MGD quote of the day
“I don’t think you need all glands to work. I’m happy if I can get 50-75% to work!”
- a presenter in an MGD session at AAO
Here is my second of I-don’t-yet-know-how-many posts about AAO….
In my previous post, I mentioned a corporate-sponsored dinner by an equipment manufacturer that I attended shortly after arriving in San Francisco. I ended up enjoying this meeting very much for many reasons.
There were three excellent presentations from which I learned a lot - Kendall Donaldson from Bascom Palmer; Rolando Toyos, the IPL-for-MGD pioneer; and Laura Periman, our neighbor in the Seattle area whose awesome presentation on cosmetics and dry eye I blogged about back int he spring.
I’ve been aware of IPL for forever, or rather, since patients of Dr Toyos began writing about their experiences in dry eye forums in the early 2000s. But I can’t say I ever learned that much about how it is believed to work, so I thoroughly enjoyed (not to be equated with “internalized” or “retained all the gory details of…”) every bit of information presented.
I’m always on the lookout for information on which MGD treatment seems to be working best for whom, about which there was a lot of discussion that evening - as indeed, throughout AAO. But the very best part of the experience was, as usual, getting to know some of the people around me and hearing how they relate to it all. There were many lively debates after the presentation, that is for sure, from a laser engineer raising sage eyebrows over some statements made to ophthalmologists who regularly use IPL and/or Lipiflow
Over the following days, IPL came up in many more MGD and dry eye sessions. I feel as though IPL has waxed and waned at times - perhaps what I mean is that it was eclipsed by Lipiflow for quite a long stretch but has been steadily growing in popularity. Setting aside comparative technical merits (about which the medical community will be debating till kingdom come), just from a patient-friendliness standpoint, I think there’s an argument for the superiority of a three-treatment approach over a single treatment approach from the standpoint of managing our own expectations and stress from treatments. There’s a lot of dashed hopes going on in the dry eye world. But then, as soon as I write this I’ll probably hear from people who quite understandably want to just get a treatment over with quickly rather than dragging it out.
Here is a condensed version of some of my observations through the days at the conference:
Cataract and LASIK patients are increasingly being targeted for MGD in-office treatments, including IPL. How much of this is necessary, versus good for cashflow? I don’t know. But it’s a continuously growing trend. I dislike the business aspect BUT I appreciate the fact that it is raising awareness of the need for cataract surgeons to talk dry eye turkey with their patients well ahead of surgery. There are still far too many people with dry eye getting cataract surgery without knowing it may cause or exacerbate dry eye.
MGD vs dry eye: One presenter stated that IPL acts on meibomian glands but also has an indirect effect on tear insufficiency. Incidentally, she also pointed out that dry eye is an off-label use of IPL. That concept gets forgotten a lot.
IPL for demodex: A presenter mentioned a study suggesting IPL may work better than tea tree oil for getting rid of demodex.
IPL vs Lipiflow: There was some discussion about how IPL is used only on lighter skins while Lipiflow may be preferred for darker skin tones. One doctor said that those with loose skin or lagophthalmos were not good candidates for Lipiflow so they preferred IPL.
To express or not to express: This was the subject of lively discussions, public and private. I found it very interesting at the Lumenis dinner that while everyone clearly has the highest respect for Dr Toyos, many flatly disagree with him about expression and about how exactly IPL works (the opinion about the former being directly related to the opinion about the latter). At my table (or half of a table) there were strong opinions against the utility of expression after IPL. Both at the dinner and at the scientific sessions there were some strong opinions in favor, and one example was described of using fingers and a Q-tip then following up with a special forcep.
More on patient selection: There was a study in 2017 which listed six different types of MGD. The presenter claimed that IPL is the only treatment that is able to address each one.
“Younger patients see results sooner” from IPL than older patients do was stated once or twice in a discussion.
What’s the right interval to re-treat? (Since IPL is typically done in a serious of three treatments or more.) There was a lot of good discussion about this and a variety of opinions but they typically aim for the 4-6 week interval and one or two explanations for this were given about factors that cause it to start losing effect if waiting weeks longer than that.
A well known eye doctor is claiming a 97% success rate, which prompted a few lip curls. The same doctor talked about the goal being to “get people off of drops”. That seemed awfully ambitious to me, as in, while it would be “nice”, people who are motivated to pay cash for IPL are probably diseased enough that they are beyond the point of caring whether they need to use drops - they just want to get more comfortable! However, he also promoted the concept of keeping patients’ home regimen as short and simple and possible, which seems a good thing to aim for.
IPL after probing? A question came up about this in a scientific session. The presenter’s answer was that she only probes selectively, after IPL, if the glands show a lot of abnormality.
What about the “dead” glands? As discussed in the previous post, an occasional theme in MGD at this conference, including for IPL, was the idea that just because a gland appears to be atrophied doesn’t necessarily mean it is irrecoverably gone.