New Paradigms and Treatments in OSD, MGD, and Demodex Blepharitis

Because the health of the cornea and eyelids has become a primary focus for all eye care practitioners, YoungMD Connect and YoungOD Connect hosted a joint workshop to educate new and aspiring ophthalmologists and optometrists about current best practices for identifying, diagnosing, and treating ocular surface disease (OSD), meibomian gland dysfunction (MGD), and blepharitis.

DEMODEX BLEPHARITIS AND MGD

M. Amir Moarefi, MD

Diagnosing MGD begins with a thorough examination of the eyelids coupled with detailed questions regarding patients’ symptoms and hygiene habits. Ask patients whether their eyes feel irritated, and, if so, at what time of day. Check to see if the gland orifices are blocked. If they express secretions, evaluate their quality—are they watery or thick? The consistency may indicate the level of inflammation present. Because MGD requires a multifaceted treatment regimen, we must educate patients on lid hygiene, dietary modifications, and even the use of moisture chamber goggles in severe cases.

Identifying a Demodex blepharitis infestation requires a similarly thorough examination. Look for telltale collarettes at the base of the eyelashes (top and bottom), especially if the patient wears makeup and/or fake eyelashes. It is exciting to now have an FDA-approved treatment for Demodex blepharitis, XDEMVY™ (lotilaner ophthalmic solution) 0.25% (Tarsus Pharmaceuticals), that can eradicate these mites from the eyelids.

THE COMPREHENSIVE DED EXAMINATION

Selina McGee, OD, FAAO

Just because patients don’t complain about their eyes doesn’t mean they don’t have an issue—signs and symptoms do not always correlate.

To me, one of the most important components of a comprehensive DED examination is the patient questionnaire. I use this tool at every visit, even follow-ups. Any score higher than 6 on the SPEED questionnaire triggers me to perform point-of-care testing. If a patient says their eyes itch, I ask them to show me where. Itchiness in the corners is usually allergies; itchiness along the lashes is usually Demodex. Fluctuating vision indicates an unstable tear film. Testing tear osmolarity is important, as a hyperosmolar condition causes epithelial cell death. Serial tear osmolarity scoring is an index of the response to treatment and/or disease progression. I also perform corneal staining, a slit-lamp examination, and meibography on every patient. For cataract surgery candidates who are on DED therapy, I wait 2 to 4 weeks after symptom resolution before referring them for scheduling.

OPTIMIZING THE OCULAR SURFACE AND LIDS PRIOR TO SURGERY

Jennifer Loh, MD

Recent studies have shown how prevalent DED is among patients who present for ocular surgery. Gupta et al found that, out of 120 patients who presented for cataract evaluation, 54% reported OSD symptoms and 89% had a least one abnormal tear test.¹ In the PHACO study, Trattler et al reported that, out of 272 eyes scheduled for cataract surgery, more than 60% had a tear break-up time of ≤5 seconds and 50% showed central corneal staining.² Moreover, according to Sheppard et al, between 70% and 90% of patients diagnosed with DED show signs of MGD.³

For cataract patients, undiagnosed OSD can result in refractive surprise, and preoperatively, it affects diagnostics and surgical planning—keratometry readings, topography maps, and toric calculations are all taken from the central cornea. For these reasons, I consider optimization of the ocular surface as part of the preoperative preparation for cataract patients.

MODERN GUIDANCE ON DIAGNOSING AND TREATING OSD

Walt Whitley, OD, MBA, FAAO

OSD, MGD, and Demodex blepharitis cause a range of visual symptoms that are irritating to patients at best, and downright debilitating at worst. Making the proper clinical diagnosis is crucial to choosing the appropriate treatment. I’d like to ask my colleagues what testing devices they are using in their clinics.

Dr. McGee: “I currently use InflammaDry (Quidel) and ScoutPro Osmolarity System (Trukera) for osmolarity, and I perform meibography on every patient.”

Dr. Loh: “I do fluorescein staining and meibography testing, and I’d like to add the new immunoglobulin E testing for allergies and lactoferrin testing for DED.”

Dr. Moarefi: “For cataract surgery candidates, I look for specific patterns of dryness in the inferior one-third of the cornea. Patients who are not symptomatic may have neurotrophic keratitis. Patients’ visual outcomes are important to me, so I spend time in the chair educating, describing treatment options, and setting expectations.”

1. Gupta Pk, Drinkwater OJ, VanDusen KW, et al. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096.

2. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.

3. Sheppard JD, Nichols KK. Dry eye disease associated with meibomian gland dysfunction: focus on tear film characteristics and the therapeutic landscape. Ophthalmol Ther. 2023;12(3):1397-1418.