Optometric Physician

Vol. 21, #14   •   Monday, April 5, 2021


Off the Cuff: Express Yourself or Maybe Not—It’s Complicated

While expression has been a cornerstone of MGD treatment, I have long ago abandoned old school cold expression with forceps or a Mastrota paddle as a cruel and inhuman punishment of already miserable patients. However, I have embraced various automated, assisted or enhanced meibomian gland clearance procedures that involve some element of heated expression.

As my understanding of treatments and experience with outcomes has grown, I have started to suspect that simple evacuation of the glands with clearance of obstruction is only part of what actually promotes normal gland function and improves patient comfort. The reason is quite complicated.

The meibomian glands are powered by the action of the orbicularis muscle during the blink. As the blink advances, pressure builds within the glands. Gland orifices at the lid margin remain sealed, encircled by the muscles of Riolan until the upper and lower lid touch as the blink completes. The muscles relax momentarily, and a measured amount of meibum is released and spread over the ocular surface as the upper lid rises. It is logical to assume that homeostatic control is involved as it is in every function of the ocular surface environment. Under normal conditions in a healthy patient with a healthy lid, the brain cycles glands on and off, keeping some in reserve and some actively functioning.

When dysfunction occurs for any number of reasons, the glands become increasingly obstructed, and internal pressures build. Normal control mechanisms likely interpret the increased pressure as the glands being filled with meibum, resulting in a compensatory down-regulation of additional production. Down-regulation leads to increased stagnation and further worsens obstruction. It’s a vicious cycle, ultimately leading to inflammation and loss of gland tissue.

While it is satisfying, if a bit gross, to watch thickened meibum spill out of gland orifices during expression, does just clearing and emptying the glands restore them to function? Based on the complexity and interwoven nature of the tears and ocular surface, such a simple return to function is unlikely. Far more likely, gland clearance signals that the glands are empty, and the brain—through homeostatic control mechanisms—actively restores the glands to activity with other ocular surface functions adjusted accordingly. Aggressively emptying the glands may not only be unnecessary, but may actually damage the very delicate gland structure.

The elegance, sheer grandeur and precise control of every aspect of ocular surface function is characterized by homeostasis. While its importance is increasingly recognized, its actual meaning and function isn’t. I will have a lot more to say about this in a future Off The Cuff.

Next week I will share some really good news for the profession. Thank you, AOA!


Arthur B. Epstein, OD, FAAO
Chief Medical Editor

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.



Ophthalmic Conditions Associated With Dementia Risk: The Cardiovascular Health Study

Ophthalmic conditions and dementia appear to overlap and may share common pathways, but research has not differentiated dementia subtypes. Diagnosis of cataracts, age-related macular degeneration (AMD), diabetic retinopathy (DR) and glaucoma were based on medical histories and International Classification of Diseases, Ninth Revision (ICD-9) codes for 3,375 participants from the Cardiovascular Health Study. Dementia, including Alzheimer's disease (AD) and vascular dementia (VaD), was classified using standardized research criteria.

Cataracts were associated with AD (hazard ratio [HR]=1.34; 95% confidence interval [CI], 1.01 to 1.80) and VaD/mixed dementia (HR=1.41; 95% CI, 1.02 to 1.95). AMD was associated with AD only (HR=1.87; 95% CI, 1.13 to 3.09), whereas DR was associated with VaD/mixed dementia only (HR=2.63; 95% CI, 1.10 to 6.27).

Differential associations between specific ophthalmic conditions and dementia subtypes may elucidate pathophysiologic pathways. Lack of association between glaucoma and dementia was most surprising from these analyses.

SOURCE: Hwang PH, Longstreth WT Jr, Thielke SM, et al. Ophthalmic conditions associated with dementia risk: The Cardiovascular Health Study. Alzheimers Dement. 2021; Mar 31. [Epub ahead of print].



Ocular Surface Disease in Psoriatic Patients in a Developing Country

To evaluate ocular surface changes among patients with psoriasis in Malaysia, a developing country in Southeast Asia, an interdisciplinary case-control study (60 psoriasis patients and 40 control subjects) evaluated the differences in ocular surface manifestations between patients with psoriasis and a group of age-, gender- and ethnicity-matched healthy controls.

One hundred and twenty eyes of 60 patients with psoriasis, and 80 eyes of 40 healthy controls without psoriasis were included in the study. Mild-to-moderate psoriasis was found in 42 patients (70%), while 18 patients (30%) had severe psoriasis. Psoriatic arthritis was found in 19 patients (32%). Of the 60 psoriatic patients, the prevalence of ocular involvement was 65% (39/60), in which 32% (19/60) had dry eyes, 27% (16/60) had lid margin abnormalities, 33% (20/60) had cataract and one had history of anterior uveitis. Compared to controls, the ocular surface of psoriatic patients showed more eyelid margin abnormalities, higher meibomian gland loss and lower tear film break-up time. The estimated odds ratio for dry eyes in the psoriasis group was 2.2 (95% CI, 0.8 to 6.9).

Ocular surface disorders encompassing eyelid margin abnormalities, meibomian gland loss and tear dysfunction occurred at an earlier and higher rate among psoriatic patients.

SOURCE: Goh Y, Kwan Z, Han WH, et al. Ocular surface disease in psoriatic patients in a developing country. Int Ophthalmol. 2021; Mar 31. [Epub ahead of print].



Increased Risk of Glaucoma Among New Onset Gout Patients Ages 20 to 39 Years: a Nationwide Population-based Cohort Study in Taiwan

To provide epidemiologic evidence of whether gout increases the risk of new-onset glaucoma, researchers conducted a 13-year nationwide, population-based, retrospective cohort study to examine the association between the history of gout and risk of glaucoma by using the Longitudinal Health Insurance Database (LHID) of Taiwan. The gout cohort included 52,943 patients with newly diagnosed gout who were recruited between 2000 and 2012. Each patient was propensity score matched 1:1 with a person without gout from the LHID. To determine glaucoma occurrence, the study population was followed up until the end of 2013. Cumulative incidence, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, sex, comorbidities and every ophthalmic visit. A Cox proportional hazard model was used to analyze the association between gout and incidence of glaucoma among patients with different potential risks.

The adjusted HR for newly diagnosed glaucoma in the gout cohort was 1.00 (95% CI, 0.93 to 1.07; p=0.931), compared with the non-gout cohort. Stratified subgroup analysis revealed that the HRs of glaucoma were 1.36 (95% CI, 1.09 to 1.70; p=0.007), 0.99 (95% CI, 0.87 to 1.12; p=0.871), and 0.95 (95% CI, 0.87 to 1.03; p=0.235) in patients with gout aged 20 to 39, 40 to 54, and ≥55 years, respectively (p for interaction = 0.011).

This nationwide population-based cohort study revealed that gout patients in the age group 20 to 39 years had a higher risk of glaucoma than non-gout controls.

SOURCE: Perng WT, Hung YM, Lai WY, et al. Increased risk of glaucoma among new onset gout patients aged 20-39 years: a nationwide population-based cohort study in Taiwan. Int J Clin Pract. 2021; Mar 31. [Epub ahead of print].





Industry News

Luneau Upgrades Visionix Eye Refract

Luneau Technology introduced its second-generation Visionix Eye Refract, a compact eye refract system that includes: an automated, binocular digital phoropter combined with wavefront-based auto-refractometry and keratometry (AR/K); a digital acuity short chart and integrated lens analyzer. Clinicians can now use keratometry data collected from the eye refract system to fit soft contact lenses, and “physiological refraction” is designed to help eye care providers quickly identify the patient’s comfort zone. Additional improvements were made to the algorithm and wavefront laser. Learn more.




Neurolens Announces the nMD2

Neurolens launched the neurolens Measurement Device, Gen 2 (nMD2). The nMD2 is an objective way to measure binocular vision, or, more specifically, eye alignment. Using more than 10,000 data points per patient, the eye tracking system can identify eye misalignment as small as 0.1 prism diopters. The nMD2 is 80% smaller, and the associated diagnostic test is 35% faster than the first-generation nMD. In addition, USB 3.0 cameras support faster eye tracking and increased fields of vision. The nMD2 will be commercially available July 1, but neurolens will starting taking orders immediately as part of a pre-sale offer. Read more.

Oasis to Launch My Oasis Cyber Platform at SECO 2021

Oasis Medical is formally launching its new patented cyber platform, My Oasis, at SECO International 2021, booth #722. The platform is designed to help eye care providers build their brand as a dry eye resource, expand the reach of their practice, and give access to solutions that can better the quality of life for dry eye suffers in their local community. Learn more.



US Ophthalmic Offers EFC-2600 Non-mydriatic Digital Fundus Camera

US Ophthalmic’s new Ezer EFC-2600 fundus camera and operating platform is a fully automated camera offering high-definition, 12 mega-pixel images of the retina without the need for pupil dilation. When choosing up to ten fixation targets, the automatic mosaic modality function combines several image fields to produce a high field of view of the retina, allowing for rapid diagnosis of diabetic retinopathy, glaucoma and other eye abnormalities. In addition, the EFC-2600 has a field of view up to 100 degrees and can take images of the cornea, iris and lens, aiding the early detection of anterior segment disorders. Learn more.

AdaptDx Pro's Onboard AI Technician Now Speaks in Multiple Languages

MacuLogix announced its first major software upgrade for its AdaptDx Pro portable dark adaptometer. Once the software is automatically downloaded and installed, the artificial intelligence-driven onboard technician, Theia, will provide patient instructions and user interfaces in multiple languages. AdaptDx Pro guided by Theia measures dark adaptation in a clinical setting quickly and effectively, using an objective, functional measurement called the Rod Intercept. Read more.

IDOC Launches Monthly Educational Webinar Series

IDOC launch eConnect, a monthly series of educational webinars designed to build on education available at The Connection, IDOC’s annual member conference. The series will explore topics of special relevance to the private practice community, with a focus on COPE-approved CE throughout 2021. The April 20 webinar at 8 p.m. ET, “Review of Ocular Nutrition and Bioavailability of Omega Fatty Acids – The Good, the Bad and the Ugly,” will be presented by Vin Dang, OD, FAAP. The webinar is supported by an educational grant from ScienceBased Health. View the events schedule.





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