Dry eyes secondary to blepharitis and or meibomian gland dysfunction, though extremely common, is an annoyingly difficult condition to treat for several patients. Part of this difficulty lies in the inability of most patients to follow intensive and often times complex eyelid cleaning instructions coupled with a large quantity of artificial tear use to improve the lipid profile of the precorneal tear film. The LipiFlow Thermal Pulsation System was designed to directly tackle meibomian gland dysfunction as this is seen as the root cause of this condition. A device that uses an insulated lid warmer, which resembles a scleral contact lens to vault the cornea and provide controlled heat to the tissues, delivers the thermal treatment. The device also has an eye cup that consists of an inflatable bladder that sits on the eyelid and pulsates to allow expression of the meibomian glands. Heat treatment with pulsation is delivered to the meibomian glands over a 12-minute period. This paper looks at the one-year results of using this new device. Thirty patients with evaporative dry eye disease with meibomian gland dysfunction and dry eye symptoms were recruited for the study, but only 18 were able to return for the one year review. The effectiveness of the device was reviewed by measuring meibomian secretion scores and tear break-up time. Dry eye symptoms were measured using the Ocular Surface Disease Index (OSDI) and the Standard Patient Evaluation of Eye Dryness (SPEED). The authors report a significant improvement in meibomian gland secretion scores from baseline measurements (4.0±3.4) to one month, which were maintained at one year (7.3±4.6; P<0.05). Baseline tear break-up time (4.9±3.0) was significantly increased at one month (9.5±6.9; P<0.05); however, this improvement was no longer evident at one year post-treatment (6.0±4.4). The improvement in symptom scores on Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness questionnaires observed at one-month (P<0.0005) was maintained at one year (Ocular Surface Disease Index [P<0.05]; Standard Patient Evaluation of Eye Dryness [P<0.0005]). The authors found no statistically significant difference between right and left eyes, and as such they averaged them for each patient; however, they do not document if a correction was applied or not. This study suggests that it is possible with a single 12-minute treatment of thermal pulsation, to improve some symptoms of meibomian gland dysfunction for up to a year. The study does not mention the cost of the device or cost of treatment, for ophthalmologists to assess whether the cost / benefit analysis is in favour of this treatment or not. Also the authors agree that the device does not tackle all aetiological causes of dry eyes, particularly as dry eye tends to be a multi-factorial condition. There is also concern about the number of dropouts from the surgery, though the authors have made an attempt to explain what happened to the 12 patients lost to follow-up. The main question for the authors will surely be how their device compares to relatively cheap and easily available latent heat devices that are now on the market. 

Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment.
Greiner JV.
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Kwesi Amissah-Arthur

Birmingham and Midland Eye Centre, Birmingham, UK.

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