Advances in the Management and Treatment of Dry Eye Disease - Episode 6
Experts discuss diagnosing meibomian gland dysfunction (MGD), the most common cause of dry eye disease.
Kendall Donaldson, MD, MS: Brandon,how about MGD [meibomian gland dysfunction]? How do you assess MGD?
Brandon Ayres, MD: Ask any ocular surface expert. If you don’t look at the lids and treat meibomian gland dysfunction, which is often coexistent with dry eye disease, then you’re not fully treating the patient. These are multifactorial treatments, and that’s what Laura was probably alluding to. You have to look, and then you have this multifactorial plan of attack to get that patient more comfortable.
Luckily, MGD or lid margin disease is pretty easy to diagnose. We start by looking. We all have slit lamps. I always look at the upper and lower lid, at the telangiectasia along the lid margin, at the opening of the meibomian glands. I push. And I grade the quality of the meibum that we can express, if we can express it, from the meibomian glands. If we want to, we then do meibography to further look at the health to see how many glands are there, how many are atrophied, and how many seem to be healthy. We can show that to the patient to reinforce that they do have this lid margin disease and we need to treat this to get them feeling better.
There are few patients to whom I say: “Your lids are completely healthy. We don’t have to worry about the oil or the meibomian gland secretions going into the tear film.” Almost all our patients end up on warm compresses and lid scrubs. We can escalate it if we think the lid margin disease is a significant component of their ocular surface symptoms.
Don’t forget about tear breakup time. All it takes is a couple seconds to put some fluorescein on the eye and say, “Blink 2 or 3 times, then hold your eye open.” If you can see rapid tear breakup time, then lid margin disease is probably a component to their ocular surface complaints.
I. Paul Singh, MD: Brandon, when it comes to tear film breakup time, what’s the best way to test for it? I know there are physicians like me and glaucoma specialists who just use some fluorescein. That’s not the best way. Tell us exactly how you diagnose using tear film breakup time? What do you do?
Brandon Ayres, MD: The way we do this in studies is use a fluorescein strip and a drop of saline, not even an artificial tear, which may coat the ocular surface artificially. We use saline and fluorescein. You don’t have to be a scientist to do this. Just take your fluorescein strip, put a drop of DSS [dextran sulfate sodium] or saline on there, and put it on your ocular surface. I put a bunch on there, not a little. I want to see that fluorescein coat the ocular surface. I live in Philly, so I say: “Blink 3 times and I’m going to count 1-Philadelphia, 2-Philadelphia, 3-Philadelphia,” and I keep going until I see the tear film breaks up in front of me. I’d like to see my patients get to 10 second—that doesn’t happen. If I get to 7, 8, or 9 seconds, I’m happy. If I’m at 4, 5, or 6, I’m concerned. If I’m at 2 or 3, we have a major problem.
Kendall Donaldson, MD, MS: Those are great pearls. To go back to what you said earlier, a lot of times, when we diagnose dry eye disease so late in the disease process, we can have other complications and permanent changes in the ocular surface and on the lids that we can’t reverse completely. I’m sure you see that a lot in your practice. I certainly do in my practice. [I have] patients who I wish were diagnosed sooner than they are, and they’ve been miserable for years.
I. Paul Singh, MD: Absolutely. Whether it’s the conjunctiva or the lid margin, you see the dropout of glands. Even if you don’t meibography, you can look at those glands and see the little pits. You’re say, “Oh boy.” Or you squeeze and nothing comes out. It’s hard. You lose these glands, and we can’t bring them back. That’s why it’s analogous to not waiting until the optic nerve is half gone before we say, “Let’s do something about it.” It’s the same thing with dry eye.
I have a story about MGD. I was traveling to Europe with my family. I got first-class upgrades with all these miles I had. I have a video of my children: for the first time, they were looking at the screen and wouldn’t blink. They didn’t blink for 10 seconds. I’m thinking, “Future dry eye sufferers.” But Laura brought up a good point. We have studies that show that even [in patients] under age 18, there are a lot of young children who are losing glands at even early ages. It’s starting much earlier than we think. Is that something you’re seeing too?
Kendall Donaldson, MD, MS: Absolutely. We never paid attention to those younger groups of individuals. We’ve talked about it a little more since COVID-19 and watching everyone on the screens. Computer vision syndrome has drawn more attention to it, even since we’ve been using meibography over the last decade. We’ve imaged some of these younger patients, and we can see that there’s gland dropout in an 8- or a 10-year-old. It’s very interesting because I never would have paid much attention to that in the younger population.
I. Paul Singh, MD: It’s amazing how early it starts. I’m not sure if anybody in the panel—have you ever heard of the Wratten filter? Has anyone used that? You have, Laura? Tell us about it because I started using it. One of my slit lamps has a little filter on it, which is great, but I’ve been able to see much more of the tear film, EBMD [epithelial basement membrane dystrophy], etc. Can you mention what that is?
Laura Periman, MD: It’s another cutoff filter that you put on when you put on your blue light. With the fluorescein, it shows up green. It cuts out other wavelengths of light so you see more of the topographic changes. It highlights everything for you. It makes it much easier to see where the mischief is.
I. Paul Singh, MD: It’s amazing. If you don’t even have1, you can go on Amazon. It’s about $10.
Laura Periman, MD: They’re very affordable. A little handheld [device] that you can go around with.
I. Paul Singh, MD: You put your blue light on, you look at the surface, and you just put it in front. You’ll be like, “Wow.” You can see tear film breakup time much better, you can see dropout better, and you can see SPK [superficial punctate keratitis] much better. For me, I was really like “Wow.” There are a lot more individuals I was missing using a cobalt blue light without having that filter. For me, it was great.
Kendall Donaldson, MD, MS: Even a glaucoma specialist.
I. Paul Singh, MD: I can see stuff now. It’s pretty cool.
Eric Donnenfeld, MD: Paul, if I could bring up a point that Laura mentioned, the key to diagnosing dry eye, especially meibomian gland disease is asking the patient. Patient history is so important. It speaks volumes about me as an individual, but I have a favorite symptom. It’s fluctuating vision.
When a patient comes in with that complaint of fluctuating vision, in the past I used to think the IOL [intraocular lens] was moving. Maybe it was a problem with LASIK. But we’ve come to realize that that 1 symptom is almost always meibomian gland disease. When a patient says, “I see well in the morning.” “I don’t see well at night,” “I look at my computer, but after 15 minutes the [screen] gets blurry,” or “I can drive, and after a little while everything gets blurry,” we’re talking about meibomian gland disease until proven otherwise.
The history is important as well. You mentioned rosacea, which is something we diagnose, but ask a patient if they had a chalazion in the past. When a patient tells you they’ve had a chalazion in the past, you know they have meibomian gland disease. That starts you on a therapeutic voyage to try to resolve the disease. It’s an easy diagnosis to make. Meibography is great. Tear breakup time is great. But simply asking the patient, listening to their symptoms, and responding to them is crucial in this diagnosis.
I. Paul Singh, MD: I love that. That’s key, and I use that a lot. Sometimes you hear pushback from colleagues: “I don’t have time to look for dry eye. I’m a busy practice. I’m going back to 50 patients a day.” As Eric was saying, ask, “Does your vision come and go when you blink your eye?” After 5 minutes of reading, does it get blurry and you have to blink to clear it up?” That’s an unstable tear film. Regardless of the cause, there’s something going on there. It can clue you in to say, “There’s disruption to the homeostasis.”
Kendall Donaldson, MD, MS: Good point.
I. Paul Singh, MD: We get caught up in whether it’s evaporative, aqueous deficiency, or exposure keratopathy. At the end of the day, if someone’s vision is coming and going, it’s a disruption to the homeostasis. Whether it’s the lipid layer, the aqueous, or the mucin, if any 1 of those layers is disrupted, it will disrupt that beautiful homeostasis, and the tear film is not going to be healthy. That’s 1 thing that Eric mentioned. If you can ask your patient that, you’re going to see many more [results]. [Regarding the] he signs-vs-symptoms disconnect, this helps [with that].
Kendall Donaldson, MD, MS: Even doctors who don’t want to treat dry eye and be a specialist in just dry eye, it affects our cataract surgeries and everything else we do. It translates to an unhappy patient. Having that symptom can mess up everything we do in our practice.
TRANSCRIPT EDITED FOR CLARITY