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Evidence Based Approach Dry Eye Meibomian Gland Dysfunction Copenhagen 2012 Teifi James MBBS DO FRCP FRCS FRCOphth Consultant Ophthalmologist Calderdale Royal Hospital

MGD — Symptoms

Declaration • • • • • • • • • •

Fees, Hospitality & expenses from

Boots Allergan Specsavers

EyeCare 3000 Spectrum Thea Bausch & Lomb CIBA / Alcon / Novartis Rotho / Mentholatum / Sooft The EyeBag Company — patent and majority shareholding

Moll secretions anterior to MGOs

The Dry Eye Pyramid - circa 20 million in UK 

Intrinsic  Meibomian Gland Dysfunction  Lid Aperture disorders – eg GO  Low blink rate – eg Parkinson's  Drug action  Ro-accutane effect on Meibomian Glands Extrinsic  Vitamin A deficiency  Preservatives in Topical eye treatments  Contact lens wear  Ocular Surface Disease  Post Corneal / laser surgery

Sjøgrens HES

Evaporative Millions with dry eye

Dry Eye • Lacrimal gland dysfunction, Sjogrens rare

• Evaporative dry eye very common • MGD is the major cause of ‘Dry Eye’.

Onions Tears?


Meibomian seborrhoea

MGD pseudoblisters with capped orifices

Transient blurred vision — Common in MGD Blob of lipid in the tear film

Loss of lipid barrier Loss of lid margin hydrophobicity Macerated lid margin – water wettable

TFOS MGD Report • • • • • • •

Definition / Classification Anatomy, Physiology, Pathophysiology

Tear Film Lipids & Lipid-Protein interactions Epidemiology & Risk Factors

Diagnosis Management and Treatment Clinical Trials

MGD — Aetiology • “Not clear” • “More research required”

MGD is The key underlying feature of‌ Dry Eye Post Laser Ocular Dryness Contact Lens Associated Dry Eye Blepharitis Chalazion Stye


Tear film has poor quality lipid layer

Break Up Time is short.

Strategies to restore it.

Diagnosis is self-evident.

Champagne bubbles on lid edge.

Blepharitis & evaporative dry eye.

Temperature Dependent Phase Change Lipid composition alters melting point

Unsaturated FAs — Increasing Saturation — Wax Esters

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Omega 3 Oily fish +++ zero butter, red meats or take a supplement Lagad Lacrima

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Omega 3 • GLA (Gamma Linolenic Acid) • Anti-inflammatory Nutrient

• EPA (Eicosapentaenoic Acid) • Omega 3 Anti-inflammatory Nutrient

Lipid chemistry Meibum is a complex soup of variable lipids and lipid derivatives. The melting point varies according to the exact composition. Properties of fatty acids and their derivative lipids depend on chain length and being unsaturated Unsaturated FAs have a lower melting point than saturated FAs of same length e.g. C18 – Stearate ( zero double bonds) melts at 69.6ºC C18 – Oleate ( one cis double bond) melts at 13.4ºC

Meibomian gland dysfunction and ocular discomfort in video display terminal workers C Fenga1, P Aragona2, A Cacciola1, R Spinella2, C Di Nola1, F Ferreri2 and L Rania2 Eye (2008) 22, 91–95; doi:10.1038/sj.eye.6703025; published online 26 October 2007

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A total of 52 subjects out of 70 (74.3%) had MGD. A statistically significant correlation between the symptoms of ocular discomfort and hours spent on VDT work was observed in the total population (r=0.358; P=0.002; 95% CI 0.13–0.54) and in the group of subjects with MGD (r=0.365; P=0.009; 95% CI 0.103–0.58). Such correlation was not shown in subjects without MGD. Conclusions The high prevalence of MGD among the subjects with symptoms of ocular discomfort suggests that this diagnosis should be considered when occupational health practitioners encounter ocular complaints among VDT operators. It appears that MGD can contribute to the development of ocular discomfort in VDT operators.

Jackson Brown — Doctor my Eyes

118 Opticians

3 blinks - 2 people

2 - 14

4 blinks - 4 people

1 - 15 0 - 16

The near response... • • • •

Convergence Miosis

Accommodation ? Decreased blink rate ??

The 20-20-20-20 rule & Return / blink button & Gamers lose a life or progress to next level

? Melts at 39ยบ C

Are you a squeezer?

Clinical Handbooks Moorfields



Wet Flannel 5mins od / bd

Warm compresses 15 mins qid


Doxy 100mgs od for 8/52

Tet 250 qid for 6/52



4 to 8 x a day

The ideal warm compress • Must raise lid temperture above 39º C • Stay above 39º C for a while • Good compliance (nice and easy to use)

• Affordable (inexpensive) • No adverse effects



Temperature changes of the external and internal eyelids using the MGDRx EyeBag Paramdeep S Bilkhu, BSc (Hons) MCOptom. N, Shehzad A Naroo, BSc (Hons) MSc PhD MCOptom FIACLE FAAO FBCLA James S Wolffsohn, BSc (Hons) MBA PhD FSB MCOptom FAAO FBCLA Aston University, Birmingham, UK

Corresponding Author:

Conclusions: Paramdeep Bilkhu et al The MGDRx EyeBag does produce an increase in external and internal eyelid temperature. Based on the results, either surface of the MGDRx EyeBag can be used but 5 minutes application using the silk surface demonstrates greater increases of eyelid temperature necessary for optimal heating

Hot Compress Survey 125 responses

Tear replacement!

Topical lubricant drops and gels • • • • • • • •

4 million UK scripts annually for Hypromellose Hyaluronate

Polyvinyl alcohol Carbomer Guar Micelle mist / sprays Mucin mimetic agents Autologous Serum

Generic Hypromellose 10 mls £ 2.99 from Amazon

£39.10 per 100 mls

£30 per 100 mls

No Recipe for hot spoon treatment!

Thank You