We always thought of dry eye disease (DED) as a condition of the cornea and conjunctiva; today we know that, for about 86% of cases, DED begins with the eyelids.1 Meibomian gland dysfunction (MGD) affects 96% of glaucoma patients on prostaglandin analogs, almost 60% of contact lens wearers and 85% of people who use digital devices.2-4 Despite these numbers, not nearly enough optometrists are treating this precursor to DED at an early stage.5 

This must start with diagnosis. Clinicians only need to take two steps to prepare themselves: buy a meibomian gland expressor and learn to spot early biofilm and blepharitis. This will add about 20 seconds to your exam, but it will generate a multitude of patients for the practice who need ongoing care. 

Cosmetics and DED

Numerous agents have been banned from human use because they cause cancer. One such example is formaldahyde, although more than 20% of current makeup products contain formaldehyde or formaldehyde-releasing chemicals. Additionally, this is just one of many harmful ingredients people apply to their eyelids, lashes and adnexa almost daily. Lash extensions and other additives to the eyelids and lashes create the perfect environment for Demodex and bacteria to colonize. Patients frequently ask about the risks of makeup and ocular surface diseases, and we must provide the proper education. 

In-office Procedures

It’s time to consider adding in-office, patient-pay options, given the success patients are experiencing with these technologies. Blepharitis caused by bacteria or Demodex requires an in-office procedure, as does almost all cases of evaporative DED where biofilm components exist. An in-office blepharoexfoliation will significantly help these patients. 

Other beneficial procedures for ocular surface disease include intense pulsed light (IPL) therapy and thermal expression and pulsation, the latter of which now has four different equipment options. The first and perhaps longest lasting option is a LipiFlow (Johnson & Johnson Vision). Research shows the effects of one treatment typically lasts three years.6 While beneficial for all patients with MGD, it’s a must for those with more than 70% gland loss to keep what few glands they have left. New in-office MGD therapies that combine heat and gland expression include the iLux (Alcon), TearCare (Sight Sciences) and the Thermal 1-Touch (OcuSoft). 

Finally, IPL is an excellent therapy for patients with evaporative DED, ocular rosacea or MGD with telangiectatic vessels along the lower eyelid, which bring inflammatory mediators to the eye and lid margin. A series of IPL treatments can treat these blood vessels and help improve MGD and evaporative DED symptoms. The newest IPL devices no longer require coupling gel and are vastly more comfortable during treatment. 

Lumps and Bumps

Clinicians should always be on the lookout for eyelid lesions, considering the most likely locations of basal cell carcinomas—the most common cancerous lesions—match the pattern of eyeglasses. These include the eyelids where the lenses would be, the nose pad area and behind the ears where the temples are. This is an easy way to remember the most frequent locations for the presentation. Other less common lesions, such as squamous cell carcinoma, malignant melanoma and sebaceous gland carcinoma, are also in our wheelhouse and should be suspected when lesions change or conditions such as blepharitis worsen even after treatment.    

Optometry’s role in caring for ocular surface disease and lid lesions is critical from diagnosis to treatment. In fact, it’s an area of medical eyecare we should own. These conditions, moreso than any others, provide an enormous opportunity for us to help more people. Incorporating better care can’t hurt our practices either.

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.

1. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8.

2. Mocan MC, Uzunosmanoglu E, Kocabeyoglu S, et al. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. J Glaucoma. 2016;25(9):770-4.

3. Machalinska A, Zakrzewska A, Adamek B, et al. Comparison of morphological and functional meibomian gland characteristics between daily contact lens wearers and nonwearers. Cornea. 2015;34(9):1098-104. 

4. Wu H. The severity of the dry eye conditions in visual display terminal workers. PLoS One. 2014;9(8):e105575.

5. Steinberg D, et al. Equity Research Americans. 2017:1-38

6. Greiner JV. Long-term (3 year) effects of a single thermal pulsation system treatment on meibomian gland function and dry eye symptoms. Eye Contact Lens. 2016;42(2):99-107.