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.