Kerala Journal of Ophthalmology

: 2022  |  Volume : 34  |  Issue : 2  |  Page : 184--185

Effects of Lipiflow treatment prior to cataract surgery: A prospective, randomized, controlled study

K Husna 
 Consultant Ophthalmologist and Phacosurgeon, Comtrust Eye Hospital, Kozhikkode, Kerala, India

Correspondence Address:
K Husna
Consultant Ophthalmologist and Phacosurgeon, Comtrust Eye Hospital, Kozhikkode, Kerala

How to cite this article:
Husna K. Effects of Lipiflow treatment prior to cataract surgery: A prospective, randomized, controlled study.Kerala J Ophthalmol 2022;34:184-185

How to cite this URL:
Husna K. Effects of Lipiflow treatment prior to cataract surgery: A prospective, randomized, controlled study. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Nov 27 ];34:184-185
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Full Text

Park J, Yoo Y-S, Shin K, Han G, Arita R, Lim DH, et al. Effects of Lipiflow Treatment Prior to Cataract Surgery: A Prospective, Randomized, Controlled Study. Am J Ophthalmol 2021;230:264–75.

Majority of the patients complain of ocular discomfort after cataract surgery, despite an uneventful and successful surgery performed by a skilled expert. Regardless of the exact mechanism, Meibomian gland dysfunction (MGD), induced by cataract surgery has been shown to be responsible for postoperative ocular discomfort and dry eye, and requires adequate treatment. A number of studies have reported the efficacy and safety of Lipiflow treatment in treating MGD and have documented the potential benefit of Lipiflow as a primary treatment option for MGD and dry eye. It is not known whether or not prophylactic Lipiflow performed before cataract surgery can alleviate or prevent MGD and dry eye associated with surgery. The aim of this study was to investigate the effects of preoperative Lipiflow treatment before cataract surgery on alleviating obstructive MGD and dry eye induced by surgery.

It was a prospective randomized controlled study conducted at Samsung Medical Centre. This study comprised 124 eyes of 124 patients with planned surgery for senile cataract. Patients were enrolled in this study at the screening visit and randomized at a 1:1 ratio to either the Lipiflow group, whose members were treated with Lipiflow thermal pulsation or the control group, whose members were managed without Lipiflow treatment. In Lipiflow treatment, a topical anesthetic was applied before treatment, followed by bilateral application of a two-part activator. The inner portion of the activator, which covers the conjunctival surface of the upper and lower eyelids, heats to a temperature of approximately 42.5°C. The outer portion of the activator covers the cutaneous surface of the upper and lower lids and is inflated by air pressure. Both eyelids simultaneously receive warming and massaging for a period of 12 min. Patients with a history of ocular trauma or ocular surgery within 6 months, active infectious blepharitis or ocular infection, obvious abnormalities in eyelid margins or severe ocular surface abnormalities other than MGD, other cause of decreased visual acuity other than cataract, or those using systemic drug-like tetracycline derivatives, antihistamines, and isotretinoin were excluded from the study.

All patients underwent conventional phacoemulsification and posterior-chamber intraocular lens (IOL) implantation, conducted by two surgeons. The study design included four visits: one on three weeks before the planned cataract surgery, one on the day of cataract surgery, and one at each 1 and 3 months after surgery.

Tear film lipid layer thickness (LLT) measurement, meibography (partial or complete loss of meibomian gland (MG) was scored with LipiView II meibography), tear break-up time (TBUT), Oxford corneal staining score, and MG assessment with slit-lamp examination were done for each patient. After the ocular examinations, each patient was asked to complete the ocular surface disease index (OSDI) questionnaire and the five-item dry eye questionnaire (DEQ).

The gland orifices were evaluated under a slit-lamp microscope, using a handheld instrument, the Meibomian Gland Evaluator, which offers a standardized method of applying fixed pressure on each eye to ensure measurement consistency. The degree of gland expressibility was determined using pressure over the lower lids and was scored according to the number of fluid secretion-expressing glands among the eight at the centre part of the lower eyelid, regardless of qualitative appearance.

The primary endpoint with respect to the effect of Lipiflow treatment performed before cataract surgery was the changes in MG function from baseline to postoperative visits after cataract surgery. The secondary endpoint was the changes in ocular surface parameters and dry eye symptom in both groups. Also, the effects of Lipiflow treatment according to preoperative MGD status were investigated.

Meiboscores indicating structural loss of MGs were similar between the control and Lipiflow groups at baseline. The control group exhibited a significant decrease in MG expressibility, worsened meibum quality, decreased LLT, and worsened corneal staining after cataract surgery. Also, dry eye symptom showed significant worsening. Conversely, the Lipiflow group showed significantly improved MG patency and meibum quality, increased tear film break-up time, and reduced corneal staining; and presented improved subjective outcomes reported on both OSDI and DEQ. The improvement of each parameter in the Lipiflow group showed a linear correlation with baseline MGD grade. Patients with more severe MGD at baseline experienced greater improvement in expressibility and quality of meibum at 3 months postoperatively when treated preoperatively with Lipiflow, compared with those with milder MGD or those without MGD.

This study was the first report ever published to offer a prospective evaluation of the role of Lipiflow thermal pulsation therapy for the treatment and prevention of MGD-related dry eye after cataract surgery. Also, this study is an unbiased clinical trial with proper randomization, evaluating each and every parameter for a thorough understanding of preoperative Lipiflow treatment. This study has some limitations. Both morphological and functional assessment of MG, were conducted only in the lower eyelids. As Lipiflow directly acts on both the upper and lower eyelids, evaluation of both might yield more evident results. Although the patients were randomly distributed, baseline DEQ was different between the two groups. As such, rather than directly comparing the two groups, changes from baseline within each group were compared in this study. And also, the patients could not be masked whether they were included in the Lipiflow or control group, as Lipiflow devices do not offer Sham treatment mode.

The authors concluded that cataract surgery can produce or aggravate MGD and increase dry eye symptoms. Preoperative treatment with Lipiflow before surgery may ensure better outcomes by triggering improvements in ocular surface and MG parameters as well as subjective dry eye symptoms. Lipiflow treatment may be a safe and effective preoperative intervention for alleviating and preventing the MGD and dry eye associated with ocular surgery. It should be recommended before ocular surgeries, not only for patients with preoperative MGD, but also for those without baseline MGD, as it can prevent the development of MGD and dry eye induced by ocular surgeries.

As we used to have a lot of unhappy patients in spite of a good visual outcome after cataract surgery, use of Lipiflow for treating and preventing dry eye due to MGD, gives a new hope for cataract surgeons.