Professional Disclosures

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1 Innovations in MGD: Raising the Standard of Care Douglas Devries, OD Josh Johnston, OD, FAAO Tom Kislan, OD, FAAO Walter Whitley, OD, MBA, FAAO Optometry s Meeting 2017 Professional Disclosures Presenters have received honorarium, consulting fees or research funding from: Doug Devries, OD Abbott Medical Optics, Alcon, Allergan, Akorn, Bio Tissue, Bruder, BVI Medical, B & L, Eyes 4 Lives, TearLab, Tear Science, RPS, RySurg, Science Based Health, Shire, Sun Pharmaceutical, OcuSoft, Ophthalmic Resources Josh Johnson, OD - Allergan, Alcon, BioTissue, Shire, J&J Tom Kislan, OD - Alcon, Allergan, Biotissue, B+L, Hoya, Katena, MiboMedical, PRN, RPS, Shire, Tear Lab Walt Whitley, OD Alcon, Allergan, Bausch and Lomb, Beaver-Visitec, Biotissue, Diopsys, Glaukos, Ocusoft, Science Based Health, Shire, Sun Pharmaceuticals, TearLab, Tearscience Overview We want you to think and behave differently about MGD by showing the importance of: 1. Utilizing evidence based medicine 2. Implementing POC diagnostics 3. Adopting current and future MGD treatments 4. Taking your practice to the next level!! Dry Eye Market Overview $3.8 Billion spent on dry eye symptom relief annually in the U.S. alone >29 Million Americans suffer from dry eye disease Most frequently encountered disease state by eye care professionals Opportunity Better clinical outcomes for patients Patient Retention & Referrals Practice Growth Market Scope 2013 Comprehensive Report on the Global Dry Eye Products Market 4 Dry Eye Supplements Fail to Address the Underlying Cause Why Treat Ocular Surface Disease? Address signs/symptoms Provide relief to patients for which there are limited treatment options Improve CL intolerance Improve outcomes in surgical procedures Beard B. Boston Foundation for Sight Survey. Report Back to the Community. Boston Foundation for Sight. July 15, To grow your practice 1

2 Better Comfort and Quality of Vision Dry Eye: Increased Clinical Focus An Important Opportunity / Ocular surface disease, even the mildest tear film abnormality, results in a significant reduction in quality of vision and comfort. Due to this, proper ocular surface treatment is critical to patient satisfaction. Mounting patient awareness Progresses with age and lack of effective treatment Driven by tear instability Exacerbated by intense, prolonged visual tasks Impacts vision as well as comfort DEWS II Released Soon!!! Updated DEWS II Definition Growing Awareness of MGD Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles. Dry Eye Healthy Meibomian Gland Function is Foundational to Ocular Surface Health MGD is the leading cause of dry eye. 1 Core mechanism of MGD: Obstruction. 1 Early intervention is best. 2 Long-term ocular surface rehabilitation requires functional Meibomian glands. Treating Dry Eye means Treating Meibomian Gland Obstruction. Routine MG Function/ Structure evaluation. MG Assessment requires the evaluation of gland function and/or structure Early Intervention optimizes outcomes 1. Nichols KK, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci Mar 30;52(4): Knop E, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci Mar 30;52(4): Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol Jul 26;10: Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol 2015;26: Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol Jul 26;10:

3 Risk Factors for MGD Who has MGD? Systemic Age Autoimmune disease Rosacea Medications Diabetes And on and on Environmental Digital devices Humidity Ocular Aqueous deficient Contact lens wear Glaucoma Lid margin disease Cosmetics Peri-menopausal women study: 91% (n = 471) had DE with 87% having MGD 1. PCOS study: 73% with PCOS had MGD vs. 62% of the controls 2 Glaucoma and MGD: 96% (using Prostaglandins) had obstructive MGD vs. 58% of those on non Prostaglandin Therapy. 3 Diabetes: 58% had MGD 4 MGD high prevalence and increased in smokers 5 VDT users 4+ hrs a day: 85% had MGD vs. 70% of those <4 hrs per day. 6 Cataract Patients: 59% (n-233) had MGD 7 Refractive surgery patients 8 Contact lens wearers: 60% had MGD Jin X, et al. Medicine (Baltimore). Hormone replacement therapy benefits meibomiangland dysfunction in perimenopausalwomen Aug;95(31):e Baser G, et al. Evaluation of Meibomian Gland Dysfunction in Polycystic Ovary Syndrome and Obesity. CurrEye Res Oct 28: Mocan MC, et al. The Association of Chronic Topical Prostaglandin Analog Use With Meibomian Gland Dysfunction. J Glaucoma Sep;25(9): Yu T, et al. Changes of meibomian glands in patients with type 2 diabetes mellitus. Int J Ophthalmol Dec 18;9(12): Wang S, et al. Impact of Chronic Smoking on Meibomian Gland Dysfunction. PLoS One Dec 28;11(12):e Wu H, the severity of the dry eye conditions in visual display terminal workers. PLoS One Aug 21;9(8):e Algamadi et al. Epidemiology of Meibomian Gland Dysfunction in an Elderly Population. Cornea Jun;35(6): CochenerB, et al. 9. MachalińskaA, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea Sep;34(9): Contact Lens Considerations Contact lens wearers with unexplainable reduced wearing time had MGD 1 CL wear accelerates MGD 2,3 60% of CL wearers had MGD 4 Surgical Considerations Approximately 10 20% of post-lasik patients may suffer from chronic dry eye disease with more severe discomfort after LASIK 1 Cataract Patients: 59% (n-233) had MGD % had TBUT < 5 sec 3 1. Henriquez AS, Korb DR. Meibomian glands and contact lens wear. Br J Ophthalmol Feb;65(2): Ong BL. Relation between contact lens wear and Meibomian gland dysfunction. Optom Vis Sci 1996;73: Arita R, Itoh K, Inoue K, Kuchiba A, Yamaguchi T, Amano S. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology 2009;116: Machalińska A, et al. Comparison of Morphological and Functional Meibomian Gland Characteristics Between Daily Contact Lens Wearers and Nonwearers. Cornea Sep;34(9): Ambrósio R Jr, Tervo T, Wilson SE. LASIK-associated dry eye and neurotrophic epitheliopathy: pathophysiology and strategies for prevention and treatment. J Refract Surg 2008; 24: Algamadi et al. Epidemiology of Meibomian Gland Dysfunction in an Elderly Population. Cornea Jun;35(6): Trattler WB, Reilly CD, Goldberg DF, et al. Cataract and Dry Eye: Prospective Health Assessment of Cataract Patient Ocular Surface (PHACO) Study. Paper presented at: ASCRS Symposium and Congress; May 25-29, 2011; San Diego, CA. Digital Devices Approximately 65 percent spend between three to nine hours per day in front of a digital device 1 While asthenopia, glare, and accommodative difficulty are all aspects of CVS, dry eye appears to contribute to a major component of symptoms reported 2 Glaucoma Consideration Glaucoma medications significantly elevate the risk and progression of MGD 1 Preservative and dry eye % of VDT users had MGD 3 1. The Vision Council. TVC DigitEYEzed Report Accessed 01/01/ Blehm CS, Vishnu S, Khattak A, et al. Computer vision syndrome: a review. Surv Ophthalmol 2005;50: Fenga C Aragona P Cacciola A. Meibomian gland dysfunction and ocular discomfort in video display terminal workers. Eye. 2008;22: Photo accessed from on 6/ Arita R, Itoh K, Maeda S, et al. Comparison of the long-term effects of various topical antiglaucoma medications on meibomian glands. Cornea Nov 31(11): Baudouin, C, Labbe, A, Liang, H, et. Al. Preservatives in eyedrops: The good, the bad and the ugly, Progress in Retinal and Eye Research, Volume 29, Issue 4, July 2010, Pages

4 Name:, DOB: / / Sex: M F (Circle) How FREQUENTLY do you experience the following dry eye symptoms? Never Sometimes Often Symptoms (0) (1) (2) Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue Date: / / Constant (3) How SEVERE are your dry eye symptoms? Bothersome Tolerable not Uncomfortable No irritating and perfect but not irritating but does not Symptoms problems interferes with uncomfortable interfere with my day (0) my day (1) (2) (3) Dryness, Grittiness or Scratchiness Soreness or Irritation Burning or Watering Eye Fatigue WHEN have you experienced these symptoms? ( ) Today ( ) Within the past 72 hours ( ) Within the past 3 months Activities Yes No Do you have difficulty reading? Do you have difficulty using a computer? Do you have difficulty driving? Do you have difficulty watching television? Do you have difficulty wearing contact lenses? Do you have difficulty being outdoors? Do your symptoms worsen throughout the day? Intolerable unable to perform my daily tasks (4) Do you use drops and/or ointment? Yes No (Circle) If yes, which drops and/or ointment do you use? How frequently do you use the drops and/or ointment? For office use only Total SPEED score (Frequency + Severity) = /28 Lid wiper epitheliopathy and dry eye symptoms. Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM, Exford JM, Blackie CA, Douglass T. Eye Contact Lens Jan;31(1):2-8.Psychometric properties and validation of the Standard Patient Evaluation of Eye Dryness questionnaire. Ngo W, Situ P, Keir N, Korb D, Blackie C, Simpson T. Cornea. 2013, Sep;32(9): /21/2017 Why Have We Not Seen a Paradigm Shift in the Treatment of MGD? A. MGD is too complex B. Cost is a barrier to entry C. Lack of efficacy in available treatment options D. I Love MGD everyone else is asleep at the wheel 8% 11% 49% 33% A. B. C. D. INNOVATIONS IN MGD: IMPLEMENTING POINT-OF-CARE DIAGNOSTICS Josh Johnston, OD, FAAO Clinic Director - Georgia Eye Partners Residency Program Supervisor ***Data from Audience Response 2016 AOA Panel on MGD Does this Patient have MGD? Do You Normally Perform? Lid expression Evaluate for lid seal SPEED Questionnaire Questionnaires SPEED Questionnaire Alternative Questionnaires Dry Eye Summit questions (2014) OSDI 1. Do your eyes ever feel dry or uncomfortable? 2. Are you bothered by changes in your vision throughout the day? 3. Are you ever bothered by red eyes? 4. Do you ever use or feel the need to use drops? 4

5 Lipiview I & II Interferometry Lipiview II Uses a light-emitting lid everter Allows for selection of images from 3 modes High resolution images utilized in patient education Keratograph 5M NIKBUT Tear meniscus height Non-contact meibography (meiboscan) Tear dynamics Topography Meibography Transillumination LipiView I, LipiView II Oculus Keratograph 5M LipiScan Meibox LipiScan LipiScan 10 seconds per eye High Definition Under normal lighting User-friendly Small footprint PROACTIVE CARE REACTIVE CARE Duct dilation, atrophy and dropout Severe atrophy and dropout 29 5

6 Meibox Meibography Anodized silver aluminum chassis USB 3.0 attachment 3 MP high resolution imaging system Adjustable camera height Universal pin mount to any slit lamp Cloud based software Meibography Research Purpose: to determine if meibography could predict meibomian gland function with regard to number of functional MGs and/or estimation of functional MG volume in patients symptomatic for dry eye Methods: n=23 symptomatic for dry eye, mean age 48 years, 5 males: 18 females Scored using the SPEED questionnaire MG function and estimation of functional MG volume were performed with meibomian gland evaluator (MGE) Meibography was performed using the Modi Topographer Lower lids were examined in three equal sections: nasal (N), central (C) and temporal (T) for the number of functional MGs and their functional volume (volume was as 1 for minimal, 2 for moderate and 3 for copious), and for MG dropout. Meibomian Gland Function Cannot Be Predicted By Meibography In Patients Symptomatic For Dry Eye, David Murakami; Caroline A Blackie; Heiko Pult; Donald R Korb Investigative Ophthalmology & Visual Science April 2014, Vol.55, 27. Meibography Research Conclusions: There appears to be no relationship between the level of apparent drop out and the number of functional MGs and/or functional MG volume. These counterintuitive results strongly indicate that standard noncontact infrared meibography cannot be used to predict MG function in terms of number of functional glands and/or functional gland volume except in the case of total gland dropout, when the glands are completely absent. Transillumination Blink Evaluation Blink Rate Various diagnostics (LipiView I, II) Manual Blink Quality Partial blinks Incomplete blinks 6

7 Tear Osmolarity Hyperosmolarity Central pathophysiologic mechanism for all forms of DED Causes inflammation and apoptosis & reduces the ability of mucins to lubricate Leads to a breakdown of homeostatic control causing tear film instability 308 mosm/l is a highly sensitive cut-off point that delineates a normal from a mild/moderate dry eye population Inter-eye difference = hallmark of DED ( > 8 mosms/l between eyes) Unstable tear film causes inter-eye differences TearLab The TearLab Osmolarity System is the first objective and quantitative test for diagnosing and managing Dry Eye patients Fast and accurate results in seconds using only 50 nanoliters (nl) of tear film to diagnose Dry Eye Disease Enables discussion with patients around a number improving compliance Incorporating osmolarity into the standard of care gives the best indication of early stage disease Tear Volume Testing Schirmer s Test Requires anesthesia 5 minute testing time Mildly irritating Normal results: > 10mm Phenol Red Thread No anesthesia required 15 seconds testing time Little discomfort Normal results: > 20mm Red Phenol Other Tear Tests Tear Meniscus Height Manual Diagnostics Tear Stability: Tear Break Up Time (TBUT, NIBUT) Less than 8-10 seconds abnormal 7

8 Dry Eye Survey Research 68 patients OSDI, Schirmer s Test, Tear Break-Up Time (TBUT) Strong inverse correlation was found between OSDI and TBUT No correlation between OSDI and Schirmer s Testing Ocular Surface Disease Index for the Diagnosis of Dry Eye Syndrome. Ocular Immunology and Inflammation, Volume 15, Issue 5, Dry Eye Disease and MMP-9 Matrix metalloproteinases (MMP) are proteolytic enzymes that are produced by stressed epithelial cells on the ocular surface 1 MMP-9 in Tears Non-specific inflammatory marker Normal range between 3-41 ng/ml More sensitive diagnostic marker than clinical signs 1 Correlates with clinical exam findings 1 Ocular surface disease/dry eye demonstrates elevated levels of MMP-9 in tears 1 [1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): InflammaDry Limit of Detection Normal levels of MMP-9 in human tears ranges from 3-41 ng/ml Type of Dry Eye Aqueous and Mucin Deficiency Lipid Deficiency/MGD POSITIVE TEST RESULT MMP-9 40 ng/ml NEGATIVE TEST RESULT MMP-9 < 40 ng/ml Meibomian Gland Evaluation Microlagophthalmos Lid Seal Exam 8

9 INNOVATIONS IN MGD: ADOPT CURRENT AND FUTURE MGD TREATMENTS LipiFlow Tom Kislan, OD, FAAO Medical Director - Hazelton Eye Specialists LipiFlow Thermal Pulsation System LipiFlow safely and effectively treats Meibomian gland obstruction in both upper and lower eyelids simultaneously In-office procedure 12 minutes 51 per eye 51 LipiFlow Offers a Solution for Patients Who Are Difficult to Treat Apply heat to the inner eyelids in both upper and lower eyelids simultaneously LipiFlow provides heat >40 C to liquefy obstructed glands Liquefy the meibomian gland contents Facilitate release of secretion from the meibomian glands Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact 53 Lid warmer Applies directional heat to inner eyelid Heat facilitates release of secretion from obstructed meibomian glands Activator Applies intermittent pressure to the outer eyelid Inflatable air bladder Treat meibomian gland obstruction in an in-office procedure (12 minutes per eye) LipiFlow Provides Heat >40 C to Liquefy Obstructed Glands Disposable eyepiece connects to a console used by the physician to control the application of heat and pressure to the eyelids Lid warmer Composed of a heater, eye insulation, and vaulted shape Heat applied to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands 9

10 Complete Gland Expression: Gland Reset Obstructive MGD results in an atrophic process in glandular tissue inside the tarsal plates of the eyelids (histopathologic investigations) LipiFlow may provide longer-term relief due to more complete evacuation of lumen contents, resetting the clock so that it may take a lot longer for symptoms to recur at the same level as pre-lipiflow Effective therapeutic expression of obstructed glands can lead to remodeling of dysfunctional glands LipiFlow Provides Pressure to Evacuate Glands Disposable eyepiece connects to a control system used by the physician to control the application of heat and pressure to the eyelids Activator Composed of an inflatable air bladder and a rigid activator Graded pulsatile pressure delivered to the outer eyelid 55 Therapeutic Goal of Pulsation Pressure and Pulsation for MGD Transiently decrease blood flow, thus increasing heat transfer efficiency Evacuate liquefied gland contents to alleviate the obstruction Apply pressure to the eyelids during the heating phase of the treatment (as opposed to after) Enable patient to experience little to no discomfort during treatment Lid warmer Applies directional heat to inner eyelid Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact Heat facilitates release of secretion from obstructed meibomian glands Activator Applies intermittent pressure to the outer eyelid Inflatable air bladder LipiFlow expresses upper and lower lids Traditional focus was on lower lids due to easier accessibility Treatment of all glands is important ~45% of gland openings are functioning at one time point 1 ~50% decrease of active glands from age 20 to 80 years Norn M. Meibomian orifices and 58Marx s line: studied by triple vital staining. Acta Ophthalmol (Copenh). 1985;63(6): Pressure and Pulsation for MGD Pressure and Pulsation for MGD LipiFlow inflates and deflates in such a way as to massage the eyelids from the terminal ends of the glands toward orifices LipiFlow provides complete, not partial, expression of glands In traditional expression, only 7% of patients could tolerate the pressure (range, 10 to 40 PSI) necessary for complete therapeutic expression along entire lower eyelid 1 LipiFlow needs to exert only ~0.6 PSI Korb DR, Blackie CA. Meibomian gland therapeutic expression: quantifying the applied pressure and the limitation of resulting pain. Eye Contact Lens. 2011;37(5): Korb D, Blackie C. Restoration of meibomian gland function post LipiFlow treatment. Poster presented at: ARVO 2011; May 1-5, 2011; Fort Lauderdale, FL. Poster D

11 Safety The globe is insulated/protected from heat during treatment Massaging pressure is not transferred directly onto the eyeball 1 Pressure required is significantly less compared with unheated manual expression, which can lead to edema and bruising MiBo ThermoFLo New technology Class II FDA approved-no 510K required vs Lipiflow is Class III w a 510K required No disposables Cost effective for practice and patient Easy for staff to perform Great ROI 1. Friedland BR, Fleming CP, Blackie CA, Korb DR. A novel thermodynamic treatment for meibomian gland dysfunction. Curr Eye Res. 2011;36(2): Korb DR, Blackie CA. Diagnostic versus therapeutic meibomian gland expression [abstract]. Presented at AAO Annual Meeting; November 11-13, 2009; Orlando, FL. Program

12 Treatment Protocol-Mild Disease 12 minute-one week later-10 minute-2 weeks later-8 minute with office visit and osmolarity and inflammadry Mibo Mask (ie $40) Out of pocket (ie $450) Treatment Protocol-Moderate Disease 12 minute-2 weeks later-12 minute-1 week later-10 minute-1 week later-10 minute-2 week later-8 minute with office visit, osmolarity and inflammadry Mibo Mask (ie$40) Out of pocket (ie$750) Treatment Protocol-Severe Disease 12 minute-1 week later-10 minute-1 week later 8 minute-1 week later office visit with osmolarity and inflammadry and lipiflow Mibo Mask (ie$40) Out of Pocket (ie$1250) Dry Eye Yearly VIP Program For severe and chronic patients (this is a chronic disease, right???) Out of pocket (ie$875) Includes unlimited miboflo treatments Lipiflow at 50% (ie$450) One 240 ct bottle of PRN Dry Eye Omega Benefits 50% off glasses Doctor cell phone Treatment Pearls Treat early and often Warm relaxing SPA environment Give patient personal pillow Relaxing music on with lights dim Some offices use essential oils for aroma 12

13 Intense Pulse Light Intense pulsed light (IPL) is a technology used by cosmetic and medical practitioners to perform various aesthetic and therapeutic skin treatments Stimulates the production of collagen, plumping up the skin and giving the patient a younger, fresher look Facial redness Acne Hyperpigmentation Sun damage Fine lines or wrinkles Meibomian gland dysfunction IPL - Indications True Tear True Tear Recently FDA approved Allergan supported Neurostimulation of all 3 layers of tear film Use qid to bid but approved to 10 x a day End of 6 month trial pts used qd to prn Painless Should be owned by ODs When to Treat MGD? A. If MGD is present, I always treat MGD first with specific MGD treatment B. If MGD is present, I sometimes treat MGD first with specific MGD treatment C. I never treat MGD before treating with all of the other treatments D. I never specifically treat MGD 44% 44% 8% 3% A. B. C. D. Do you routinely prescribe warm compresses and for how long? A. I do not prescribe a specific time B. 1-5 minutes as in shower C. 10 minutes D. I do not prescribe warm compresses 5% 29% 63% 2% A. B. C. D. 13

14 INNOVATIONS IN MGD: TAKING YOUR PRACTICE TO THE NEXT LEVEL!! Implementation Billing and Coding Success With MGD Doug Devries, OD Co-founder - Eye Care Associates of Nevada Associate Clinical Professor - Pacific University From the Patient Perspective, MGD Management has? From the Provider Perspective, MGD Management has? A. No improvement on my patients B. Mild improvement for my patients C. Moderate improvement for my patients D. Significant improvement for my patients 40% 36% 24% 0% A. B. C. D. A. No improvement for my patients B. Mild improvement for my patients C. Moderate improvement for my patients D. Significant improvement for my patients 45% 33% 20% 1% A. B. C. D. ***Data from Audience Response 2016 AOA Panel on MGD ***Data from Audience Response 2016 AOA Panel on MGD From the Practice Perspective, MGD Management has? Lipiview II A. No/negative impact on my practice B. Mild positive impact on my practice C. Moderate positive impact on my practice D. Significant positive impact on my practice ***Data from Audience Response 2016 AOA Panel on MGD 9% 36% 27% 29% A. B. C. D. 14

15 Lipiview II New measurement options of the Keratograph 5M Lid Transillumination Static Illumination Dynamic Illumination OCULUS Meibo-Scan 1. Korb DR, Blackie CA. Meibomian Gland Function Cannot Be Predicted By Meibography Unless There Is Total Meibomian Gland Drop Out In Patients With MGD. AAO 2013 ABSTRACT B.Sc. Florian Winzig Meibomian Gland Evaluator (MGE ) The number of FUNCTIONAL Meibomian Glands correlates with dry eye symptoms New measurement options of the Keratograph 5M OCULUS TF-Scan - Tear meniscus height measurement With Symptoms 1 (n=133) Severe Moderate Minimal Symptoms Symptoms Symptoms Asymptomatic healthy eyes 2 (n = 24 glands) Overview of the curvature along the lid Symptom Score, SPEED (0-28) 10 (14.4 ± 0.7) 6 9 (7.3 ± 0.2) 5 (2.3 ± 0.2) 0 Digital measuring of the height and automatic documentation Number of functional MGs for lower eyelid 4.1 ± ± ± ± 2.6 The NIKTMH measurement can be performed under infrared light conditions now no influences on the tear film conditions!! Automatic calibrated and digital measuring of the TMH FUNCTIONAL MGs in the Lower Lid , treatment necessary, (if glands present) 5-6, intervention highly advised 7-9, preventive treatment (PRN) DRY NOT DRY Notes: 1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10): Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3): B.Sc. Florian Winzig New measurement options of the Keratograph 5M OCULUS TF-Scan NIKBUT (Non Invasive Keratograph Break-Up Time) New measurement options of the Keratograph 5M OCULUS TF-Scan Lipid Layer The Lipid Layer: The NIKBUT measurement can be performed under infrared light conditions now no influences on the tear film conditions!! The thickness of the lipid layer is a key indicator of tear film stability and evaporation! coat the underlying aqueous thereby impeding evaporation create a hydrophobic barrier to avert the overflow of tears act as a lubricant to prevent friction between the eyelid and ocular surface B.Sc. Florian Winzig Thin Lipid Layer Thick Lipid Layer B.Sc. Florian Winzig facilitate in creating a smooth refractive surface of good optical quality Thick Lipid Layer 15

16 New measurement options of the Keratograph 5M OCULUS TF-Scan: Tearfilm Dynamic Tear movement correlates significantly with tear film thickness! The Tearfilm Dynamic: Slow movement is associated with a thick lipid layer and a high-viscous tear film Lipiview C factor ICU s/nanometers Partial/complete blinks Video display Rapid movement after a blink is negatively correlated with the tear film thickness and the viscosity B.Sc. Florian Winzig Micro-blepharoexfolication BlephEx Treatment Pre-Treatment Post-Treatment 9 4 Lid Hygiene Surgical Considerations Types of Blepharitis: Anterior Staphylococcal Seborrheic Demodex Angular Posterior Meibomian Gland Dysfunction (MGD)

17 Lid Hygiene Surgical Considerations THERMODYNAMIC TX TO EXPRESS AND EVACUATE MGs A new thermodynamic treatment to express & evacuate the MGs Topical: Lid wipes/foam Hypochlorous acid solution Tea tree oil wipes/foam Mechanical: BlephEx Oral: Ivermectin Heat applied to both inner lid surfaces Pulsatile pressure applied to outer lids The device applies controlled heat to the inner upper and lower palpebral conjunctival surfaces and lid margins, while simultaneously applying pulsating pressure over the upper and lower (outer) eyelids. THE LIPIFLOW (TearScience Inc., Morrisville, NC) FDA approved LipiFlow July 2011 HydroEye Powerful Dry Eye Relief Not the environment for success! Patients buy what is on sale, end up with inappropriate combos, may not follow recommendations. Retail: $32.95 Wh/sale: $19.50 Staff: $13.25 Patented, clinically tested oral formula provides continuous relief from the inside out. Contains unique omega (GLA) clinically backed in 7 dry eye trials; not found in diet/flax/fish. Provides other omegas, nutrient cofactors Stimulates tear production, eases inflammation Effective for almost any dry eye (i.e. contact lens, postrefractive, post-menopausal, allergy-related, Sjögren's, other types) Guaranteed relief within 60 days or money back; works for 80-85% of users TearScience Solution MGD TREATMENT LipiView OSI LipiFlow Auto Warm compresses Meibomian gland scrubs Home expression Blinking Office expression Secretagogues Androgens Meibomian Gland Evaluator Disposable Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in the U.S. Limited by United States law to investigational use

18 New! Ophthalmic Surgical Instruments Collins Expressor Forceps (Item 98610) For aggressive expression of the Meibomian gland. Livengood Expressor Paddles Angled (Item 98620) & Flat (Item 98630) For mild or gentle expression of the Meibomian gland. 1)$ 158 box ( 10) Maskin Probe Treatment 108 degrees Initial:12 min/lid 1 week:10 min/lid 2 weeks: 8 min/lid Dual eye pad cuts time in half 2) 1,2,4,6 MM intraductals 3) Aluminum Handle $104 With a cut-off filter of 560 nm Wavelength (nm) Intensity First, IPL: Then, EXP: From ear to ear, including nose 18

19 OSD Procedures Meibomian Gland Expression Manual MeiboFlow Thermal Pulsation LipiFlow Punctal Occlusion Demodex Treatment In Office Cliradex Swab, OcuSoft Swab Micro Blephroexfoliation Amniotic Membrane LipiView II with Dynamic Meibomian Imaging (DMI) Dynamic Illumination Adaptive Transillumination Dual-Mode DMI Normal Gland Structure Gland Truncation & Dilation Gland Drop Out + = + = + = Demodex Mite In Office Demodex Treatments OcuSoft Contains Tea Tree Oil + Buckthorn seed oil Ung QHS OcuSoft Cleansers Cliradex In Office Swab Tea Tree Oil (4 Terpineol) Preservative Free 112 Merchandising and Compliance Bottom Line Re-Appointment Level II $45.30 Re-Appointment Level III $74.09 to Re-Appointment Level IV $99.21 to Punctal Occlusion OU $ to Ant Seg Photos $17.35 to Amniotic Membrane $ to Osmolarity Testing $12.57 to Inflammadry $10.57 to LipiView $65.00 to LipiFlow OU $ to Manual Expression $ to

20 Bottom Line Bottom Line Examples BlephEx $ to Demodex Tx $ to Supplements $ ($ Net) Scrubs,Tears,Masks, Moisture Wear ($ Net) 4 Visits,Tears, Scrubs, Diagnostics, Net $577 4 Visits, Plugs, Tears, Scrubs, Diagnostics, Net $ Visits, Plugs, Tears, Scrubs, Diagnostic, BlephEx Net $948 6 Visits, Plugs, Tears, Scrubs, Diagnostic, BlephEx, LipiView, LipiFlow Net $ Visits, Plugs, Tears, Scrubs, Diagnostics, BlephEx, LipiView, LipiFlow, 1 Amniotic Membrane $ Visits, Plugs, Tears, Scrubs, Diagnostics, BlephEx, LipiView, Lipiflow, 2 Amniotic Membranes $ If you were going to start a dry eye clinic, which technology would you look invest first? A. I would not invest in technology B. Diagnostic technology (Anterior Segment Camera, Keratograph 5M, Lipiscan, Lipiview II) C. Treatment/Management (BlephEx, Lipiflow, MiboThermoflo) 2% 40% 58% A. B. C. LET S DISCUSS CASES ***Data from Audience Response 2016 AOA Panel on MGD Unable to wear CL s greater than 2 hours K.H. 54 year old Caucasian female Symptoms increase with computer use and prolonged near work Burning, scratchy eyes OU, foreign body sensation OHx: Failed CL s Current Tx: AT s, Tobradex, Lotemax PRN MGD 20

21 MGD Clinical Data Baseline Data Osmolarity 308 OD, 296 OS MGE: O OD,OS- >80% gland loss OU PB OD: 7/7, 5/6 ICU: 32 OD, 49 OS MMP9 Neg. OU Diagnosis MGD & KCS Anterior Blepharitis Conjunctivochalasis OU Ocular Rosacea - main issue MGD/Ocular rosacea/poor blink reflex/blink rate Mild micro lagophthalmos - S/P Blepharoplasty OU- uppers and lowers Treatment Bruder mask QHS OU, HydroEye PO, ATs PRN, Avenova QHS OU, Lotemax BID OU, start Restasis BID OU, Blink exercises, UNG/Humidifier QHS, removed plugs RLL/LLL,.003 brimonidine QD OU PRN Will plan for BBL and Lipiflow staged procedures later- poor potential outcome w/severe gland loss. Treatment Update S/P BBL (4 treatments) S/P Bilateral Lipiflow Dispense TrueTear 5/25/17 MGD Treatment Options Azithromycin Restasis Lid hygiene- scrubs, foams, sprays Warm compresses Oral Doxycycline, azithromycin PO Antibiotic/steroid combination drops/ointments Lid/Gland Expression IPL/BBL Omega 3 Supplementation Gland Ductal Probing LipiFlow Thermal Pulsation System TrueTear 21

22 16 yo WF Presented for 3 rd opinion CC can t wear CLs more than 5-6 hours First OD switched from AV2 to Oasys to Ultra with no improvements Second OD switched from Ultra to Oasys one day to DT1 with slight improvement to 7-8 hours ITF Guidelines ITF 1-lissamine stain of conjunctiva ITF 2-visual fluctuations and/or peripheral corneal stain ITF 3-central stain and/or filaments ITF 4-RCE/neurotrophic ulcers Slit Lamp Exam Lids: telangiectasia, capped glands, atrophy Conj: hyperemic, lissamine green stain Cornea: ITF 2, severe peripheral stain along lid margins, TBUT 2 seconds Osmolarity: OD 330 OS 335 Inflammadry: Positive OU Keratograph: See picture Treatment Limit device time, discussed regular blinking Lotemax bid Restasis bid TG Omega mg/day Systane balance qid 22

23 10 week follow up ITF 2 still TBUT 2 sec still Inflammadry: positive to negative Osmolarity: 330/335 to 315/310 Performed 12 minute Mibo, 1 week later 10 minute Mibo, 1 week later 8 minute Mibo Mibo Mask 10 minute/day 8 week follow up Still on lotemax, restasis, TG Omega 3, systane balance qid Inflammadry: still negative Osmolarity: 300/301 ITF 1 TBUT 7 seconds Performed Lipiflow Lotemax bid x 4 weeks then d/c 8 week follow up Still on Restasis, TG Omega 3, systane balance Inflammadry: Negative Osmolarity: 296/301 ITF 1 Continue present treatments and MiboMask 10 min/day Mom asked about accutane for acne-ugh!!!! Case Example 76YOWF Present for follow up for Glaucoma and dry eye disease. Compliant with drops OU. Vision has been blurry and eyes irritated more in the past few months Previous treated with topical azithromycin Current Ocular Meds: Restasis BID OU, latanoprost qhs OU Numerous systemic meds including singulair, synthroid How do you address OSD and Glaucoma? Does glaucoma stage make a difference? What testing and treatment? SPEED Score: 33 Tear Osmolarity 308 / 315 SLE: 2+ MGD OD / 3+ MGD OS / 1+ SPK OU Cloud secretions OU MG Structure: See images IOP: 14/13 HVF: Stable OU 23

24 Post Treatment Early to Moderate Structural Changes to Meibomian Glands Advanced Gland Atrophy / Dropout 6 Weeks Post Treatment Post Tx Osmolarity 300/299 Post Lipiflow Management Heat masks qhs OU Hydroeye as directed Restasis BID OU Lipid based tear BID OU Latanoprost qhs OU F/u 3 months dry eye Order tear osmolarity Order inflammadry SPEED Questionnaire Conclusion Decide on your practice philosophy Educate your entire staff Add an MGD assessment (function/structure) to all patient encounters Include and prioritize the treatment of obstruction Know that this will benefit your patients and your practice Thank you! Doug Devries, OD - drdevries@nveyelaser.com Josh Johnston, OD - jkjohnston1@yahoo.com Tom Kislan, OD - foreeyes@ptd.net Walt Whitley, OD - wwhitley@vec2020.com 24