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Comfort in the bag

By Professor Teifi James FRCP, FRCS, FRCOphth Todmorden is a small town nestled among the hills on the border between Yorkshire and Lancashire. As a consultant ophthalmologist, I held a weekly ophthalmology clinic at the GP surgery in the town and that was where I met Mrs D: a formidable local lady from Todmorden.

She first came to see me because her eyes were uncomfortable, sore, irritated and scratchy. She described the classic symptoms of dry eye, complaining bitterly about the discomfort – but also the disturbance of her eyesight with blurring of vision, which happened "every now and then".

When I examined Mrs D, she clearly had problems with blocked meibomian glands, which were all plugged with solid material. None of the glands secreted any oil when I squeezed them gently at the slit lamp the way they should have.

Having diagnosed her problem as dry eye with meibomian gland dysfunction (MGD), I gave her one of the sheets of A4 paper that we kept handy in the eye clinic – along with standard instructions for making and applying a warm compress to the eyes and cleaning the eyelid edges with diluted baby shampoo and a cotton bud. Every eye doctor in every eye clinic had a similar sheet of 'advice for warm compresses’, and we used to give them out to patients several times at every clinic.

A fortnight later, Mrs D turned up without an appointment and I called her through to my consulting room. She flung the piece of paper with the warm compress advice, across the desk and said quite reasonably: “Have you ever tried to do this yourself?” I admitted that I had never actually tried to follow the instructions, but promised that I would follow them myself when I got home to see what had infuriated her.

When I tried to follow the instructions on the sheet that Mrs D had returned to me with more than a smidgeon of indignation, I realised what a farce the process was. I felt embarrassed to know that the advice we had been giving out to so many patients was

The Blepha EyeBag is an effective treatment for a variety of conditions

almost impossible to follow, and pretty much useless even if you did manage to follow it.

This situation suited eyecare professionals very nicely. Because nobody was able to follow the advice properly, compliance was dreadful. No-one followed the hot wet flannels and baby shampoo treatment. So, whenever patients returned to the eye clinic and complained again that their symptoms were just as bad and hadn’t improved at all, we could always say without fear of contradiction: “You haven’t been doing the warm compresses properly, twice every day, have you?”

Patients would sheepishly admit that they had failed to follow the instructions and we were able to blame the patient. It was their fault that their symptoms hadn’t improved.

LIGHTBULB MOMENT This whole episode set me thinking about warm compresses. We were still telling people to buy a flannel or face cloth, dunk it in a basin of hot water and place it across their closed eyes. Then, to take a few drops of baby shampoo in an egg cup and fill it with cooled boiled water and use a clean cotton bud to wipe the eyelids and lashes with this solution. It really did seem a bit like following the recipe from a grimoire.

I had spent the years from 1993 to 1996 doing laboratory research in the Molecular Medicine Unit at Leeds University and knew that everyone in the lab had used the microwave oven to heat re-agents, prepare solutions for experiments, melt solids and generally as a laboratory tool.

So, I decided to create a warm compress that could be heated quickly in a microwave, be re-heated time and time again, wouldn’t burn the patients’ skin or damage their eyes in any way, that wouldn’t drip water down the arms, elbows, face and hair and would be pleasant to use.

I knew that regular use of an effective warm compress would relieve the dry eye symptoms and treat MGD. I also realised that compliance was the key. If I could come up with something quick and easy to warm, and pleasant to use, then people would be much more likely to carry out this treatment at home. And that’s how I came up with the idea for the EyeBag.

After several prototypes, I settled on all the materials used in the EyeBag and these are the same as the Blepha EyeBag today. The black side of the EyeBag is made from a thick 100 per cent cotton material called moleskin. I chose moleskin because it has the physical property of insulation, so it

Professor Teifi James, EyeBag inventor

would keep the heat in and slow cooling, thus maintaining the temperature of the heated EyeBag and prolonging cooling time.

I chose silver silk for the other side because the thin top-quality silk allows rapid transfer of heat and has been worn next to the most sensitive skin for literally thousands of years. Both cotton and silk have an excellent track record of wearability with neither material being an irritant.

I tried several fillings for the EyeBag and experimented with comfort, fit, heat profile and re-usability. I settled on flax seeds because they are small and quite dense. The small dense seeds move freely about within the silk and cotton so they conform to all the different facial morphologies that our patients have.

STRAPLESS IS BEST The EyeBag is not a blindfold, but you shouldn’t walk about while it’s covering your eyes because it completely blocks your vision. This means you don’t need a strap to keep it in place; it should stay where it is under its own gentle weight.

I was also keen to avoid any prolonged extra pressure on the eyeballs. Head size can vary a lot from person to person, which is why there are so many hat sizes. Because head circumference shows a ‘normal distribution’, about half the population have a head that is larger than the average.

Warm compresses held in place by velcro on an elasticated strap will exert a greater force on the eyes when the head is larger. Furthermore, eyeball size is relevant here, because myopic eyes are larger and may protrude. Therefore, greater pressure will be applied to the eyes of a myopic patient with a large head.

All these risks seem completely unnecessary, particularly when you remember that elasticated straps serve no purpose and have no role in the treatment of MGD.

HYGIENE: CLOTHES ARE NOT ‘STERILE' Eye make-up is not sterile. Mascara is not sterile. Eye pencils are not sterile. Millions – actually billions – of people across the world apply non-sterile products to their eyelashes, eyelids and eyelid margins every day without any infections or problems with ‘hygiene’.

As already mentioned, silk and cotton have both been used against the skin without adverse reaction for centuries. The department of optometry at Aston University carried out a microbiological study on the EyeBag, comparing it with hot wet flannels, and found the EyeBag to be safe. In fact, the EyeBag was found to be much less likely to harbour Pseudomonas when compared to a flannel1 .

Detergents and washing powders are known to cause or exacerbate dermatitis, and so it is also best to avoid washing the EyeBag with any of these substances when their use really is unnecessary. I have heard people suggest that warm compresses should be wiped down with a ‘baby wipe’ – but these too can cause dermatitis2 because some contain methylisothiazolinone.

USING THE BLEPHA EYEBAG The Blepha EyeBag is a reusable warm compress that works by emitting a warmth that helps to soften the oily secretions in the eyelids, aiding the release of natural oils to maintain tear film and ocular comfort. It provides effective treatment for a range of eye conditions including MGD, blepharitis, stye, chalazion and dry eye disease, which is important when considering one study found that 86 per cent of dry eye patients also had MGD3. It has also been shown to relieve the symptoms of these conditions including grittiness, tiredness, redness, dryness and eye irritation after as little as 14 days of use4 .

The new Blepha Eyebag has a patient instruction leaflet in each pack, which explains how patients should use it. Simply use the warm compress for five to 10 minutes twice a day for the first fortnight then two or three times a week after that as needed. You can reheat a Blepha EyeBag up to 200 times, so it usually lasts for six months before it needs to be replaced.

An appropriate daily eyecare routine is recommended by experts to keep the eyes and eye lids healthy, particularly for those patients with common eye conditions such as dry eye, blepharitis and MGD. Théa has devised a threestep method to help support patients: 1. Warm and massage: using the Blepha EyeBag to warm and melt the oily secretions of the meibomian glands, followed by massage which helps to release the oil. 2. Cleanse: using Blephaclean to help remove the crusts, debris and secretions. 3. Hydrate and lubricate: using Thealoz Duo preservative-free eye drops, which hydrate, lubricate and protect the ocular surface.

I am really pleased to hand over the future of the EyeBag to Laboratories Théa. It’s the perfect addition to their Blepha range as the first step in an effective eyelid routine and I hope that people continue to enjoy its benefits.

To order the Blepha EyeBag, contact your local Théa representative or call 01782 381698. For further education on MGD, visit www.thea-pharmaceuticals.co.uk/academy

REFERENCES

1. Bilkhu P et al. Microwave decontamination of eyelid warming devices for the treatment of meibomian gland dysfunction. Contact Lens & Anterior Eye 2016 39:293-297. 2. Boyapati A. et al. Allergic contact dermatitis to methylisothiazolinone: exposure from baby wipes causing hand dermatitis. Australas J. Dermatol. 2013 Nov;54(4):264-7. 3. Lemp MA et al. Distribution of aqueousdeficient and evaporative dry eye in a clinicbased patient cohort: a retrospective study. Cornea 2012; 31(5):472-8. 4. Bilku PS et al. Randomised masked clinical trial of the MGDRx EyeBag for the treatment of meibomian gland dysfunction-related evaporative dry eye. Br. J. Ophthalmol. 2014 Dec;98(12):1707-11.

Note: Mrs D died some years since, but her voice and stories live on. You can hear her speaking about her early life and describing memories of a bygone era at www.incredible-edible-todmorden.co.uk/ history/people01 ■