dry eye

Approaching MGD With Science

Introducing the Report of the International Meibomian Gland Workshop

Kelly Nichols, O.D., M.P.H., Ph.D.

There have been occasions when I've heard that my lectures are “more science-y” than most other ocular surface talks. I've learned to take that as a very high compliment—it is a characteristic I have no intention on changing.

The same approach and respect for “science” became my mantra throughout the two-plus years process as chair of the International Meibomian Gland Workshop, a Tear Film and Ocular Surface (TFOS) society-sponsored report. “What does the literature say?” became a constant mantra. And not surprisingly, in many instances, the answer was “there is a lack of evidence” in many aspects related to meibomian gland dysfunction (MGD). But while gaps in our knowledge exist, the evidence can be assimilated to create a consensus overview to powerfully move the field forward.

A new approach to MGD

The report of the MGD workshop, featured in this column, published in Investigative Ophthalmology & Visual Science (Special Issue 2011, Vol. 52, No. 4) and presented as a double-sided pull-out insert in this issue, can be downloaded through a link at www.tearfilm.org. (See “Progress Toward a Better Understanding of MGD” at the end). Most notably, the report presents a new consensus algorithm for the diagnosis and management of MGD.

What does this mean clinically? Early in my research career, I was significantly influenced by the 1995 NEI/Industry Report on Clinical Trials in Dry Eye published in CLAO Journal (now Eye and Contact Lens). I regarded it as a blueprint for future clinical research in dry eye disease (e.g. the kind of research to make a difference in patient care). I picked dry eye as a research area because I felt it was a disease that was salient and accessible to optometrists.

Flash forward, and indeed, dry eye disease has become an optometry mainstay. More O.D.s are prescribing therapies for ocular surface diseases than ever before. In fact, the number-one prescribed ocular medication by O.D.s is for dry eye (cyclosporine ophthalmic emulsion 0.05%, Restasis, Allergan). Many O.D.s have adopted a medical model approach and are increasingly including Ocular Surface clinics as part of their practice's business plan. If you look at optometric practice management seminars, dry eye is always included. That was not the case 10 years ago.

Mark my words: Management of MGD as a component of dry eye disease will become a defining and value-added service in optometric clinical practice. It is a perfect fit.

Changing times

I have recently written about our ability as clinicians to access, read and assimilate research into practice (www.optometric.com/article.aspx?article=105146) as well as the vagaries of managing dry eye (www.optometric.com/article.aspx?article=105365). In both cases, I believe we are experiencing a paradigm shift. In today's internet-centric world, a vast quantity of information is available at our fingertips. Deciphering the good is a challenge, and a valid approach to this problem is to hope and expect that someone else will do this for us. Besides my dry wit (pun intended) and charm, it may be why you read this column. And, I feel strongly that the information I discuss is valid and thought-provoking—yes, “science-y.”

It has also been documented that clinicians highly value a well-written yet succinct review article on a topic of interest that carries with it clinical pearls and/or cases. What can be said for the comprehensive yet lengthy review article? They are rated as highly valuable by clinicians, but are perhaps harder to assimilate in a short time frame. When I lecture, I often discuss the Dry Eye WorkShop (DEWS) report (also sponsored by TFOS). I generally get a response that about 30% of the audience has read some portion of the report (also available at www.tearfilm.org). Is there a better way to get consensus review materials into the clinician's hands?

Information download

In planning the publication of the current MGD report, we made the decision to have several versions of the report. The full report is published in IOVS and consists of nine papers (168 pages in total), which includes the Executive Summary (eight pages). The PDFs of all papers in the report are open-access on the IOVS website (see link at the TFOS website above). Complete or partial translations of the report are offered in numerous languages, including English, Dutch, French, German, Greek, Italian, Japanese, Polish, Portuguese, Spanish, Turkish and Russian and will be distributed around the world.

In addition, a two-page (front and back) summary was created for wide distribution through clinical media and is published here, as well as in OM's sister magazines Ophthalmology Management and Contact Lens Spectrum. Therefore, material is available to meet the needs of the reader.

This type of programmatic change—the paradigm shift I see occurring in which quality information is appropriately distilled or broken down to make it accessible—is not a one-size-fits-all model. And while I do not subscribe to the less is more mentality in terms of knowledge, I would not expect a clinician with a focus in a different area, e.g. glaucoma, to read the full report—a two-page standard of care summary might suffice.

So is MGD dry eye?

In the end, while most believe MGD contributes significantly to evaporative dry eye, the largest subcategory of dry eye disease, this question remains unanswered. I believe that not a day goes by in clinical eye care in which a patient with MGD is not sitting in every office. It may be a patient awaiting cataract surgery, a symptomatic contact lens wearer, a postmenopausal woman, a patient taking glaucoma medications, the student on isotretinoin therapy or the family member of the previously described patient. It is our choice how to diagnose and manage these patients, our job to sort through their ocular surface disease. Continued clinical experience will provide the impetus to design studies to answer this critical question.

Presenting …

So with that, please read the two-page summary included in this issue of OM (MGD: Get Your Ducts In A Row). Carefully remove it for further use, and consider downloading and reading all or part of the full report. It has been my pleasure to work with such talented and passionate clinicians, scientists and industry leaders on this project. I sincerely hope we continue to see documents like this from other fields so we can enhance the way in which we do our jobs. I also hope that some young clinician scientist will read this report as a blueprint for tomorrow, as I did years ago, and it will change his/her life. OM

Progress Toward a Better Understanding of MGD

By Kelly K. Nichols, O.D., M.P.H., Ph.D. and Gary N. Foulks, M.D.

The millions of patients who suffer from dry eye eagerly await any interventions that might help them cope with—if not cure outright—their ocular surface disorder. So, we must make sure our clinical skills reflect the very latest research and the consensus opinion of the experts conducting leading-edge research in the field.

One such group of experts, the Tear Film and Ocular Surface Society (TFOS), is a nonprofit organization with the primary mission of advancing research, literacy and educational aspects of the scientific field of the tear film and ocular surface (www.tearfilm.org) across the globe. In addition to conferences held every three years, the most publicized projects supported by TFOS are its “workshops.” For instance, in 2007 the “Report of the International Dry Eye Workshop (DEWS)” was published in The Ocular Surface and has since been translated into six languages. One could argue that this document as a whole has had the most significant impact on the field in terms of increasing worldwide awareness of dry eye disease. Excitingly, we may be on the cusp of a similar breakthrough for the subset of dry eye conditions rooted in dysfunction of the meibomian glands.

The MGD Workshop

In late 2008, TFOS initiated a workshop on meibomian gland dysfunction. More than 50 international experts participated in the effort, which occurred through a two-year period. The process was sponsored generously through industry support via unrestricted grants to TFOS, allowing volunteers to come together to create a consensus overview of the field. In addition to an exhaustive international literature-based review of the salient clinical, translational and basic research, emerging concepts, such as a new diagnostic and management algorithm, are also included. Thus, this report, published in the March 2011 issue of Investigative Ophthalmology & Visual Science (Special Issue 2011, Vol. 52, No. 4) is the most current, definitive summary of the meibomian gland in health and disease.

A two-page perforated pull-out summary of the full report, compliments of TFOS, is included in this issue of Optometric Management article “MGD: Get Your Ducts In A Row.” The full report can be downloaded through a link at the TFOS website (www.tearfilm.org). Highlighted in the summary are the following:

► A consensus definition and classification scheme for MGD.
► An evidence-based diagnosis and management algorithm.
► A current schematic of the etiology and associated pathophysiology of MGD.
► A review of the prevalence and associated risk factors for MGD.

Evidence-based Approach

Evidence-based principles guided the preparation of the MGD Workshop report. The same evidence guidelines were used in the DEWS process and are a modification of the American Academy of Ophthalmology Preferred Practice Patterns guidelines. As such, the new diagnosis and management algorithm presented in the report is an assimilation of the clinical research published to date. However, it is important to note that evidence on MGD management is somewhat limited. The existing studies are often relatively small and are neither randomized nor placebo controlled, and most management and therapeutic techniques are used off-label. Thus, the recommendations reported likely will continue to undergo evaluation in both clinical practice and clinical research.

Key Clinical Findings

It is believed that MGD may be the most common cause of evaporative dry eye and may also have some association with aqueous-deficient dry eye. Therefore, a complete dry eye examination should include symptom evaluation, clinical assessment of the meibomian glands, meibomian gland expressibility and evaluation of the quality of meibomian gland secretions. Co-existing dry eye should be evaluated through assessment of tear film instability and ocular surface staining. It is our hope this report will motivate clinicians to look at the meibomian glands more closely, as well as to inspire future clinical and translational research with the ultimate goal of improving care of MGD and dry eye patients across the world.