MANAGING THE LID MARGIN AND LASHES: IN-OFFICE PROCEDURES. Scott Schachter, OD Pismo Beach, CA

Transcription

1 MANAGING THE LID MARGIN AND LASHES: IN-OFFICE PROCEDURES Scott Schachter, OD Pismo Beach, CA 1

2 DISCLOSURES Allergan Bausch and Lomb BioTissue RySurg ScienceBased Health Sun Pharma TearScience 2

3 WHY OFFER IN-OFFICE PROCEDURES OCULAR SURFACE DISEASE IS PREVALENT, EVERY DAY, ALL DAY OSD IS OFTEN MULTI-FACTORIAL AND REQUIRES MORE THAN ONE APPROACH DIFFERENTIATE YOUR PRACTICE HIGHER LEVEL OF PATIENT SATISFACTION (PAYMENT IMPLICATIONS, MACRO, ACO, ETC 3

4 WHY OFFER IN-OFFICE PROCEDURES CREATES A CULTURE OF WELLNESS, PROACTIVE, NOT REHABILITATIVE IN MY PRACTICE, WE WANT OUR PATIENTS TO LOOK, FEEL, AND SEE THEIR BEST DIVERSIFY REVENUE STREAM IMMUNE TO DOWNWARD PRESSURE FROM INSURANCE LESS DEPENDENT ON VISION PLANS 4

5 CONDITIONS TO CONSIDER COMMON CONDITIONS SEEN DAILY IN THE OPTOMETRIC PRACTICE. THIS COURSE WILL REVIEW THE PREVALENCE, DIAGNOSIS, AND THEN FOCUS ON IN-OFFICE TREATMENTS OPTIONS FOR EACH. MEIBOMIAN GLAND DYSFUNCTION ANTEROPLACEMENT AND THICKENING OF LINE OF MARX DEMODEX BLEPHARITIS 5

6 MEIBOMIAN GLAND DYSFUNCTION IN-OFFICE PROCEDURES MGD LIPIFLOW MiBoFlo ThermoFlo MASKIN PROBING Manual Expression ThermiEye (new!) ALTERATIONS IN LINE OF MARX Debride Scale BLEPHARITIS Blephex 6

7 MEIBOMIAN GLAND DYSFUNCTION DEFINED Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease. -TFOS INTERNATIONAL WORKSHOP ON MGD,

8 MEIBOMIAN GLAND DYSFUNCTION PREVALENCE The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on the Epidemiology of, and Associated Risk Factors for, MGD Debra A. Schaumberg,1 Jason J. Nichols,2 Eric B. Papas,3 Louis Tong,4 Miki Uchino,5 and Kelly K. Nichols2 8

9 MEIBOMIAN GLAND DYSFUNCTION DIAGNOSIS Grade the function and anatomy of the glands Express glands, ideally with Meibomian Gland Evaluator (MGE), which mimics blink pressure, or your thumb Count the number of functioning glands. Minimum of 6 should secrete oil Visualize glands with transillumination or Lipiview, Lipiscan, or Keratograph 9

10 GRADING MG ANATOMY MEIBOSCALE 10

11 GRADING MG FUNCTION DIAGNOSIS AND MANAGEMENT OF MEIBOMIAN GLAND DYSFUNCTION: OPTOMETRISTS' PERSPECTIVE Dominick L Opitz, 1 Jennifer S Harthan, 1 Stephanie R Fromstein, 1 Scott G Hauswirth 2 1 Department of Clinical Education, Illinois College of Optometry, Chicago, IL, 2 11 Minnesota Eye Consultants, Minneapolis, MN, USA

12 IMAGING MEIBOMIAN GLANDS TECHNIQUES AND IMAGES TRANSILLUMINATION OCULUS KERATOGRAPH TEARSCIENCE LIPISCAN TEARSCIENCE LIPIVIEW II 12

13 IMAGING MEIBOMIAN GLANDS THE WHY Disease prevalence expected to increase with device use Get a baseline on all patients to watch for progression Helps patients understand a complicated disease state Drives compliance with treatment plans, since signs and symptoms often do not match 13

14 IMAGING MEIBOMIAN GLANDS TRANSILLUMINATION Darken the exam room, evert the lower lid with transilluminator as patient looks up Slit lamp light is off There should be around 25 glands in the lower lid Pros: inexpensive and quick, can do on next patient! Cons: this method include a limited field of view, low contrast between structures limiting visualization of details and some discomfort for the patient, cannot image uppers, need anterior segment camera if you want to image 14

15 IMAGING MEIBOMIAN GLANDS TRANSILLUMINATION Work to get good lid eversion Adjust transillumination light level to maximize contrast and visualization Look temporally, medially, and nasally 15

16 IMAGING MEIBOMIAN GLANDS TRANSILLUMINATION Meibomian glands are dark, like tiger stripes Note limited field of view 16

17 IMAGING MEIBOMIAN GLANDS OCULUS KERATOGRAPH Multi-function instrument: Corneal topography Anterior seg photography Zernike, Fourier analysis Contact lens fitting software Keratometry JENVIS REPORT Tear meniscus height Lipid layer thickness Meibomian gland imaging Tear film break-up time photo by Oculus Uses IR for gland imaging Images not as clear as TearScience products 17

18 IMAGING MEIBOMIAN GLANDS OCULUS KERATOGRAPH JENVIS REPORT 1) Tear meniscus height 2) Lipid layer thickness 3) Tear film break-up time 4) OSDI 5) Lid parallel conjunctival folds 6) Meibography photo by Oculus 18

19 IMAGING MEIBOMIAN GLANDS OCULUS KERATOGRAPH 25 yo female Note gland tortuosity SPEED 24 19

20 IMAGING MEIBOMIAN GLANDS TEARSCIENCE LIPISCAN The first and only dedicated high definition (HD) gland imager that allows eye care professionals (ECPs) to efficiently evaluate meibomian glands in busy practices. The new rapid imager was created with end users in mind. Fast and intuitive, LipiScan harnesses patented dynamic meibomian imaging (DMI) technology to produce high definition images of meibomian glands. LipiScan allows ECPs to assess meibomian gland structure during routine workups in any practice setting. Press Release Designed for SCAN EVERYONE approach photo by TearScience 20

21 IMAGING MEIBOMIAN GLANDS TEARSCIENCE LIPISCAN Note gland tortuosity 21

22 IMAGING MEIBOMIAN GLANDS TEARSCIENCE LIPIVIEW II Indications for Use: The LipiView II Ocular Surface Interferometer is an ophthalmic imaging device that is intended for use by a physician in adult patients to capture, archive, manipulate and store digital images of: Specular (interferometric) observations of the tear film. Using these images, LipiView II measures the absolute thickness of the tear film lipid layer. Also blink quality. Meibomian glands under near-infrared (NIR) illumination. The ocular surface and eyelids under white illumination. -TearScience photo by TearScience 22

23 IMAGING MEIBOMIAN GLANDS TEARSCIENCE LIPIVIEW II photo by TearScience 23

24 IMAGING MEIBOMIAN GLANDS MEIBOX MEIBOGRAPHER Dynamic image processing allows enhanced outlines of the Meibomian Glands. Inversion ability is used to enhance areas that may be difficult to see in traditional views. Intelligent lighting allows for quick lighting enhancements of the glands with a click of a button. photo by Meibox 24

25 IMAGING MEIBOMIAN GLANDS MEIBOX MEIBOGRAPHER Dynamic image processing allows enhanced outlines of the Meibomian Glands. Inversion ability is used to enhance areas that may be difficult to see in traditional views. Intelligent lighting allows for quick lighting enhancements of the glands with a click of a button. photo by Meibox 25

26 MGD TX TEARSCIENCE LIPIFLOW The LipiFlow Activator, a single-use sterile device, safely and comfortably delivers automated therapeutic energies to each meibomian gland while protecting the delicate structures of the patient s eye. Supported by 36 patents and seven years of dedicated research, LipiFlow provides a level of accuracy and quality that allows eye care professionals to treat their MGD patients with confidence and ease. Takes 12 minutes to do both eyes (at the same time) Comfortable to patients Has consumable costs Has peer-reviewed studies Designed to cost under 1K Done once per year or two photos by TearScience 26

27 Apply activators Ensure good contact Use tape to hold in place Tech sits with patient Can be paused if needed Best in cooler room photos by Scott Schachter 27

28 Heats skin to 42 C MGD TX THERMISMOOTH (OFF LABEL) Takes 8-10 minutes per eye Heats meibum May have a neurostimulaton effect Designed to reduce wrinkles Found dry eye improved Cost approx 50K Consumables $20 per eye 28

29 The Thermi250 Advantage MGD TX THERMISMOOTH (OFF LABEL) Power and Frequency: 250 watts at 470 khz has the deepest potential penetration compared to other devices Temperature Control: Enables clinician to use temperature as clinical endpoint; no focal pain; reduced risk of arcing; slow movement Temperature and Impedance Monitoring: Constant computerized power output adjustments to deliver accurate and gentle temperature endpoints Capacitive Electrodes: Insulated monopolar electrodes transmit an energy field into tissue, which is deeper and more uniform in the volume of tissue Monopolar and Bipolar: Dual modes enables highest level of versatility Wide Array of Electrodes: (7 monopolar, 1 bipolar) Electrodes range in sizes from 20mm to 100mm; choose appropriate electrode for anatomical area and targeted tissue (10 mm for the eye) Precision Depth Control: User selected depths (by electrode) from 20mm -100mm 29

30 MGD TX THERMISMOOTH (THE RESEARCH) Evaluation of Radio Frequency Thermistor for Use in MGD Dry Eye Treatment David Meadows, PhD 1 ; Mike Christensen, OD, PhD 2 ; Rachel Grant, OD 2 ; Whitney Hauser, OD 2 ; Christina Newman, OD 2 ; Al Kabat, OD 2 ; Greg Almond 1 1. ThermiGen LLC; 2. Southern College of Optometry INTRODUCTION Meibomian Gland Dysfunction (MGD) can be the result of capped, plugged or non-functioning glands (partial to complete gland atrophy). Studies have demonstrated that the majority of dry eye, up to 86%, is evaporative in nature, and this is often a direct result of MGD. 1,2 As a result, more emphasis is being placed on MGD treatment for dry eye. Current treatments include LipiFlow from TearScience, MiBo ThermoFlo from Pain Point Medical, hot packs and lid scrubs (commercial to home treatment), Xenon Flash Lamp (Intense Pulse Light), and Omega 3 oral supplement (DREAM study). Hot packs and lid scrubs are superficial and have not been shown to be very effective. Intense Pulse Light is restricted to lighter skin tones and has been shown to effect MGD. 3 LipiFlow, is effective in removing obstructions with reported symptom relief of approximately 50%. 4 A disposable activator has to be replaced prior to each treatment. Finally, the DREAM study is on-going so results of that omega-3 study is not yet available. ThermiEyes technology is currently used in dermatological and general surgical procedures for electrocoagulation and hemostasis, under the trade name ThermiSmooth face. It has been shown to be well tolerated and safe. 5 The ThermiEyes system delivers constant, gradual radiofrequency energy deep into the skin causing heat to build up where the skin and fat layer meet stimulating collagen remodeling. The penetrating heat escalates to approximately C, which has been shown to liquefy coalesced meibum 6 and therefore should improve meibomian gland function. Additionally, since evaporative dry eye may also be impacted by poor lid-globe apposition, the reduction of tissue laxity and improved elasticity of the lid may help to further diminish those signs and symptoms classically associated with dry eye. The purpose of this pilot study was to evaluate the safety and efficacy of the ThermiEyes treatment and its effects on dry eye and MGD. MATERIALS AND METHODS Out of the 31 subjects screened, 18 qualified and completed the study. Subjective OSDI and SPEED questionnaires were completed at each visit. A masked investigator evaluated both eyes on Days 1, 15, 30 and 45. Treatment of the randomized test eye was done by an unmasked investigator after the eye exams on Days 1, 15 and 30. Treatments lasted approximately 12 minutes at temperatures of C resulting in some redness. The two weeks between exams was done to maintain masking by allowing the skin around the eye to return to its normal color and to allow time for treatment effects to take place. OSDI and SPEED questionnaires were used to evaluate symptoms. Self and doctor assessment of periocular wrinkles were done. A Keratograph was used to measure the Tear Meniscus Height and NITBUT. LipiView was used to measure lipid layer thickness and for meibography. D.E.T. (Dry Eye Test) sodium fluorescein strips were used for TFBUT and corneal staining (NEI scale: 15 pts max). 5 µl of 1% non-preserved lissamine green was used for conjunctival staining (Interpalpebral Zones: 6 points max). ENROLLMENT CRITERIA Subjective and objective indicators for periorbital skin laxity or wrinkling grade 2 or greater out of a 4 point scale OSDI score > 28 <85 µl lipid layer thickness as measured by the LipiView 2 instrument TFBUT <7 sec Grade 1 or greater Meibomian Gland Dropout (Meibography) on at least one lid in both eyes. Excluded was grade 4 on any lid. FIGURE 1. Image of the treatment procedure with the ThermiEyes unit. RESULTS FIGURE 2. Image of a typical pre- and post-treatment results on wrinkle reduction. A comparison of measures between Visit 1 and the Exit visit on Day 45 showed the following: 88% demonstrated an improvement in OSDI and 78% improvement in the SPEED questionnaire (Figures 3 and 4) OSDI VISIT 1 VISIT 2 VISIT 3 VISIT FIGURE 3. A graph of OSDI scores per visit S D ISI 1 ISI 2 ISI 3 ISI 4 OS visit 1; pt 105 Untreated Eye FIGURE 4. A graph of showing SPEED questionnaire results per visit. OS visit 4; pt 105 Treated Eye FIGURE 5. This is a representative image of the meibomian glands of the treated eye on one patient at entry and exit. Four of the objective measures (NIBUT, LLT, DET TFBUT and NaFl staining) showed encouraging changes in the treated eyes for 50% or more of the patients. 9/18 of the patients showed some incremental improvements with DET TFBUT and NaFl corneal staining 12/18. 9/18 demonstrated improvements in Lipid Layer Thickness and 10/18 improved with NIBUT which is encouraging since the treatment was not on the lid or near the meibomian glands but on the surrounding tissues (Figure 1). Lissamine Green. Tear Meniscus Height and visible changes to the meibomian glands (Figure 5) showed no change or improvement over the course of the study. Interestingly, the contralateral eye also showed almost equivalent improvements in the same four objective measures LLT 12/18 and NaFl corneal staining 10/18 and 9/18 for NIBUT and DET TFBUT. The ThermiEyes treatment did not provide improvement for any other objective signs evaluated in more than 6/18 patients. Thirteen of the 18 patients requested their 2nd eye be treated. After this 2nd treatment, patients were contacted about their impressions of the treatment and if there were any lasting effects on their dry eye. 13 patients (72%) said the treatment did improve their dry eye symptoms. The range was from just a little bit to a strong yes. Seven patients noticed a delayed effect with the eye improving over a couple of weeks. 12 patients responded that the treatment effects lasted from 3 weeks to several months. 12 patients responded that the treatment effects lasted from 3 weeks to several months. CONCLUSIONS This pilot study shows significant improvement in dry eye symptom scores and some improvements in signs using the ThermiEyes treatment. Further studies are needed to determine if increasing frequency of treatment or increasing duration of treatment would have an impact on objective and subjective measures. Future studies would also establish refinements in patient selection to optimize treatment outcomes. The mechanism of action is not well established and may be linked to neurostimulation of the nerves supporting the meibomian glands. This study also hints at a simultaneous contralateral sympathetic effect. REFERENCES 1. HOM MM, Martinson JR, Knapp LL, Paugh JR. Prevalence of Meibomian gland dysfunction. Optom Vis Sci 19901;67: Bron AJ, Tiffancy JM. The contribution of meibomian disease to dry eye. Ocul Surf 2004;2: Craig JP, Chen Y, Turnbull PRK. Prospective Trial of Intense Pulsed Light for the Treatment of Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci ;56: TearScience CEO statement at 2016 ASCRS meeting. 5. Key, DJ. Integration of Thermal Imaging with Subsurface Radiofrequency Thermistor Heating for the Purpose of Skin Tightening and Contour Improvement: A Retrospective Review of Clinical Efficacy. J of Drugs in Dermatology. Dec 2014:13(12): Blackie CA, Solomon JD, Greiner JV, Holmes M, Korb DR. Inner Eyelid Surface Temperature as a Function of Warm Compress Methodology. Optom and Vis Sci. 2008; 85(8):

31 MGD TX MIBOFLO THERMOFLO The MiBoFlo Thermoflo is a new therapeutic device for the treatment of dry eye. It employs a proprietary thermoelectric heat pump designed to liquify inspissated secretions and improve meibomian glandular function. The MiBo delivers an effective temperature of 108 degrees within a variance of less than 3%. The unit has an adjustable timer allowing for physician-controlled customization of therapy. Perform three consecutive treatments. The first is 12 minutes per lid, the second is performed 1 week later and lasts 10 minutes per lid, and the third is performed 2 weeks later and lasts 8 to 10 minutes per lid. No consumables photo by MIBOFLO 31

32 MGD TX MIBOFLO THERMOFLO concerns: effectiveness corneal warpage from heat Lacks peer-reviewed research photo by MIBOFLO 32

33 MGD TX MASKIN MEIBOMIAN GLAND INTRADUCTAL PROBE A cannula used to open obstructed glands Topical anesthetic is used Seems to provide relief, between 1-6 months, up to 18 months Can provide quick relief, but may be uncomfortable and cause orifice heme 33

34 MGD TX MANUAL EXPRESSION Titanium. Smooth. Designed to gently and effectively express meibum from the meibomian glands. When positioned behind the anesthetized eyelid parallel to the glands, gentle digital pressure on the outer lid prompts meibum egress. Heat with Bruder mask or similar for 7-10 minutes Instill 1 drop proparacaine Wear gloves, can use cotton bud. Start nasally and work temporally Work from the distal end of the gland toward proximal Use firm, steady pressure. Give thickened oil time to express. Pros: inexpensive, gives symptomatic relief Cons: uncomfortable for patients, uncontrolled force, may need to be repeated often, time consuming (warm compresses prior) ARE WE KILLING GLANDS? 34

35 MGD TX MASTROTA PADDLE If this occurs, may need to wipe the excess oil away periodically. photo by photo by CL Spectrum 35

36 ANTEROPLACEMENT OF LINE OF MARX REVIEW OF ANATOMY The line of Marx is the mucocutaneous junction between palpebral conjunctiva and the eyelid just posterior to the meibomian glands, is around 0.1mm wide, and visible upon upgaze without lid eversion. It is the separation of keratinized and non-keratinized epithelium. Goblet cell-dense Mucins decrease friction Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM, Exford JM, Blackie CA, Douglass T. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens Jan;31:

37 DONEC QUIS NUNC Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM, Exford JM, Blackie CA, Douglass T. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens Jan;31:

38 ANTEROPLACEMENT OF LINE OF MARX DIAGNOSIS APPLY LISSAMINE GREEN LOOK AT THE LINE OF MARX NORMAL IS A THIN, STRAIGHT LINE LOOK FOR ENCROACHMENT TOWARD MEIBOMIAN GLANDS AND ELEVATION STAINING TOWARD THE EYE IS LID WIPER EPITHELIOPATHY (FRICTION) 38

39 ANTEROPLACEMENT OF LINE OF MARX DIAGNOSIS Note encroachment toward MGs LWE also present 39

40 ANTEROPLACEMENT OF LINE OF MARX 40

41 ANTEROPLACEMENT OF LINE OF MARX DONEC QUIS NUNC 41

42 LID WIPER EPITHELIOPATHY GRADING SCALE Pult, H. "Dry eye in soft contact lens wearers." Cont Lens Spect 7 (2011):

43 ANTEROPLACEMENT OF LINE OF MARX THE PROCEDURE Apply proparacine or tetravisc in the eye and have the patient blink Instill lissamine green Visualize the Line of Marx (LOM) Use a golf club spud or chalazion scoop Debride entire width of the keratinized lower lid margin, going over the meibomian glands, followed by debridement of the stained LOM Do not debride the lid wiper region 43

44 ANTEROPLACEMENT OF LINE OF MARX Go over LOM and then over MGs. Direct patient gaze away. Often will see oil come out. May need to wipe off the spud occasionally. SUBSET OF MGD: DEBRIDE SCALE 44

45 DEMODEX BLEPHARITIS DIAGNOSIS Cylindrical dandruff is pathognomonic Other signs: conjunctival redness madarosis misdirected lashes weak, brittle lashes lid hyperemia lid telangiectasia lash distention 45

46 DEMODEX BLEPHARITIS PREVALENCE Demodex blepharitis was present in 32.4% of all subjects (Scott E Schachter; Aubrey Schachter; Milton M Hom; Scott G Hauswirth, ARVO, 2014) 46

47 DEMODEX BLEPHARITIS MICROSCOPIC APPEARANCE photo by Scott Schachter 47

48 DEMODEX BLEPHARITIS 48

49 DEMODEX BLEPHARITIS CLINICAL CASE 22 yo male. Note uneven lid line and lash distribution, lash distention,collarettes Before and after 1 month, Cliradex wipes, bid, OU 49

50 DEMODEX BLEPHARITIS BLEPHEX BY RYSURG Blephex Instill a drop of Tetravisc Soak! (saturate) tips in Blephex solution It should be foamy as you go Use a new tip for each lid Work along lash line and lid line over MGs Push harder if it tickles too much Do touch up behind the slit lamp Use gloves Rinse thoroughly after 50

51 DEMODEX BLEPHARITIS BLEPHEX BY RYSURG Push the button once to start, again to switch directions, and again to turn off. Work the base of the lashes and the lid margin. Check your work at the slit lamp and can touch up there. If a lot of CD, can use cotton bud/ TTO first to loosen. 51

52 DEMODEX BLEPHARITIS BLEPHEX BY RYSURG Push the button once to start, again to switch directions, and again to turn off. Work the base of the lashes and the lid margin. Check your work at the slit lamp and can touch up there. CD can be stubborn. 52

53 BLEPHEX, BEFORE AND AFTER photo by Scott Schachter 53

54 BLEPHEX, BEFORE AND AFTER photo by Scott Schachter 54

55 EVIDENCE-BASED PROCEDURES Read the research to support your treatment decisions Google Scholar is an excellent resource 55

56 THE RESEARCH LIPIFLOW CONCLUSIONS: A single VTP treatment can deliver a sustained mean improvement in meibomian gland function and mean reduction in dry eye symptoms, over 12 months. A single VTP treatment provides significantly greater mean improvement in meibomian gland function and dry eye symptoms as compared to a conventional, twice-daily, 3-month regimen. Early VTP intervention for meibomian gland dysfunction is associated with improved treatment outcomes. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye Blackie CA, Coleman CA, Holland EJ Clinical Ophthalmology Jul;2016(10):

57 THE RESEARCH MASKIN PROBING CONCLUSIONS: Intraductal meibomian gland probing seems to improve meibomian gland lipid levels, and it may be a good treatment option for cases of o-mgd that are resistant to conventional treatment. Analysis of Meibum Before and After Intraductal Meibomian Gland Probing in Eyes With Obstructive Meibomian Gland Dysfunction Nakayama, Naohiko MD; Kawashima, Motoko MD, PhD; Kaido, Minako MD, PhD; Arita, Reiko MD, PhD; Tsubota, Kazuo MD, PhD Cornea Oct;34(10):

58 THE RESEARCH DEBRIDE SCALE CONCLUSIONS: The debridement-scaling of the LOM and lower lid margin provides statistically significant symptom relief and improvement in the MG function. The novel procedure should be considered in the management of MGD and evaporative dry eye. Debridement-scaling: a new procedure that increases Meibomian gland function and reduces dry eye symptoms. Donald R. Korb, Caroline A. Blackie Cornea Dec; 32(12): doi: /ICO.0b013e3182a

59 THE RESEARCH MANUAL EXPRESSION Gifford SR. Meibomian glands in chronic blepharoconjunctivitis. Am J Ophthalmol 1921; 4: McCulley JP, Sciallis GF. Meibomian keratoconjunctivitis. Am J Ophthalmol 1977; 84: Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc 1980; 51: "It has been known for over 150 years that treatment for MGD/obstruction to be optimally effective the stagnated contents of the glands must be evacuated. Until recently, the only known method to evacuate stagnated gland contents has been to manually express the glands using physical force. This procedure although effective is also extremely uncomfortable. In fact, it has been reported that the primary limitation to efficacy of manual expression is pain. Caroline Blackie 59

60 IN-OFFICE LID TREATMENTS PATIENT AND PRACTICE BENEFITS Higher level of care Distinguish your practice Proactive is better than reactive Prevalence of ocular surface disease is increasing as our patients vision demands increase Has a cash pay component immune to downward pressure from insurance Provides symptomatic relief for patients 60

61 IN-OFFICE PROCEDURES PRACTICE PEARLS Present with conviction and sincerity, believe it Use patient communication sheets (join ODs for Ocular Surface Disease on Facebook for resources) Doesn t have to take long to explain Recommend, check boxes, staff reviews with the patients 61

62 IN-OFFICE PROCEDURES PRACTICE PEARLS Check treatment in 1-2 months. 3 months is too long Use anterior segment photos to explain their condition Show before and after Blephex picture Recommend at-home care and sell in your practice compresses, omegas, tears 62

63 SINCERE THANKS FOR YOUR ATTENTION QUESTIONS? FACEBOOK: ODS FOR OCULAR SURFACE DISEASE 63