Does in-office manual expression for Meibomian Gland Dysfunction (MGD) work?

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Conference Paper October 2015 READS 30 2 authors: Leslie E.

1 See discussions, stats, and author profiles for this publication at: Does in-office manual expression for Meibomian Gland Dysfunction (MGD) work? Conference Paper October 2015 READS 30 2 authors: Leslie E. O'Dell Salus University 15 PUBLICATIONS 2 CITATIONS Milton M Hom Independent Researcher 62 PUBLICATIONS 536 CITATIONS SEE PROFILE SEE PROFILE Available from: Milton M Hom Retrieved on: 25 May 2016

2 Does in-office manual expression for Meibomian Gland Dysfunction (MGD) work? Leslie O Dell, OD, FAAO Milton M. Hom, OD, FAAO S

3 Disclosures Unsponsored research S

4 Purpose S Does in-office manual expression improve symptoms for patients with MGD? S Does in-office manual expression improve MG function for patients with MGD?

5 Meibomian Gland Dysfuntion Nichols KK, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):

MGD S Meibomian Gland Dysfunction (MGD) is the most common cause of dry eye 1-4 1. Goto E, Monden Y, Takano Y, et al.

6 MGD S Meibomian Gland Dysfunction (MGD) is the most common cause of dry eye Goto E, Monden Y, Takano Y, et al. Treatment of non-inflamed obstructive meibomian gland dysfunction by an infrared warm compress device. Br J Ophthalmol 2002;86: Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009;7(2 Suppl):S1-S 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): Shimazaki J, Sakata M, Tsubota K. Ocular surface changes and discomfort in patients with meibomian gland dysfunction. Arch Ophthalmol. 1995;113(10):

7 Manual Expression S Forced expression has been a treatment for obstructed glands dating back to S Manual expression of the MG is proven to be an effective treatment 6 however is widely underutilized 7 5. Duke-Elder WS, MacFaul PA. The ocular adnexa, part II, diseases of eyelids. IN: System of Ophthalmology. London, United Kingdom, H. Kimpton, 1974, v. XIII, pp Korb DR. Greiner JV. Increase in tear film lipid layer thickness following treatment of meibomian gland dysfunction. Adv Exp Med Biol 1994;350: Blackie CA, Kor DR. Meibomian gland expression: Forces of Expression, types of secretion and the limitation of resulting pain. Invest Ophthalmol Vis Sci 2010;3385/D971.

8 Methods S Single site evaluation of the effectiveness of manual expression on MG function and symptom relief S N=24 subjects: S M:F 6:18 S Mean age 63.5 years old (37 to 81 years).

9 Methods S Inclusion criteria: S >18 years S Self reported dry eye S H/o chronic MGD S Consent to treatment with manual expression S Exclusion criteria: S Active inflammation/infection S Ocular surgery within 3 months S Contact lens use S Symptoms were evaluated using OSDI and SPEED validated questionnaires - Baseline/2 weeks/1 month

10 OSDI S S S Validated, used to diagnose any type of DED 12-item questionnaire S Graded 0-4 Scoring S 0-100* (Schiffman et al, Arch Ophthalmol 2000) S Dry if score > 12* (Miller et al, Arch Ophthalmol, 2010 )

SPEED Patient Name: RIGHT EYE S Validated Date: DRY EYE QUESTIONNAIRE - SPEED LEFT EYE Please answer the following questions by checking the box that best represents your answer.

11 SPEED Patient Name: RIGHT EYE S Validated Date: DRY EYE QUESTIONNAIRE - SPEED LEFT EYE Please answer the following questions by checking the box that best represents your answer. Select only one answer per question. S Evaluates frequency and duration of symptoms S Scored 0-28 S Mild dry eye 5 S Moderate dry eye =6-9 S Severe dry eye Report the type of SYMPTOMS you experience and when they occur: WITHIN PAST WITHIN PAST AT THIS VISIT SYMPTOMS 72 HRS 3 MONTHS YES NO YES NO YES NO Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue 2. Report the FREQUENCY of your symptoms using the rating list below: SYMPTOMS Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue 0 = Never 1 = Sometimes = Often = Constant Report the SEVERITY of your symptoms using the rating list below: SYMPTOMS Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue 0 = No problems 1 = Tolerable not perfect but not uncomfortable 2 = Uncomfortable irritating but does not interfere with my day 3 = Bothersome irritating and interferes with my day 4 = Intolerable unable to perform my daily tasks use eye drops for lubrication? YES NO If yes, how often? 4. Do you Korb DR, Blackie CA, Meibomian Gland Diagnostic Expressibility: Correlation with Dry Eye Symptoms and Gland Location. Cornea Vol 27; 10:

12 Methods S Gland function was assessed using Meibomian Gland (MG) secretion score S Meibomian Glands Yeilding Liquid Secretion (MGYLS) S Grading 15 meibomian glands of the lower eyelid S Scale of 0-45 where 45=normal Grade Quality of MG secretion 0 No secretion 1 Inspissated 2 Liquid colored 3 Clear oil

Warming the lids S External heat was applied to both eyes using commercially available eyelid warming mask for 10 minutes prior to expression S (From

13 Warming the lids S External heat was applied to both eyes using commercially available eyelid warming mask for 10 minutes prior to expression S (From the report of Murakami et al OVS (2015), this approach is effective is raising internal eyelid temperature for an effective treatment time (> 4 minutes))

14 Methods S Manual expression performed on one eye S Performed on both upper and lower lids immediately following heat therapy S Glands expressed distal to proximal nasal to temporal S Glands were expressed for secs

15 Expressing the glands S Manual expression one eye at the slit lamp with Maskin Meibum Expressor (Rhein medical) S Expressed glands distal to proximal for both upper and lower lids

17 Results Significance was found in symptom relief using both SPEED an OSDI S

18 Subjective improvement with SPEED Baseline 2 weeks 1 month Treated eye Untreated Eye

Subjective improvement with SPEED 28 26 24 22

08 Test eye change from baseline: 2 weeks p=0.

19 Subjective improvement with SPEED Test eye change from baseline: 2 weeks p=0.004 and 1 month p< Baseline 2 weeks 1 month 7.76

20 Subjective improvement- OSDI Statistically significant change from baseline in treated group at 2 week and 1 month, no significant change from baseline in control Treated Eye Untreated Eye 10 0 Baseline 2 weeks 1 month

Objective findings MG secretion score 45 40 35 30 25 20

21 Objective findings MG secretion score Baseline 2 week 1 month treated eye untreated eye

22 Conclusions S

23 Conclusions S One time manual expression using forceps shows significant improvement in symptoms at two weeks and one month when compared to the control eyes S Symptoms improve with manual expression despite no improvement in objective MGD scores

24 Technique considerations S Heat each eye individually prior to expression to maintain liquefaction of meibum S Pain associated with manual expression S Potential for MG loss with manual expression??

25 LEO- Liquefy, Express, Observe In-office manual expression LEO: Liquefy, Express, Observe Version Please check with us for permission if you want to publish Corresponding author: Leslie O Dell leslieod@hotmail.com!! Pre%treatment!! 1. Confirm!Meibomian!Gland!(MG)!Obstruction! addressing!4!components!of!mg!dysfunction!(mgd)! a. Meibum!Composition%!Evaluate!the!MG! secretions!using!finger!compression!or!cotton!bud!to! press!on!the!outer!portion!of!the!lower!lid!margin.!! Additionally,!meibomian!gland!evaluator!could!be! used!to!assess!the!quality!of!meibum.! b. Terminal!duct!and!MG!orifice!obstruction!! c. Inflammatory!load!generated!by!primary!or!

26 Thank You S

Medical and/or Vision Insurance plans do not cover the Specialty Dry Eye Testing or LipiFlow services.

Medical and/or Vision Insurance plans do not cover the Specialty Dry Eye Testing or LipiFlow services. ADVANCED BENEFICIARY NOTICE (ABN) Patient s Name: Date of Birth: The purpose of this form is to help you make an informed choice about your visit today. Before you make a decision about your options, you