Integrating MGD Care Into the LASIK Workflow

It is not unusual for patients to seek LASIK because they have become contact lens intolerant, often due to underlying ocular surface problems such as meibomian gland dysfunction (MGD). Although MGD was once thought primarily to be a disease of postmenopausal women, we now know that it is a component in 86% of dry eye cases.¹ Younger patients, including children,² can have MGD (Figure 1). MGD is found in about 60% of contact lens wearers, who are more likely to have abnormal meibum, hyperemia, lid margin telangiectasia, and plugged meibomian orifices compared to age-matched controls.³

If MGD is not addressed before a patient presents for LASIK, it is a huge missed opportunity for that patient’s primary care practice, in my opinion. Once the patient gets to a surgical practice, there is a risk for poor patient satisfaction if the ocular surface is ignored. My preference is always to treat MGD before surgery to improve the accuracy of our measurements, the quality of the tear film, and the patient’s comfort after surgery.

TREATMENT OPTIONS

There are several in-office procedures available for the treatment of MGD, including LipiFlow (Johnson & Johnson Vision), iLux (Alcon), TearCare (Sight Sciences), and MiBo ThermoFlo (MiBo Medical). Because these procedures generally represent an additional out-of-pocket cost for patients, the conversation and workflow surrounding them must be handled carefully. Using the four strategies outlined here, we have been able to successfully integrate MGD treatment to the point that about 90% of our patients with significant MGD and 50% of those with mild MGD opt to address it before surgery.

Commit to Diagnosing MGD

It’s important to screen every LASIK candidate for MGD. At a minimum, patients should be asked probing questions such as whether their contact lens comfort has changed over the years or if their eyes are more irritated at the end of the day. A helpful approach is to evaluate both gland function and anatomy as part of the preoperative workflow. We have our LipiScan meibographer next to the autorefractor (Figure 2), and our technicians scan every LASIK candidate, regardless of symptoms. In addition, I perform a simple diagnostic expression to see whether the glands are secreting oil, thickened meibum, or nothing at all.

Educate Patients About Why MGD Matters

If our technicians see any gland atrophy on a patient’s meibography, they tell the patient, “It looks like you have some gland blockage and gland loss. The doctor will discuss this with you, but you may need to address it before surgery.”

I like to use the images to educate patients about their gland health. I also tell patients how MGD affects the quality of their tear film. I explain that, unlike other areas of the body, the front of the eye has no blood supply, so it is dependent on the tear film to provide all the nutrients and healing factors needed to recover from surgery. The better we prepare the tear film for surgery, I tell the patient, the better they will see and feel afterward.

This explanation goes a long way to help patients understand why dry eye matters in the surgical setting.

Make It an Easy Choice

Pricing for MGD treatments has evolved. For the procedure that we do, LipiFlow, the activator fees have come down tremendously as the technology has matured, and we are able to pass that cost saving on to the patient. What once cost $700 or more per eye can now be as little as $700 for bilateral treatment. We also offer a discount when the treatment is bundled into surgery, which has increased our adoption rate by about 40%. If you offer financing programs, MGD treatment can be included in those as well.

Get the Timing Right

We try to perform the MGD treatment in the office on the same day as the LASIK consult whenever possible. But I don’t like to pressure patients, so, if they need time to digest the information we’ve provided, the surgical scheduler will make an appointment for a later date.

Ideally, MGD treatment should be completed about 3 to 4 weeks before surgery. This allows the treated, unobstructed glands to refill and begin functioning, and it gives the tear film time to improve before surgery. If we have prescribed topical antiinflammatory drops such as cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), lifitegrast ophthalmic solution 5% (Xiidra, Novartis), or cyclosporine ophthalmic solution 0.09% (Cequa, Sun Pharma), those also take 2 to 4 weeks to start reducing inflammation and symptoms. We have a hard-and-fast rule that patients must be out of contact lenses for 3 weeks before surgery, so waiting 3 to 4 weeks for tear film recovery does not typically delay surgery.

TREATING MGD PAYS OFF

Overall, I would say that MGD treatment has been one of the best additions to our practice in the past 10 years. Not only has it had a tremendous impact on patient comfort and satisfaction, but it has also been a positive revenue generator for the practice.