An MGD Tool for Every OD

Dry eye disease affects from 5% to 50% of the general population.¹ By using common screening methods in a general optometry practice, you can get a clear picture of the problem in your own patient population and use those numbers to guide how you prepare to manage them. As you classify patients’ dry eye disease, you will find a large majority of patients have evaporative dry eye caused by meibomian gland dysfunction (MGD) destabilizing the tear lipid layer.

As our knowledge of dry eye disease and MGD has grown in the past decade, so has the list of accurate screening and diagnostic methods and effective tools. Changing our approach to dry eye management from a reactive one to a proactive one means screening every patient for dry eye disease and MGD, as well as providing patient education, a range of in-office options, or potentially referral to a dry eye disease expert. As a dry eye specialist, I encourage you to think about addressing MGD yourself in ways that make sense for your practice.

MGD Screening and Traditional Options

A transilluminated slit lamp view can tell you a lot about a patient’s glands. It doesn’t cost you anything to take that quick step because you already have a transilluminator in every lane. This simple test is the first step in identifying patients with MGD within your practice, followed by evaluation of gland function at the slit lamp.

Meibography is a good initial investment for the dry eye side of your practice. We have two in our center—one portable, one stationary—and they both give me the information I need for diagnosis and tracking, as well as the images that make patient education so much easier. Patients are much more open to getting the treatment they need once they can see the problem. In addition, point-of-care testing of tear osmolarity and MMP-9 levels allows one to better understand a patient’s tear quality and quantity. These tests help guide the treatment plans for all of my dry eye patients.

Traditionally, tools for MGD have included supplementation with lipid-based artificial tears, re-esterified omega 3 supplements, at-home warm compresses or heated eye masks, and behavioral changes such as taking frequent breaks from screen time. If you identify MGD in your patients and offer these measures, they will likely experience some relief, particularly if they have mild disease. To control the condition long term or to provide a tool for more moderate or advanced MGD, you will need to offer one or more MGD devices in your practice.

Offering cutting-edge MGD Options

There are many advantages to offering innovative MGD tools in your practice. Most importantly, knowing that up to half of your patients have dry eye disease and most of those patients have MGD, innovative options will allow you to give existing patients the care they need and deserve.

Use of MGD devices also provides a way to boost revenues while clearing obstruction in current patients. The prevalence of MGD is so high that providing in-office experiences with out-of-pocket fees can make a significant impact.

For a practice that has yet to take this plunge into evacuating the meibomian glands, TearCare (Sight Sciences, Inc.) is a good starting point. TearCare is one of the tools we use with our MGD patients. It’s also an affordable and straightforward choice if you’re new to MGD devices. If you’ve been recommending nutraceuticals and a heat mask, this is a good next step to get more involved.

With some devices, space is sometimes a concern. The TearCare SmartHub is the size of a hockey puck—with its small footprint, you almost certainly have enough room for it (Figure 1). Disposable costs are reasonable. Using the TearCare device takes only about 20 to 30 minutes, including the heating period and gland clearance.

TearCare’s appeal to patients makes it a good early acquisition as well. I find most patients respond positively to the device. Most patients actually tell me, “Wow, that feels good!” They’re happy to use their smartphones or chat while they have the procedure, which they love. I love the fact that their blink during the heating process is already starting to express the warmed/melted meibum, making final clearance even easier. And the price point for TearCare makes it an easy decision for folks who want a tool for MGD.

How TearCare Works

When my colleagues and I were considering adding more MGD equipment to our practice, we liked the TearCare pilot study results,^2,3 the device's small footprint, and brief, well-tolerated process. We also appreciated that TearCare allows us to warm and express both the upper and lower eyelids; with the clearance tool, we can be attentive to every single meibomian gland.

The TearCare system includes a small SmartHub that controls heat duration and temperature, as well as SmartLids, which are wearable heating elements that adhere to patients’ top and bottom lids (Figure 2). TearCare gives patients what Sight Sciences calls a “personalized open-eye experience,” with a 15-minute SmartLid session, heating up to 45˚C, and gland clearing by the doctor.

SmartLid session—The first part of TearCare is the warming of the eyelids and meibomian glands. It is imperative that the patient arrives with a clean, makeup-free face for treatment. Prior to the application of the SmartLid, we prepare the skin to remove any makeup and residual oils that could interfere with adhesion. With the patient’s eyes closed, we place the superior SmartLid, followed by the inferior SmartLid with the patient looking upward. Patients generally find it very easy to open their eyes and read or use their phones during treatment. We encourage patients to blink naturally because this takes advantage of the natural meibum clearance process of the blink. The device remains on the patient’s eyes for 15 minutes.

Adjustable heat—The SmartLid temperature is controllable, so if an older patient has thin skin, for example, we can lower the temperature a degree at a time. The default temperature is comfortable for virtually all of my patients, and I've found that I rarely need to adjust the default temperature, but it is nice to have the option.

Meibum clearance—Once the SmartLids are removed, we use the system’s Clearance Assistant tool to clear the warmed, thinned meibum from the meibomian glands. This tool is a bit different from others I’ve used before because it has a wider service area. The tool allows me to clear three or four glands at a time. I usually start clearing lower-lid glands temporally and move nasal, and then do the same on the second eye, followed by the superior lids. While the meibum is still warm, I take a second pass through all of the glands to make sure I’m pushing out as much meibum as possible.

I think the clearance step is something doctors will like because it allows us to see the meibum release and be physically involved in removing it. In the process, we see what happens after the glands are heated and get a better understanding of the gland’s function. At the silt lamp, we can assess what kind of oil comes out—thick or thin, easy or difficult to remove, cloudy or clear. At times, with other devices, we don’t see what’s expressed. With TearCare, we can see the meibum and even get video of the clearance process if we want to show patients what’s been stuck inside their lids.

Preliminary Outcomes, Follow Up, and Retreatment

Once TearCare is complete, I schedule a follow-up visit at 3 to 4 weeks. In a pilot study of TearCare (n = 24 subjects), patients showed significant improvement in TBUT very quickly after TearCare, so I don't feel like I have to wait 2 to 3 months to see them back.² After the first follow-up visit, I usually schedule another appointment 5 months later, 6 months postop, to check patients' progress.

Patients in the study went from an average baseline TBUT of about 3 seconds to about 14 seconds at week 2, remaining the same before decreasing to about 8 seconds at 6 months (Figure 3).² Considering normal TBUT is about 10 seconds, this is a very satisfactory outcome for patients who start at 3 seconds. This should result in better end-of-the-day symptoms for our patients, as well as possibly less fluctuating vision, eye fatigue, or burning. Sight Sciences is currently conducting a large multi-center randomized controlled trial which, at its conclusion, should provide more data to support the device's safety and effectiveness.

An extension to the pilot study showed that when patients were retreated at 7 months, TBUT increased to about 17 seconds and remained at 10 seconds 6 months later, which may indicate that the second treatment is well maintained.³ Before retreatment at 7 months, Ocular Surface Disease Index (OSDI) scores were still improved over baseline (down from 41 to 31), and they decreased again after retreatment to about 21 at 13 months.

Dry eye disease and MGD are chronic and progressive, so I always know that patients will continue to need management in the future. In determining when to bring patients back for another TearCare session, some doctors use the patient’s symptoms as their cue. I look at both symptoms and gland function. I use the Meibomian Gland Evaluator (Johnson & Johnson Vision), which tells me how many glands are secreting clear meibum. Comparing those numbers to baseline, I know how many glands are now working following use of TearCare, and over time, I use the numbers to gauge whether additional treatment is needed.

Progressive Considerations for a Progressive Disease

Managing dry eye disease has many parallels to managing glaucoma in terms of the progressive nature of both conditions and the relationship between staging and intervention. We might start an early glaucoma patient on a single eye drop to manage pressure, and then add a second drop as the disease progresses, finally moving on to surgical options if necessary. Similarly, the hope for the future is that if we catch MGD early, we can use MGD tools such as TearCare to provide a long-term benefit to patients.

If a patient has moderate to severe MGD, I recommend an approach based on the number of lost glands and the level of dysfunction in the remaining glands. I might combine TearCare with other measures, such as an anti-inflammatory eye drop, or I may recommend more frequent visits and gland clearance. The robust technology is a great first step for optometrists who want to offer an alternative to warm compresses, and for specialists, it’s an excellent addition with intriguing potential for the future.

Indications for Use: TearCare® is indicated for the application of localized heat when the current medical community recommends the application of a warm compress to the eyelids. Such applications would include Meibomian Gland Dysfunction (MGD), Dry Eye, or Blepharitis. TearCare may not be right for everyone. Please see Instructions for Use or visit TearCare.com for Contraindications, Warnings, and Precautions.

TearCare® is a registered trademark of Sight Sciences.

SmartLids™, SmartHub™, and Clearance Assistant™ are trademarks of Sight Sciences and for use only by Sight Sciences.

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