Microblepharoexfoliation for the Surgical Dry Eye Patient. Frank W. Bowden, III, M.D., FACS

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1 Microblepharoexfoliation for the Surgical Dry Eye Patient Frank W. Bowden, III, M.D., FACS

2 Disclosures Shire TearScience TearLab RySurg Bausch & Lomb/Valeant BioTissue

3 Surgical Dry Eye The surgical dry eye patient requires a careful assessment of the ocular surface. Dry eye is usually accompanied by both anterior and posterior blepharitis (MGD). Preop management involves treatment of lid margin disease.

4 Surgical Dry Eye Traditional surgical preparation of ocular surface -lid scrubs -warm compresses -antibiotics Compliance with lid hygiene measures have been inconsistent and/or ineffective for many patients. Microblepharoexfoliation (MBE) represents a quick and effective office procedure to clean the lids.

5 MBE Implementation Integrated Approach Dry eye screening of all surgical patients Technician identification and workup Counselor introduction of dry eye services and surgical options Surgeon exam and recommendations

6 MBE Implementation Technicians Validated dry eye questionnaire (SPEED/OSDI) Point of service testing Osmolarity MMP-9 Lipid Layer Thickness (LLT) Meibography Partial Blink Rate Allergy Symptoms Identified

7 MBE Implementation Counselors Dry eye Counseling Video/brochures Discussion regarding dry eye services Pertinent Surgical Counseling Video/brochures Introduction of procedural options

8 MBE Implementation Surgeon Review of SPEED and dry eye diagnostics Slit lamp exam of the ocular surface Staining pattern ( fluorescein/lissamine) Tear BUT Meibomian gland score and count Recommend MBE and perioperative dry eye treatment plan based on findings and symptoms Confirm the surgical procedure

9 MBE Implementation Asymptomatic dry eye with lid margin disease Patients are often unreceptive to dry eye discussion Advise lid hygiene measures, lubricants, and antibiotic Suggest MBE Document dry eye discussion

10 MBE Implementation Symptomatic dry eye with lid margin disease Must educate patients regarding visual impact of dry eye and the need to delay surgery Begin lid hygiene measures, lubricants, and antibiotics Initiate topical cyclosporine and steroids along with oral Omega 3 Advise MBE Address obstructive MGD Thermal pulsation therapy Meibomian gland probing/expression

11 MBE Implementation Microblepharoexfoliation Greater patient acceptance with symptomatic dry eye 10 minute treatment at interval dry eye visit prior to preop testing Proceed with ocular surgery in 1-2 weeks

12 Microblepharoexfoliation (MBE) BlephEx device Developed by J. Rynerson, M.D Consists of a spinning microsponge tip soaked in lid cleanser solution mounted on hand held device Microsponge tip spins at 2,000 rotations per minute in either direction Fresh tip for each lid

13 MBE for surgical dry eye patients Dry eye is associated with lid margin disease which may involve microbial proliferation. Bacterial persistence is facilitated by production of a protective biofilm and adaptive protein upregulation (quorum sensing).* Staphylococci may further promote ocular surface inflammation with exotoxin release. * O Brien TP. Ocul Surf. 2009; 7(2 Suppl):S21-22.

14 MBE for surgical dry eye patients MBE effectively debrides the lid margin Scurf Collarettes Demodex sleeves Keratin debris MBE effectively eliminates bacteria and exotoxins Biofilm disruption* Bacterial population reduction *Black CE and Costerton JW Surg Clin North Am. 2010;90:

Microblepharoexfoliation Technique Proparacaine drops Assemble the BlephEx device Stabilize the lid Patient gaze away from treated lid Scrub lid

15 Microblepharoexfoliation Technique Proparacaine drops Assemble the BlephEx device Stabilize the lid Patient gaze away from treated lid Scrub lid margin and lashes with gentle pressure Fresh cleanser soaked microsponge for each lid Saline rinse the eyes and lids Apply thermal mask Resume dry eye care

16 Microblepharoexfoliation Technique

17 Microblepharoexfoliation preop postop

18 Microblepharoexfoliation preop postop

19 Microblepharoexfoliation preop postop

20 Conclusion Microblepharoexfoliation (MBE) is an effective procedure to prepare the ocular surface for surgery in the dry eye patient. Mechanical debridement of lid margin debris, scurf, and collarettes along with bacterial biofilm and exotoxins with the BlephEx device may effectively optimize the ocular surface for surgery. Patient acceptance of MBE has been very favorable. MBE performed 2-3 times per year along with regular lid hygiene may reduce the need for more invasive dry eye therapies.

Dry Eye Disease Diagnosis and Treatment Pearls from the Trenches (2 hours) Mile Brujic, O.D Kensington Blvd. Bowling Green, OH 43402

Dry Eye Disease Diagnosis and Treatment Pearls from the Trenches (2 hours) Mile Brujic, O.D. 1409 Kensington Blvd. Bowling Green, OH 43402 Summary As our understanding of dry eye disease has evolved, so