Saturday, December 5, 2009

Abstract: Smartplugs, canaliculitis & plug removal

Prevalence of canaliculitis requiring removal of SmartPlugs.
Ophthal Plast Reconstr Surg. 2009 Nov-Dec;25(6):437-9.
Prevalence of canaliculitis requiring removal of SmartPlugs.
Hill RH 3rd, Norton SW, Bersani TA.

PURPOSE: To report the first accurate prevalence of canaliculitis associated with the use of the SmartPlug.

METHODS: All patients from a single private ophthalmology practice who received SmartPlugs from 2002 to 2007 were identified. All patients from the private ophthalmology practice that developed canaliculitis secondary to SmartPlug insertion were referred to a single private ophthalmic plastic and reconstructive surgery office. A retrospective review of those 17 patients was performed.

RESULTS: From 2002 to 2007, a total of 235 patients were identified from a single private ophthalmology practice with a total of 402 SmartPlugs inserted. Of those 235 patients, 17 developed canaliculitis and were referred to a single private ophthalmic plastic and reconstructive surgery office. The prevalence of canaliculitis per patient was 7.23%. The prevalence of canaliculitis per SmartPlug inserted was 4.73%. The average time from SmartPlugs insertion to onset of symptoms was 3 years. All affected patients required canaliculotomy and plug removal.

CONCLUSIONS: This is the first study reporting the prevalence of canaliculitis associated with the use of the SmartPlug. All affected patients required surgical intervention, after which many continued to have dry eye and one required bilateral Jones tubes. Ophthalmologists using the SmartPlug for the treatment of dry eye syndrome should carefully weigh the risks and benefits of their use.

Thursday, December 3, 2009

Moorfields' new dry eye site

UK users... Moorfields recently launched a new website dedicated to dry eye.

Dry Eyes Medical

Nothing spectacular as dry eye websites go, but all the same it's nice to see UK resources and attention to dry eye expanding. In treatments, it mentions moisture chambers and sclerals which most sites of similar superficiality don't.

Treating MGD early

There was an interesting 'panel' discussion on PCON recently about whether to treat lid margin disease (MGD) in patients who do not yet have symptoms (don't hurt). I'm posting some highlights here because I think this is a very timely topic. While I'm not sure I'm crazy about the idea of them prescribing all these drugs to people with a very mild case, on the other hand the fact that they are identifying the signs and educating their patients about it absolutely thrills me. That's surely a sign of significant progress. This is not, obviously, knowledge diffused evenly through optometric circles, else we would not still be hearing so frequently from people with raging lid margin disease who were not properly diagnosed, let alone treated, by their first four doctors. But progress leads to more progress.

Panel: Treating asymptomatic lid disease improves comfort, long-term results

We now understand the profound influence of adequate meibomian gland secretions on ocular comfort and quality of vision.
(Dr. William Townsend)

Define "we", please? :-)

Perhaps this could be rephrased as "We all ought to, and a growing number of us actually do now understand..."

We treat all patients with active meibomian gland dysfunction to prevent ongoing inflammation and tissue damage. Therapeutic modalities such as warm compresses, lid expression, systemic tetracyclines, oral omega-3 essential fatty acids and cyclosporine A have been shown to positively affect meibomian gland disease. While the immediate benefits of therapy such as increased gland output and visual enhancement are desirable, the real benefits of long-term therapy (preserving meibomian gland function and preventing atrophy) are the real effects that the patient will appreciate years later.

The management of lid disease is particularly challenging because although the provider may recommend appropriate treatment, the task of carrying out the administration of the various therapies falls on the patient. Early detection and treatment may save him or her from the discomfort and annoyance of advanced meibomian gland disease years later.
(Dr. William Townsend)

Currently, AzaSite, as well as Restasis, is an off-label treatment option for blepharitis and meibomianitis. However, with evidence growing that drugs such as these are proving beneficial and offering our patients an actual treatment vs. palliative care, I have begun prescribing treatment to previously asymptomatic patients. My “go to” treatment plan includes the standard warm compresses and lid hygiene (preferably with some type of commercial lid scrub) and AzaSite twice daily for 2 days and then once daily for the next few weeks. It is the treatment plan I put myself on.
(Dr. Blair Lonsberry)

When I treat asymptomatic patients with signs of blepharitis, I take the basic philosophical approach that no patient ever starts with severe lid margin disease. Most patients start with a mild case that, left untreated, progresses to more severe forms. That being said, I explain to patients with lid margin disease that an infection or inflammation of the lid margin left untreated can progress to significant symptoms that include itching, burning, chronic redness and uncomfortable contact lens wear and that it can also make other conditions such as dry eye worse. After a thorough explanation most patients decide to pursue treatment.
(Dr. Scot Morris)

Patients are not always as asymptomatic as they seem at first glance. Asymptomatic and completely satisfied are two different things. I ask patients about dryness, contact lens wearing time and red eyes. I always discuss my findings, as well as the risks of doing nothing and benefits of treatment.

Foaming eyelid cleansers, such as OcuSoft Lid Scrub Foaming Eyelid Cleanser (OcuSoft, Rosenberg, Texas) make it easy for patients to treat mild blepharitis in the shower. It is surprising how many asymptomatic patients return much happier, simply with a minimal routine change.
(Dr. Christine Sindt)

Heading to Boston at last

Aaaaaah. I have been trying to work in a trip to Boston Foundation for how many months now? Finally, finally it has worked out. Leaving Sunday, returning Wednesday with brand new eyeballs. Well, not quite that, but new prostheses (did you know sclerals are actually prosthetic devices?). Hurray, hurray.

MG Expressor Kit

...And in that same EyeWorld article, there was mention of a new kit for doctors to express those glands for the rest of us. Personally I don't see why a kit's needed (rice anyone? and fingers?) but hey, the more medical devices around for it the more doctors will, hopefully, be learning about the need to be conversant in meibomian gland manipulation. WAKE UP, DOCTORS. The population is aging. MGD is booming. Patients are shopping around for doctors on the basis of how meibomianitis literate they are. Are you? And by the way, stock analysts care about dry eye. Do you? Well, OK, if you're reading this blog you probably do. Maybe you could forward a link to a colleague who doesn't... yet.

For less severe cases of meibomian gland dysfunction, Mario Gutierrez, OD, FAAO, has developed the MG Expressor Kit (Gulden Ophthalmics), which combines the traditional therapies of warm compresses and massage, though in a more rigorous form. The kit includes a gel mask that can be warmed, the expressor tool and sanitary caps that can be placed over the roller. Dr. Gutierrez described the technique.

“Once the lids are warm, it liquefies the contents of the meibomian glands,” he told PCON. “Then, we basically roll the tool on the eyelid near the eyelid margin, and that helps express the liquefied meibomian gland content.

“I typically warm up the eyelids, use the roller, really work the nasal eyelids — the glands — a little bit more,” he continued. “This seems to help the patient become less symptomatic if we can get the nasal meibomian glands working well. Then I’ll go back and warm the lids a little bit more, maybe for a minute or two more, and then go back and roll it one more time to try and liberate as much of the expressions as possible.”

According to Daniel Adams, OD, the expressor is best used at a horizontal angle, working from the lash line upwards.

“The gel pack should only be used for 3 minutes to warm the glands, and then the expressor tool should be rolled horizontally — not vertically — over the eyelid, forcing the meibum upwards,” Dr. Adams said in an interview. “You want to soften the oil that’s congealed in the gland, and once you are able to get it to a ‘soft butter’ stage, roll the glands and try to express it out.”

Maskin probe

Noticed all the buzz lately about the new Maskin probe?

EyeWorld discussed it in a recent article about "aggressive" (i.e. beyond doxy, azasite and classic compress/scrub routines) treatments for meibomian gland dysfunction.

The Maskin Meibomian Gland Intraductal Probe (Rhein Medical), developed by Steven L. Maskin, MD, helps remove obstructions within the duct. Dr. Maskin told Primary Care Optometry News that clinicians can enter the meibomian gland with the probe and provide “dramatic and immediate” relief to patients.

Blockages within the gland may be caused by fibrovascular tissue that grows into the duct with new blood vessel formation as well as an abnormal hyperplastic keratinized ductal epithelium or scarring in or over the orifice, he said.

“What I found when I entered the meibomian gland was that there was frequently some resistance deeper inside, within the duct, which was able to be relieved with mild pressure,” Dr. Maskin said. “When you apply that pressure, you’ll be able to penetrate through that and there will be a ‘pop’ characteristic of a fibrovascular membrane. You can create a patent open duct from orifice to the deeper duct. Patients’ lid tenderness dramatically and immediately improves.”

...But wait, lest you interpret my "beyond doxy, azasite, etc", bear in mind that it's probably in addition, not instead of:

...Marguerite McDonald, MD, shared her protocol with PCON. She first holds lidocaine gel against the lid margin to anesthetize the area where the probe will be inserted. Afterward, she prescribes a combination of topical and sometimes oral medications to treat the disease.

“For patients with moderate to severe meibomian gland disease, I place them on ‘soaks and scrubs’ twice daily, as well as on AzaSite (azithromycin 1%, Inspire), one drop in both eyes twice daily for 2 days followed by one drop daily for at least a month,” she said. “Some severe patients stay on AzaSite indefinitely.

“I ask the patients to rub the drop into the base of their lashes for a few seconds while their lids are gently closed, immediately after instilling the drop,” she continued. “In addition, many patients are placed on oral doxycycline (100 mg) twice daily for a week to 10 days, then 20 mg once daily for a few months, if not indefinitely.”

And of course, on DryEyeTalk it's been a subject of discussion for some months past, as in this thread.

Dropless ad

Have you seen the Lacrisert "Dropless" ad?

I can't post it because their site doesn't let you pinch its pix, but it's a shot of a comely and presumably 50yo+ lady with the photo cut off just below her shapely, bare shoulders. The text says "Freedom to go dropless."

In the staid world of ophthalmic pharmaceutical advertising where edgy means snapping a photo of the bottle from a new and different angle and progressive Restasis commercials are showing up on websites like, I thought it was pretty cute.