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StraightOutofTears:TreatingandManagingMGD,

LidBugsandOtherLidThugs!

MarcR.Bloomenstein,OD,FAAO

Scottsdale,AZ

Disclosure

•  Presenterisonspeakerspanelof:Akorn,Alcon,Allergan,J&J,

B+L,BlephEX,Lunovas,OcuSOFT,TearLab

•  PresidentofMRBEyeConsultants

•  AOACEChairman

•  Past-PresidentoftheOptometricCouncilonRefractiveTechnology

(OCRT)

•  OSSOBoardMember

•  PresenterhasNOfinancialinterestinanyproductsmentioned

IncidenceandPrevalenceof“DryEye”

•  25%ofteen-adults

•  28millionexperiencesymptomsfrequently

•  2015GallupPoll-

– 30millionAmericansaffected

ProactiveandPreventive

•  RiskFactorsforOcularSurfaceInflammation

–  Females

–  Sjogren’s–  Aging–  EnvironmentalIssuse

–  RefractiveSurgery

–  Vitamindeficiency

– Medications

SeaChange•  Managingthediseaseinthechair

–  Insurancevisits•  Glaucomamodel

•  3-4visitsayear

– Compensation

•  Vision“plan”

•  MedicalInsurance

•  Cashpay-ABN

SeaChange

– Patientretention

– Patientreferrals

– CuttingEdgeTreatment

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Symptoms

•  #1mostimportant–

VISIONCHANGES

–  Blurred

–  Fluctuating

–  Hazy

–  Refractivechanges

•  Pain

–  Lightsensitivity

–  Gritty

•  Redness

–  Lidmargin

–  Conjunctival

•  Itch

Signs,Signs,everywhereSigns!

•  LidDebris

– Frothytears

– “collarettes”

AnteriorBlepharitis SeborrheicBlepharitis

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SignsandSymptoms

Morningcrusting

Foreignbody

sensation

Recurrenthordeola

Lossoflashes

Conjunctivalhyperemia

Collarretes

(scalesthat

encirclelash)

Staph

immunedisease• Phlyctenula• Pannus• Catarrhalinfiltrates

• etc

SequelaetoBlepharitis

Blepharitis

Chalazia/hordeola Dryeyes Punctate

keratitis Phlyctenules “Recurrentconjunctivitis” Pannus Corneal

ulceration Endophthalmitis

MGD

PathophysiologyofMeibomianGlandDisease

•  Normalmeibomianglandsecretionsconvertfrom

unsaturatedlipidsthatmeltatbodytemperature

tosaturatedfatsthatinspissatethemeibomian

glands

•  Lidbacteriasecretelipasesthatbreakdownlipids

fromsoapstofattyacids

BacterialLipasesBreakDownLipidstoSoaps

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NON-OBVIOUSMGD

Photos courtesy of Justin Webb, OD, Alcon Research Ltd., 2010.

Remove those pesky caps: MacGruber!

ExamplesofmeibumstagnationandchangesthatcorrespondtoMGD

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Clear liquid secretion (glands are functional using the MGE)

Cloudy liquid secretion (glands are functional using the MGE)

Opaque solid secretion (glands not functional; requires more force than the MGE)

Opaque solid secretion (glands not functional; requires more force than the MGE)

Absence of secretion (glands not functional; even significant force does not yield secretion)

Notching at gland orifice (indicates atrophy/drop out)

Blepharitis

Blepharitis

Anterior

Posterior

Inflammation mainly centered around the eyelash and follicles

Inflammation that involves the meibomian gland orifices

Isthemostcommonandarguablythemostimportantdiagnosispresentingtotheoptometry

BIOFILM

TheBiofilm

•  Biofilm:Abiofilmcommunitycanbeformedbyasingle

bacterialspecies,butinnaturebiofilmsalmostalways

consistofrichmixturesofmanyspeciesofbacteriaina

polysaccharidematrix

–  Thrivesinmoisture

–  Smoothsurface

– Bacteria

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Treatment

Blepharitis….MGD

BlephEx Treatment

30

BlephEx Treatment

31

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MiboMedicalGroup

ADJUNCTIVE THERAPY FOR MGD

Lipid/Oil-BasedLubricantEyeDrops

Palliative–NonetreatthecauseDownsidecanbeblurring&stingingwithcastoroilemulsions

Retaine® MGDTM

•  A main issue is the loss of product while

blinking

•  A unique cationic oil-in-water

nanoemulsion addresses unmet needs

–  Lipid compound + innovative cationic

(positively charged) technology

•  Better attraction to the ocular surface

→ Improvement of the residence time

•  Better spreading on the ocular surface

→ Better adsorption

•  Enhanced tear film and corneal

epithelium1,2

Introducing the cationic emulsion

36

1.LallemandF,etal.JDrugDeliv.2012;2012:604204.2.DaullP,etal.,Benefitsofcetalkoniumchloridecationicoil-in-waternanoemulsionsfortopicalophthalmicdrugdelivery.Draftforpublication,2013.

OILY CORE

SURFACTANT

CATIONIC AGENT

Solubilizes the drugs

Stabilizes the interface

Brings the positive charges

Seborrheic Blepharitis

Seborrheic blepharitis is caused by seborrheic dermatitis, a skin condition that creates flaking and scaling — including on the eyelids. Regular cleansing with eyelid scrubs can provide significant relief and improve the appearance of eyelids. Signs and Symptoms Red, irritated, itchy eyelids and the formation of dandruff-like scales on the eyelashes.

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Seborrheic Blepharitis (continued)

Take Home Recommendation OCuSOFT ® Lid Scrub ® Eyelid Cleanser Original Formula OCuSOFT ® Lid Scrub ® removes oil, debris, and desquamated skin from the eyelids and is non-irritating to the eyes.

39M15-05612/15

TheraTears®SteriLid®

SoothesandCleansesAwayExternalIrritantsTheraTears®Sterilid®removesoil,debrisandothercontaminantsthatcanaccumulateoneyelidsandeyelashes.

Need More Eyelid Relief

The root cause of anterior blephartitis is the overproduction of oils. Mild surfactants in OCuSOFT® Lid Scrub® PLUS eyelid cleanser act to dissolve and remove oil, debris, and desquamated skin. Other formulas do not. Hypochlorous Acid is produced by white blood cells as part of the body’s natural defense mechanism against pathogens.

What Is Hypochlorous Acid?

Hypochlorous acid is a weak acid that is formed when chlorine dissolves in water. Its chemical formula is HOCL. An acid is a pH below 7 (neutral). Above 7 is considered base/basic or alkaline. Tap water is generally a pH of 7 whereas citric acid from lemons is highly acidic at around a 2. The pH of HOCL is between 6-7.

Hypochlorous Acid

HypoChlorOCuSOFT® HypoChlor™ is a 0.02% concentration of

Hypochlorous acid in both Spray and Gel formulation

Avenova

NovaBayAvenovawithNeutrox

isa0.01%concentrationof

Hypochlorousacid

WorkingtheMGD..Lipiflow(J&J) iLUX(TearfilmInnovations)

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IntensePulseLight

MGD–Research(IPL)•  Prospective,double-masked,

placebo-controlled,paired-eye

study

•  28participantsunderwentIPL

treatment,withhomogeneously

sequencedlightpulsesdeliveredto

oneeyeandplacebotreatmentto

thepartnercontroleyeat:

–  1day

–  15days

–  45days

2

ProspectiveTrialofIntensePulsedLightfortheTreatmentofMeibomianGlandDysfunctionJenniferP.Craig;Yen-HengChen;PhilipR.K.Turnbull,InvestigativeOphthalmology&VisualScienceMarch2015,Vol.56,1965-1970

MGD–Clinical(IPL)

•  Potentialmechanismsof

action:

–  Heating/looseningof

meibum

–  Reductionintelangiectasias

–  Decreaseinbacterialloadonface

DRWHITNEYHAUSER

IntensePulseLight

DR.WHITNEYHAUSER

Photospre-IPLtreatment

MGD–Clinical(IPL) IntensePulseLight

DR.WHITENYHAUSER

Photospost-IPLtreatment

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InflammatoryDryEyeAlterstheTearFilm

DryEyeDiseasereducesmucins,andaltersconcentrationsofgrowthfactorsandtearproteins1,2.Fewertearscanleadtoincreasedinflammatoryoutputfromthelacrimalgland,whichcancauseocularsurfacedamageandalteredtearproduction.Theresultingchronicinflammatorystimulicanthenleadtofurtherdecreasedtearproduction3-5

Imageusedwithpermission.

TreatingTheInflammation•  Restasis(Allergan)

–  Primarytreatmentoption

–  Multiplemediatorsofinflammatory

cascade

–  Increasegobletcellsdensityandemulsion

vehicle

–  Proven

•  Xiidra(Shire)–  ICAM-1decoy

–  Balancedsalinevehicle

TreatingTheInflammation

•  Steroids

•  AmnioticMembrane

Best MGD Treatment?? •  Warmupthelids

•  Inofficeexpression

•  RetaineMGD/Restasis/Xiidra

•  Lowdosetetracyclinederivatives

•  LidHeatoptions

•  Omegafattyacids

•  Getthepatientearly..do

itall!!!

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Demodex

ThatotherThug!

HANDBOOK OF MEDICAL ENTOMOLOGY

Dr. WM. A. RILEY, Professor of Insect Morphology and Parasitology, Cornell University

Dr. O. A. JOHANNSEN, Professor of Biology, Cornell University

1915

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RosaceaandDemodex?•  Rosaceaanddemodex

–  Meta-analysisof48studies

–  10differentcountries

–  28,527subjects

–  Rosaceapatients7-8xchancehaveDemodex

ZhaoYE,WuLP,PengY,ChengH.Retrospectiveanalysisofthe

associationbetweenDemodexinfestationandrosacea.Arch

Dermatol2010;146:896Y902.

RememberBiofilm….

Biofilmisapolysacharride

PerfectfoodsourceforaDemodexinfestation

MICROBLEPHAROEXFOLIATION(MBE)Doctorcenteredapproachtolidhealth

● Spinsamicro-sponge2,500RPMalongmargin

● Resultsincompletelycleanlids

● Repeatedevery4-6months● Privatepayprocedure,typically$150-$250

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In Office Treatment

•  Patientswithheavyscruffmayneedaninoffice

treatmenttoremovescruff(Blephex)orTTOwillnever

gettothetarget.

•  IuseofCliradex/Oustforthoserecalcitrantcases

•  Typicallydoing2differentinofficeTTO,rarelythird

•  Maintenanceon:Cliradex,Oust,BlephaDex

Demodex Infestation of the Eyelids

Recommended Treatment In-office procedure: Cleanse eyelids and eyelashes in-office utilizing OCuSOFT® Lid Scrub® PLUS Swabstix™ and Oust™ Demodex® Swabstix™. Oust™ Demodex® Swabstix™ contain 50% Tea Tree Oil, 40% Sea Buckthorn Oil, and 10% Caprylic Acid. These single-use, disposable, self-saturating Swabstix™ provide convenient in-office use to effectively eradicate demodex and remove oil, debris, and other contaminants on the eyelids in-office. A complete Demodex Kit is available for in-office use.

BlephaDex

•  Aqua

•  CoconutOil

•  Glycerol

•  AloeBarbadensisGel

•  SodiumLaurylSulfate

•  CocoamidopropylBetaine

•  DMDMHydantoin

•  LaurelGlucoside

•  MelaleucaAlternifolia(TeaTree)Leaf

Oil

EasierWayToStartIn-Office

•  RegularMaintenance-Liketeethcleaning

– UseBlephadexswab,withBlephEx,forannual

(bi-annual)inofficetreatment

–  At-hometreatmentwithBlephadexpadsorfoam

•  Continuetouseeverydayformaintenance

Treatment Goal: •  NOT to eradicate 100%

•  Want to knock down the “load” and reduce symptoms –  Watering

–  Crusting

–  Itching of lids

•  Like to see some visible reduction in cylindrical dandruff

•  Improve redness profile of eye, lid and face

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Conclusion

•  Differentiatetheconditioninyourpractice

•  ThinkBiofilm

–  Removethedebris

–  In-officetreatments

•  Havetheoptionsinyourpractice–  Provideoptions–  Utilizetheproducts

•  NewcomfortableDemodextreatments