Revitalizing the Eye Waterfront: Treating Lid Disease

4 02 2013

Managing patients with dry eye disease (DED) over this past year has transformed the foundation for my clinical decisions with regard to the ocular surface.  Going back to basics has  had a profound impact on my patients with ocular surface disease (OSD).  In November 2012, I wrote a piece on eyelid plaque and its role in OSD which spread to eye physicians globally, all asking about how and why this hasn’t been done before and if I have any examples that I could share.

The answer as to why Line of Marx (LOM) debridement technique isn’t well documented lies in the fact that LOM isn’t robustly described in scientific literature nor has significant emphasis been put on this area in academic institutions or research arenas.  Well if it is not trickling down to clinicians yet, it soon will.  Already, the 2012 American Academy of Optometry meeting in Phoenix featured a lecture being leading experts Dr. Kelly Nicols and Dr. Caroline Blackie in which Dr. Blackie mentioned LOM debridement as an effective adjunct for MGD patients.  In a recent article in the Review of Optometry, a Lifetime of Dry Eye, Dr. Cheryl Murphy mentions this technique while quoting Dr. Blackie.  I would keep your eyes and ears open at CE and research meetings in 2013 for works related to LOM as a source of chronic  DED.

before_afterLOMdebride

In the mean time I will share an example of a recent case of a longstanding chronic DED patient.  This female patient in her late 30’s underwent LipiFlow Thermal Pulsation 7 months ago and has been relatively asymptomatic since that time.   She uses oil emulsified drops once daily.  Prior to her therapy, she presented with mg atrophy and notching L>R, but symptoms were always greater on her left side which happened to be the side with more mg notching and atrophy.  She has poor lid apposition (lid seal) and is a partial blinker – which is exacerbated at night by exposure.  On Friday’s presentation she reported significant burning OS of gradual onset throughout the week.  Clinically she presented with moderate to severe superficial nasal and temporal keratitis.  Her LOM was anteriorly displaced (no progression since LipiFlow) and had moderate devitalized epithelial accumulation.  I performed LOM debridement and meibomian gland expression to her left eye and advised to increase lubrication to twice a day (vs. once daily).  Historically she responded well to this, however if this was an initial presentation on a new patient, I would add topical antibiotic for coverage and add an overnight ointment.

The patient returned 3 days later for follow-up and as can be seen in her slit lamp image with fluorescein staining, the keratitis was vastly improved and symptoms were resolved.  And so it goes with many of my dry eye patients.   A burdened cornea needs less burden which is why I did not add copious lubrication, and therefore copious preservatives, to the regimen.  This technique offers a management alternative to loading the ocular surface with agents that may mask the true etiology of the problem.  Ideally this patient should do well with a preservative-free option, however she hasn’t found relief in this in the past and was using PF drops 10-15 times a day with limited relief.  With lid therapy we managed to lighten the financial burden as well

This is a chronic patient, and by no means am I or is she expecting a cure-all of her OSD.   The ‘after’ is still not perfect, but it is a safer cornea.   We will continue to work together to as doctor and patient to customize her therapy all while maintaining her lid surface regularly.

LOM_mgoWhen I originally read Bron’s work (Ocul Surface, April 2011) about  the solute gradient created in hyperosmolar tears and how it relates to LOM and MG damage, it was hypothetical at best to me and I had a hard time picturing it.  In this picture, the process comes to life as you can visualize the LOM with little ‘teeth’ straying periodically toward individual MG orifices.  This is the path to damage and helps to explain why a notched lid has that v-shaped appearance – it is not unlike a high speed river creating a pathway clearing anything in its way to get to the drain, which in this case is the meibomian gland.  Once this pathway is created, the gland is now at the mercy of inflammatory factors and the solute gradient created at the base of the tear film.

Clearing this devitalized epithelium from this pathway may serve to disrupt the cycle and slow the progression of lid disease.  With research and new drugs being aimed at reducing ocular surface inflammatory mediators, eye care providers can make a difference by monitoring this tissue closely and revitalizing it periodically.

sidenote

SideNote:  All the clinical images were taken with a smartphone through a slit lamp.  This is a simple yet effective way to monitor the anterior segment and can be done with relative ease.  There are a number of smart phone adapters available, however none that are universal.  The variations in eye piece diameter make this difficult, however I managed to align these images manually.  

 

 

 

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca

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