Comparison of Self-applied Heat Therapy for Meibomian Gland Dysfunction

Evidence-Based Strategies for Warm Compress Therapy in Meibomian Gland Dysfunction

AIM

Despite promising results from technological therapies like intense pulsed light application, warm compress therapy is a mainstay in meibomian gland dysfunction (MGD). However, applying warm compresses (WC) to the eyelids is palliative rather than curative and not always dispensed with specific instructions. The range of eyelid warming treatments available and lack of clear directives for use creates uncertainty for patients accustomed to explicit dosage information. This report examines data from clinical studies across the past 20 years to identify effective protocols for three types of WC-hot towel, microwavable eye mask, and self-heating eye mask (EM).

METHOD

Literature search for studies on WC and MGD published between 2004 and 2023 in English was conducted. Studies wherein hot towel, microwavable EM, and self-heating EM were used in a treatment arm were included and those wherein they served only as control or were used in conjunction with another intervention were excluded. 20 resulting studies were separated into 3 groups: 5 on temperature profiles of WC, 6 with single application of WC, and 9 with repeated applications. Study methods and outcomes were tabulated, and a qualitative review was performed, attending to WC protocol and efficacy, as indicated by measures of tear film, meibomian gland health, and dry eye questionnaires.

RESULTS

Data from the aforementioned studies revealed that each method can achieve target eyelid temperature of 40 °C. A single application of WC-ranging from 5 to 20 min-can significantly improve tear quality, while repeated applications significantly relieve symptoms associated with dry eyes from MGD and, in most studies, significantly improve meibomian gland health. Hot towels, however, require frequent reheating to maintain eyelid temperatures above 40 °C, rendering them relatively ineffective in longitudinal studies. Microwavable EM retain heat well across 10 min and were found to improve tear break-up time and/or meibomian gland score. Self-heating EM have variable activation times and were typically applied for longer periods, showing benefits akin to microwavable EM in short-term studies. Studies monitoring compliance indicate greater deviation from protocol with higher application frequencies or longer-term use. Evidence suggests superior heat retention and therapeutic effects on specific contributing factors in MGD (such as Demodex) with moist-heat compress.

CONCLUSION

Considering decreased patience adherence to therapy with increased usage frequencies, and balancing needs to provide succinct instructions for various compress types, an advisable strategy is for patients to apply a moist-heat generating EM (microwavable or self-heating) to each eye for at least 10 min, prepared according to manufacturer's instructions.

Thermal effect on eyelid and tear film after low-level light therapy and warm compress

CLINICAL RELEVANCE

The warming effect of low-level light therapy may contribute to its therapeutic mechanism which is beneficial for dry eye management.

BACKGROUND

Low-level light therapy is proposed to work via cellular photobiomodulation and a potential thermal effect in dry eye management. This study examined the change in eyelid temperature and tear film stability after low-level light therapy compared to warm compress.

METHODS

Participants with no to mild dry eye disease were randomised into control, warm compress, and low-level light therapy groups. The low-level light therapy group was treated with Eyelight mask (633 nm) for 15 minutes, the warm compress group with Bruder mask for 10 minutes, and the control group with an Eyelight mask having inactive LEDs for 15 minutes. Eyelid temperature was measured using the FLIR One® Pro thermal camera (Teledyne FLIR, Santa Barbara, CA, USA), and clinical measures of tear film stability were evaluated before and after treatment.

RESULTS

Thirty-five participants (mean age ± SD, 27.3 ± 4.3 years) completed the study. Eyelid temperatures for external upper, external lower, internal upper and internal lower eyelids were significantly greater in the low-level light therapy and warm compress groups immediately after treatment compared to the control group (all p < 0.001). No difference in temperature was observed between the low-level light therapy and warm compress groups at all time points (all p > 0.05). Tear film lipid layer thickness was significantly greater after treatment (mean (95% CI), 13.1 nm (5.3 to 21.0), p < 0.005) but not different between groups (p > 0.05).

CONCLUSION

A single treatment of low-level light therapy increased eyelid temperature immediately after treatment, but the increase was not significantly different from warm compress. This suggests that thermal effects may in part contribute to the therapeutic mechanism of low-level light therapy.

Noninvasive Ocular Surface Workup in Patients with Meibomian Gland Dysfunction Using Microwave-Heated Eye Bag

Purpose

To report the outcomes of a novel microwave heating device (Blepha EyeBag®) used serially for the treatment of meibomian gland dysfunction (MGD).

Patients and Methods

This prospective single center study was conducted at University Magna Graecia of Catanzaro. Patients were instructed to apply the compress twice daily for 15 days and once per day every two days, as reported in the package insert. Outcome measures were i) ocular surface disease index (OSDI) score, ii) tear meniscus height (TMH), iii) non-invasive keratograph break-up time (NIKBUT) (first and average), iv) meiboscore, v) bulbar redness. Evaluations were performed at baseline (T0) after 15 days (T1) and after 45 days of therapy (T2).

Results

Overall, 19 patients with MGD (8 males, 11 females; mean age 64.58 ± 9.72 years) were included. The mean value of OSDI score showed a significant decrease from 28.16 ± 17.46 at T0 to 13.69 ± 7.62 at T2 (p=0.008). The mean value of NIKBUT first significantly increased from 6.67 ± 3.51 seconds (s) at T0 to 10.46 ± 4.64 at T2 (p=0.0121); in parallel, the mean value of NIKBUT average increased significantly from 11.09 ± 4.15 s at T0 to 14.95 ± 4.85 at T2 (p=0.0049). No significant differences were detected at each time point for bulbar redness, meiboscore and TMH. Throughout the entire study, no adverse events were recorded.

Conclusion

The microwave-heated eye bag treatment is both safe and effective for treatment of MGD, being able to significantly ameliorate both patient-reported symptoms and tear film stability.

Skin temperature change in patients with meibomian gland dysfunction following intense pulsed light treatment

Purpose

We investigated the change in skin temperature of treated areas during intense pulsed light (IPL) treatment in patients who have meibomian gland dysfunction (MGD) to determine whether there is superficial telangiectatic blood vessel ablation.

Methods

The medical records of 90 patients (90 eyes) with MGD who underwent IPL treatment were reviewed. The patients had undergone IPL treatment four times every 4 weeks. Ocular Surface Disease Index (OSDI) scores, dry eye (DE), and MGD parameters were obtained before the first and after the fourth IPL treatments. The skin temperatures of the upper and lower lids were measured before every IPL treatment.

Results

The skin temperatures of the lower lids were 31.89 ± 0.72°C at the first IPL (IPL#1), 30.89 ± 0.63°C at the second IPL (IPL#2), 30.14 ± 0.95°C at the third IPL (IPL#3), and 29.74 ± 0.87°C at the fourth IPL (IPL#4) treatments. The skin temperatures of upper lids were 32.01 ± 0.69°C at IPL#1, 31.13 ± 0.75°C at IPL#2, 30.34 ± 1.07°C at IPL#3, and 29.91 ± 0.76°C at IPL#4. The skin temperature of the upper and lower lids significantly decreased with every IPL treatment. Schirmer 1 test (ST) result was 12.97 ± 10.22 mm before IPL#1 and 14.45 ± 9.99 mm after IPL#4. Tear break-up time (TBUT) was 3.15 ± 1.38 s before IPL#1 and 5.53 ± 2.34 s after IPL#4. Corneal staining scores (CFS) was 1.61 ± 3.09 before IPL#1 and 0.50 ± 0.78 after IPL#4. Lipid layer thickness (LLT) was 71.88 ± 26.34 nm before IPL#1 and 68.38 ± 24.16 nm after IPL#4. Lid margin abnormality score (LAS) was 1.96 ± 0.62 before IPL#1 and 0.86 ± 0.67 after IPL#4. Meibum expressibility (ME) was 1.67 ± 0.87 before IPL#1 and 1.03 ± 1.67 after IPL#4. Meibum quality (MQ) was 18.18 ± 6.34 before IPL#1 and 10.16 ± 5.48 after IPL#4. OSDI was 35.38 ± 19.97 before IPL#1 and 15.48 ± 34.32 after IPL#4. OSDI scores, DE, and MGD parameters significantly improved after the fourth IPL treatment but not ST and LLT.

Conclusion

Our study showed that the occurrence of superficial telangiectatic vessels were indirectly reduced by the decrease in skin temperature accompanying IPL treatments in patients with MGD.

Immediate and Quantitative Changes in Tear Film Parameters and Meibomian Gland Structures after Warm Compression and Meibomian Gland Squeezing in Meibomian Gland Dysfunction Patients and Normal Subjects

Meibomian gland dysfunction (MGD), a chronic abnormality of meibomian glands, causes various dry eye symptoms. Principal treatments for MGD are warm compression and mechanical squeezing of the eyelids. In this study, the immediate impact of this treatment on tear film lipid layer thickness (TFLLT) and the meibomian gland (MG) structure in MGD and normal groups was investigated to establish its efficacy and potential side effects. Nineteen MGD patients and seven normal subjects were enrolled. TFLLT and blinking parameters were evaluated before and after warm compression. Morphological changes of MG structures after mechanical squeezing were analyzed using Image J and Fiji. Differential analysis of the MGD and the normal groups of TFLLT changes after warm compression showed a significant increase in the normal group. In normal eyes, the average, maximum, and minimum TFLLT were significantly increased, and in the MGD group, only the minimum TFLLT was improved. Blinking parameters showed no significant change in either group. Morphometric analysis showed no damages of the MG after MG squeezing. A significant increase in MG length was observed in normal eyes. Warm compression immediately increased TFLLT more significantly in the normal group than in the MGD patients. Mechanical expression is a safe therapeutic option without remarkable structural MG damages.

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.

Reliability and clinical applicability of a novel tear film imaging tool

PURPOSE

The aim of our research was to investigate the reliability and clinical applicability of a modern tear film imaging tool by comparing the inter- and intragrader difference. The further goal was to compare the non-invasive tear break-up time (NIBUT) measured with the LacryDiag® device with traditional tear film break-up time (TBUT).

METHODS

Comprehensive ophthalmological examination was performed, including LacryDiag® (Quantel Medical, France) (lower tear meniscus height measuring (LTMH), superior and inferior eyelid meibography (MeibS MeibI), interferometry (INT), NIBUT), slit lamp examination, and TBUT. Two independent, well-trained graders selected and analyzed the LTMH, MeibI, MeibS, and INT. The second grader reanalyzed the data 1 month later. Intra- and inter-examiner reliabilities were evaluated using intraclass correlation coefficients (ICC), while for categorical variable, Cohen's kappa statistics were provided. The Bland-Altman plot was used for visualization of the agreement between measurements.

RESULTS

Fifty healthy volunteers were examined. For LTMH both the inter- and intragrader variabilities were excellent. Between two graders, the ICC of MeibI was poor; however, between two graders, the ICC of MeibS was good, and the intragrader variability in MeibI and MeibS was excellent. For the INT, both intra- and intergrading were in fair and moderate agreement, although the intragrader agreement was higher. Comparing the NIBUT and TBUT, the agreement was slight.

CONCLUSION

Based on our results, examination of a patient during follow-up should be performed by the same examiner, because of the slight agreement. The LacryDiag® is a non-invasive, easy-to-use device, which can examine the tear film and save the recordings for easier follow-up.

Demographic and lifestyle risk factors of dry eye disease subtypes: A cross-sectional study

PURPOSE

To evaluate demographic and lifestyle factors associated with aqueous deficient and evaporative dry eye disease.

METHODS

A total of 1125 general public visitors (707 females, mean ± SD age, 33 ± 21, range 5-90 years) at the Royal Society Summer Science Exhibition were recruited in a cross-sectional study. A demographic and lifestyle factor questionnaire was administered, and dry eye symptomology (DEQ-5 score), ocular surface characteristics (conjunctival hyperaemia, and infrared meibography), and tear film parameters (tear meniscus height, non-invasive breakup time, and lipid layer grade) were evaluated for the left eye of each participant within a single session. The diagnostic criteria for dry eye disease subtypes were adapted from the rapid non-invasive dry eye assessment algorithm.

RESULTS

Overall, 428 (38%) participants fulfilled the diagnostic criteria for dry eye disease, 161 (14%) with aqueous deficient dry eye disease, and 339 (30%) with evaporative dry eye disease. Multivariate logistic regression demonstrated that advancing age, female sex, reduced sleep duration, higher psychological stress, and poorer self-perceived health status were independently associated with aqueous deficient dry eye disease (all p < 0.05). Significant risk factors for evaporative dry eye disease included advancing age, East and South Asian ethnicity, contact lens wear, increased digital device screen exposure, higher psychological stress, and poorer self-perceived health status (all p < 0.05).

CONCLUSIONS

Both subtypes of dry eye disease were associated with several unique and shared demographic and lifestyle factors. The findings of this study could inform future research design investigating the utility of targeted screening and risk factor modification for the prevention and management of dry eye disease.

An Emerging Method to Assess Tear Film Spread and Dynamics as Possible Tear Film Homeostasis Markers

Purpose: This study aims to assess the performance of an analysis method to measure in vivo the movement speed of tear film particles post-blink as a measure of tear film spreading.Materials and methods: Ocular surface parameters and the recording of tear film particles' spreading post-blink were assessed in eighty-one healthy volunteers (43.7 ± 27.0 years) using Keratograph 5 M. The developed software automatically decomposed the video into frames to manually track particles' position for 1.75 seconds after a blink. The following tear film-dynamic metrics were automatically calculated: mean, median, maximum, and minimum particles' speed at different times after blinking and time for particle speed to decrease to <1.20 mm/second. Repeatability of each tear film-dynamic metric and its correlations with ocular surface signs and symptoms were analyzed. Binomial logistic regression was performed to assess the predictability of new metrics to ocular parameters.Results: Repeatability tended to be lower just after blinking (variability of 12.24%), whereas the metrics from 0.5 s onwards had acceptable repeatability (variability below 10%). Tear film-dynamic metrics correlated positively with Non-Invasive Break-Up Time (NIKBUT) while negatively with meibomian gland drop-out. Binomial logistic regression analysis revealed that tear film-dynamic metrics were able to predict NIKBUT. Nevertheless, no statistically significant association was found with gland drop-out. This means that higher particle speed is related to larger NIKBUT. The metric "time for particle speed to decrease to <1.20 mm/second" can be considered the best metric to assess the quality of the tear film, since it was more strongly correlated with NIKBUT (r = 0.42, p = .004), it was more strongly associated in the binomial logistic regression analysis with NIKBUT and showed good repeatability (variability = 5.49%).Conclusions: Tear film-dynamic metrics are emerging homeostasis parameters for assessing indirectly the tear film quality in natural conditions with acceptable repeatability.

Modifiable lifestyle risk factors for dry eye disease

PURPOSE

To examine the association between modifiable lifestyle factors and dry eye disease.

METHODS

Three hundred and twenty-two community residents (186 females, 136 males; mean ± SD age, 41 ± 22 years) with no major systemic or ophthalmic conditions (other than dry eye disease) were recruited in a cross-sectional study. A lifestyle factor questionnaire was administered, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports.

RESULTS

A total of 111 (34 %) participants fulfilled the TFOS DEWS II diagnostic criteria for dry eye disease. Multivariate regression analysis demonstrated that advancing age, female sex, East Asian ethnicity, and increased digital screen exposure time were positive risk factors for dry eye disease (all p < 0.05), while increased caffeine consumption was a protective factor (p = 0.04).

CONCLUSIONS

Increased digital screen exposure time and reduced caffeine consumption were modifiable lifestyle factors associated with higher odds of dry eye disease. These findings might contribute to informing the design of future prospective research investigating the efficacy of preventative intervention and risk factor modification strategies.

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.

A Review on Evidence-Based Treatments for Meibomian Gland Dysfunction

OBJECTIVES

To evaluate recent studies on available therapies for meibomian gland dysfunction (MGD).

METHODS

A literature search on recent publications, within the last five years, concerning treatment options for MGD was performed.

RESULTS

A total of 35 articles were reviewed after curation by the authors for relevance. In general, all modalities of treatments were shown to have clinical efficacy in alleviating dry eye signs and symptoms, although the extent of improvement and persistency of outcomes varied between the different treatments. Evidence from published studies demonstrate that thermal pulsation produces the longest lasting effect per treatment, but it also incurs the highest per-treatment cost. Reusable methods for warm compress with lipid/semi-fluorinated alkane-containing eye drops are recommended as first-line treatment for mild-to-moderate dry eye patients, because this option is most technically feasible and cost-effective in clinical practice. Intense pulsed light (IPL) therapy and thermal pulsation may be suitable as second line for patients unresponsive to warm compress therapy; however, their respective limitations need to be considered. For refractory MGD with features of periductal fibrosis or severe blepharitis, supplementary treatment with meibomian gland probing or oral antibiotics may be used.

CONCLUSIONS

All eight forms of treatments, including self-applied eyelid warming, thermal pulsation, IPL, MG probing, antibiotics, lipid-containing eye drops, and perfluorohexyloctane, were effective against MGD, although with varying extent of clinical improvements. A better understanding on the mechanisms of actions may guide physicians to make better treatment decisions targeting the root causes.

Prophylactic action of lipid and non-lipid tear supplements in adverse environmental conditions: A randomised crossover trial

PURPOSE

To evaluate the prophylactic benefits of lipid-based and non-lipid-based artificial tear lubricants, in dry eye disease, after adverse environmental exposure.

METHODS

Twenty-eight participants with dry eye disease were recruited in a prospective, double-masked, randomised crossover trial. On separate days, participants were randomised to receive a single application of a lipid-containing tear supplement (Systane Complete) to one eye, and a non-lipid containing eye drop (Systane Ultra) to the contralateral eye. Participants were then exposed to a previously validated simulated adverse environment. Symptoms, non-invasive tear film breakup time, lipid layer grade, and tear meniscus height were assessed at three time points; baseline, following eye drop instillation, and after exposure to the adverse environment.

RESULTS

Both treatments effected improvements in symptoms and non-invasive tear film stability following instillation (all p < 0.05), although an improvement in lipid layer quality was limited to the lipid-containing nano-emulsion tear supplement (p = 0.003). Although protective effects were conferred by both treatments following exposure to the simulated adverse environment, more favourable symptomology scores, non-invasive tear film stability, and lipid layer quality were observed in the lipid-containing tear supplement group (all p < 0.05). No significant changes were observed in tear meniscus height in both treatment groups (all p > 0.05).

CONCLUSIONS

Both the lipid and non-lipid-based artificial tear supplement demonstrated prophylactic benefits in a simulated adverse environment. However, the ability to preserve tear film quality and reduce dry eye symptomology was greater with the lipid-containing eye drop.

TRIAL REGISTRATION NUMBER

ACTRN12619000361101.

Ageing and the natural history of dry eye disease: A prospective registry-based cross-sectional study

PURPOSE

To investigate the impact of ageing on ocular surface parameters, and empirically determine optimal prognostic cut-off ages for clinical markers of dry eye disease, aqueous tear deficiency, and meibomian gland dysfunction.

METHODS

A total of 1331 community residents (785 females, 546 males; mean ± SD age, 38 ± 19 years) were recruited in a prospective registry-based cross-sectional study. Dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports.

RESULTS

Multivariate regression analysis demonstrated positive associations between ageing and clinical markers of dry eye disease (all p ≤ 0.001). The Youden-optimal prognostic cut-off ages for signs of meibomian gland dysfunction occurred during the third decade of life (24-29 years); the optimal predictive ages for lid wiper epitheliopathy, tear film instability, hyperosmolarity, and dry eye symptoms occurred during the fourth decade of life (31-38 years); while the optimal prognostic thresholds for signs of aqueous tear deficiency and ocular surface staining occurred in the fifth and sixth decades of life (46-52 years).

CONCLUSIONS

Advancing age is a significant risk factor for dry eye disease, which represents a growing public health concern with the ageing population worldwide. Signs of meibomian gland dysfunction appeared earlier in the natural history of disease progression, and the brief delay prior to the development of other clinical dry eye signs might represent a window of opportunity for preventative interventions in the young adult age group.

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.

The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis

Purpose: To investigate and compare the effect of warm compresses on meibomian gland dysfunction and Demodex folliculorum blepharitis.Methods: Forty-two subjects (13 males, 29 females; mean age of 56.45 years) enrolled and completed the two-month warm compress treatment study. Three warm compress therapies were compared: Warm face cloth, MGDRx EyeBag® and OPTASE^TM Moist Heat Mask. Subjects attended for four visits: baseline, two weeks, four weeks, and eight weeks. Subjective symptoms, osmolarity, non-invasive tear break-up time, ocular surface staining, Schirmer I test, meibum expressibility and clarity, and eyelash manipulation and epilation to assess for the presence of Demodex folliculorum, were measured at each visit.Results: Meibomian gland dysfunction, based on a composite score of meibum quality and expressibility, reduced significantly with the MGDRx EyeBag® and the OPTASE^TM Moist Heat Mask (p < .05). There was no significant difference in efficacy for treating meibomian gland dysfunction between the two devices (p = .29). No improvement in meibomian gland dysfunction was detected with the warm face cloth. Only the OPTASE^TM Moist Heat Mask significantly reduced the quantity of Demodex folliculorum over eight-weeks of treatment (p = .036, only baseline to week eight significant p = .008). Symptoms and ocular surface staining improved significantly in all three groups (p < .05). There was no significant change observed in osmolarity, non-invasive tear break-up time or Schirmer I test within each group (p > .05, respectively).Conclusion: The MGDRx EyeBag® and the OPTASE^TM Moist Heat Mask exhibited superior efficacy in treating signs and symptoms of meibomian gland dysfunction, compared to the use of a warm face cloth, over the eight-week period. The OPTASE^TM Moist Heat Mask demonstrated dual therapeutic abilities, treating both meibomian gland dysfunction and Demodex folliculorum blepharitis. Repeated application of heat for the treatment of meibomian gland dysfunction may continue to present a good home-remedy option for patients.

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.

Dry Eye Disease: Emerging Approaches to Disease Analysis and Therapy

Dry eye disease (DED) is among the most common ocular disorders affecting tens of millions of individuals worldwide; however, the condition remains incompletely understood and treated. Valuable insights have emerged from multidisciplinary approaches, including immunometabolic analyses, microbiome analyses, and bioengineering. Furthermore, we have seen new developments in clinical assessment approaches and treatment strategies in the recent past. Here, we review the emerging frontiers in the pathobiology and clinical management of DED.

Randomised trial of the clinical utility of an eyelid massage device for the management of meibomian gland dysfunction

PURPOSE

To compare the single application and two week treatment effects of device-applied (Eyepeace) and manually-applied eyelid massage techniques, as an adjunct to warm compress therapy, on ocular surface and tear film parameters.

METHODS

Twenty participants (11 females, 9 males; mean age, 27 ± 11 years) with dry eye symptoms were recruited in a two week, investigator-masked, randomised, contralateral-eye trial. Following 10 min of warm compress therapy application (MGDRx EyeBag^®) on both eyes, eyelid massage therapy was applied to one eye (randomised) by device, and to the fellow eye by manual eyelid massage, once daily for 14 days. Ocular surface and tear film measurements were conducted at baseline, and 15 min post-application by a clinician, then again after 14 days of self-administered daily treatment at home.

RESULTS

Baseline clinical measurements did not differ between the treatment groups (all p > 0.05). Following two weeks of treatment, tear film lipid layer grade improved significantly with device massage (p = 0.008), and was marginally greater than manual massage by less than 1 grade (p = 0.03). Although immediate post-treatment improvements in tear film stability were observed in both groups (both p < 0.05), no significant long-term cumulative effects or inter-treatment differences in stability measures were detected (all p > 0.05). Visual acuity, tear meniscus height, conjunctival hyperaemia, ocular surface staining, and meibomian gland dropout did not change during the treatment period (all p > 0.05).

CONCLUSIONS

Two weeks of treatment with the eyelid massage device, as an adjunct to warm compress therapy, effected marginally greater improvements in tear film lipid layer thickness than the conventional manual technique, which were statistically but not clinically significant. Future parallel group trials with longer treatment periods and a greater range of disease severity are required.

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.

CONSORT 2010 statement: extension checklist for reporting within person randomised trials

Evidence shows that the quality of reporting of randomised controlled trials (RCTs) is not optimal. The lack of transparent reporting impedes readers from judging the reliability and validity of trial findings and researchers from extracting information for systematic reviews and results in research waste. The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the reporting of RCTs. Within person trials are used for conditions that can affect two or more body sites, and are a useful and efficient tool because the comparisons between interventions are within people. Such trials are most commonly conducted in ophthalmology, dentistry, and dermatology. The reporting of within person trials has, however, been variable and incomplete, hindering their use in clinical decision making and by future researchers. This document presents the CONSORT extension to within person trials. It aims to facilitate the reporting of these trials. It extends 16 items of the CONSORT 2010 checklist and introduces a modified flowchart and baseline table to enhance transparency. Examples of good reporting and evidence based rationale for CONSORT within person checklist items are provided.

Ethnic differences between the Asian and Caucasian ocular surface: A co-located adult migrant population cohort study

PURPOSE

To investigate the ethnic differences in tear film quality, ocular surface parameters, and dry eye symptomology between co-located Asian and Caucasian populations.

METHODS

Two hundred and six participants (103 East Asian and 103 Caucasian) were recruited in an age and gender-matched cross-sectional study. Dry eye symptomology, ocular surface parameters, and tear film quality were evaluated for each participant within a single clinical session.

RESULTS

The mean ± SD age of the 206 participants (82 male, 124 female) was 45 ± 16 years. Overall, a greater proportion of Asian participants were symptomatic of dry eye and fulfilled the TFOS DEWS II dry eye diagnostic criteria than Caucasian participants (74% versus 51%, p = 0.002), with an odds ratio (95% CI) of 2.7 (1.5-4.8) times. Poorer OSDI scores, tear film stability, lipid layer quality, tear osmolarity, lid wiper epitheliopathy, meibomian gland dropout, and expressed meibum quality were observed in the Asian group (all p < 0.05). A significantly higher proportion of participants exhibited incomplete blinking in the Asian group than the Caucasian group (81% versus 45%, p < 0.001).

CONCLUSIONS

Asian participants exhibited more severe dry eye signs and symptoms than Caucasian participants. The poorer meibomian gland function and higher degree of incomplete blinking observed among Asian participants may potentially contribute towards the ethnic predisposition towards dry eye development.

Exploring the Asian ethnic predisposition to dry eye disease in a pediatric population

PURPOSE

To investigate the differences in ocular surface characteristics, tear film parameters, and dry eye symptomology between co-located pediatric populations of Asian and Caucasian ethnicity.

METHODS

Seventy New Zealand-born pediatric participants, aged between 5 and 18 years, were recruited in an age and environmentally controlled cross-sectional study. Participants were classified into three groups according to ethnicity and eyelid morphology: Asian single lid (ASL), Asian double lid (ADL), and Caucasian double lid (CDL). Ocular biometry, tear film parameters, ocular surface characteristics, and dry eye symptomology were evaluated in a single clinical session.

RESULTS

Overall, no significant intergroup differences were observed in tear film quality, dry eye symptomology, and meibomian gland dropout. A higher proportion of ASL and ADL participants exhibited incomplete blinking than the Caucasian group (both p < 0.001). Meibomian gland shortening was more frequently observed among the two Asian groups (both p < 0.05), while gland tortuosity was more common in the Caucasian group (both p < 0.001). ASL participants exhibited greater inferior lid wiper epitheliopathy grades than ADL participants (p = 0.01), and corneal astigmatism was more pronounced in the ASL than CDL group (p = 0.02).

CONCLUSIONS

Ethnic differences in meibomian gland morphological patterns were observed in the current pediatric cohort, although overall meibomian gland dropout did not differ between groups. Asian participants exhibited a higher degree of incomplete blinking, and more marked inferior lid wiper epitheliopathy and corneal astigmatism were observed in the ASL group. These findings would suggest that eyelid anatomy and tension may potentially be implicated in the development of ethnic differences in dry eye disease later in life.

Impact of blinking on ocular surface and tear film parameters

PURPOSE

To investigate the influence of blinking on tear film parameters, ocular surface characteristics, and dry eye symptomology.

METHODS

A total of 154 participants were recruited in an age, gender and ethnicity-matched cross-sectional study, of which 77 exhibited clinically detectable incomplete blinking, and 77 did not. Blink rate, dry eye symptomology, tear film parameters, and ocular surface characteristics were assessed in a single clinical session.

RESULTS

Overall, a higher proportion of participants exhibiting incomplete blinking fulfilled the TFOS DEWS II dry eye diagnostic criteria (64% versus 44%, p = 0.02), with an odds ratio (95% CI) of 2.2 (1.2-4.2) times. Participants exhibiting incomplete blinking had higher Ocular Surface Disease Index scores (18 ± 13 versus 12 ± 9, p = 0.01), and greater levels of meibomian gland dropout (41.3 ± 15.7% versus 27.5 ± 14.1%, p < 0.001). Furthermore, poorer tear film lipid layer thickness, non-invasive tear film stability, expressed meibum quality, eyelid notching, and anterior blepharitis grades were also observed in those exhibiting incomplete blinking (all p < 0.05). Blink frequency did not correlate significantly with any ocular surface parameters (all p > 0.05).

CONCLUSIONS

Incomplete blinking was associated with a two-fold increased risk of dry eye disease. The greater levels of meibomian gland dropout, as well as poorer expressed meibum quality and tear film lipid layer thickness, observed would suggest that incomplete blinking may predispose towards the development of evaporative dry eye.

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.

Therapies for Meibomian Gland Dysfunction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction

Meibomian Gland Dysfunction (MGD) is a common, often overlooked, chronic condition affecting eyes for which various therapies are being evaluated. Considering the absence of a systematic review and meta-analysis, the present review was carried out.

Methods

An appropriate search strategy eligibility criteria were framed and electronic databases were scrutinized for appropriate literature. Randomized Controlled Trials (RCTs) enrolling patients diagnosed with MGD were included. Outcome measures were Tear Break Up Time (TBUT), Schirmer's test, Meibomian Gland (MG) secretion score, MG plugging score, OSDI and SPEED. Cochrane's tool was used to assess the risk of bias and Forest plot were generated either with fixed or random effects model, with Standardized Mean Difference (SMD).

Results

TBUTs, Schirmer's test and OSDI scores for systemic antimicrobials with placebo were 1.58 [1.33, 1.83], 2.93 [0.78, 5.09] and -3.58 [-4.28, -2.89] respectively. No quantitative synthesis was attempted for either mebiomian plugging or meibomian secretion scores and no significant changes were observed with any other outcome parameter.

Conclusion

Only the systemic antimicrobials were found to improve the clinical features of meibomian gland dysfunction. Varying effects of different therapeutic agents (heat therapies, omega-3-fatty acids and castor oil) were identified for MGD but the risk of bias pertaining to randomization and allocation concealment was found to be associated with most of the current RCTs. More high quality evidence is required to confirm the findings of the present review.

Tear lipid supplement prophylaxis against dry eye in adverse environments

PURPOSE

To compare the prophylactic efficacy of single application of lipid and non-lipid containing tear supplements, prior to exposure of symptomatic dry eye subjects to a simulated adverse environment.

METHODS

Thirty subjects with mild-to-moderate dry eye symptoms participated in the prospective, randomised, double-masked, paired-eye trial. A lipomimetic drop (Systane^® Balance) was applied to one eye (randomised), and a non-lipid containing drop (Systane^® Ultra) applied simultaneously to the contralateral eye. Subjects were subsequently exposed to a validated simulated adverse environment model created by a standing fan directed towards the eye, at a distance of 1m, for 2.5min. Low contrast glare acuity, lipid layer grade (LLG), non-invasive tear break-up time (NIBUT), temperature variation factor (TVF), and tear meniscus height (TMH) were evaluated at baseline, following eye drop instillation and following simulated adverse environment exposure.

RESULTS

Both therapies resulted in increased NIBUT (both p<0.001), and prevented its decline below baseline with simulated adverse environment exposure (both p>0.05). However, only the lipomimetic drop increased LLG (p<0.001) and precluded its fall below baseline post-adverse environment exposure (p=0.15). Furthermore, post-instillation and post-exposure LLGs and NIBUT were significantly higher in the lipomimetic group (all p<0.05). No significant changes were observed in glare acuity, TVF and TMH (all p>0.05). More subjects (67%) reported greater ocular comfort in the eye receiving the lipomimetic.

CONCLUSIONS

Single application of both lipid and non-lipid containing eye drops conferred protective effects against exposure to adverse environmental conditions in subjects with mild-to-moderate dry eye, although the lipomimetic demonstrated superior prophylactic efficacy.

Preclinical development of MGO Manuka Honey microemulsion for blepharitis management

Objective

To evaluate the in vitro antimicrobial effects of cyclodextrin-complexed and uncomplexed Manuka honey on bacteria commonly associated with blepharitis, and in vivo rabbit eye tolerability of a cyclodextrin-complexed methylglyoxal (MGO) Manuka Honey microemulsion (MHME).

Methods and analysis

In vitro phase: Bacterial growth inhibition was assessed by area under the growth curve (AUC) for Staphylococcus aureus, and the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) for S. aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa with cyclodextrin-complexed and uncomplexed Manuka honey were determined.

In vivo phase: Six rabbits were administered 20 µL of MHME (at 1:10 dilution) to the right eye (treated) and 20 µL of saline to the left eye (control) daily, for 5 days. Tear evaporation, production, osmolarity, lipid layer, conjunctival hyperaemia and fluorescein staining were assessed daily, before and 15 min after instillation.

Results

In vitro phase: The relative AUC for cyclodextrin-complexed Manuka honey was lower than that of uncomplexed honey at both 250 and 550 mg/kg of MGO (both p <0.05). Cyclodextrin-complexed honey had lower MIC and MBC than uncomplexed honey for both S. aureus and S. epidermidis, but not P. aeruginosa.

In vivo phase: No significant changes were observed in the parameters assessed in either treated or control eyes (all p >0.05).

Conclusion

Overall, antimicrobial potency of cyclodextrin-complexed Manuka honey was greater than uncomplexed honey. No significant immediate or cumulative adverse effects were observed with MHME application on rabbit eyes, supporting future conduct of clinical safety and tolerability trials in human subjects.

Randomised masked trial of the clinical safety and tolerability of MGO Manuka Honey eye cream for the management of blepharitis

Objective

To assess the clinical safety and tolerability of a novel MGO Manuka Honey microemulsion (MHME) eye cream for the management of blepharitis in human subjects.

Methods and analysis

Twenty-five healthy subjects were enrolled in a prospective, randomised, paired-eye, investigator-masked trial. The MHME eye cream (Manuka Health New Zealand) was applied to the closed eyelids of one eye (randomised) overnight for 2 weeks. LogMAR visual acuity, eyelid irritation symptoms, ocular surface characteristics and tear film parameters were assessed at baseline, day 7 and day 14. Expression of markers of ocular surface inflammation (matrix metalloproteinase-9 and interleukin-6) and goblet cell function (MUC5AC) were quantified using impression cytology at baseline and day 14.

Results

There were no significant changes in visual acuity, eyelid irritation symptoms, ocular surface characteristics, tear film parameters and inflammatory marker expression during the 2-week treatment period in treated and control eyes (all p>0.05), and measurements did not differ significantly between eyes (all p>0.05). No major adverse events were reported. Two subjects experienced transient ocular stinging, presumably due to migration of the product into the eye, which resolved following aqueous irrigation.

Conclusion

The MHME eye cream application was found to be well tolerated in healthy human subjects and was not associated with changes in visual acuity, ocular surface characteristics, tear film parameters, expression of markers of inflammation or goblet cell function. The findings support future clinical efficacy trials in patients with blepharitis.

Trial registration number

ACTRN12616000540415.

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.