Looking at the meibomian glands during an exam for dry eye, most of us are surprised to find that 70% of patients with dry eye symptoms have signs of meibomian gland disease. Unfortunately, finding relief for these patients is much more difficult than identifying the cause.

First, let's put a nail in the coffin of warm compresses. As a rule, patients don't do them — at least not long enough to consider them a meaningful solution. Most will give a few tries, find temporary relief, and soon forget about them. Docs who recommend baby shampoo scrubs will find even faster attrition of compliance. Detergents like baby shampoo sting.

However effective these age-old treatments, they become irrelevant for most patients.

Another approach is surgical meibomian gland expression performed in the office. Using two cotton-tip applicators, the examiner can apply bimanual pressure to the glands of the lower lid, expressing the opaque, inspissated, staph-laden material. (Upper lids can be expressed also but it leads to greater patient discomfort.) If you've ever performed this lipid catharsis, you know from somewhat grotesque personal experience the sheer amount of "gunk" that can be painstakingly (and painfully) removed with proper technique. The masochistic patients who return periodically for this time-consuming procedure do seem to experience true and prolonged relief. Why else would they ask for this procedure again?

In my own experience with this procedure, most patients experience discomfort for about 24 hours afterwards, with extensive pus production and stinging of the lids. This can be treated by the patient regularly irrigating the lids with eye wash for the first day and applying a topical antibiotic/steroid for 72 hours. It is worthwhile to clearly warn patients about this postoperative ordeal prior to the procedure.

A new device from Tear Science is designed to detect patients in whom meibomian gland expression might be most helpful and will soon be on the market. The company hopes to pair with it a device (not yet approved) that automates the process of gland expression. The gland expression device, which first heats then gently squeezes a patient's tarsal plates in about a 12-minute procedure, already has been shown to provide symptomatic relief of meibomian gland disease for 10 to 18 months. I am eager to see how it performs after FDA approval.

How about meibomian gland probing, as taught by Steven Maskin, MD? The tiny wire probes available from Rhein Medical are used surgically to explore the meibomian glands. Many glands become "capped" externally with keratin or plugged internally with meibum. These glands often lead to acute chalazia or chronic tenderness and swelling. Simply opening these caps can restore flow and provide meaningful, symptomatic relief. This procedure too is painstaking for the surgeon and somewhat uncomfortable for the patient. However, it is the only way we currently have to get inside those blocked glands and restore flow. Its ultimate success, in my personal experience really depends on fully treating the underlying meibomian gland disease with all the tools in our arsenal.

See Dr. Hovanesian share more expert insight live at OSN New York 2010, to be held November 19-21, 2010 at the Sheraton New York Hotel & Towers. Learn more at OSNNY.com.

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The unsung heroes of the ocular surface — the limbal stem cells — are under assault nearly every day for so many of our patients who take chronic medications, artificial tears and use other preserved products on and in their eyes. Preservatives such as benzalkonium chloride (and, even worse, thimerosal) are extremely effective killers of fungal and bacterial contaminants of eye drops, but their long-term administration is not without side effects.

Take, for example, a patient who was recently referred to me for management of dry eye. She was 72 years old and had been taking topical antiglaucoma drops for more than 30 years. Her tear production was in the normal range (no aqueous deficiency), and her meibomian glands produced clear, liquid lipid (no meibomian gland dysfunction), but her cornea had a circumferential superficial vascular pannus extending 3 mm from the limbus. Worse yet, the whole of her corneal epithelium was irregular.

She had virtually no functional limbal stem cells

Patients like this are very difficult to treat because their eyes lack a fundamental need: a source of new, healthy cells to replace sloughed corneal epithelial cells. While limbal transplantation from the contralateral eye can help some patients with limbal stem cell disease, this isn't an option in someone who takes medications in both eyes.

It's a great relief to see the pharmaceutical industry embracing topical meds with new-generation preservatives or no preservatives at all. Making these new offerings affordable will be their next challenge.

See Dr. Hovanesian share more expert insight live at OSN New York 2010, to be held November 19-21, 2010 at the Sheraton New York Hotel & Towers. Learn more at OSNNY.com.

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By now, most of us have heard that femtosecond lasers are being developed to assist in cataract surgery. The U.S. Food and Drug Administration has already granted 510(k) clearance for creation of anterior capsulotomies. Currently three (maybe more) companies are pursuing this technology: OptiMedica, LenSx and LensAR.

Using microforceps, a surgeon removes the capsular remnant created after a circular capsulotomy made by a femtosecond laser. (Image courtesy of LensAR, Inc.)

It has been proposed that these lasers, in addition to creating highly precise corneal incisions, can "soften" the nucleus of the lens by disrupting the lens tissue within the capsule. They can then make a perfectly round, perfectly centered capsulotomy. The surgeon's role, then, would be to open the already created incision, pull away the anterior capsule remnant, vacuum out the nucleus and place an implant.

Some have guessed that the availability of this technology will simplify cataract surgery to the point that technicians with limited training will be able to do the procedure — that we just won't need cataract surgeons any more.

That's quite unlikely.

It's true, femtosecond lasers can standardize some steps in surgery. Having a highly predictable capsule opening will probably improve the predictability of IOL position and refractive outcome. It will also simplify our lives for IOLs of the future, such as the Visiogen (now Abbott Medical Optics) Synchrony, which demands a just-so capsulotomy, or lens-filling technologies. Softening the nucleus will also reduce phaco energy. That means faster surgery, less fluid and quicker postoperative rehabilitation.

But what about eyes with dense cortical opacity? Femtosecond lasers cannot penetrate beyond white anterior opacity. A morgagnian cataract will (for now) remain the surgeon's challenge to remove.

Femtosecond lasers also can't do cortical cleanup for us — one of the steps most likely to cause capsular breakage. You need an experienced surgeon for that.

Small pupil? Posterior synechiae? Floppy iris? Pseudoexfoliation? How will a machine make it possible for an inexperienced human to tackle these? Score more points for the good guys.

Lastly, no laser device can or will substitute for the on-the-fly judgment that cataract surgeons use to handle the many surprises that occur on our OR days.

Femtosecond lasers are indeed likely to change the way we think about cataract surgery, opening a host of possibilities for new technologies that require greater precision than our hands can deliver. For now, though, we surgeons can still plan on showing up on surgery day with our game faces on for a good number of years to come.

Get more expert perspective from Dr. Hovanesian live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.

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