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tional gland volume than the temporal section. However, somewhat counter-intuitively, the amount of gland atro- phy was significantly highest in the nasal section, and the atrophy didn't correlate with gland function or volume (except in the case of total gland dropout). While this was a small study involving 23 eyes, the take-home mes- sage for me is that if meibography shows gland atrophy, it doesn't necessarily mean LipiFlow treatment won't be successful. We still may be able to stimulate the glands to fully function and relieve symptoms. I also use intense pulsed light therapy (IPL, DermaMed) for patients with MGD. IPL was originally developed to address irregular skin pigmentation but has been reengineered for this new use. A treatment involves six to eight pulses of Xenon flash lamp light applied to the malar region on each side of the face. e mecha- nism of action isn't fully understood. It may be related to a decrease in bacterial load, or the regression of telangiec- tasia, but it has worked very well for select patients in my practice. at said, we must be aware that IPL shouldn't be performed on patients who have darker skin; it's safest for those with skin types 1 to 5 on the Fitzpatrick scale. BlephEx (Rysurg), which we usually think of as a treatment for Demodex and blepharitis, can be effective for MGD, too. BlephEx is essentially exfoliation for the lid margin. Using the handpiece and micro-sponge along the edge of the eyelids and lashes, the clinician removes excess debris, bacteria, and biofilm that can lead to inflam- mation and dry eye problems. In a study of 20 patients with MGD who were examined and tested prior to and 4 weeks after one BlephEx treatment, mean score on the Dry Eye Ocular Surface Disease Index questionnaire improved by 53%, mean tear break-up time improved by 65%, and mean severity of both blepharitis and MGD on the Efron scale improved by 54%. 4 Although most of our treatments for MGD are on the outside of the body, we can also work from the inside by recommending omega fatty acid supplements. eraTears Eye Nutrition (Akorn) and HydroEye Support for Dry Eyes (ScienceBased Health) are two options. e eraTears product provides omega-3s (EPA, DHA, ALA) from fish oil and flaxseed. HydroEye contains the omega fatty acid GLA, which is derived from black cur- rant seed oil, as well as omega-3s (EPA, DHA) from fish oil. Most of my patients who are using HydroEye are dedicated to taking it. Several patients say they can tell when they miss a dose. MORE TO LEARN Our current treatments for MGD are a big help for patients and for us as we manage this potentially complicated and uncomfortable condition. Our understanding of the disease will continue to improve and bring us additional therapies to help patients that much more. y REFERENCES 1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. 2. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016;100(3):300-306. 3. Murakami D, Blackie CA, Pult H, Korb DR. Meibomian gland function cannot be predicted by meibography in patients symptomatic for dry eye. Invest Ophthalmol Vis Sci. 2014;55(13):27. 4. Connor CG, Choat C, Narayanan S, Kyser K, Rosenberg B, Mulder D. Clinical effectiveness of lid debridement with BlephEx treatment. Invest Ophthalmol Vis Sci. 2015;56(7):4440. JANUARY 2017 9 MGD CLINICAL TIP Staining the Line of Marx with vital dye, lissamine green in particular, can serve as a fast and simple indicator of meibomian gland dysfunction (MGD). 1 Marx's Line is a row of cells located on the upper and lower eyelid at the junction of keratinized eyelid epithelium and palpebral conjunctiva. As evaporative dry eye progresses, the line shifts. It moves from behind the meibomian glands (entirely on the conjunctival side) to partly touching the glands, to transecting the glands, to in front of them (entirely on the eyelid margin side). As you can imagine, when this thickened line of cells interferes with blinking, meibum isn't able to reach the ocular surface properly. Reference 1. Yamaguchi M, Kutsuna M, Uno T, Zheng X, Kodama T, Ohashi Y. Marx line: fluorescein staining line on the inner lid as indicator of meibomian gland function. Am J Ophthalmol. 2006;141(4):669-675. Figure 2. MGD can begin with microbial changes at the eyelid margin. Gland blockage Microbiological changes Resulting in MGD Increased melting temperature of meibum Dr. Hauser is an assistant professor at Southern College of Optometry and she practices in the college-affiliated TearWell Advanced Dry Eye Treatment Center in Memphis, Tenn.