Drs. Scott Hauswirth and Marc Bloomenstein discuss how meibography influences their diagnosis and treatment of dry eye disease. Learn why and how meibography makes a real difference in patient care.
Dr. Whitney Hauser: Hi. I’m Dr. Whitney Hauser with Dry Eye Coach Podcast. Thank you for joining us. Today we’re going to be talking to Dr. Mark Bloomenstein of the Schwartz Laser Eye Center. We’ll also be talking with Dr. Scott Hauswirth, Assistant Professor and Director of the Ocular Surface Clinic at the University of Colorado. Welcome, gentlemen. How are you today?
I’m great, Whitney.
Dr. Whitney Hauser: Good. Good. Well, thanks for joining us. This is a first for Dry Eye Coach Podcast. Typically, we feature one doctor at a time. So, we’re going to really, we’re really going to take a look at our skills today and see if we can not talk over each other too much. So, I’m going to go ahead and start the questions. And we’re going to be talking about meibography today and the role that it plays in your practice. So, just to start off, you know, Dr. Hauswirth, can you tell us how you’re using meibography in your practice right now? And really, what patients you’re typically using it on?
Dr. Scott Hauswirth: Yeah. So, meibography is an essential part of our dry eye evaluations. Anyone that’s coming in who’s either referred, either internally or from the external community, into the Ocular Surface Clinic, receives meibography. Generally speaking, we’re using that to image the lower glands, or the glands of the lower lids first. And if there’s significant change or drop-out, then we’ll image the uppers. We also use it following any type of meibomian gland procedures to check for changes either in [obstructure] or how it matches up to function. So, we do it on our initial evals and then anything that we do that may affect the meibomian gland function. We’ll reimage them usually about six months later.
Dr. Whitney Hauser: Now, I guess the follow-up that I would have to that, and I think a lot of our colleagues who are listening might want to know is, why lowers most often and sometimes why lowers only?
Dr. Scott Hauswirth: Yeah. That’s a good question. I think, first off, time does play a role. Even though we have a little bit longer appointment slots for our patients, the lower lids typically are where we’re going to see the majority of early dropout occur. And so, we’re targeting that first. It also saves our technicians, and me, a little bit of time. And again, like I said, if there’s significant change there then we’ll go and image the upper lid. There can be a striking difference between the lowers and the uppers in some patients.
Dr. Whitney Hauser: So, Dr. Bloomenstein, what about you? How are you using meibography in practice?
Dr. Mark Bloomenstein: Yeah. I take a little bit different approach. I think my practice and Scott’s practice is probably a little bit different. You know, him being in a university setting and having a dry eye moniker, I think he’s probably seeing a little bit more challenging cases. The practice that I’m in, we’re essentially, you know, doing comprehensive eye exams and we’re doing patients who are referred in for cataract surgery or refractive surgery. My goal, now, of late, and actually probably the last eighteen months, is really to kind of carpet bomb every patient. Just to look at every person’s meibomian glands, and draw a distinction between, as Scott said, form and function. And to be quite honest with you, he probably is the person, I heard that years ago, we can look at the glands and that doesn’t always tell us what they’re really doing or what’s coming out of them.
Dr. Whitney Hauser: Right.
Dr. Mark Bloomenstein: And so, for me, every patient that comes in the door now for a comprehensive eye exam or anybody who’s considering having surgery, and obviously the patients that are symptomatic, we are doing a meibography on. And to that same point…
Dr. Whitney Hauser: Do you…
Dr. Mark Bloomenstein: Go ahead.
Dr. Whitney Hauser: Well, I was going to say, do see any trends from that? You know, because Scott and I were seeing these highly symptomatic patients a lot of times.
Dr. Mark Bloomenstein: Right.
Dr. Whitney Hauser: So, sometimes it skews our perspective on what things are like. If you’re doing, as you said, the carpet bomb approach, what trends are you seeing?
Dr. Mark Bloomenstein: Well, the irony of that is that, I think that we as clinicians are biased.
Dr. Whitney Hauser: Right.
Dr. Mark Bloomenstein: And I think that our bias always leads towards, you know, well, you’re a young, male, you know, so the likelihood of you having dry eye or even meibomian gland dysfunction, which we know to be extremely prevalent in dry eye patients, is probably low so I’m not going to do that. And, for example, like you know, glare testing. You know, doing up that. We don’t do a brightness acuity test on a twenty-five year old. And the main reason being is that we don’t anticipate or expect there to be glare. However, I think that with this disease state, and with our capabilities now of evaluating what the glands look like, we have to readjust or, kind of like, create a sea change if you will, in the way we think about this, of dry eye. So, what the trend I’m seeing is, is that patients that I never would have thought were going to have a problem, I’m seeing tremendous amount of 19, 25, 30% of dropout or a lot of tortuosity on younger patients, as well as, you know, patients who have just, who aren’t symptomatic yet. And I think that there’s a huge difference, too, between wellness, you know, us like saying let’s do something to stop it from getting worse, so they don’t become symptomatic. Or, versus, now that we’re in the throes of this, what can we do to reverse it or slow it down?
Dr. Whitney Hauser: Right.
Dr. Mark Bloomenstein: My trend is that I’m just shocked by how much, how much gland changes I’m actually seeing.
Dr. Whitney Hauser: Do those gland changes that you’re seeing in those, sort of, atypical demographic patients, the men, the younger patients, is there, is there a discordance with signs and symptoms between those patients? Do you see, you know, shorter truncated glands, some element of what we would arguably define as atrophy? And then, are they asymptomatic or does it seem to correlate?
Dr. Mark Bloomenstein: I think it’s kind of all of the above, to be quite honest with you.
Dr. Whitney Hauser: Yeah.
Dr. Mark Bloomenstein: And then, Scott? You can agree or disagree.
Dr. Scott Hauswirth: Yeah. I would agree with that, actually. And it’s striking, Mark, I think you touched on a really important point. In fact, I like your approach of carpet bombing. And here it’s a little bit different because, you’re right, we’re getting a lot of patients that are basically here specifically for, you know, secondary or tertiary, you know, diagnosis and management of ocular surface disease. But I think that the thing that’s most striking to me is that we have growing literature support for evidence of this occurring at a much, much younger age. You know, Preeya Gupta’s paper from 2018 showed 42% of pediatric patients actually showed some level of atrophy. And so, that’s a whole entire demographic that I think most of us would probably have sort of shook our heads at and thought, oh no, that’s probably going to be a normal patient. Well, this stuff probably is happening much earlier than we initially gave it credit for. So, I think it’s important to try to capture that and I’m glad you’re doing that, Mark.
Dr. Whitney Hauser: So, one thing…
Dr. Mark Bloomenstein: Wait, Whitney. Honestly, I think, I look at meibography now the way we did 25 years ago with topography. You know, it was kind of an elitist, kind of like, ooh, special to have a topographer in your practice.
Dr. Whitney Hauser: Right.
Dr. Mark Bloomenstein: And I think, I think it’s more rare not to have a topography today. And I really do feel that meibography is going in that direction.
Dr. Whitney Hauser: Right.
Dr. Scott Hauswirth: Certainly, with some of the newer technologies, we’re seeing, you know, prices coming down and it’s becoming a lot more accessible to the clinician that’s in a regular primary care practice. And so, I agree with Mark on this, that we’re going to probably see, and I think we’ve already started to see sort of a ground swell of this being incorporated into a number of traditionally primary care practices across the country. And it’ll be, I think, one of those things that we’re going to capture on our pediatric patients on a pretty regular basis, and it’s another important way of tracking patients and making sure that the end of, or the later years of their life are, you know, just as comfortable and productive as the earlier.
Dr. Whitney Hauser: Right. You’re right. You both raise great points. So, I guess one of the things that I think that a lot of our colleagues want to know is, and being able to ask experts like you is a great opportunity, when do you do it again? So, a patient comes in, you’ve carpet bombed them, you’ve done the, you’ve done the photography, when are you going to do that meibography again? Are you going to do it three months later? Six months later? A year? When do you follow up on that one?
Dr. Scott Hauswirth: Yeah. Well, like I mentioned earlier, for anyone that actually receives, like, any kind of meibomian gland-oriented procedure, like clearing, expression, probing, etc., we’re trying to repeat that, at the very latest, six months after. And on some patients, I’m capturing at three months. On patients that are receiving more kind of medically or pharmaceutical oriented therapy, then we’re probably capturing it just once a year. What about you, Mark?
Dr. Whitney Hauser: Right. What about you, Mark?
Dr. Mark Bloomenstein: Yeah. So, vey similar. I mean, to me, I look at it just like I would any other test that we do in the practice. You know, whether it be intraocular pressure, whether it be visual acuity, whether it be, I mean, if something’s not right, then I look at it and say, okay, let’s, you know, we’re going to interject, we’re going to do something different. Or let’s reevaluate it. And so, I bring them back sooner. I feel with this disease state, though, I feel cause we’re kind of, I really feel we’re kind of at the infancy of it. You know, and I keep referring back to like topography. You know, back in the day, we would look at somebody with pellucid and we thought it was just an irregular against the cyl astigmatism. Against the rule, excuse me, astigmatism and now we realize that, no, it’s a ectatic disorder that we could see early on. Or forme fruste or other things. So, I feel like we don’t have a great bead as to determining whether or not we’re looking at glands that have basically just kind of either completely atrophied or even, or collapsed on each other. And so, I kind of want more information so I tend to bring patients back a little sooner. But I, 100%, when they come in for their either comprehensive eye exam or they come in for like, you know, prior to surgery I’m doing it every time, and going back and looking and showing patients, you know, where we’ve gone and where we are now.
Dr. Whitney Hauser: Yeah. And that’s exactly where I was heading with that. My next question, Mark, is how has it helped you in educating your patients? And do you think there’s an impact to treatment compliance based on meibography?
Dr. Mark Bloomenstein: You know, Whitney, if I was to basically put, if I was to rate the things in my practice that are the most beneficial for patient education, bar none, pictures are a thousand words. And meibography, to me, is more, is probably the best education tool that I’ve ever had in the practice. And the main reason why is because we can look at something and say, look. This is cause and effect. This is where you started, and this is, and I can show pictures of what, you know, abnormal looks like, or stages of abnormal can, before I ever show a patient what their topography, er, their topography, but their meibography looks like on that given day, I will show them what we expect it to look like if you’re a young, healthy person. But, you know, also, this is what it would look like if we’re starting to age and wear and tear and all that’s normal. And then, before I’m even done, they will sit there and ask me, well, what does mine look like? You know, where am I at?
Dr. Whitney Hauser: Right.
Dr. Mark Bloomenstein: And it’s just, it’s actually a really, really great opportunity to have discussions about, you know what’s happening; the glands are getting clogged, they’re getting inflamed, you know, through this obstruction. And this inflammation discussion, to me, really is kind of a launching point for all the other inflammatory or just environmental aspects of dry eye. And meibomian gland dysfunction, to give patients a “what’s in it for me?” you know, what’s the [12:36] for both them and for me?
Dr. Whitney: Right. You know, in my clinical experience, meibography, above almost any test that I’ve done in dry eye, really fills an educational void for the patients. A lot of these dry eye patients, especially the moderate to severe ones, come in really starved for reliable, good clinical information. And they always tend to lean in and say the same thing, “you just told me something no one’s ever told me.” And it’s, it provides great clinical evidence. It helps us educate. But it also, it’s a point of practice distinction. While I think we’re going to see more and more of it, as Scott said, about accessibility, still, it stands out that that practice takes dry eye seriously above a lot of their competitors. So, Scott, go ahead.
Dr. Scott Hauswirth: I was going to say, I’m going to basically jump in on this and say, I agree 100% that it’s probably the most impactful tool that we have in terms of patient education. I think we do need to be, I think we need to be a little bit careful about using verbs like, you know, changing or, you know, losing glands.
Dr. Whitney Hauser: Right. I agree.
Dr. Scott Hauswirth: I mean, I think what we’re doing right now is imaging, you know, at a certain timepoint, and we can kind of see how that changes. But we don’t have great longitudinal studies to kind of show at what rate this happens in average individuals with obstructive MGD. Or, if there’s a high level of inflammation even, we just don’t have good data to show at what rate those things occur. That being said, I think it’s actually a call to action for those people that are in the trenches as clinicians, to try to image, you know, at least once a year, maybe every six months, so that we can better understand the rate at which those things change. I think this is an area that optometry could really, you know, step into the lead and really kind of educate the entire medical community on how these changes occur and at what rate they occur. So, I think that knowledge gap that we as, you know, clinicians could really, could really fill over the next couple of years.
Dr. Whitney Hauser: Go ahead, Mark.
Dr. Mark Bloomenstein: What I was going to say, too, is that, from an educational tool, one of the things that I love explaining to patients is, is that I can’t, you know, my crystal ball has fallen off my desk, you know, years ago. So, especially when patients say, “well, how long do I have before my cataracts turn bad?” It’s like, dude. I can’t give you any indication as to what’s going to happen. And when we look at the meibography, one of the things that’s always striking is patients like, “so what does this mean for me?” And, I can be frank with them and say look, I don’t know. But what I do know is that it’s changing. And it’s going to have some impact on the quality of your vision. So, I’d rather do something to try to stave that off or stop it or, you know, create, not stop. It’s not the right word. Sorry, Scott. I know you don’t like that. Or to, you know, slow it down, whatever I can, and get them to buy into the fact that, you know what? I don’t know what it’s going to be like, but let’s do something today so that hopefully it’s not something that we have to, you know, aggressively work with later.
Dr. Scott Hauswirth: The earlier you can treat it the better it is for patients, in all cases.
Dr. Whitney Hauser: And I think most people, you know, subscribe to that. You know, they may not always act on it 100%, but they subscribe to the theory that wellness is important, especially when it comes to things like these obstructive and inflammatory type of conditions. So, Scott, what treatments are you using to treat MGD? And that is a huge question and I’m going to throw that to Mark as well. But, really, you know, what are some things, and I know you can’t list them all, for time’s sake, but what are some of the things that, that really resonate with you, at least from an initiation standpoint, perhaps for patients in your clinic?
Dr. Scott Hauswirth: Yeah. Well, I’ve always kind of taken the approach, regardless of whether it’s MGD or, you know, I guess aqueous deficient-type dry eye that inflammation is still a really important part of this. And so, every patient that we see, if they’ve got even advanced MGD, I’m still starting them on some type of topical immunomodulation. And it’s actually, you know, been shown just over the years, I mean, Nick [16:58 Opeds] did a paper a few years ago looking at Lotemax in MGD and showing that the use of, you know, topical steroids improved meibomian gland function. And then most recently, there was even a paper by Joe [Talber] that showed that Lifitegrast even showed effects of improving meibomian glad dysfunction. So, I think that’s an important part of it; controlling that. Now, as we kind of expand out from there, you know, making sure that they’ve got, you know, their dietary needs, you know, they’re monitoring that stuff, or on some type of Omega supplement. And then, as the level of obstruction or dysfunction increases, then we’re, and if they’ve been on immunomodulation for a little while, then we’re looking at, you know, more meibomian gland procedural type intervention to try to jumpstart the glands to get them to function better, you know. So, things like, Lipiflow which has been around now for a while. Or the new Tear Care or even meibomian gland probing. We’re offering all of those as kind of secondary and tertiary level treatments to try to make sure patients can improve and engage with their dysfunction.
Dr. Whitney Hauser: Yeah. Excellent. That was well-done. Comprehensive yet concise. Mark? What do you say?
Dr. Mark Bloomenstein: I’m right there, you know, obviously along the same lines. And, for me, it’s like what I want patients to understand, Whitney, and we kind of circle back to the question you asked before about education, is why I feel showing them the glands as a launching point, because we can talk about the inflammatory aspect and we can also talk about the obstruction aspect. And I want patients to know why we’re doing something. And so, you know, having something like, you know, a, like a Bruder Mask or, you know, or a specific kind of, you know, a mask that they can use to kind of warm up the glands to kind of break some of that obstruction and why that’s relevant and important to do; you know if not daily or at least every other day or even just once a week. Something. Using something to break up the, like a surfactant or even a hypochlor, you know, hypochlorous acid or something, on a daily basis, that they can use to kind of reduce some of the lipid or the bacterial load. I’m big into, now, you know, getting my patients to understand why I’ll come by and do like a, remove some of the keratin to kind of expose and open up those glands when they come in. To me, and then, like Scott said, too. I mean, 100% every one of these patients is on some form of immunomodulating anti-inflammatory to hit that inflammator. And we have three drugs out that are approved right now. You know, whether it be the cyclosporines or whether it be Lifitegrast, there should be no reason why, if a patient has any symptoms, that they shouldn’t be on that. And like Scott said, I mean, to me, at that initial discussion, point two I talk about how, like dentists do teeth cleaning. And they do deep clean. We have ways now of using thermal pulsation to heat up the glands above the body temperature and basically kind of, you know, get them to pulsate out and remove that. And whether it be a manual one like the iLux or the Tear Care or even something like a one [20:12] the OCuSOFT device, something in the office. And, you know, the Lipiflow being self-contained is something that we can bring them in as well we have in our practice. And then lastly, it’s like what Scott said. I mean, to me, it’s all about making sure that our patients understand that these glands are like any other glands in our body and, you know, being on a good, you know, nutraceutical, you know, a doctor-recommended nutraceutical or just talking to them about their own diet and their own environment. Just to be conscious of that, you know, when they’re on a monitor to think about blinking and kind of looking away. I mean, so I think the challenge that I find especially with patients is that if they don’t know why they’re doing it, then there’s no impetus to do it. So, to me, going back to what we said about just telling them why we’re doing these things, I think patients really, really respect that and they can understand why the treatments are there.
Dr. Scott Hauswirth: I agree with you, Mark. And that’s a super important point is if they don’t understand why it is that we’re recommending certain things. I mean, I think that drives compliance way, way down. So, again, that sort of is another, ties into the benefits of using meibography so that they can, you know, attach those treatment recommendations to what they saw and how we explained it to them in the exam room.
Dr. Whitney Hauser: Well, I think you’ve both very well laid out the necessity, if you will, of meibography and how it’s changed your practices and your clinical care. I really appreciate you joining us today. Thank you very much to both of you.
Alright. Thank you for having us.
Dr. Whitney Hauser: Yeah. And thank you for joining us for Dry Eye Coach Podcast. Stay tuned. We’ll have new podcasts coming on soon.