warm compress therapy. What do you tell your patient? Who trains him on this treatment, and what materials does he take home to reinforce what he has been told? Many patients, especially if they are confused or unsure about what we mean by “warm compress therapy,” will turn to the Internet for help. Do you know what they will find there?

What I learned from Siri

In today’s technology-based world, information is always at our fingertips. Or as the Apple iPhone’s intelligent assistant, Siri, says she is there to help. So I asked Siri, “How do you do warm compress therapy?” She promptly directed me to the Internet, where she Googled my question. The first hit was The Dry Eye Zone (www.dryeyezone.com), a patient-oriented website and blog. The site contains an active forum regarding the condition, and its site owner, Rebecca Petris, regularly updates numerous product pages as well as a page describing the status of research on potential therapies for dry eye syndrome. The following is abstracted from this site:

“Warm compresses may be applied over the eyelids as a treatment for meibomian gland dysfunction. They work by loosening up hardened oil that clogs the oil glands in the eyelids. For many people who have chronic meibomian gland dysfunction, heat treatment is an effective ‘maintenance’ treatment. Heat treatment, using warm compresses, is intended to loosen up hardened oil that is clogging the glands and keep it flowing better. Even better, you can follow up a warm compress with lid scrubs/lid massage to express the now softened oil from icky clogged glands. How can you do a warm compress?”

The site goes on to describe common techniques for warm compress therapy, such as using a warm washcloth or a rice “baggy,” a technique described as “. . . a favorite among dry eye treatment ‘connoisseurs’ and veterans of meibomian gland dysfunction.” In fact, the site offers its own rice baggy for sale at The Dry Eye Shop, noting, “We find that rice baggies work better than washcloths because the rice retains heat well, and the weight helps it distribute the heat evenly and effectively. Rice baggies can be reused many times but for safety’s sake should be replaced periodically.”

When it comes to the “how to” part of warm compress therapy, there are literally hundreds of ways warm compress therapy can be done when conducting a search via the Internet, with seemingly no consensus on the best technique.

Simplifying MGD Management
Define and adhere to a treatment plan.
With so much inconsistent and often inaccurate information available on the Internet, it behooves us to define and help our patients adhere to a treatment plan. The following to-do list can help.
1. Create an instruction sheet for warm compress therapy and lid hygiene. Include a list of informative websites that you have personally vetted.
2. Personally hand the instruction sheet to the patient, and briefly review it with your patient.
3. Have your staff reinforce your instructions, perhaps with a demonstration.
4. Follow up with a postcard or an information sheet by mail or e-mail two weeks after the diagnostic visit.
5. Schedule a follow-up visit based on presenting signs and symptoms and initial disease severity.

In addition to a warm washcloth and rice in a baggie or sock, other suggested compresses run the gamut from simple, inexpensive wet gauze to pricey spa masks. Instructions also exist on how to use a baked potato or a hard-boiled egg as a compress. Although I have never been a huge fan of using food for warm compress therapy, researchers have found these items effective.

For instance, a 2007 study revealed hard-boiled eggs are safe and effective for warm compress use.1 In terms of the concern that the pressure of the egg would distort the corneal shape, the researchers found that placing the egg close to, but not touching the eyelid, should melt the meibomian gland secretions without distorting the corneal shape.

When describing how much heat to apply for warm compress therapy, recommendations from online sources range from none (cold compresses to soothe the eyes) to tap water-warmed, microwaved and boiled.

In terms of frequency of application, this ranges from once or twice per treatment to 20 times per session for 30 seconds or five minutes or 15 minutes. It’s no wonder patients become confused and stop — or never start — therapy. (See “Simplifying MGD Management: Define and adhere to a treatment plan,” page 66.”)

Warm compress efficacy

Patients may ask whether warm compresses will really help cure their MGD. Clinical studies do indeed exist that support the use of this therapy. In a 2003 study, for instance, researchers applied warm, moist compresses to the skin of the closed eyelids of subjects who had MGD.2 Five minutes after treatment began, tear-film lipid layer thickness increased by more than 80%; after 15 minutes of treatment, it increased an additional 20%. This indicates that changes to the lipid layer can occur with therapy lasting five minutes or less.

In a follow-up study, researchers reported four minutes of warm compress therapy at approximately 45°C (113°F) optimizes this therapy. 3 They noted contact between the warm compress and the outer eyelid surfaces is required, and that the compress should be reheated frequently through the four-minute period to achieve an inner lower eyelid temperature greater than or equal to 40°C. Longer therapy may be necessary for more severe disease.

These data suggest that a precise, customized, labor-intensive warm compress procedure is necessary to optimize treating MGD and gland obstruction. Is this level of compliance realistic, even for the committed patient? In the end, your patient might not be very good at maintaining therapy. There may be another option.

An alternative treatment

Recently, the LipiFlow Thermal Pulsation System (TearScience Inc.), which reportedly liquefies and evacuates meibomian gland obstructions, received FDA clearance. 4 TearScience says this second-generation device includes a more robust graphical user interface and enables bilateral treatment in the office with the associated fee-for-service.

Regardless of the therapy chosen, an honest discussion of the merits and realities associated with managing MGD is warranted. (See “Don’t Say “Crud:” How do you explain less-than scientific terminology?,” below.)

Fine-tune your dialogue

MGD and evaporative dry eye have become more commonplace terms, but the terminology is still confusing to patients. So, we must make an extra effort to understand the diagnosis from a patient’s perspective. Emerging clinical science, such as LipiFlow, will be of great interest to practitioners and patients alike. Fine-tuning dry eye syndrome discussions and being mindful of other sources patients may tap into goes a long way toward ensuring their understanding and compliance. OM

1. Lam AK, Lam CH. Effect of warm compress therapy from hard-boiled eggs on corneal shape. Cornea 2007 Feb;26(2): 163-7.
2. Olson MC, Korb DR, Greiner JV. Increase in tear film lipid layer thickness following treatment with warm compresses in patients with meibomian gland dysfunction. Eye Contact Lens. 2003 Apr;29(2): 96-99.
3. Blackie CA, Solomon JD, Greiner JV, et al. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008 Aug;85(8):675- 83.
4. TearScience: The Evaporative Dry Eye Experts. TearScience Achieves FDA Clearance for Second Generation LipiFlow Thermal Pulsation System. www. tearscience.com/en/tearscience-achieves-fda- clearance-for-second-generation-lipiflow- thermal-pulsation-system (Accessed 2/27/12)

DR. NICHOLS IS A FOUNDATION FOR EDUCATION AND RESEARCH IN VISION (FERV) PROFESSOR AT THE UNIVERSITY OF HOUSTON COLLEGE OF OPTOMETRY. SHE LECTURES AND WRITES EXTENSIVELY ON OCULAR SURFACE DISEASE AND HAS INDUSTRY AND NIH FUNDING TO STUDY DRY EYE. SHE IS ON THE GOVERNING BOARDS OF THE TEAR FILM AND OCULAR SURFACE SOCIETY AND THE OCULAR SURFACE SOCIETY OF OPTOMETRY. SHE IS A PAID CONSULTANT TO ALCON, ALLERGAN, B+L, CELTIC, ELEVEN BIOTHERAPEUTICS, MERCK, SARCODE AND TEARLAB. CONTACT DR. NICHOLS AT KNICHOLS@OPTOMETRY.UH.EDU. TO COMMENT ON THIS ARTICLE, E-MAIL OPTOMETRICMANAGEMENT@GMAIL.COM.

Don’t Say “Crud”
How do you explain less-than-scientific terminology?
An online search for “warm compress therapy” produces a somewhat limited list of websites related to dry eye with often questionable information. Alternatively, you can search for “lid hygiene,” but the information is just as “boiled down” (pun intended) as what you will find on warm compresses. What I mean is the terminology is less than scientific. Many sites describe “crud” or “congealed oily stuff” coming from the meibomian glands or the “oil glands of the eye.”
No one wants “crud” on their eyelids, but does the word convey the seriousness of the underlying condition, and does it emphasize the importance of adhering to therapy? When it comes to “crud” on the eyelashes or being expressed from the glands, I believe a picture is worth a thousand words. I also believe you can describe the condition in an educated manner, present yourself as a top-tier clinic and improve compliance without having to say “crud.”


Optometric Management, Volume: 47 , Issue: March 2012, page(s): 66 68 69