Eyedolatry: See Clearly Vision

Diagnosing Meibomian Gland Disease

diagnosing meibomian gland dysfunction dry eye 7:09

For the estimated 30 million Americans suffering from dry eye, the initial diagnosis is often the biggest barrier to experiencing relief. In a world where spending 9+ hours a day on screens and devices is considered normal (1/3 of Americans do!), we can often normalize our ocular discomfort as just “being tired.” But redness, watering, fluctuating vision, and eye fatigue are signals of a much more serious underlying medical condition. Dry eye isn’t just uncomfortable eyes – it’s a progressive inflammatory condition that can result in permanent structural damage and even vision loss. The initial diagnosis is key to getting treatment to prevent severe damage to the ocular tissue.

Dr. Lyerly spends a lot of time talking about meibomian gland disease in her practice.

Where to look first?

Since the 1980s, there has been an abundance of research and evidence showing that dry eye often begins at the level of the meibomian gland. In fact an estimated 86% of people diagnosed with dry eye have underlying Meibomian Gland Dysfunction. Every human has around 20 glands in their inferior eyelid and 30 in their upper eyelid that secrete tear film oil (called meibum) onto the surface of the eye with each blink. These glands produce the top layer of the tear film, the important oil layer that holds the tear film onto the surface of the eye to prevent watering and evaporation. If the meibomian gland secretion becomes blocked or irregular, tear film evaporates at a much faster rate, causing eyes to burn, water, and vision to fluctuate. But more importantly (and detrimentally), the body’s own protective feedback loop to prevent dry eye is initiated. If the corneal nerves sense that the eye is too dry, they send feedback to the lacrimal and meibomian glands to produce more tear film. But if the glands are blocked or obstructed, no matter how much tear film gets produced, nothing can be secreted when the person blinks. The result is inflammation: the glands are hyperactive to try to overproduce missing tear film, but no relief occurs, so more hyperactivity is turned on. It’s a devastating feedback circle that can result in a persistent cycle of worsening pain, redness, and blurry vision.

The yellowish circles here are the meibomian glands of the superior eyelid. Inflammation is clearly evident in my patient; the lid margin is very injected (red) - a hallmark of chronic dry eye.

Detecting Meibomian Gland Dysfunction

How does your doctor discover underlying problems with your Meibomian glands? We have a variety of techniques and diagnostic devices to help us find early signs before the patient may even experience any symptoms, which is of course the best time to intervene!

“Not every patient who presents with dry eye or meibomian gland dysfunction is symptomatic. Typically, however, patients will notice some occasional foreign body sensation, irritation, redness, blurred, or fluctuating vision,” says Dr. Christine Wisecarver of See Clearly Vision. In addition to just asking about symptoms, doctors may also use questionnaires like the Ocular Surface Disease Index (OSDI) or Standard Patient Evaluation of Eye Dryness(SPEED). These surveys are designed to unlock dry eye complaints that may be passed off by the patient as “normal” and thus underreported when the doctor directly asks.

Dr. Leslie O’Dell of Mechanicsburg Eye also recommends asking patients about specific activities and times of their day to unlock possible meibomian gland dysfunction-related symptoms. She asks patients how their eyes feel in the morning when they wake up – AM watering or burning could be associated with inflammatory eyelid conditions like blepharitis or demodex mites, or not fully closing the eyes when we sleep (called lagophthalmos). Another useful question is asking about how eyes feel after being on the computer for several hours. The average person blinks 50% less often when looking at screens, which results in less meibomian gland expression (the glands only secrete when we blink). Blinking less can have a devastating toll on the glands as it can also result in higher incidence of clogged glands. If oil stays in the gland too long it can begin to harder and obstruct, eventually choking the gland off from nutrients and causing gland atrophy and death.

Symptoms of watering are extremely common indicators of dry eye. “When our technicians meet with patients who present with dry eye, and their main complaint is excessive tearing, the patient is extremely confused to hear they have dry eye,” states Dr. Wisecarver. “WE must explain that the tear film is made up of three different parts. If the eye isn't producing all three parts in the correct proportions, your eye will over produce others, thus causing excessive tearing.”

Blurry vision is another indicative complaint Dr. Wisecarver sees in her dry eye practice. “Some patients also have the misconception that their blurred vision means they simply need to change their glasses prescription. We often explain that blurred vision may not be a prescription change but rather a consequence of an unstable tear film or other ocular disorder.”

In the Microscope

Physically assessing the glands at the microscope is an essential way for doctors to detect early signs of dry eye disease. “Clinically, we look for blocked, or capped, glands, thickened and red lid margins, and dilated blood vessels at the lid margin. The doctor will often gently press on the lids to see the consistency of the oil secretion,” states Dr. Wisecarver.

Evaluating the meibomian glands with the Korb Meibomian Gland Evaluator via

The key to evaluating meibomian gland expression is gentle pressure. Our blink offers only a minimal amount of force on the glands, but a doctor using their finger to manually push on the gland to determine expression can falsely indicate the glands are working better than they really are. Meibomian gland guru Dr. Donald Korb invented the Korb Meibomian Gland Evaluator to prevent this issue. The device uses the exact amount of pressure a blink would naturally put on the gland to prevent overestimating expression. There is much debate within eyecare about the potential dangers of manually and forcefully expressing the glands (could it damage the glands or cause increased gland inflammation?), so using this gentle gland evaluation method is preferred.

There are also great tools to visibly evaluate the length of the meibomian gland. Gland dilation and shortening (or atrophy) is evidence of advanced disease, so observing damaged and dying glands requires immediate intervention. Doctors can use a transilluminator held to the eyelid skin to visibly see the glands to evaluate length and regularity, or higher tech imaging systems that can show the glands in all of their subtle detail.

A doctor uses a transilluminator to see the meibomian glands. To do this, turn the slit lamp and room lights off, place the transillumintor on the bottom eyelid and gently evert the lower lid. via

Imaging systems offer a great tool for both the doctor and the patient to be able to see damaged meibomian glands. The LipiView imaging system uses infrared light to highlight the glands (below). Also available is the Oculus Keratograph with its Meibo-Scan software.

The LipiView system by TearScience is the method used where Dr. Lyerly practices, Triangle Visions Optometry. The patient pictured here is in her 20s and unable to wear contact lenses anymore due to dry eye and fluctuating vision with lenses.

Take Home

Once the doctor diagnoses Meibomian gland disease, the most important thing for the patient is to understand is that dead and damaged glands is not normal – it’s a sign of advanced disease that can result in permanent discomfort and visual distortion. Waiting to intervene will only worsen the severity of the disease, so there is no better time to start treating the eyes than when minimal or even no symptoms yet exist.

“MGD is a chronic condition,” states Dr. Wisecarver. “We are able to improve the function of the meibomian glands, but not necessarily reverse damage that has already been done through years of gland blockage. Treatment will reduce symptoms but consistency is key to managing the problem and preventing the long term damage.”

“Ultimately, educating patients as to WHY we recommend following a certain protocol for treatment will encourage the patient to continue with the regimen. Just like dentistry, you get cavities if you don't brush your teeth well. However, if you brush your teeth, your risk of decay is greatly reduced. Similarly, treating MGD daily reduces a patient's risk of styes, dry eye and damage to the oil glands themselves.”

Whether treatment includes heating the glands to remove obstruction with Lipiflow, daily heated Bruder masks, eyelid hygiene, nutritional supplements, or medication, daily maintenance is key to preventing worsening ocular health, comfort, and vision.

A big thanks to Irina Price and Dr. Christine Wisecarver for contributing on this post!

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Upgrading to Multifocal and Toric IOLs

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In today's world, cataract surgery is typically met with excitement moreso than dread. Why? Many patients have been waiting for years to be more independent from glasses and contact lenses, and the intraocular lenses (IOLs) used after cataract removal can greatly reduce their need for glasses after surgery. If you or a loved one is undergoing cataract surgery, the choices for IOL designs can be overwhelming. Do you want multifocal implants, to help you see with a range of vision both near and far? Do you need toric implants to reduce your astigmatism and limit the chance you'll need glasses for clear driving vision? These options exist, but they are options you have to choose to pursue out of your own pocket. Insurance only covers standard implants--they won't correct your reading vision, and they won't correct moderate to high amounts of astigmatism; you will need glasses after cataract surgery for a majority of your visual needs with a standard implant. How do you know if pursuing premium IOLs is worth your investment? Your cataract surgeon and your personal optometrist that is comanaging your care can walk you through the best choices for your individual needs. Today we're bringing you the basics courtesy Dr. Dawn Williams, an optometrist at See Clearly Vision who routinely provides pre- and post-operative cataract care, and Irina Price, their surgery coordinator.

What can a patient expect with a successful multifocal IOL after surgery? Success, from my perspective, is defined as increased functionality and decreased dependence on spectacles and/or contact lenses. I would suspect we are about 95% successful. Patients have to know that they will still need to use glasses sometimes; reading small print, reading in dim lighting, perhaps even for crystal clear driving vision. Success is highly dependent on setting realistic expectations prior to surgery. Preparing a patient for real expectations is a combined effort of every staff member who meets with the patient. From the surgeon, to optometrist to surgical counselors. This is where surgical counselors can play a big part in helping patients understand their expectations in comparison to their goal or surgical outcome. It is important for each patient to understand that the goal is to reduce dependency -- not eliminate the need for glasses. When a patient selects a multifocal they expect to be glasses free, however, when they’re sitting down at the sewing machine or trying to remove a splinter from a grandchild’s hand, they need to be educated that they may need assistance with reading glasses for these high visual demand situations.

Multifocal IOLs have rings of distance and near vision to achieve a range of vision near to far. via

Are there any side effects with multifocal IOLs?

The possibility of halos at night are a negative side effect of multifocal IOLs due to their multiple ring design. Halos and glare aren't a big issue with the other type of near focusing implant, accommodating IOLs, but these implants tend to have more trouble with unclear near/reading vision. The implant has to move within the eye, and if the patient's ocular tissue doesn't adequately support this movement then reading vision will be limited. This is something that doctors can't really screen for, which is why there is such variability in the success rate of accommodating IOLs. This is where every doctor and eyecare provider who comes in contact with the patient needs to be educating the real expectations for what each implant can and can't do. Here's an example of our dialogue:

“Mrs. Smith, a multifocal is going to give you a range of vision, however, the goal is to reduce your dependency on glasses. That being said, you still may need reading glasses for doing fine hand work or to correct residual astigmatism at distance”.

Accommodating IOLs have to flex within the eye to focus your vision between near and far. The range of vision achieved post-operatively depends on the anatomy of the patient's eye and how much flexure is accomplished. via

Can someone with high astigmatism or high prescription have multifocal IOLs? Or are there certain Rxes that are just not possible for this type of lens?

High amounts of cylinder (astigmatism) or highly ametropic (high prescription) patients are not excluded from having premium lenses unless they have corneal scarring, retinal pathology, or amblyopia. As long as the necessary IOL is within the range of available lenses, even in cases where the IOL would leave some residual refractive error, if it will reduce the patient's dependency and increase functionality it may be a good option. Patients with a high risk of residual prescription need to understand though that for their best vision they will still need glasses; these implants will reduce their need, but they won't give them crystal clear vision.

What conditions would prevent a patient from being a good candidate for multifocal IOLs?

Corneal scarring, retinal pathology like diabetic retinopathy or macular degeneration, and amblyopia (lazy eye) are a few things that would preclude a person from a premium IOL. Both eyes have to have a high level of function to be successful in these implants. The ring design of a multifocal IOL can greatly increase your risk for glare or halos at night or in dim lighting, so if the retina or cornea has a condition that causes visual distortion, the chance that the patient will be visually successful in this implant is very low. In the process of assisting patients in selecting their IOLs, physicians are able to guide patients towards certain lenses based on their overall ocular health. During the pre-op surgical evaluation, the doctor carefully examines the retina with dilated views and OCT imaging, and performs corneal topography for prospective multifocal patients; these results will help guide a patient towards, or away from, a premium IOL.

What's hiding behind that cataract? A thorough retinal examination is needed to make sure each patient is a good candidate for premium IOLs.

When do you recommend monovision implants (one eye set for reading, one eye set for distance) versus multifocal (both eyes see a range of distance and reading) IOL implantation?

The most successful IOL recommendations are made based on the patient's prior visual correction and their goals. If a patient has had monovision before in their contact lenses with good success, it's generally very easy to achieve success with a monovision IOL surgery. But if a patient has never worn monovision before, it is not their best choice. It's very difficult to demonstrate monovision with the presence of a cataract in one or both eyes, so the patient won't be able to try it out in contact lenses prior to surgery in most cases to know if they like it or not. If a patient has not had monovision in the past, we would like recommend presbyopic (multifocal or accommodating) IOL

When do you recommend toric (or astigmatism) IOLs?

A good candidate for a toric IOL will have a cylinder power of -1.25 to around -5.00 diopters.

When do you recommend Laser Assisted cataract surgery?

Laser-assisted cataract surgery is FDA approved for the treatment of low amounts of astigmatism, with a maximum correction of up to -1.50 diopters. It can also be beneficial in patients with very dense cataracts or corneal endothelial disorders (Fuch's Dystrophy). It’s important to remember that the goal of laser-assisted cataract surgery is to help reduce patient dependence on glasses following surgery. Patients who have worn contact lenses all their lives may be more inclined to select laser-assisted cataract surgery to reduce their dependence on eyewear as that is the goal of contact lenses in the first place -- to reduce your dependence on glasses. As a surgical counselor, I find that many contact lens patients are excited at the thought of less dependence on contacts and glasses after surgery.

What should optometrists referring their patients for cataract surgery talk to their patients about before the referral?

Discuss the possible IOL options and realistic expectations for what premium IOLs can do; as an optometrist you've been caring for your patient for years and know their personality and needs better than anyone! Many patients that are referred to our offices have been utilizing the benefits of monovision for years. It is beneficial if the referring OD is able to discuss with the patient whether or not they would like to maintain monovision following surgery as well as provide the contact lens prescription the patient has worn in the past to achieve success.

When an optometrist takes over the post-operative care for their patients after premium IOL implantation, are there any common patient issues with these types of lenses that ODs should be familiar with or know how to troubleshoot?

Reassure the patient that vision after multifocal and accommodating IOLs keeps changing and improving after surgery. For most, the best vision will be achieved about 4 weeks after surgery, so don't panic if the vision is not quite perfect at the 1 week post-op. The brain needs time to learn to use it's new vision, and there is still healing going on from the surgery itself in the first few weeks, so we don't expect perfect clarity right away. Always remind pre and post-operative patients that healing takes time, patience and rest. Having worked as a technician and surgical counselor, I’ve often been known to remind patients that if they had knee surgery they wouldn’t be up running a marathon the next day so they need to give their eye the same amount of time to heal. It helps remind patients that they need to be realistic about healing and not consider their cataract surgery to be providing them with a bionic eye.

Check out Dr. Williams, Irina Price, and the whole See Clearly Vision team at their website and on their Instagram account to learn more.

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What You Need To Know Before Corneal Collagen Crosslinking

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April 18th, 2016 was a life-changing day for people living with keratoconus in the USA; corneal collagen crosslinking, the revolutionary treatment that's been performed in Europe since 1999, was finally approved by the FDA. Keratoconus affects as many as 1 in every 500 people, causing potentially severe vision loss. But it's progression and causes are poorly understood. During the disease process, the cornea tissue thins and weakens, causing the cornea to prolapse forward like a steepening mountain. The resulting warpage and associated scarring wrecks havoc on vision, often requiring severely invasive procedures like full thickness corneal transplant as the condition worsens. In corneal collagen crosslinking, the goal is to stop the progression of keratoconus while the damage is still mild and vision is still usable, long before more aggressive surgical interventions would be needed. Using riboflavin and UV light, doctors are able to strengthen the connections of the collagen fibers of the cornea so that they hold tighter and stronger together, locking the cornea in place.

Because the procedure is so new here in the USA, most people living with keratoconus are being offered corneal crosslinking as a surgical option for the first time. Confusion about the procedure and its possible outcomes abounds. I interviewed Dr. Christine B. Wisecarver, an optometrist practicing at See Clearly Vision who manages the care of patients before and after corneal crosslinking surgery, and their surgical coordinator, Irina Price about what patients need to know before corneal crosslinking.

Who do you consider a good candidate for corneal collagen crosslinking? There has been a paradigm shift in the management of keratoconus patients. Patients with evidence of keratoconus should now be treated with collagen crosslinking as soon as possible. Once they have been cross linked, patients should be managed with spectacles and contact lenses as needed. Collagen crosslinking is currently FDA approved for the treatment of progressive keratoconus only. It is not currently covered by any insurance company, and much like refractive surgery, is considered at the discretion of the doctor. Candidates for crosslinking are patients who have been diagnosed with keratoconus and are cleared for crosslinking by their physician.

At what age would you consider treating a young patient with keratoconus that was advancing rapidly? Safety and efficacy has not been established in patients under the age of 14 years old.

What can a patient expect visually from the procedure? Crosslinking helps prevent progression of the disease. It does not reverse keratoconus, and is not a refractive procedure (meaning it will not correct a patient's vision). Some patients get a mild flattening effect as they heal, but this does not happen for every patient. All crosslinking patients are advised that if they are wearing specialty contact lenses before the procedure, they will likely need them following their treatment. Since the cornea will be changing in the first 6 months after the procedure, a new refraction and contact lens refit will be needed.

Corneal collagen crosslinking does not improve vision in keratoconus patients. The sole purpose of crosslinking is to halt the progressive steepening and thinning of the cornea. Having said that, it is currently the ONLY treatment that can reduce and ultimately halt the progression of the disease.

What can a patient expect of the procedure itself? The procedure is about 1 hour long with drops instilled every 2 minutes and UV light exposure to the cornea for 30 minutes. A bandage contact lens is then placed on the eye to allow the surface cells to heal. After 5 to 7 days, the bandage contact lens is removed. The healing time is very similar to PRK (except here patients get drops and UV light instead of laser). Patients may be uncomfortable for the first 3 days while the surface is healing. Antibiotic and steroid eye drops are used in the immediate post-operative period. Using a copious amount of preservative-free artificial tears can help to speed up the healing process.

How long after the procedure does it take to see results? Patients will likely not appreciate any visual result from treatment. The cornea usually stabilizes (i.e., curvature changes and prescription changes) by the 6 month mark. After that time, topography can be used to demonstrate that the procedure has helped to slow the progression of keratoconus.

Besides keratoconus, are there other conditions you would treat with corneal crosslinking? There is no current FDA approval for treatment with corneal crosslinking beyond that of progressive keratoconus. Off-label treatments for corneal disorders other than keratoconus (for example, corneal ectasia following refractive surgery), are at the discretion of the corneal specialist.

What do you see for the future using corneal crosslinking technology? Future indications for collagen crosslinking are currently being studied in the US and abroad. One possible indication is LASIK/PRK Xtra (crosslinking at the time of refractive surgery) to prevent post-refractive ectasia in higher risk patients like high myopes, young patients, and those with thin corneas. Additionally, surgeons are exploring targeted crosslinking where the aim is to achieve a visually improving refractive result in addition to preventing progression of keratoconus. Combination treatments like these, and the use of crosslinking for patients at risk for corneal perforation are areas in which cross linking may play a role in the future.

Do you live in the Virgina/Washington D.C. area? Dr. Rajesh Rajpal is a celebrated surgeon performing crosslinking treatments, as well as other corneal and refractive procedures at See Clearly Vision. You can contact their offices directly to schedule an appointment to see if you are a candidate for this exciting new treatment!

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