To Convince Dry Eye Patients to Stick with Treatment, One Meibography Image can be Worth a Thousand Words
By Marguerite McDonald, MD, FACS
Among the millions of people in the United States afflicted with dry eye, there are a few common traits. Though we now have many young patients with dry eye due to their constant use of digital devices, the classic dry eye patients tend to be older, the majority are women, and up to half of them report no symptoms. In addition, research tells us, between 86 percent and 92 percent of them also have meibomian gland dysfunction (MGD).1
When the presence of MGD and the absence of dry eye symptoms occur simultaneously, the result may be a patient who doesn’t comply with recommended treatment regimens.
In our practice we’ve found one very effective way to convince patients to stick to a treatment regimen: meibography.
MGD can be difficult to diagnose. But meibography produces images that not only help make a definitive diagnosis, but also convince the patient they have a condition that requires treatment. It’s truly a case of one picture being worth a thousand words.
In the United States, three devices are approved for taking meibography images: the OCULUS Keratograph 5M, the HD Analyzer from Visiometrics, and the LipiScan/LipiView units from J&J Vision.
We have developed a protocol for using the images. We start by explaining that meibomian glands secrete meibum, which is made up of lipids that coat the aqueous layer and help provide tear stability, which helps maintain a healthy ocular surface. When the glands are dysfunctional, irritation, itching and visual disruption can result.
The next step is to present to the patient a chart that contains three photographs: one of a healthy lid with normal meibomian glands, a second image with moderate gland loss, tortuosity, truncation and inspissation, and a third image of a lid with near-total loss of glands.
Finally, we show them meibography images of both their lower lids. Altogether, this process takes about one minute, but can produce a dramatic response from the patient. And it also can produce a lasting patient commitment to a treatment program.
The visual evidence from the meibography images often convinces patients, even those experiencing mild symptoms or no symptoms at all, of the importance of treating the condition. They also can be helpful in convincing a preoperative cataract or LASIK patient that it’s important to restore the ocular surface as much as possible in order to obtain accurate preoperative measurements.
In patients with MGD, I wait at least six months before taking repeat images, because the anatomy seems to change slowly. In my experience, lost glands typically do not recover. Rather, the goal of treatment is to prevent further tissue damage.
Currently there is no specific billing code for meibography. Some practices bill for the images using the "external photography" code, while others do not bill at all, as they are waiting for a specific meibography code. Even if one doesn’t charge for meibography, the images can be extremely valuable, helping to convince patients to comply with treatment, and in increasing the conversion rate for in-office procedures such as microblepharoexfoliation and thermal pulsation therapy.
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.
Marguerite McDonald, MD, FACS, with OCLI on Long Island, NY, is clinical professor of Ophthalmology at NYU Langone Medical Center, NY, and clinical professor of Ophthalmology at Tulane University Health Sciences Center, New Orleans, Louisiana.