Grant Watters on 'Meibomian Gland Dysfunction and Contact Lenses'

Grant Watters latest article on “Meibomian Gland Dysfunction and Contact Lenses” in the latest issue of N.Z.Optics.

Also referred to in the latest issue of N.Z.Optics is  the latest treatment technology for Dry Eye, IPL (intense pulsed light) which Mortimer Hirst will be launching in October.

Meibomian gland dysfunction and contact lenses: our challenge

BY GRANT WATTERS*

Awareness of meibomian gland dysfunction (MGD)—and its role in ocular surface discomfort and contact lens intolerance—has been raised by the Tear Film and Ocular Surface Society (TFOS) workshop. Working towards understanding the mechanisms contributing to MGD and the implications of MGD on ocular surface health, the TFOS came up with a definition of MGD: 

MGD is a chronic, diffuse abnormality of the meibomian glands, commonly characterised by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.

Because it is well established that all types of contact lenses (CL) can disrupt the lipid layer of the tears, it stands to reason that any MGD will exacerbate the situation, and cause an increase in evaporative dry eye and contact lens intolerance. Add to this the “hostile” environment of air conditioned offices, heating in cars and at home, and a lowered blink rate during long hours of computer work and you end up with a surprising number of patients struggling, especially with the added “double whammy” of impending presbyopia.

These “Peter Pan Presbyopes” want solutions. Their eyes are drying out, causing blurred vision, and their near focus is also deteriorating. CL technologies for presbyopia can still be limiting, especially as we absolutely require wettable CL materials with good stable optics. A bridge too far? 

To provide some sort of a solution in our practice, we have become more assertive in offering in-house MGD therapy. We recommend the purchase of an eye wheat bag to replace the use of facecloths at home for more sustained heat release and for longer heat exposure periods of four to five minutes. We perform regular in-house expression programmes: first with eye wheat bags to warm up the MG’s; then, a golf club spud for lid margin debridement of any keratin over the MG’s; and finally with MG expression using mastrota paddle tweezers. We are also considering buying an E>EYE IPL machine, which has shown great promise (see separate story). The problem is that MGD, like blepharitis, can be chronic and recurrent—two ominous words—and patients are time-poor and even lazy when it comes to doing their own home therapy. Usually when things are going better, patients tend to stop doing their home treatments and then of course things take a turn for the worse. Educating them is therefore key so they know how to get back on track.

In-house MGD therapy actually achieves two things: you motivate the patient into keeping it up and you give them a “head start” for their home sessions; plus it allows you to diagnose far more accurately the degree or grade of blockage. Are the ducts completely plugged? Or, if expressible, what is the texture and colour like? Is it cloudy or creamy like tooth-paste or fairly clear? Does the patient show improvement with time? Are the lid margins looking less red and inflamed? Is there any improvement in corneal staining? I tell patients that one session in-house is the equivalent of them doing it for about two weeks at home to help motivate them.

If after a month of weekly in-house and home sessions there is little or no improvement, I write to the patient’s GP to ask for additional oral doxycycline or azithromycin supply, explaining why. Most GP’s will send out a script without insisting on a consultation and the mucolytic effect of tetracyclines can often soften up the blockages, improving treatment outcomes.

With a bit of effort and teamwork from us and the (motivated) patient, we can usually make good progress. Keeping them on an on-going home maintenance programme of eye wheat bag warm compresses and digital massage for 2-3 sessions a week also seems to help avoid regression.

Finally, there are two other groups of CL wearers who have to have a good stable tear film: orthokeratology (OK) wearers and keratoconics. The hydraulic engineering the tear film must achieve in OK lens wearers is massively affected by marginally dry eyes. While a lot of keratoconics have little choice other than to tolerate CLs for at least 16 hours a day in all sorts of crazy conditions. I have had to “pre-treat” OK children for MGD before proceeding, as it’s much easier to do first than having to backtrack! It is also not unusual for OK kids and keratoconics to have rosacea which has been overlooked. Also do a little bit of investigative work to see if any of your teenage OK wearers are on Roaccutane? Plus, MGD is known to be more prevalent in the Asian population.

In general we need to be more attentive to MGD therapy to help our CL patients maintain asymptomatic wear for reasonable periods. Our patients certainly enjoy their in-house “day spa” sessions and get on board with some positive education, after all “a problem shared is a problem halved!”

* Grant Watters is a qualified TPA optometrist and co-owner of Mortimer Hirst in Auckland. He specialises in keratoconus, Ortho-K (orthokeratology), complex contact lens fitting and management and contact lens troubleshooting. He’s also a lecturer and researcher with the Departments of Optometry and Vision Science and Ophthalmology, University of Auckland.

REFERENCES:

• Craig JP, Chen Y-H, Turnbull PRK. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthal Vis Sci 2015; 56(3):1965-1970.

• Nichols KK et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. Invest Ophthal Vis Sci 2011; 52(4):1922-1929.

• Pult H, Riede-Pult BH, Nichols JJ. Relation Between Upper and Lower Lids’ Meibomian Gland Morphology, Tear Film, and Dry Eye. Optom Vis Sci 2012; 89(3):310-315.

• Kunnen C, Nichols JJ. Meibomian Gland Dysfunction: An Update. CL Spectrum 2015; 30:22-27.

• Efron N. Contact Lens Complications (3rd.Ed) 2012 Elsevier.

Dry Eye Treatment*

E>Eye gets the thumbs up in latest NZ patient research

More than 80 per cent of patients who received E>Eye intense pulsed light (IPL) treatments at Merivale Optical in Christchurch reported their dry eye symptoms had improved, while 95.7 per cent said they would recommend the treatment to others.

The results come as part of a survey of E>Eye patients at Merivale treated over a 10-month period. Of the 86 respondents, 74.4 per cent were over 60 years old, 23.3 per cent were between 20 and 40 years old and 2.3 per cent were between 20 and 40. The research was conducted by John Veale, optometrist at Merivale and New Zealand distributor for France Medical’s E>Eye machine.

The E>Eye machine has been specifically designed for treating dry eye due to meibomian gland dysfunction (MGD). The device works by producing a calibrated series of IPL. These light pulses are precisely set at a specific energy and frequency to stimulate the meibomian glands and help them to recover their function.

Other results from Merivale’s research include 98.5 per cent saying the treatment was “no problem” or “okay”, and 55 per cent reporting they no longer needed to use eye drops following treatment.

A double-blind, placebo-controlled clinical trial of 28 patients with MGD by Associate Professor Jennifer Craig from the Ocular Surface Laboratory in Auckland University’s Department of Ophthalmology found 82 per cent of patients showed improvement after three treatments with the E>Eye device of at least one lipid layer grade on day one with 86 per cent noting reduced symptoms by day 45. There was also significant improvement in non-invasive tear breakup time (NIBUT) vs controls*.

For more information on the E>Eye visit: www.dryeyetreatment.co.nz. 

*Source: Craig, Jennifer P., Yen-Heng Chen, and Philip RK Turnbull. “Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction.” Investigative ophthalmology & visual science 56, no. 3 (2015): 1965-1970.

Virtual Reality Headsets And Your Eyes

As virtual reality (VR) headsets become more widespread, it's important for people to consider how they could negatively impact eyesight, according to a New Zealand optometrist.

Alan Saks, from Mortimer Hirst Eyecare in Auckland, says the growing use of VR headsets could potentially cause long-term damage to our eyesight including, myopia, retinal damage and macular degeneration.

It’s predicted that augmented and VR hardware will become a $5.8 billion global market in the next three years.

Saks says as the major electronic manufacturers develop lighter and more functional headsets there is an increasingly rapid consumer uptake, yet the long-term impact of these devices on our eyesight is still not fully understood.

In fact, several new models of the technology are already available in the New Zealand market.

However, already VR headsets have been known to cause a number of issues including ‘accommodative convergence problems’, and limited research has been done into the long term effects of these devices.

“Virtual reality works by tricking your brain into believing that you’re seeing a physical depth that isn’t actually there, but the fact that the screen is in reality only a few centimetres from the eyeball confuses the eye’s natural tracking and focusing processes when users try to readjust to their spatial environment.

“These processes normally work together, but with most VR headsets, because the object appears far away but the screen is only centimetres from the eyeball it creates a conflict for the eyes and visual system,” he says.

Saks says there are also issues with people who do not have binocular vision, which allows us to use both eyes in conjunction with each other - for instance, some people have problems viewing 3D movies.

Without knowledge of the long-term effects of VR headset use, a proliferation of the headsets could drive up myopia cases, Saks says.

Myopia, or nearsightedness, means the eye does not refract the light precisely onto the retina - which allows it to see clearly - but instead focuses light in front of the retina.

Therefore, distant objects will appear blurry but close objects will usually be clear, except in extreme cases.

According to Saks, myopia cases are already at epidemic levels in some Asian countries and on the rise in New Zealand and around the world.

“There is also a risk that by increasing the concentration of high energy blue light a person is exposed to that it will alter their normal sleep cycles and risk causing retinal damage and macular degeneration (a loss of vision in the centre of a person’s field of vision),” Saks says.

While VR headsets have existed since the late 1960s, they have not yet experienced widespread uptake because the older headsets were generally too heavy to be used for long periods and technological limits like slow motion-to-video reaction times caused nausea in users, Saks says.

Modern technology has overcome these problems, enabling the creation of lighter and more responsive headsets that seem set for widespread market adoption.

Some of these headsets come with warnings that the device is unsuitable for people younger than 13-years old, and to stop use if the wearer experiences symptoms ranging from eye strain and motion sickness to involuntary movements, twitching and even seizures.

While these effects are usually short term, it is not known if VR headsets could cause longer-term issues to a person’s vision, particularly with repeated heavy use, Saks says.

Until the long-term impacts are known, people should avoid heavy use and if they experience headaches or eyestrain to stop use and seek optometric advice, he says.

Air Optix Colours

The NEW Alcon Air Optix colours monthly contact lenses have been launched and are available now at Mortimer Hirst.

This is the most oxygen permeable coloured contact lens available on the market. There are 9 natural looking, beautiful colours available in power ranges +6.00 to -8.00.

If you are after a subtle colour change there are 5 colour options; Pure Hazel, Green, Blue, Gray, Brown.

If you are after a vibrant colour change there are 4 colour options; Honey, Gemstone Green, Brilliant Blue, 

Sterling Gray

The colour change is achieved by 3 components;

1. The outer ring which defines and emphasises the outer edge of the iris

2. The primary colour which transforms the eye colour

3. The inner ring which brightens the eye colour and adds eye colour depth

Consistent comfort is provided throughout the whole day with Air Optix colors due to the dual action of the coloured pattern being embedded into the back surface of the contact lens and the plasma surface moisture protection technology.

To help you decide which eye colour change you are after, there is an AIR OPTIX COLORS Colour Studio available http://www.airoptix.com/colors/colors.shtml. This allows you to “virtually try on” all the different colours. Mortimer Hirst clients have found this Colour Studio very useful prior to their Air Optix Colours contact lens assessment. Please call the friendly team at Mortimer Hirst to book your Air Optix Colours contact lens assessment today.  

Maintaining Good Eye Health

Regular eye examinations are an essential part of maintaining personal health and well-being, they are not just for people experiencing difficulty with their eyesight. Prevention of eye disease is best and our Optometrists and Contact Lens Specialists can offer advice on ways to guard your eyes against the harmful effects of conditions that may run in your family history, due to your work environment or due to the environment we live in.

Sun protection is crucial for young and old as chronic UV exposure can contribute to the aging processes of the eye. UV blocking sunglasses are recommended not just in summer but all year round to protect the cells on the eye surface and within. Mortimer Hirst customizes lens tints to suit your activities or provide options in polarized lens materials that enable more comfortable viewing in high glare. They can also advise on which contact lenses are manufactured with a UV blocking capacity.

Mortimer Hirst also offers preventative lenses offering protection against harmful blue light. Emitted by the sun and also by artificial light sources such as LEDs and computers or smartphones, chronic exposure is a risk factor in retinal cell degeneration which can contribute to the development of cataracts and Age Related Macular Degeneration.

A diet rich in antioxidants has a proven protective role in maintaining healthy cells within the retina. We should aim to eat plenty of leafy greens and fresh fruit daily, a handful of nuts a week and 2-3 servings of fish a week.

During an eye examination our clinical team look inside your eye to make sure the pathway that light travels is clear of any obstructive elements and that the light detecting cells and supporting structures at the back of your eye are working optimally. According the World Health Organisation 75% of the world’s blindness is preventable. Early detection is key in guarding against more serious outcomes.

Your optometrist will be looking to detect the earliest signs of conditions such as Glaucoma and Macular Degeneration, amongst others, by using a series of diagnostic tests, examination and imaging tools. Some of these checks can pick up systemic conditions such as Diabetes, Hypertension and Hypercholesterolaemia.

New 1-Day Multifocal Contact Lenses

Mortimer Hirst is pleased to announce they are among the first practices in the world to offer the latest in technology 1-Day ACUVUE MOIST MULTIFOCAL contact lenses for presbyopia.

After age forty the human eye loses the ability to focus (accommodate) for near vision. People comment their arms are getting too short, they need to hold things further away to read and that they need more light to read especially when tired.

Traditionally people have used reading glasses, bifocal or multifocal spectacles. Various contact lenses have been prescribed to correct this malady but each has their pros and cons.

When we age we need stronger near prescriptions and at the same time our pupil size reduces. This creates problems with multifocal contact lenses.

The new 1-Day ACUVUE MOIST MULTIFOCAL have 183 unique, tailored lens designs for varying prescriptions, reading additions and optical zones to counter these changes over time.

Optometrist and Contact Lens Specialist Alan Saks was part of the initial launch in Sydney.

Mortimer Hirst are among only four practices in New Zealand to have pre-launch access to this exciting new presbyopic contact lens option.

Oliver Peoples - Introducing the Executive Series

In continuation of the Vintage Circa 1987 collection, Oliver Peoples is pleased to debut

the Executive Series. This limited edition capsule collection celebrates two iconic lens shapes from the Oliver Peoples archive and reinvents them into modern combination designs, seamlessly blending vintage with contemporary appeal.

These unique frames were designed for those culturally discerning individuals who appreciate the best and strive for perfection.  Epitomizing this description is Matteo Marzotto, business tycoon, style icon, and bon vivant.  Partnering with Man of the World, a quarterly magazine and web site chronicling the best in international style, travel, food, art, and culture, Matteo Marzotto showcases the new collection with his own personal sense of style.

The semi-rimless eyewear features a lightweight, extremely thin titanium wire with barrel and screw, rather than a standard nylor thread. The flexible and lightweight beta-titanium temples, along with the hand-inlaid plaque and bridge, are enhanced with intricate filigree detailing for the most discerning connoisseur. A thin acetate brow bar in an array of tortoise shell hues complements the titanium structure in a rich mixture of materials. The result is sophisticated, rarified eyewear crafted to perfection and immaculately hand finished with exceptional attention to detail.

The optical styles of the Executive Series are now available exclusively at Mortimer Hirst in New Zealand with Sun styles coming soon.

Mortimer Hirst Welcomes New Optometrist

Mortimer Hirst is delighted to welcome Optometrist Emilie Langley to the clinical team. Emilie has worked part time for Mortimer Hirst over the past two year and has recently joined us full time. Emilie is a Therapeutically Qualified Optometrist and works from both High Street and St Heliers practices.

Emilie completed a Bachelor of Biomedical Science majoring in Functional Human Biology, studying at the University of Otago. The neurophysiology that Emilie was exposed to during the biomedical degree along with Emilie’s passion for working with and helping people were the driving forces to further study Optometry.

Emilie then completed her second degree, Bachelor of Optometry with Honours and Ocular Therapeutics, from the Department of Optometry and Vision Science (DOVS), University of Auckland.

Emilie tailored her Optometry studies around her interest in myopia progression and Orthokeratology (OrthoK).

In 2011, Emilie was chosen to be part of the Antipodeans Abroad Healthcare Volunteer Team to Nepal. This included Rural Outreach clinics and a 6 week internship at Manipal Teaching Hospital, Optometry and Ophthalmology Department, Pokhara, Nepal.

In 2012, Emilie was awarded a summer studentship scholarship from the New Zealand Association of Optometrists (NZAO) to help further research the theory of myopia progression inhibition, which her results are contributing to a paper that is soon to be published.

In 2014, Emilie was part of a team that completed leading research on OrthoK regression, supervised by Grant Watters and Dr. Wanda Lam, which won a New Zealand College of Optometrists (NZCO) award.

Emilie is a member of the NZAO and the Cornea and Contact Lens Society (CCLS). Emilie has a particular interest in contact lens practice including Ortho-K and ocular therapeutics.