EyeWorld Asia-Pacific June 2012 Issue

44 EWAP CORNEA June 2012 Chul Young CHOI, MD Assistant Professor, School of Medicine, Sung Kyun Kwan University Cornea & Refractive Surgery Services, Dept. of Ophthalmology, Kangbuk Samsung Hospital 108 Pyoung Dong, Jongno-Ku, Seoul, Korea, 110-746 Tel. no. +82220012444 Fax no. +82220012262 sashimi0@naver.com M eibomian gland dysfunction (MGD) Historically, MGD was considered an infectious disorder with inflammation and hypersecretion. 1 The current understanding of MGD includes non-obvious obstructive MGD (NOMGD), where inflammation and other signs of pathology may be absent unless special examination techniques are employed. 2 Patients usually have symptoms such as burning, irritation, itching, dry eye sensation, and fluctuating vision, and morphological changes of the eyelid margins and meibomian gland orifices needed to be found to diagnose it. In contrast, NOMGD may have none of the obvious clinical signs observable with a slit lamp, rendering clinical diagnosis problematic. 2 There are several techniques or tools to diagnose the MGD, such as the use of digital force on the outer eyelid, the Mastrota paddle, semiquantitative method by Shimazaki et al., but there is no standardized method. The treatments for MGD are: (1) physical expression to relieve the obstruction, (2) warm compression to the eyelids to liquefy gland contents, (3) eyelid scrubs to open the orifice blockage, and (4) antibiotics medication (doxycycline, tetracycline, and minocycline) and topical androgens, Omega-3, -6 essential fatty acid supplements, and intraductal meibomian gland probing. We hope that newer technologies including thermal pulsation will be helpful in well-designed clinical trials of MGD treatment, and in a cost-effective manner. Autologous serum For many decades, autologous serum treatment in various clinical situations, including dry eye, recurrent corneal erosions and neurotrophic corneal ulcer, were recommended and very helpful in most cases. There have been few reports about complications such as deposition of immunoglobulins 3 and potential microbial contamination; some investigators have therefore considered adding an antibiotic to serum eyedrops to counteract this infection risk. In many patients who need to use autologous serum eyedrops, an extended period of time is needed to improve the ocular surface. Every 1 or 2 months, blood samples need to be obtained from patients. These are the major obstacles to widespread use of autologous serum. Also, there are so many factors that can affect healing in treatments including serum concentrations (20-100%), clotting time, and centrifuge time and speed. Although autologous serum treatment is efficacious in a variety of ocular surface diseases, there still remain issues for the development of proper therapeutic guide lines for each disorder. References 1 Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease. Classification and grading of lid changes. Eye . 1991;5(pt 4):395–411. 2. Blackie CA, Korb DR, Knop E, Bedi R, Knop N, Holland EJ. Nonobvious obstructive meibomian gland dysfunction. Cornea . 2010 Dec;29(12):1333-45. 3. McDonnell PJ, Schanzlin DJ, Rao NA. Immunoglobulin deposition in the cornea after application of autologous serum. Arch Ophthalmol . 1988;106(10):1423-1425. Views from Asia-Pacific Louis TONG, MD Consultant, Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 Tel. no. +6598186221 Fax no. +6562277290 Louis.tong.h.t@snec.com.sg D ry eye is a common multi-factorial disorder of the tear and ocular surface. The lipiflow and autologous serum treatments are important treatment options for the management of meibomian gland dysfunction, which is present in many patients with dry eye and contributes to the pathology of evaporative dry eye. Perhaps some have not sufficiently emphasized that treatment modalities other than eyedrops may sometimes be as helpful or even more effective than eyedrops. In our practice at the Singapore National Eye Centre, we design a holistic therapeutic plan for each dry eye patient taking into consideration occupational, lifestyle, and other personal factors. Other non-pharmaceutical therapies not mentioned include the use of humidifiers, nutritional supplements (such as omega-3 lipids), punctal occlusion, and the use of moisture occlusion eyewear. For more severe dry eye, options may include the prosthetic replacement of ocular surface ecosystems and tarsorrphaphy. Editors’ note: Dr. Tong has no financial interests related to his comments. be done in a sterile environment.” Studies have shown the contamination rate can be upward of 40% for bottles cultured in an outpatient setting. The good news, however, is in those studies the contamination didn’t lead to clinical infection. Finding someone to make AST can be a bit of a problem. Most compounding pharmacies won’t prepare it because it’s a biologic. “Patients haven’t been tested for HIV and hepatitis, so most pharmacies are not going to want to touch it,” Dr. Glasser said. “If you’re at an academic center, you can have it done. Sometimes you can ask an eye bank to prepare it for you. [AST] can be helpful, but it’s not used frequently because of the hassle that comes with making it.” Intense pulsed light In 2002, Rolando Toyos, MD , medical director and founder, Toyos Clinic, Memphis, Tenn., USA, discovered intense pulsed light (IPL), normally reserved for rosacea and skin rejuvenation patients, came with a happy side effect: It reduced the severity of dry eye symptoms. “We started doing studies in 2004 to look at this further,” he explained. “What we saw in our studies is if we did IPL, patients systematically were getting better and their tear break-up time increased.” IPL is suitable for patients with moderate to severe meibomian gland dysfunction. “Essentially what we found when we did IPL on these patients [was] small abnormal telangiectasia that were around the gland were closed off,” he explained. “We found this light was absorbed in the dermal area, so it bypasses the epidermal and goes into the dermas. It melts these thick secretions and dilates the glands so we can do easy gland expression.” Patients can have some relief from IPL alone, but to get the full effect of the treatment, Dr. Toyos recommended gland expression. Insurance does not cover the full cost of IPL. Dr. Toyos charges US$400 a treatment, but other physicians charge up to US$800. Physicians interested in trying IPL for dry eye shouldn’t dust off any old IPL equipment lying around. “When people read IPL helps Non-pharmaceutical - from page 43 continued on page 46