In our surgical practice, we believe preoperative thermal pulsation is so effective in optimizing the tear film to improve surgical outcomes and patient satisfaction that we include it in all premium and advanced technology lens packages.

We also recommend thermal pulsation for all patients undergoing LASIK. But this procedure is one that I believe could and should be performed in primary care optometry practices far more than it currently is. Unfortunately, many of the thermal pulsation referrals we get are for patients with late-stage dry eye. However, earlier treatment leads to a better long-term prognosis. Practices that do not recognize this are missing easy opportunities to improve patient satisfaction and practice revenues at the same time.

In my opinion, the largest potential pool of candidates for thermal pulsation therapy are contact lens wearers who have become intolerant or are struggling to wear their contact lenses comfortably. As many as 50% of contact lens wearers struggle with discomfort, usually caused by an inadequate tear film resulting from meibomian gland dysfunction (MGD). Patients think this is normal, but we have a great opportunity to help them continue to wear contact lenses more comfortably.

A simple technique for determining whether someone can benefit from thermal pulsation is to ask whether their vision fluctuates. If it does, they probably have evaporative dry eye. Other signs are end-of-day dryness and replacing their contact lenses more frequently than scheduled. TearScience LipiFlow (Johnson & Johnson Vision), which was the first thermal pulsation treatment approved, has been shown to increase comfort and roughly double contact lens wearing time (Blackie et al.).

People believe MGD mostly occurs in perimenopausal women and older patients, but it is increasingly common in younger adults, teens and even children. Digital devices and computers are major contributors because users blink less or incompletely when concentrating on the screen. Blinking helps the meibomian glands express and maintain the flow of meibum. Without adequate compression, this olive oil-like secretion solidifies and obstructs the gland, leading to increased risk for meibomian gland atrophy and loss. The tear film also evaporates more rapidly without a sufficient lipid layer to maintain stability.

Evaporative stress also occurs in patients wearing face masks in medical settings or to reduce the spread of COVID-19. Their breath blows up into their eyes, and the tear film evaporates more quickly. I have also recently seen an increase in MGD among patients dealing with poor air quality. I saw a 20-year-old firefighter who could not refract to 20/20 due to ocular surface problems. He had trace to 1+ superficial punctate keratitis on his inferior cornea and had already lost two meibomian glands on each eye. We performed the TearScience LipiFlow treatment to help improve function in the remaining glands and reduce the risk for further loss.

Finally, consider recommending thermal pulsation therapy for patients with MGD-associated red eyes. These patients may be self-treating with redness reliever eye drops, which can lead to rebound and worsening dry eye, whereas thermal pulsation treats the root of the problem.

There are several ways to integrate thermal pulsation into your workflow.

Educate patients. Take a few minutes during the exam to explain how thermal pulsation therapy can help prepare the patient for surgery or improve their contact lens comfort. I describe how thermal pulsation unclogs their oil glands to maximize oil production. This improves the tear film, promotes healing and prevents their natural tears from evaporating so quickly.

Schedule immediately. Ideally, we like to perform thermal pulsation the day of the examination, if possible, which facilitates patient flow. Although we also recommend home therapy, they may not follow through, and we see the most reward from this treatment.

Continue the conversation. Just as a dentist will consistently recommend flossing even if patients are not consistently doing it, it is important to keep thermal pulsation as part of the discussion during every visit. You are planting a seed so that patients will know that treatments are available.

Reappoint. If refraction is difficult, we prescribe home treatments, provide handouts and ask patients to return for a dry eye evaluation and refraction recheck because their poor tear film is affecting their refraction. I tell patients that new glasses will not help if their prescription is inaccurate or if their vision is fluctuating due to a poor tear film. The dry eye appointment can then be billed as a separate medical visit.

Engage staff. Staff members help educate patients and reinforce messaging. After I make my recommendations, I hand off the patient to a staff member who further discusses their condition and treatments. This saves chair time and helps us provide exceptional patient care and education.

Embracing medical optometry is key in confronting the epidemic of dry eye that is underdiagnosed and undertreated. Educate your patients about the role of their meibomian glands and the options you have for treating them. By integrating thermal pulsation into your practice, you can retain patients and help them be successful with nearly every other recommendation you make.

Casey Claypool, OD, is director of ocular surface disease at Empire Eye Physicians in Spokane, Washington. He can be reached at casey.claypool@empireeye.com.

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