Frank W. Bowden, III, M.D., FACS

Microblepharoexfoliation for the Surgical Dry Eye Patient

Disclosures

Shire RySurg

TearScience Bausch & Lomb/Valeant

TearLab BioTissue

Surgical Dry Eye

The surgical dry eye patient requires a careful

assessment of the ocular surface.

Dry eye is usually accompanied by both

anterior and posterior blepharitis (MGD).

Preop management involves treatment of lid

margin disease.

Surgical Dry Eye

Traditional surgical preparation of ocular surface

Compliance with lid hygiene measures have been

inconsistent and/or ineffective for many patients.

Microblepharoexfoliation (MBE) represents a quick

and effective office procedure to clean the lids.

-lid scrubs

-warm compresses

-antibiotics

MBE Implementation

Dry eye screening of all surgical patients

Technician identification and workup

Counselor introduction of dry eye services

and surgical options

Surgeon exam and recommendations

Integrated Approach

MBE Implementation

Technicians

Validated dry eye questionnaire (SPEED/OSDI)

Point of service testing

Osmolarity

MMP-9

Lipid Layer Thickness (LLT)

Meibography

Partial Blink Rate

Allergy Symptoms Identified

MBE Implementation

Counselors

Dry eye Counseling

Video/brochures

Discussion regarding dry eye services

Pertinent Surgical Counseling

Video/brochures

Introduction of procedural options

MBE Implementation

Surgeon

Review of SPEED and dry eye diagnostics

Slit lamp exam of the ocular surface

Staining pattern ( fluorescein/lissamine)

Tear BUT

Meibomian gland score and count

Recommend MBE and perioperative dry eye treatment plan

based on findings and symptoms

Confirm the surgical procedure

MBE Implementation

Asymptomatic dry eye with lid margin disease

Patients are often unreceptive to dry eye discussion

Advise lid hygiene measures, lubricants, and antibiotic

Suggest MBE

Document dry eye discussion

MBE Implementation

Symptomatic dry eye with lid margin disease

Must educate patients regarding visual impact of dry eye and the need to delay surgery

Begin lid hygiene measures, lubricants, and antibiotics

Initiate topical cyclosporine and steroids along with oral Omega 3

Advise MBE

Address obstructive MGD

Thermal pulsation therapy

Meibomian gland probing/expression

MBE Implementation

Microblepharoexfoliation

Greater patient acceptance

with symptomatic dry eye

10 minute treatment at

interval dry eye visit prior to

preop testing

Proceed with ocular surgery

in 1-2 weeks

Microblepharoexfoliation (MBE)

BlephEx device

Developed by J. Rynerson, M.D

Consists of a spinning microsponge tip soaked in lid cleanser solution mounted on hand held device

Microsponge tip spins at 2,000 rotations per minute in either direction

Fresh tip for each lid

Dry eye is associated with lid margin disease

which may involve microbial proliferation.

Bacterial persistence is facilitated by

production of a protective biofilm and adaptive

protein upregulation (quorum sensing).*

Staphylococci may further promote ocular surface inflammation with exotoxin release.

MBE for surgical dry eye patients

* O’Brien TP. Ocul Surf. 2009; 7(2 Suppl):S21-22.

MBE effectively debrides the lid margin

Scurf

Collarettes

Demodex sleeves

Keratin debris

MBE effectively eliminates bacteria and exotoxins

Biofilm disruption*

Bacterial population reduction

MBE for surgical dry eye patients

*Black CE and Costerton JW Surg Clin North Am. 2010;90:1147-1160.

Microblepharoexfoliation

Technique Proparacaine drops

Assemble the BlephEx device

Stabilize the lid

Patient gaze away from treated lid

Scrub lid margin and lashes with

gentle pressure

Fresh cleanser soaked micro-

sponge for each lid

Saline rinse the eyes and lids

Apply thermal mask

Resume dry eye care

Microblepharoexfoliation

Technique

Microblepharoexfoliation

preop postop

Microblepharoexfoliation

preop postop

Microblepharoexfoliation

preop postop

Conclusion

Microblepharoexfoliation (MBE) is an effective procedure to

prepare the ocular surface for surgery in the dry eye patient.

Mechanical debridement of lid margin debris, scurf, and

collarettes along with bacterial biofilm and exotoxins with the

BlephEx device may effectively optimize the ocular surface for

surgery.

Patient acceptance of MBE has been very favorable.

MBE performed 2-3 times per year along with regular lid hygiene

may reduce the need for more invasive dry eye therapies.