Evaluation of the ocular tolerance of a novel eyelid-warming device used for meibomian gland dysfunction

Potential benefits of Malva sylvestris in dry-eye disease pathology in vitro based on antioxidant, wound-healing and anti-inflammatory properties

Dry eye disease (DED) is a common chronic ocular surface disease. Available therapies are effective but often associated with side effects. This study investigates the potential of a Malva sylvestris L. flower extract and two defined preparations, a mucilage and a polyphenol rich fraction, on cells that are essential for the DED pathology. Furthermore, single compounds were isolated and characterised out of the polyphenol fraction. The M. sylvestris extract and its two fractions reduced reactive oxygen species (ROS) in an ultraviolet-induced model and promoted wound healing capacity of HCE-T cells, but only the polyphenol fraction and the flower extract exhibited significant radical scavenging activity. The flower extract and the polyphenol fraction inhibited cytokine secretion (IL-6, TNF-α, IL-8) from HCE-T cells and THP-1 cells. In contrast, the mucilage fraction led to an increase in mediator secretion. The NF-κB activity and calcium influx in THP-1 and Jurkat cells, respectively was decreased by treatment with the flower extract and the polyphenol fraction, whereas the mucilage fraction had no influence on these parameters. Moreover, the flower extract and the mucilage fraction at low concentration could stimulate meibomian gland cells' lipid accumulation. The isolated single compounds showed no effect on analysed parameters, except a coumarin derivative and malvin which showed ROS inhibition effects.

A Review on Dry Eye Disease Treatment: Recent Progress, Diagnostics, and Future Perspectives

Dry eye disease is a multifactorial disorder of the eye and tear film with potential damage to the ocular surface. Various treatment approaches for this disorder aim to alleviate disease symptoms and restore the normal ophthalmic environment. The most widely used dosage form is eye drops of different drugs with 5% bioavailability. The use of contact lenses to deliver drugs increases bioavailability by up to 50%. Cyclosporin A is a hydrophobic drug loaded onto contact lenses to treat dry eye disease with significant improvement. The tear is a source of vital biomarkers for various systemic and ocular disorders. Several biomarkers related to dry eye disease have been identified. Contact lens sensing technology has become sufficiently advanced to detect specific biomarkers and predict disease conditions accurately. This review focuses on dry eye disease treatment with cyclosporin A-loaded contact lenses, contact lens biosensors for ocular biomarkers of dry eye disease, and the possibility of integrating sensors in therapeutic contact lenses.

Eyelid Warming Devices: Safety, Efficacy, and Place in Therapy

Meibomian gland dysfunction (MGD) is characterized by the obstruction and/or inflammation of the meibomian glands that result in decreased and altered meibum secretion. This results in deficiencies in the tear film lipid layer which contributes to increased evaporation and destabilization of the tear film. One of the mainstay therapies for MGD is medical devices that apply heat and/or pressure to the eyelids and promote the liquification and outflow of meibum into the tear film. Over the past two decades, there have been a surge of interest in diagnosing and managing MGD. As a result, numerous medical devices have been developed and each have their own unique approach to treating MGD. This narrative review was conducted to summarize the current state of knowledge on eyelid warming devices, specifically warm eye coverings, devices that direct heat and/or pressure to the eyelids, moisture chamber goggles, and light-based therapy. This review summarized 58 human clinical studies and found that most eyelid warming devices were efficacious in improving signs and symptoms in a wide range of MGD severities and were generally safe to use.

[Thermal pulsation system (LipiFlow®) for treatment of meibomian gland dysfunction (MGD) from the perspective of an ophthalmologist in private practice]

PURPOSE

Thermal pulsation (LipiFlow®, Johnson&Johnson, Santa Ana, CA, USA) has been advocated for meibomian gland dysfunction (MGD) treatment and was found to be useful in many studies. The aim of this study was to show the efficacy of the method and to compare it to a daily eyelid margin massage in a non-university institution.

METHODS

A non-blinded, single-center interventional study comparing thermal pulsation with eyelid margin massage for the treatment of MDD. In this study 30 patients were recruited during daily office hours. Symptoms (OSDI) and ocular surface (NIK-BUT, tear ferning test, tear meniscus height, LIPCO folds, meibography, meibomian gland evaluator) were assessed before treatment. A total of 15 patients (9 women) underwent thermal pulsation (single session), while 15 patients (8 women) performed eyelid margin massage (once daily) as instructed for 3 months.

RESULTS

Before the two treatment methods, there were no differences in the above parameters, gender and age were also normally distributed. After treatment, both subjective and objective criteria improved in the two groups but significantly more in the thermal pulsation arm. In particular, the limited compliance of 30% in the eyelid margin massage arm should be noted. Safety parameters, such as visual acuity and intraocular pressure (IOP) remained normal in all patients.

CONCLUSION

A single session of thermal pulsation showed significantly better results in the efficacy and safety profile after 3 months compared to eyelid margin massage once daily; however, the high costs for the patients due to the single use mode of the activators must be taken in account.

Evaluation of the MGDRx eyebag treatment in young and older subjects with dry eye symptoms

OBJECTIVES

This study aims to evaluate the relationship between application of the MGDRx thermal eyebag and dry eye signs and symptoms in young and older subjects and to compare the results between the two groups.

METHODS

Thirty young, healthily volunteers between 18 and 31 years of age (23.95±3.94 years) and thirty older subjects between 61 and 90 years of age (77.97±8.11 years) participated in this study. Ocular surface parameters were assessed using the Oculus Keratograph 5M, following the guidelines of the Tear Film and Ocular Surface Dry Eye Workshop II Diagnostic Methodology report. Only subjects with a positive score on at least one questionnaire and an initial Non-Invasive Keratograph Break-Up Time (NIKBUT) under 10seconds were included in the study. After thermal bag self-application in both eyes every day for 2 weeks, the protocol was carried out again. Lid massage was performed after lid warming. Compliance and degree of improvement were also assessed.

MAIN RESULTS

The young volunteer group showed an improvement in NIKBUT, lipid layer score, upper eyelid gland drop-out percentage and dry eye symptoms over the two week treatment period. Improvements in meibum quality, gland obstruction, telangiectasia scores, and dry eye symptoms were found in the older subjects. Mixed ANOVA revealed better NIKBUT and lipid layer values in the young subjects. Despite the treatment compliance being statistically higher in the older group than in the younger subjects (P=0.002), there were no significant differences in subjective improvement between groups (P=0.097).

CONCLUSION

Dry eye-related symptoms were improved after thermal bag application, while NIKBUT and lipid layer thickness were improved only in the younger subjects.

TheraPearl Eye Mask and Blephasteam for the treatment of meibomian gland dysfunction: a randomized, comparative clinical trial

Meibomian gland dysfunction (MGD) is the most common cause of dry eye disease (DED). In this study, we aimed to compare the effects of eyelid warming treatment using either TheraPearl Eye Mask (Bausch & Lomb Inc., New York, USA) or Blephasteam (Spectrum Thea Pharmaceuticals LTD, Macclesfield, UK) in a Norwegian population with mild to moderate MGD-related DED. An open label, randomized comparative trial with seventy patients (49 females, 21 males; mean age 53.6 years). Patients were randomly assigned to treatment with Blephasteam (n = 37) or TheraPearl (n = 33). All received a hyaluronic acid based artificial tear substitute (Hylo-Comod, Ursapharm, Saarbrücken, Germany). Patients were examined at baseline, and at three and six months initiation of treatment. Treatment efficacy was primarily evaluated by fluorescein breakup time (FBUT) and Ocular Surface Disease Index (OSDI) scores. Other outcome measures included ocular surface staining (OSS), Schirmer’s test, and meibomian quality and expressibility. Baseline parameter values did not differ between the groups. After six months of treatment, Blephasteam improved FBUT by 3.9 s (p < 0.01) and OSDI by 13.7 (p < 0.01), TheraPearl improved FBUT by 2.6 s (p < 0.01) and OSDI by 12.6 (p < 0.01). No difference between treatments was detected at 6 months (p = 0.11 for FBUT and p = 0.71 for OSDI), nor were there differences in the other tested parameters between the treatment groups. Blephasteam and TheraPearl are equally effective in treating mild to moderate MGD in a Norwegian population after 6-months of treatment.

Clinicaltrials.gov ID: NCT03318874; Protocol ID: 2014/1983; First registration: 24/10/2017.

Chambered warm moist air eyelid warming devices - a review

BACKGROUND

Eyelid warming is an important treatment for meibomian gland dysfunction (MGD). Specialized chambered devices, using warm moist air have been developed.

PURPOSE

To critically evaluate the literature on the safety and efficacy of chambered warm moist air devices in MGD treatment and pinpoint areas of future research.

METHODS

PubMed and Embase were searched on 06 June 2021. The search term was '(warm OR heat OR steam OR goggle OR spectacle OR moist air) AND (meibomian OR MGD OR blepharitis OR eyelid OR dry eye OR DED)'. All relevant articles with available English full text were included.

RESULTS

Eighteen articles assessing the application of chambered warm moist air eyelid warming devices were identified. In single-application studies, steam-based eyelid warming increased the eyelid temperature and improved symptoms, lipid layer thickness, and tear film breakup time (TBUT). In treatment studies, the steam-based devices improved TBUT and symptom scores. However, in the only randomized controlled trial (RCT) comparing chambered steam-based heat to hot towel treatment, there was no difference between groups for the primary outcome measure; the proportion of subjects noting symptom improvement after 4 weeks.

CONCLUSION

Currently available chambered warm moist air eyelid warming devices are safe and effective at raising eyelid temperature to therapeutic levels and improving signs and symptoms of dry eye. However, it is not clear if they provide a greater benefit than other eyelid warming therapies. Further well-conducted RCTs comparing moist and dry heat devices should be conducted on patients across the range of DED severities and subtype spectrum.

Quantifying the Effect of Spectacle Frame Dimensions on Wind-Induced Ocular Plane Evaporation Using an in Vitro Model

PURPOSE

To quantify the effect of spectacle frame dimensions on wind-induced ocular plane evaporation.

METHODS

A drop of 0.5 μL water was pipetted onto an eye of a mannequin head. The face was fitted with a spectacle frame. A fan positioned 10 cm away directed air (185 CFM) toward the face and the time required for the drop to evaporate was recorded. This procedure was repeated with 31 different frames to obtain evaporation times for various eye sizes, vertical heights, vertex distances, temperature, and humidity. This was also repeated 30 times without spectacle wear to obtain evaporation times for various temperature and humidity conditions.

RESULTS

Spectacle wear increased evaporation times compared with nonspectacle wear, in both high (>35%) and low humidity (<30%) conditions (both P<0.01). Humidity was correlated with evaporation time, regardless of spectacle and nonspectacle wear (both P<0.01). Evaporation time did not correlate with spectacle eye size, vertical height, or vertex distance (all P≥0.21).

CONCLUSION

This study showed that spectacle wear guarded against wind-induced evaporation at the ocular plane compared with nonspectacle wear. However, once spectacles were worn, eye size, vertical height, and vertex distance were not correlated with evaporation times. Humidity drove evaporation independent of spectacle wear.

Therapeutic Instruments Targeting Meibomian Gland Dysfunction

The most prevalent type of meibomian gland dysfunction (MGD), which is obstructive, is the main cause of evaporative dry eye and is characterized by changes in the meibum composition and duct obstruction. Eyelid hygiene has usually been the most common clinical approach. However, alternative therapies for MGD are emerging on the market. Some warming and humidity devices have led to an improvement in the signs and symptoms in MGD patients. Likewise, eyelid massaging and cleaning devices are also beneficial for ocular signs and symptoms; however, patients usually need more than one session to maintain the therapeutic effect. Thermal pulsation has been reported to be more efficient than other strategies, and the effects can last up to 12 months. Moreover, intense pulsed light therapy has been demonstrated to improve ocular signs and symptoms alone and in combination with other therapies. Proper counseling of clinicians considering MGD status and patient compliance will help patients to undergo the adequate technique that best suits their condition.

Correlation between Blood Flow and Temperature of the Ocular Anterior Segment in Normal Subjects

Purpose: To determine a correlation between temperature and blood flow in the ocular anterior segment, and their effects on corneal temperature. Methods: In experiment 1, we recruited 40 eyes and measured the temperature and blood flow in the ocular anterior-segment (upper/lower eyelid skin, palpebral and bulbar conjunctiva, and cornea) before and after application of warm compresses. In experiment 2, we recruited 20 eyes and measured the same tissues before and during stimulation using water and capsaicin solution in the oral cavity. Results: In experiment 1, the temperatures of the upper/lower eyelid skin and cornea increased significantly until 15 min after the application of the warm compress; the temperatures of the palpebral and bulbar conjunctiva increased significantly until 10 min. The blood flow in the upper/lower eyelid skin and bulbar conjunctiva increased significantly until 10 min, and that of the palpebral conjunctiva increased significantly until 15 min. In experiment 2, the temperatures were correlated significantly with the blood flow in the upper and lower eyelid skin and palpebral and bulbar conjunctiva. The temperature of all locations and palpebral conjunctival blood flow contributed independently to the corneal temperature. Conclusions: In the ocular anterior segment, the temperature and blood flow were correlated significantly, and contributed to the corneal temperature.

Infrared thermography: different options of thermal eyelid warming

PURPOSE

Current therapies of Meibomian gland dysfunction (MGD) include thermal eyelid warming. It was the aim of the study to investigate the temperature run after eyelid warming using 3 different techniques (hot compresses, Blephasteam® (Thea Pharma GmbH, France), and having a sauna) in patients with MGD compared with normal subjects by infrared thermography.

METHODS

A prospective case-control study was done. Temperature profiles of the eyelids were investigated in 93 subjects (49 normals, 44 MGD patients) after warming of the eyelids by 3 methods: hot compresses, Blephasteam®, and having a sauna. Temperature runs of the eyelids were measured with an infrared thermal imaging camera (VarioCAM® HD research 675/30 mm, InfraTec GmbH) at baseline and after eyelid warming for 10 min. Statistical analysis were done by Wilcoxon test or t tests for unpaired samples.

RESULTS

The initial eyelid temperature was significantly increased after the use of Blephasteam® compared with hot compresses in MGD and normal patients (p < 0.001). Having a sauna showed a similar warming effect of the eyelids than Blephasteam^® in normals and MGD patients (p > 0.05). Additionally, the warming effect of the eyelids after having a sauna was significantly longer than after the use of Blephasteam® in MGD (p = 0.016) and normal patients (p = 0.01).

CONCLUSION

Eyelid temperature after having a sauna was similar to commonly used warming devices; yet, the duration of the eyelid warming effect was longer. Thus, having a sauna might be an alternative option for warming of the eyelids.

Non-pharmaceutical treatment options for meibomian gland dysfunction

This review examines currently available non‐pharmaceutical treatment modalities for meibomian gland dysfunction. A detailed search of the PubMed and MEDLINE databases was performed to identify original articles in English that have evaluated such nonpharmaceutical therapies in patients with this condition. Conventional therapies such as application of a warming compress, the practice of lid hygiene, and manual expression of meibomian glands as well as more technologically advanced approaches such as intraductal probing, thermal pulsation, and intense pulsed light therapy are included in the review. These non‐pharmaceutical treatment options may each have a role to play in the management of meibomian gland dysfunction, but more studies are necessary to compare treatments directly under identical experimental conditions in order to determine their relative efficacy. Additional large‐scale, randomised, controlled trials are also required to provide more information such as the specific indications best suited to each treatment modality, the efficacy of such approaches in combination with pharmaceutical‐based therapy, and the mechanisms of action of some of the more technologically advanced systems.

Therapeutic profile of a latent heat eyelid warming device with temperature setting variation

PURPOSE

To compare the effects on ocular temperature and tear film parameters following a single application of a latent heat eyelid warming device at a range of temperature settings.

METHODS

Fifteen subjects were enrolled in a prospective, investigator-masked, randomised, cross-over trial. On separate days, participants were randomised to 10-minute application of a research latent heat device (Laboratoires Théa) at device temperature settings of 45 °C, 50 °C and 55 °C. Outer eyelid and corneal temperatures, tear film lipid layer grade, and non-invasive tear film breakup time (NIBUT) were measured at baseline and immediately after 10 min of device application.

RESULTS

Baseline measurements did not differ between treatment groups (all p > 0.05). Ocular temperatures, lipid layer grade and non-invasive tear film stability rose significantly following device application in all treatment groups (all p < 0.05). The 55 °C setting effected a mean ocular surface temperature rise in the order of +4 °C from baseline, which was 1.46 and 1.26 times greater than at the 45 °C and 50 °C temperature settings, respectively (all p < 0.05). Similarly, improvements in mean non-invasive tear film stability from baseline in the order of +7 s were observed, which were 2.43 and 1.66 times greater than those at the lower temperature settings of 45 °C and 50 °C, respectively (all p < 0.05).

CONCLUSIONS

At all temperature settings, the latent heat device resulted in clinically and statistically significant increases in ocular temperature, lipid layer grade, and non-invasive tear film stability. However, the 55 °C setting proved to be most effective at raising ocular temperature (in the order of +4 °C from baseline) and improving tear film stability.

Efficacy of Vectored Thermal Pulsation and Warm Compress Treatments in Meibomian Gland Dysfunction: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

Meibomian gland dysfunction is the main cause of dry eye disease (DED) and is traditionally managed using warm compress treatment (WCT). Vectored thermal pulsation treatment (VTPT) is a novel method for treating DED.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials that compared the efficacy of VTPT and WCT in treating DED. The primary outcome was the gland function. The secondary outcomes were the tear breakup time, Schirmer test, tear osmolarity, lipid layer thickness, Standard Patient Evaluation for Eye Dryness, and the improvement of subjective symptoms as assessed by using the Ocular Surface Disease Index. PubMed, Embase, Cochrane Library, and ClinicalTrials.gov registries were searched for studies published before July 2018.

RESULTS

This study consisted of 4 trials with 385 patients. Significantly greater improvement was observed in meibomian gland function [mean difference (MD): 2.19 (95% confidence interval (CI), 0.95, 3.43)], tear breakup time [MD: 1.08 (95% CI, 0.06, 2.10)], and Standard Patient Evaluation for Eye Dryness [MD: -2.76 (95% CI, -4.22, -1.30)] at 2 to 4 weeks in the VTPT group than in the WCT group. A significantly greater decrease in Ocular Surface Disease Index was observed at 2 to 4 weeks [MD: -8.61 (95% CI, -13.62, -3.61)] and 3 months [MD: -6.92 (95% CI, -11.95, -1.89)] in the VTPT group than in the WCT group.

CONCLUSIONS

A single 12-minute VTPT was more efficacious than traditional WCT in treating DED either in objective or subjective measurements. We recommended choosing an appropriate treatment after shared decision-making.

An Eyelid Warming Device for the Management of Meibomian Gland Dysfunction

PURPOSE

To determine the effectiveness of the MGDRx EyeBag in managing meibomian gland dysfunction.

METHODS

This was a prospective, randomized, controlled, observer-masked, bilateral eye study that enrolled 29 participants. Participants were randomized into either the EyeBag group or the control group. The EyeBag group used the EyeBag 10minutes 2x/day, and the control group remained on their own dry eye treatment regimen (if applicable). All participants were observed at baseline, 2 weeks (2wk) and 4 weeks (4wk). At 4wk, participants in the EyeBag group were asked to stop using the EyeBag. All participants were seen again at 8 weeks (8wk). Primary outcomes were the Ocular Surface Disease Index (OSDI), Current Symptoms Questionnaire (CSQ), meibomian gland score (MG score), and non-invasive tear breakup time (NIBUT).

RESULTS

Twenty-five participants completed the study (mean age 38±15 years, 7 male). There was a significant change in OSDI over time for the EyeBag group (mean[lower 95% CI, upper 95% CI], baseline: 39.1[31.1,47.0], 2wk: 26.8[19.7,33.9], 4wk: 26.6[16.5,36.7], 8wk: 27.7[18.4,37.0]; p=0.01), but not in the control group (p=0.22), but no significant difference between groups at all time points (all p>0.27). Symptoms immediately improved after conducting the EyeBag based on at-home CSQ scores (Δ=-5.0 points, p<0.01), but not in the control group. For both groups, there was no significant change (p-value EyeBag,p-value control) in MG score (0.21,0.17) and NIBUT (0.49,0.06) over time.

CONCLUSIONS

The EyeBag may relieve symptoms of dry eye, but the effect on meibomian gland function and tear stability when used for only 4 weeks was undetectable.

The optimum temperature for the heat therapy for meibomian gland dysfunction

PURPOSE

Numerous devices have been developed to warm the eyelid as a therapy for Meibomian gland dysfunction. The optimum temperature for such therapy was determined.

METHODS

Meibum lipid disorder versus temperature was calculated from previously published phase transition parameters measured using infrared spectroscopy. Phase transitions parameters were calculated from meibum obtained from donors with Meibomian gland dysfunction (MMGD), donors who were susceptible to dry eye after hematopoietic stem cell transplantations (MHSCT) and meibum from donors without dry eye (Mn).

RESULTS

Heating Mn to 40 °C increases the lipid disorder by 20.4%-90%. Heating the meibum another 4° increases the disorder to 95%. MMGD is 73.2% disordered with no heating. Heating MMGD to 41.5 °C increases the disorder by 26.8%-90% disordered. Heating MMGD another 5.1 °C increases the disorder to 95%. As MHSCT is much more ordered, 56.9% disordered compared with Mn and MMGD, a higher temperature above safety limits, 52 and 59 °C is need to disorder MHSCT to 90 and 95% disorder.

CONCLUSIONS

Heating the eye lid above the phase transition temperature of meibum increases the disorder of meibum lipid which could ameliorate dry eye symptoms. The optimum temperature for disordering Mn and MMGD to 90% maximum disorder is 40 and 41.5 °C, respectively. Safety issues and discomfort should be considered in obtaining an optimal level of disorder, especially for severe cases of dry eye.

Intense Pulsed Light Therapy In The Treatment Of Meibomian Gland Dysfunction: Current Perspectives

Dry eye disease (DED) is among the most common condition encountered during ophthalmic practice, reducing patient's quality of life and work productivity. Most of DED cases have an evaporative component originated from a meibomian gland dysfunction (MGD). Conventional treatments such as tear substitute, warm compresses, topical anti-inflammatory agents and/or antibiotics often are not able to provide a complete and long-term relief of symptoms and signs. Intense pulsed light (IPL) has been widely used in the field of dermatology to treat various skin conditions, and it has been recently introduced in the ophthalmic practice for the management of DED due to MGD. To date, several clinical studies showed positive results of IPL as adjuvant therapy for DED in terms of both safety and efficacy. The treatment is usually well accepted among patients for its non-invasive nature; very rare are the major adverse reactions. Moreover, results can be maintained over time with periodic sessions of IPL. This review summarizes the clinical outcomes of IPL therapy in MGD patients pointing out its potential role in the therapeutic algorithm of the disease. Further clinical investigations are desirable to identify factors able to predict the positive outcomes of the procedure and therefore to select in advance those patients who best benefit from IPL therapy.

Tear film evaluation and management in soft contact lens wear: a systematic approach

The human tear film is a highly ordered structure consisting of a thin layer of lipid on the surface and a thicker aqueous-mucin phase, which increases in mucin concentration toward the corneal epithelial cell layer. The health of the tear film and ocular surface influences the likelihood of being able to achieve successful contact lens wear. Contact lens discomfort and dryness are the most frequent reasons why contact lens wearers experience reduced wearing times, which can eventually lead to contact lens discontinuation. Comprehensive clinical assessment of tear film integrity and ocular surface health is therefore essential prior to commencing contact lens wear, to enable the ocular surface environment to be optimised to support lens wear. These parameters should also be evaluated over the course of contact lens wear, in order to identify any aspects requiring clinical management and ensure maintenance of optimal lens-wearing conditions. This review summarises current knowledge relating to the effects of soft contact lens wear on the tear film and ocular surface. It also provides a systematic approach to evaluating tear film and ocular surface integrity, in order to guide the clinical management of tear film anomalies with respect to contact lens wear.

TFOS DEWS II Clinical Trial Design Report

The development of novel therapies for Dry Eye Disease (DED) is formidable, and relatively few treatments evaluated have been approved for marketing. In this report, the Subcommittee reviewed challenges in designing and conducting quality trials, with special reference to issues in trials in patients with DED and present the regulatory perspective on DED therapies. The Subcommittee reviewed the literature and while there are some observations about the possible reasons why so many trials have failed, there is no obvious single reason other than the lack of correlation between signs and symptoms in DED. Therefore the report advocates for conducting good quality studies, as described, going forward. A key recommendation for future studies is conduct consistent with Good Clinical Practice (GCP), including use of Good Manufacturing Practice (GMP) quality clinical trial material. The report also recommends that the design, treatments, and sample size be consistent with the investigational treatment, the objectives of the study, and the phase of development. Other recommendations for pivotal studies are a priori selection of the outcome measure, and an appropriate sample size.

Clinical Trial of Thermal Pulsation (LipiFlow) in Meibomian Gland Dysfunction With Preteatment Meibography

Supplemental Digital Content is Available in the Text.

Objectives:

Thermal pulsation (LipiFlow) has been advocated for meibomian gland dysfunction (MGD) treatment and was found useful. We aimed to evaluate the efficacy and safety of thermal pulsation in Asian patients with different grades of meibomian gland loss.

Methods:

A hospital-based interventional study comparing thermal pulsation to warm compresses for MGD treatment. Fifty patients were recruited from the dry eye clinic of a Singapore tertiary eye hospital. The ocular surface and symptom were evaluated before treatment, and one and three months after treatment. Twenty-five patients underwent thermal pulsation (single session), whereas 25 patients underwent warm compresses (twice daily) for 3 months. Meibomian gland loss was graded using infrared meibography, whereas function was graded using the number of glands with liquid secretion.

Results:

The mean age (SD) of participants was 56.4 (11.4) years in the warm compress group and 55.6 (12.7) years in the thermal pulsation group. Seventy-six percent of the participants were female. Irritation symptom significantly improved over 3 months in both groups (P<0.01), whereas tear breakup time (TBUT) was modestly improved at 1 month in only the thermal pulsation group (P=0.048), without significant difference between both groups over the 3 months (P=0.88). There was also no significant difference in irritation symptom, TBUT, Schirmer test, and gland secretion variables between patients with different grades of gland loss or function at follow-ups.

Conclusions:

A single session of thermal pulsation was similar in its efficacy and safety profile to 3 months of twice daily warm compresses in Asians. Treatment efficacy was not affected by pretreatment gland loss.

Effects of a warm compress containing menthol on the tear film in healthy subjects and dry eye patients

Menthol is thought to stimulate lacrimation via activation of cold-sensitive primary afferent neurons in the cornea. We evaluated a warm compress containing menthol as a potential treatment for dry eye by examining its effects on the tear film in healthy subjects (n = 20) and dry eye patients (n = 35). Disposable eyelid-warming steamers that either did (MH) or did not (HO) contain menthol were applied to one eye of each subject either once only for 10 min or repeatedly over 2 weeks. Single application of MH significantly increased tear meniscus volume (P = 8.6 × 10⁻⁵, P = 1.3 × 10⁻⁵) and tear film breakup time (P = 0.006, P = 0.002) as well as improved meibum condition in healthy subjects and dry eye patients, respectively. Repeated application of MH significantly increased tear meniscus volume (P = 0.004, P = 1.7 × 10⁻⁴) and tear film breakup time (P = 0.037, P = 0.010) in healthy subjects and dry eye patients, respectively. Repeated application of MH thus induced persistent increases in tear fluid volume and tear film stability in dry eye patients, suggesting that repeated use of a warm compress containing menthol is a potential novel treatment for dry eye disease.

Effect of Moisture Chamber Spectacles on Tear Functions in Dry Eye Disease

PURPOSE

To evaluate the effect of moisture chamber spectacles (MCS) on tear functions in dry eye subjects.

METHODS

In this short-term study, 30 subjects with dry eye were recruited and randomly divided into two groups. Fifteen subjects (MCS group) were instructed to wear the appropriately sized MCS for a total of 90 min. Another 15 subjects (control group) received a drop of sterile nonpreserved 0.9% sodium chloride solution immediately after baseline measurement. Ocular comfort, tear meniscus height (TMH), noninvasive tear film break-up time (NIBUT), tear film lipid layer, and conjunctival hyperemia were evaluated in both groups at 15-min intervals for a period of 90 min (baseline and 15, 30, 45, 60, 75, and 90 min).

RESULTS

There were significant improvements in ocular comfort, TMH, NIBUT, and lipid layer in the MCS group compared with those in the control group (p < 0.05). After wearing MCS, values of ocular comfort, TMH, NIBUT, and lipid layer continuously increased across time and reached the maximum at 60 min and then slowly decreased but still remained higher (p < 0.05) than baseline values. No significant differences were observed in conjunctival hyperemia in either group or between groups across time (p > 0.05).

CONCLUSIONS

Wearing MCS provided improvement in ocular comfort and tear film stability. Moisture chamber spectacles seem to be a safe and promising alternative treatment for dry eye, especially for patients who work in adverse environmental conditions.

The pathophysiology, diagnosis, and treatment of dry eye disease

BACKGROUND

Dry eye disease (DED) is common; its prevalence around the world varies from 5% to 34%. Its putative pathogenetic mechanisms include hyperosmolarity of the tear film and inflammation of the ocular surface and lacrimal gland. Dry eye is clinically subdivided into two subtypes: one with decreased tear secretion (aqueous-deficient DED), and one with increased tear evaporation (hyperevaporative DED).

METHODS

This review is based on pertinent publications retrieved by a selective PubMed search and on the authors' own clinical and scientific experience.

RESULTS

The diagnostic evaluation of dry eye disease should include a detailed patient history, thorough split-lamp examination, and additional tests as indicated. Few randomized controlled therapeutic trials for dry eye have been published to date. Artificial tears of various kinds are recommended if the symptoms are mild. Lid hygiene is helpful in the treatment of hyperevaporative dry eye, while collagen or silicon plugs can be used for partial occlusion of the efferent lacrimal ducts to treat severe hyposecretory dry eye. The benefit of long-term topical anti-inflammatory treatment of moderate or severe dry eye disease with corticosteroids or cyclosporine A eye drops has been documented in clinical trials on a high evidence level. Orally administered tetraycycline derivatives and omega-3 or omega-6 fatty acids are also used.

CONCLUSION

The treatment of dry eye has evolved from tear substitution alone to a rationally based therapeutic algorithm. Current research focuses on pathophysiology, new diagnostic techniques, and novel therapies including secretagogues, topical androgens, and new anti- inflammatory drugs.

Microwave decontamination of eyelid warming devices for the treatment of meibomian gland dysfunction

PURPOSE

The role of bacteria in meibomian gland dysfunction is unclear, yet contamination of compresses used as treatment may exacerbate this condition. This study therefore determined the effect of heating on bacteria on two forms of compress.

METHODS

Cotton flannels and MGDRx EyeBags (eyebags) were inoculated by adding experimental inoculum (Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa; one species for each set of 3 eyebags and flannels). One of each were then randomised in to 3 groups: no heating (control); therapeutic (47.4±0.7°C); or sanitisation (68±1.1°C). After treatment, bacteria cell numbers were calculated. The experiment was repeated in triplicate.

RESULTS

There was a statistically significant difference between each treatment with the eyebag for S. aureus (control=7.15±0.11logC/ml, therapeutic heating=5.24±0.59logC/ml, sanitisation heating=3.48±1.43logC/ml; P<0.001) and S. pyogenes (7.36±0.13, 5.73±0.26, 4.75±0.54; P<0.001). P. aeruginosa also showed a significant reduction (P<0.001) from control (6.39±0.34) to therapeutic (0.33±0.26) and sanitisation (0.33±0.21), but the latter were similar (P=1.000). For the flannels, there was significant difference between each treatment for S. aureus (6.89±0.46, 3.96±1.76, 0.42±0.90; P<0.001). For S. pyogenes, there was a significant reduction (P<0.001) from control (7.51±0.10) to therapeutic (5.91±0.62) and sanitisation (5.18±0.8), but the latter were similar (P=0.07). For P. aeruginosa, there was a significant difference (P<0.001) from control (7.15±0.36) to sanitisation (5.83±0.44); but not to therapeutic (6.84±0.31) temperatures (P=0.07).

CONCLUSIONS

Therapeutic heating produces a significant reduction in bacteria on the eyebags, but only sanitisation heating appears effective for flannels. However, patients should be advised to heat the eyebag to sanitisation temperatures on initial use.

Comparison of Self-applied Heat Therapy for Meibomian Gland Dysfunction

PURPOSE

To compare the effects on ocular temperature, lipid layer grade, tear film stability, and tear meniscus height after a single application of two commercially available warm compresses in mild-to-moderate dry eye and to report participant treatment preference.

METHODS

Forty-one subjects with mild-to-moderate dry eye symptoms were enrolled in a randomized, paired-eye, investigator-masked trial. Heat was applied simultaneously to one eye (randomized) with a portable eye mask (EyeGiene) and to the contralateral eye with a microwave-heated flaxseed eye bag (MGDRx Eye Bag). Outer and inner eyelid temperatures, tear film lipid layer grade (LLG), and noninvasive tear film breakup time (NIBUT) were measured at baseline and immediately after 10 minutes of device application.

RESULTS

Outer and inner eyelid temperatures, LLG, and NIBUT did not differ before treatment between eyes assigned to eye mask and eye bag therapy. All measurements were significantly increased from baseline, after warming with both devices (all p < 0.05). Outer and inner eyelid temperature changes were significantly greater with the eye bag than with the eye mask (outer eyelid, +3.5 ± 1.0°C vs. +2.4 ± 0.8°C; inner eyelid, +3.5 ± 1.0°C vs. +2.5 ± 0.9°C; all p < 0.001), although there was no significant difference in LLG and NIBUT improvement between treatments (all p > 0.05). A majority of subjects (78%) preferred the application of heat with the eye bag over the eye mask.

CONCLUSIONS

Both the EyeGiene mask and the MGDRx Eye Bag are convenient eyelid warming devices that result in clinically and statistically significant increases in NIBUT and LLG in patients with mild-to-moderate dry eye symptoms. The MGDRx Eye Bag is more effective in raising ocular temperature and is the preferred treatment method among subjects.

Evaluation of the efficacy, safety, and acceptability of an eyelid warming device for the treatment of meibomian gland dysfunction

Meibomian gland dysfunction (MGD) is widespread and has significant impact on patients' quality of life. Eyelid hygiene is the mainstay of treatment but is unstandardized and requires commitment from the patient and encouragement from the ophthalmologist. Blephasteam(®) is an eyelid warming device designed to be an easy-to-use and standardized treatment for MGD. In the present study, 73 patients were treated for 21 days with twice daily Blephasteam(®) sessions. The primary efficacy variable, a symptomatology visual analog scale score, declined from 63.07±21.23 (mean ± standard deviation) on day 0 to 41.90±25.49 on day 21. There were also improvements in a number of secondary efficacy variables including subjective ocular symptoms and clinical signs and symptoms of MGD and dry eye, though tear film breakup time and tear osmolarity were not improved. Global efficacy was assessed as satisfactory or very satisfactory in 83.8% of cases. Patient-reported subjective ocular symptoms declined during the study, and a majority of patients rated the efficacy of Blephasteam(®) as satisfactory or very satisfactory. Most patients found the device comfortable and were able to continue with normal activities (reading, watching TV, using a computer) during the Blephasteam(®) session. No safety or tolerability issues were identified.

Application of infrared thermography in computer aided diagnosis

The invention of thermography, in the 1950s, posed a formidable problem to the research community: What is the relationship between disease and heat radiation captured with Infrared (IR) cameras? The research community responded with a continuous effort to find this crucial relationship. This effort was aided by advances in processing techniques, improved sensitivity and spatial resolution of thermal sensors. However, despite this progress fundamental issues with this imaging modality still remain. The main problem is that the link between disease and heat radiation is complex and in many cases even non-linear. Furthermore, the change in heat radiation as well as the change in radiation pattern, which indicate disease, is minute. On a technical level, this poses high requirements on image capturing and processing. On a more abstract level, these problems lead to inter-observer variability and on an even more abstract level they lead to a lack of trust in this imaging modality. In this review, we adopt the position that these problems can only be solved through a strict application of scientific principles and objective performance assessment. Computing machinery is inherently objective; this helps us to apply scientific principles in a transparent way and to assess the performance results. As a consequence, we aim to promote thermography based Computer-Aided Diagnosis (CAD) systems. Another benefit of CAD systems comes from the fact that the diagnostic accuracy is linked to the capability of the computing machinery and, in general, computers become ever more potent. We predict that a pervasive application of computers and networking technology in medicine will help us to overcome the shortcomings of any single imaging modality and this will pave the way for integrated health care systems which maximize the quality of patient care.

A Randomized, Controlled Treatment Trial of Eyelid-Warming Therapies in Meibomian Gland Dysfunction

Aim

The main treatment for meibomian gland dysfunction (MGD), a major cause of dry eye, is eyelid warming. Lack of compliance is the main reason for treatment failure. This has led to the development of eyelid-warming devices that are safe, effective and convenient. To obtain robust evidence demonstrating their efficacy, the authors conducted a 3-arm randomized clinical study.

Methods

The authors conducted a 3-month assessor-blinded, randomized, controlled trial of patients from the Singapore National Eye Centre experiencing at least one of eight dry eye symptoms ‘often’ or ‘all the time’. Patients who wore contact lenses, had an active infection or known diagnosis of thyroid dysfunction and rheumatoid arthritis were excluded from the study. MGD participants were randomly assigned to warm towel (n = 25), EyeGiene^® (Eyedetec Medical Inc., Danville, CA, USA) (n = 25) and Blephasteam^® (Spectrum Thea Pharmaceuticals LTD, Macclesfield, UK) (n = 25) treatments. The primary efficacy and safety outcomes included the proportions of participants with improved symptoms and changes in best corrected visual acuity (BCVA), respectively. Other outcomes included tear break up time (TBUT), Schirmer test, corneal fluorescein dye staining and number of visibly occluded meibomian gland (MG) orifices.

Results

The study population was 53.5 ± 11.1 years old and predominantly Chinese. For severity of symptom after 3 months of treatment, 78.3% Blephasteam^® participants reported improvement compared to 45.5% warm towel participants (p = 0.023). The corresponding proportions for improvement in the frequency of symptoms were 82.6% and 50.0%, respectively (p = 0.020). The proportions of improvement of symptoms in EyeGiene^® patients were not significantly different from warm towel intervention. At 1 month of treatment, the crude odds ratio of improvement of severity of irritation for Blephasteam^® compared to control was 3.0 (95% CI 0.88–10.18). However, the odds ratio adjusted by age was 5.67 (1.30–24.66). The lid-warming treatments did not significantly change the TBUT, Schirmer test results or number of visibly occluded MGs in the study period. All treatment modalities did not worsen BCVA after 3 months.

Conclusion

Blephasteam^® is more effective than warm towel for MGD treatment, with warm towel and EyeGiene^® being comparable effective. Older age might predict for treatment efficacy. All studied therapies were safe for visual acuity (VA) for 3 months of treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-014-0025-8) contains supplementary material, which is available to authorized users.

Randomised masked clinical trial of the MGDRx EyeBag for the treatment of meibomian gland dysfunction-related evaporative dry eye

Background/aims

To investigate the efficacy and safety of the MGDRx EyeBag (The Eyebag Company, Halifax, UK) eyelid warming device.

Methods

Twenty-five patients with confirmed meibomian gland dysfunction (MGD)-related evaporative dry eye were enrolled into a randomised, single masked, contralateral clinical trial. Test eyes received a heated device; control eyes a non-heated device for 5 min twice a day for 2 weeks. Efficacy (ocular symptomology, non-invasive break-up time, lipid layer thickness, osmolarity, meibomian gland dropout and function) and safety (visual acuity, corneal topography, conjunctival hyperaemia and staining) measurements were taken at baseline and follow-up. Subsequent patient device usage and ocular comfort was ascertained at 6 months.

Results

Differences between test and control eyes at baseline were not statistically significant for all measurements (p>0.05). After 2 weeks, statistically significant improvements occurred in all efficacy measurements in test eyes (p<0.05). Visual acuity and corneal topography were unaffected (p>0.05). All patients maintained higher ocular comfort after 6 months (p<0.05), although the benefit was greater in those who continued usage 1–8 times a month (p<0.001).

Conclusions

The MGDRx EyeBag is a safe and effective device for the treatment of MGD-related evaporative dry eye. Subjective benefit lasts at least 6 months, aided by occasional retreatment.

Trial registration number

NCT01870180.

Evaluation of a novel eyelid-warming device in meibomian gland dysfunction unresponsive to traditional warm compress treatment: an in vivo confocal study

The purpose of the study was to evaluate the efficacy and safety of wet chamber warming goggles (Blephasteam(®)) in patients with meibomian gland dysfunction (MGD) unresponsive to warm compress treatment. We consecutively enrolled 50 adult patients with low-delivery, non-cicatricial, MGD, and we instructed them to apply warm compresses twice a day for 10 min for 3 weeks and to use Blephasteam(®) (Laboratoires Thea, Clermont-Ferrand, France) twice a day for 10 min for the following 3 weeks. We considered "not-responders" to warm compress treatment the patients who showed no clinically significant Ocular Surface Disease Index (OSDI) improvement after the first 3 weeks. Clinical and in vivo confocal outcome measures were assessed in the worst eye (lower BUT) at baseline, after 3 weeks, and after 6 weeks. Eighteen/50 patients were not-responders to warm compress treatment. These patients, after 3 weeks of treatment with Blephasteam(®), showed significant improvement of OSDI score (36.4 ± 15.8 vs 20.2 ± 12.4; P < 0.05, paired samples t test), increased BUT (3.4 ± 1.6 vs 7.6 ± 2.7; P < 0.05), and decreased acinar diameter and area (98.4 ± 18.6 vs 64.5 ± 14.4 and 8,037 ± 1,411 vs 5,532 ± 1,172, respectively; P < 0.05). Neither warm compresses nor Blephasteam(®) determined adverse responses. In conclusion, eyelid warming is the mainstay of the clinical treatment of MGD and its poor results may be often due to lack of compliance and standardization. Blephasteam(®) wet chamber warming goggles are a promising alternative to classical warm compress treatment, potentially able to improve the effectiveness of the "warming approach."