As a child, I heard my father opine many times at the dinner table about his work. At the time, he worked at a renowned military contractor where he explained his job was bigger than him—one of which was a responsibility to keep men and women out of harm’s way. His position as a software and hardware engineer required a keen sense of observation where he conveyed how nature might influence a redesign of the aeronautics within the cockpit or a reconnaissance workstation. Once the meal was complete, he would push away his plate and quote the famous words once uttered by the famed Frank Lloyd Wright. “Form follows function— that has been misunderstood. Form and function should be one, joined in a spiritual union”.
Donald Korb and his protégés over the years have teased out the subtle nuances in lid anatomy. While disease states such as blepharitis are a household name, meibomian gland dysfunction (MGD) and lid wiper epitheliopathy are newer iterations in our vernacular. As we have spoken of in past editions, glandular blockage has a definitive link with dry eye disease accounting up to 85% of cases.1
Meibomian glands are sebaceous glands within the tarsal plates, numbering approximately 30 and 25 glands in the upper and lower eyelids, respectively.2 These glands are composed of clusters of acini, measuring in length 5.5 mm for the upper and 2 mm for the lower lid.2 Although contraction of the orbicularis oculi muscle facilitates glandular secretions, nevertheless, MGD obstruction illustrates a lack of discharge through the aging process, alteration of sex hormones, bacterial and mite overpopulation, blink abnormalities, and rosacea, to name a few. When the glands are continuously insulted, the ensuing signs thereafter could come in the form of epithelial hyper-keratinization that causes duct obstruction, stasis, cystic dilation, and, ultimately, glandular atrophy.3-5
With this information in hand, what is the path forward? Keeping in line with the theme, Korb tirelessly worked on his prototypes for some time prior to the official incorporation of TearScience in 2005. What became evident to him rather quickly was traditional warm compresses were not achieving the thermal melting point (approximately 110°F/43°C) along with the lack of a routine behavior similar to brushing of teeth.4,5 Fast forwarding to 2011, FDA approval of LipiView/LipiFlow (Johnson and Johnson Vision Care, Jacksonville) allowed doctors to finally have a tool for in-office use to both measure and treat MGD effectively on a regular basis.
Key pearls gleaned from the original work were the thoughts that direct contact with the glands internally, utilizing the eye cup via vector based heat and the automated air bladder for 12 minutes at a stable temperature, allowed for material softening of the meibum.5 Acknowledging this is a simplistic representation of the treatment, it is the elegant use of a technology to facilitate potential gland revitalization and, more realistically, preservation of the tissue.
Building on these ideals, MiBo ThermoFlo (MIBO Medical Group, Dallas) was released to market as a cost-effective alternative starting in 2012. While utilizing a stainless steel paddle heated to the appropriate temperature, the user applies the device externally over ultrasound gel attempting to achieve the melting point of the meibum. There have been studies in the literature including case reports calling into question the efficacy of external heating methods.6
Similar to the TV infomercials— wait, there’s more! New entrants in the past 6-12 months include TearCare (Sight Sciences, Menlo Park) and iLux (Alcon, Geneva/Ft Worth). Each of these units is mobile and efficient, which means it is not just another piece of equipment that you will have to find a home on your counter.
TearCare has a self-contained “hockey puck” heat induction device called a SmartHub using naturally contoured SmartLid pads with removable mild silicone adhesive, applied to the exterior lids to deliver a comfortable open eye heating experience. The temperature is set to the industry standard, but can be customized similar to LipiFlow. After the procedure is complete, they have been kind enough to supply a starter pack of stainless steel forceps for which has been angled to allow for ease of expression to clear the glands in a timely fashion.
The iLux device is a handheld device originally pioneered by TearFilm Innovations, recently being acquired by Alcon. With a magnifying window, the unit is placed under the lid to visualize the glands which is a very thoughtful design element. The heating method is unique in that it utilizes yellow LED light. Additionally, there is a time and pressure display informing the doctor (or technician) when to express along with how much force is allowable to provide the patient an all-in-one comfortable and safe encounter.
Is your mind blown yet?! Wait for the next edition when we shed some more “light” to breakdown the ROI on each of these devices to see which one may best fit your practice.
Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5): 472-478.
International Dry Eye Workshop. The definition and classification of dry eye disease: report of the International Dry Eye Workshop. Ocular Surf. 2007;5: 75-92.
Greiner JV, Glonek T, Korb DR. Volume of the human and rabbit meibomian gland system. Adv Exp Med Biol. 1998;438: 339-43.
Nicolaides N et al. Meibomian gland studies: comparison of steer and human lipids. Invest Ophthalmol Vis Sci. 1981;20(4): 522-36.
Knop E, Knop N, Miller T, Sullivan DA. The international workshop of meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011;52(4): 1938-78.
Kenrick CJ, Alloo SS. The Limitation of Applying Heat to the External Lid Surface: A Case of Recalcitrant Meibomian Gland Dysfunction. Case Rep Ophthalmol. 2017;8(1): 7–12.
Michael S. Cooper, OD currently practices and is the Director of Research and Technological Innovation at Solinsky EyeCare in the Greater Hartford area. He specializes in anterior segment disease, treating a variety of conditions including dry eye and external lid diseases, allergy, and uveitis. He has produced research, participated on expert ocular surface disease round tables, and lectured domestically on topics such as corneal disease states, uveitis management, Lyme disease, emerging pathogens, complex glaucoma management, sports-related eye injuries in children, and AMD pedigree relationships. Currently, he is actively involved in global clinical studies for novel anti-infective therapeutics, ocular surface diagnostic validation, and AMD genetic research.