DEBS (Dry Eye and Blepharitis Syndrome) and Microblepharoexfoliation
By Marguerite McDonald, MD, FACS and Perry Fumuso, MS, MBA
For decades, conventional wisdom held that dry eye disease and blepharitis were distinct conditions. That is changing, thanks to the work of James Rynerson, MD. In research first published in 2016 in The Journal of Clinical Ophthalmology, Rynerson proposed that dry eye is a late-stage manifestation of decades of chronic blepharitis.
According to Rynerson’s thesis, which is steadily gaining acceptance among physicians and researchers, the process linking the diseases is this: bacteria colonize the lid margins with a biofilm. Biofilm, a sticky polysaccharide film, is, Rynerson argues, the missing link in understanding dry eye disease. Biofilm triggers mechanisms that result in inflammation, which, in turn, lead to meibomian gland dysfunction. All this, over decades, leads to lid destruction and the familiar signs and symptoms.
Just as our understanding of the disease process of dry eye and blepharitis is evolving, so are the effective tools we have available for treating the conditions. One of the most effective lid cleansing approaches is known as microblepharoexfoliation (MBE), which involves the use of a 2500 rpm rotating sponge soaked in lid cleanser to remove the biofilm. BlephEx is the name of this handheld rechargeable device, which was developed by Dr. Rynerson. In our experience, MBE is a highly effective treatment for removing the biofilm that is a major catalyst for progression of blepharitis and dry eye disease.
In a treatment that lasts about five minutes per eye, the small rotating sponge provides a thorough cleaning to remove altered meibum, scurf, living and dead bacteria, Demodex mites, and other debris and foreign matter from the margins of the eyelids. To perform the BlephEx treatment, a numbing drop first is placed in each eye. A new sponge tip is applied to the tool and it is dipped into the liquid cleanser. Then, the lid margin is gently but thoroughly scrubbed by passing the rotating sponge head across each lid. Each eye is rinsed with a sterile saline solution. A fresh tip is used for each lid; four tips are used in each patient’s treatment. The treatment is very well-tolerated by patients; it is not painful, although some report a mild tickling sensation of the lids.
In my practice, most patients tell me they notice improved comfort almost immediately after the procedure. In fact, relief can be so immediate and noticeable that it’s a good idea to remind patients they must continue their lid-cleaning routine at home. The home cleansing routine will help debulk the biofilm as it reforms, though MBE sessions need to be repeated every four to six months. This is similar to regularly scheduled professional teeth cleaning sessions at the dentist, as tartar also is the product of a biofilm.
What patients report is confirmed by a growing number of studies. Recently research in Australia confirmed that BlephEx increased tear production among contact-lens wearers.
Like any piece of equipment or device, BlephEx requires initial investment. However, statistics and experience indicate that initial investment will ultimately contribute to positive margins for most practices. Currently, BlephEx treatment is not covered by Medicare or private insurance, so for the time being it is a private-pay procedure, and most patients will need multiple treatments over the course of a year.
In my opinion, BlephEx is a vital tool in any Dry Eye Center of Excellence. It achieves two major goals for any center: it provides patients with substantial and effective symptom relief, and provides ongoing financial benefit.
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.