The combination of punctal occlusion, topical cyclosporin (0.2 %) and topical lubricants prescribed by RM’s ophthalmologist was, at the time of referral, well tolerated by the patient and was proving sufficient to maintain a modest volume tear meniscus. The management plan for this aspect was not altered, therefore, particularly in light of reported sensitivities to a number of eye products previously, including a lipid/aqueous combination product. The account of symptoms of dry mouth, as well as dry eye, however, suggested the possibility of underlying systemic disease and prompted serological evaluation, to test for auto-antibodies pertinent to Sjögren’s syndrome. These included rheumatoid factor (RF), anti-nuclear antibodies (ANA), anti-SS-A/Ro and anti-SS-B/La. While RM tested sero-negative to these antibodies, at this time, it was recognised that unequivocally discounting a diagnosis of Sjögren’s syndrome was not justified. Antibodies against SSA/Ro are identified in only around 50 % of patients with Sjögren’s syndrome, while antibodies against SSB/La are found in even fewer, around 30 % of patients with Sjögren’s syndrome (Huo et al. 2010). Fractionally borderline results for some of the antibodies in RM’s case indicated that repeat evaluation in the future might be warranted.

With serological testing underway, the next step following referral to the Ocular Surface Laboratory was to direct treatment towards RM’s meibomian gland dysfunction and its sequelae. On presentation, RM had been performing regular, twice-daily lid cleansing with a commercial lid preparation, followed by 10-min, warm compress treatments with a microwave-heated wheat bag, according to the advice of her ophthalmologist. Subjectively RM reported modest symptomatic relief from these treatments. After confirming appropriate lid cleansing, warming and expression techniques were being performed by RM; further advice was provided with regard to environmental exposure. The modification to the environment recommended in this case involved, not only minimising exposure to low relative humidity environments created by air conditioning and exposure to high air flow environments but also avoiding exposure to airborne chemicals with the potential to destabilise the tear film. RM described having worked in a building situated adjacent to a vehicle paint-spraying site where exposure to noxious fumes from paint and associated chemicals was a regular occurrence. Paint thinner, for example, is primarily a mixture of aliphatic hydrocarbons, the vapours of which are recognised to induce conjunctival and corneal irritation and inflammation (Bulbulia et al. 1995). Goggles that create a seal around the skin protect the local environment which can help with maintaining higher levels of moisture around the exposed ocular surface (Alex et al. 2013; Korb and Blackie 2013b) and can also reduce exposure to airborne irritants. Spectacles with foam inserts perform a similar function, with superior cosmetic acceptability, and therefore were recommended in this instance (http://​www.​7eye.​com/​) and resulted in symptomatic improvement. Interestingly, in this case, the patient’s subsequent decision to change her job made a further noticeable difference to the severity of her ocular discomfort symptoms, corroborating the belief that airborne pollutants were a significant factor in exacerbating her dry eye condition.

RM’s low-lipid delivery state was deemed to be the result of obstruction of the gland orifices due to significant keratinisation that could be observed extending onto the lid margin surface (Fig. 8.2a). Hyperkeratinisation of the meibomian ductal system is recognised to be a core mechanism in the development of obstructive MGD (Henriquez and Korb 1981; Knop et al. 2011).

The decision was made to debride the lid margin, in an effort to facilitate egress of the meibomian fluid from the inferior glands (Korb and Blackie 2013a). Topical anaesthesia of the eyelid margin with oxybuprocaine 0.4 %, (Bausch & Lomb) was followed by staining with lissamine green (Fig. 8.2b) to highlight the keratinised areas. Utilising the magnification of the slit lamp, the surface of the lid margin was carefully debrided with a golf club spud (Fig. 8.2c), and the excess keratinised material gently removed. The resulting lid margin profile was significantly smoother as seen in Fig. 8.2d, and the number of glands yielding secretion markedly increased. To date, this improvement has been maintained for over 8 months, post-treatment.

Debridement was thus successful in facilitating meibum outflow from the glands, but, somewhat disappointingly, it was observed that the lipid layer created, following debridement, was of poor quality and the tear film lacked stability, as indicated by a non-invasive break-up time of less than 4 s. The abnormal coloured fringes that were visible (Fig. 8.3a) suggested the presence of lipid globules amidst areas of little or no lipid cover (Guillon and Guillon 1993). Without confluence, such a layer is believed incapable of performing its required function of inhibiting tear evaporation (Craig and Tomlinson 1997).

A means of modifying the lipid quality was therefore sought. Low-dose doxycycline taken over an extended period (e.g. 50 mg daily for 2–3 months) is a well-established therapy for improving gland function in MGD (Sobolewska et al. 2014) and was thus considered as a potential therapy. Reflecting their anti-inflammatory rather than anti-bacterial properties, low-dose tetracyclines improve lipid quality on account of their ability to suppress the production of the bacterial lipases which otherwise serve to destabilise the tear film in MGD (Dougherty et al. 1991). Our patient, however, had not tolerated doxycycline well during a previously prescribed course and was reluctant to commence further doxycycline treatment. It was elected therefore to adopt a more natural approach to lipid layer alteration, through diet. Essential fatty acid supplementation has recognised anti-inflammatory effects throughout the body, due competitive inhibition, between the omega-3 fatty acid, eicosapentaenoic acid, and omega-6 fatty acid, arachidonic acid, to synthesise mediators with anti-inflammatory properties over potentially harmful inflammatory mediators (James et al. 2000). Mounting evidence suggests positive effects in MGD from dietary supplementation with omega-3 fatty acids, with a recent randomised, placebo-controlled, trial describing improvements in symptomatology as well as in clinical signs such as lid margin inflammation, meibomian gland expression, tear film stability and tear production (Olenik et al. 2013).

Such improvements were, indeed, realised following a conscious effort by RM to increase her omega-3 intake, both naturally from the regular consumption of smoked salmon and in the form of a nutritional supplement. After an 8-week period, her non-invasive break-up time was noted to have increased by around 3.5 s, in tandem with an improvement in her lipid layer quality to a marmoreal/wave combination pattern (thickness around 60–80 nm), implying presence of a confluent lipid layer (Fig. 8.3b) (Guillon and Guillon 1993). Tear evaporation rate was correspondingly decreased.

A concurrent reduction in bulbar conjunctival hyperaemia (Fig. 8.4) and symptoms was also noted, following the lid margin debridement and the described change in diet.

Following the dietary changes, RM’s tear film and ocular surface condition was observed to stabilise and symptoms were described as tolerable, although not fully ameliorated. With the hope of achieving further symptomatic relief, RM thus opted to engage in an opportunity to trial treatment with the E > Eye Intense Pulsed Light (IPL) device for MGD within the Ocular Surface Laboratory. The potential benefits of IPL technology, as an MGD therapy, were discovered during cosmetic IPL skin treatments for patients with acne rosacea, where it was noted that individuals with associated ocular rosacea experienced concurrent improvements in their dry eye condition following IPL treatment on the upper cheek area of the face (Mark et al. 2003). Toyos in the United States is a firm proponent of IPL for MGD on the basis of his personal clinical findings (Toyos et al. 2005). However, the reports of these open-label treatments require validation with randomised, placebo-controlled trials to confirm the true benefit. Certainly, from an anecdotal perspective, patient RM has experienced further improvement in meibomian gland function since commencing monthly IPL treatments, with both immediate and sustained increases in lipid layer quality. She currently exhibits an amorphous/normal coloured fringe pattern, corresponding to lipid grade 4/5 (Fig. 8.5), and this has been associated with a reduction in ocular discomfort symptoms.

At the present time, RM is enjoying significantly reduced irritation symptoms, in comparison to those on presentation, and is delighted with the reduction in her red eye appearance. Her quality of life has improved significantly, such that she can now work a full day without marked restrictions on her activities. She continues with cyclosporin therapy, punctal occlusion and artificial lubricants as required, supplemented with ointment at night. Due to hypertrophy of the punctum secondary to silicone punctal plugs, which was causing intermittent mechanical irritation, a more permanent solution to punctal occlusion has recently been sought with cautery to replace the silicone plugs. Lid hygiene, warm compress therapy and manual expression form part of a daily routine for RM. These ongoing strategies, applied in conjunction with lid margin debridement, dietary regulation and monthly IPL treatments, have, in the words of this individual, ‘given her back her life’.