Managing Meibomian Gland Dysfunction in Lens Wearers
BY KELLY K. NICHOLS, OD, MPH, PHD
Contact lens-related dry eye is classified as an evaporative dry eye disease according to the 1995 NEI/Industry Report (Lemp, 1995). Disorders of the meibomian glands, such as meibomitis, are also in the evaporative category. Clinically, many symptomatic contact lens patients have lid margins that look less than pristine. How should you manage lens-wearing patients who have lid disease?
Almost any published information regarding management of lid disease mentions the use of a warm compress for five to 10 minutes, two to three times each day. Studies have evaluated the impact of warm compresses on tear break-up time, tear stability and tear evaporation rate (Olson et al, 2003; Mori et al, 2003; Paugh et al, 1990). The findings in all studies generally showed an improvement in the measured test following administration of the warm compress.
Interestingly, many reports that recommend warm compresses neglect to describe how to prepare or use one. In addition, at a recent meeting I heard a prominent leader in the dry eye/anterior segment disease field report that a patient who had lid disease and who was using oral antibiotic therapy showed a lack of improvement mostly because the patient failed to use prescribed warm compresses effectively.
This begs the question...how should we instruct a patient to use warm compresses? The primary goals are to encourage patients to commit to using them and to teach patients how to sustain that activity with minimal burden.
Testing Different Methods
To define the best warm compress, I tried several techniques at home. A warm washcloth in the morning shower scored high for ease, but relatively low for sustained warmth to the eye area. In contrast, the boiled egg and potato in the microwave approaches scored low, both in terms of heat control (especially with more than one use) and burden.
Next, I took one cup of uncooked white rice and poured it into a clean sock. I chose a sock long enough to create a surface area of at minimum six inches when I tied a knot in the end. I found that 30 seconds in the microwave provided excellent warmth without being too hot (microwave times may vary). This made a good, re-usable, inexpensive spa mask that scored high for both convenience (once made) and warmth. The slight downside was a nutty smell when warm, but I preferred it to the other food-based warm compresses.
I also located several warmable spa masks on the Internet (~$20). Warming these products requires immersing them in very hot water for a period of time, but once warm they're odor-free.
When Warm Compresses Fail
Many patients prefer a therapy that requires no prescription. Specifically, if patients can manage meibomian gland disease with aggressive use of a warm compress, they may opt for that first.
However, failure of warm compress therapy (too time consuming) may require the addition of an oral antibiotic. Currently, low-dose minocycline (50mg) and doxycycline (Periostat 20mg) options are available that have a lower side effect profile and potential for long-term use (in some cases up to nine months), and many more of my contact lens patients who have lid disease are using oral therapy. Through personal experience and discussions with colleagues, I find oral therapy is most effective in combination with appropriate lid hygiene, which includes aggressive use of warm compresses. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #123.
Dr. Nichols is an associate professor at The Ohio State University College of Optometry in the area of dry eye research.