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Today's Practice | Mar 2013

Understanding Evaporative Dry Eye Disease

How does meibomian gland disease affect dry eye management?

Dry eye symptoms have long been attributed to reduced tear production, and use of the phrase dry eye disease encourages us to target management strategies toward aqueous replacement. However, recent research1-7 shows that meibomian gland disease (MGD) is often the underlying cause of dry eye. In these cases, the origin of dry eye symptoms is not the absence of the aqueous component of tears but rather the presence of an unhealthy lipid deficiency—a scenario better described by the term evaporative dry eye disease.


I was recently an investigator for a trial evaluating the safety and effectiveness of the LipiFlow System (TearScience) in 139 patients with MGD and dry eye symptoms.8 The study assessed the factors of dry eye disease that showed an association with symptoms and improvement in meibomian gland function.8 Half the patients were randomly allocated to receive a single bilateral LipiFlow thermal pulsation treatment, and the other half received daily warm compress therapy and were assessed prior to being crossed over to LipiFlow therapy at 2 weeks. Across treatment groups, there were no significant differences in age, sex, or, for women, menopausal status.

We assessed meibomian gland function and dry eye symptom severity before and 2 weeks after treatment using a meibomian gland (MG) assessment scale and self-reported ocular surface disease index (OSDI) score. The MG scale grades the quality and quantity of material produced by each of 15 meibomian glands located along the lower eyelid on a scale of 0 (no substance produced by the gland) to 3 (perfect function). We used the Meibomian Gland Evaluator (TearScience) to obtain all MG scores. This device assesses MG function by applying standardized pressure to the lid margin and simulating a forced blink.

At the end of week 2, we found that patients who received LipiFlow therapy showed significantly greater improvement of MG and OSDI scores compared with the warm compress group. Additionally, patients who received LipiFlow treatment and had a low pretreatment MG score and a high OSDI score were most likely to show marked improvements in MG score. In my opinion, this suggests that LipiFlow therapy effectively improves subjective and objective measures of evaporative dry eye disease.


Since carrying out the study, my practice has integrated the Meibomian Gland Evaluator, LipiView Interferometer, and LipiFlow treatment device into the management protocol for dry eye disease. We use the Meibomian Gland Evaluator and LipiView devices to assess function in general dry eye patients and in preoperative laser refractive and cataract surgery patients. This allows us to better predict which patients are at increased risk of new-onset dry eye or worsening of dry eye symptoms postoperatively. Once an increased risk is identified, patients can be treated preemptively with LipiFlow along with eye drops and lid hygiene processes, rather than waiting for symptoms to worsen after surgery. Screening patients in this manner gives eye care providers the opportunity to improve postoperative outcomes and patient satisfaction.

It is important to highlight that LipiFlow therapy is not intended to replace the usual methods of managing dry eye symptoms. On the contrary, it may be used in conjunction with other recognized therapies, such as warm compresses and lubricating drops. The primary causes of dry eye symptoms are MGD, aqueous-deficient dry eye, inflammatory dry eye, and allergies. We have found that many patients experience a combination of these conditions, and, as a result, treatment must be targeted at all three issues. LipiFlow provides another avenue for improving the MGD portion of evaporative dry eye in addition to warm compresses and topical azithromycin. The inflammatory portion of dry eye symptoms is addressed with cyclosporine, and antiallergy medications are used to remedy the allergic component.

Overall, we have observed very good patient response to the LipiFlow. Patients report fewer symptoms and better quality of life once their symptoms are reduced. Because the treatment is given as a single in-office procedure, compliance is not an issue. The effect of a single LipiFlow treatment may last between 9 and 15 months; a study is under way to determine LipiFlow’s duration of effect with greater certainty. The only downside voiced by patients is that it can sometimes take 1 or 2 months to experience symptomatic improvement, even though gland improvement is almost immediate. However, we find that if this is explained to patients prior to treatment, realistic expectations are set, and the patient does not become frustrated or lose faith in the therapy during the first month after treatment. It is also paramount to explain to patients that although LipiFlow improves gland function and often symptoms as well, it is not a cure. Because MGD can be a chronic condition, periodic upkeep, much like a thorough dental cleaning, may be necessary every 6 to 15 months.


The development of devices such as the Meibomian Gland Evaluator, LipiView, and LipiFlow reflect the important change of direction that dry eye management must take if patients are to finally obtain longterm relief from this chronic and irritating condition. Ophthalmic physicians are now more aware of the importance of the role of MGD in patients with evaporative dry eye symptoms. The fact that effective MGDspecific therapies are now available puts physicians and patients in a better position than before. It is now up to ophthalmic specialists to embrace the new understanding of MGD’s role in evaporative dry eye and the latest advanced treatments to provide the best care for patients with evaporative dry eye.

David R. Hardten, MD, FACS, is the Director of Refractive Surgery, Minnesota Eye Consultants, Bloomington, Minnesota. Dr. Hardten states that he has participated in clinical trials using the LipiFlow and LipiView devices and has been a speaker for and consultant to TearScience. He may be reached at tel: +1 612 813 3632; e-mail: drhardten@mneye.com.

  1. Nichols KK, Foulks GN, Bron AG, et al. The International Workshop on Meibomian Gland Dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52:1922-1929.
  2. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The International Workshop on Meibomian Gland Dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52:1930-1937.
  3. Knop E, Knop N, Millar T, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011;52:1938-1978.
  4. Green-Church KB, Butovich I, Willcox M, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on tear film lipids and lipid-protein interactions in health and disease. Invest Ophthalmol Vis Sci. 2011;52:1979-1993.
  5. Schaumberg DA, Nichols JJ, Papas EB, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci. 2011;52:1994-2005.
  6. Tomlinson A, Bron AJ, Korb DR, et al. The International Workshop on Meibomian Gland Dysfunction: report of the diagnosis subcommittee. Invest Ophthalmol Vis Sci. 2011;52:2006-2049.
  7. Geerling G, Tauber J, Baudouin C, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52:2050-2064.
  8. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012;31(4):396-404.