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Department of Ophthalmology, Sørlandet Hospital Arendal, Arendal, NorwayDepartment of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, NorwayDepartment of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, the NetherlandsDepartment of Medical Biochemistry, Oslo University Hospital, Oslo, NorwayInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
Department of Medical Biochemistry, Oslo University Hospital, Oslo, NorwayInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
Department of Medical Biochemistry, Oslo University Hospital, Oslo, NorwayInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
Department of Ophthalmology, Institute for Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenDepartment of Ophthalmology, Sørlandet Hospital Arendal, Arendal, Norway
School of Optometry, College of Health & Life Sciences, Aston University, Birmingham, United KingdomDepartment of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, the NetherlandsDepartment of Ophthalmology, Vestfold Hospital Trust, Tønsberg, NorwayDepartment of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the NetherlandsDutch Dry Eye Clinic, Emmastraat 21, 6881SN, Velp, the Netherlands
Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 20 Staniford St., Boston, MA 02114, United States
Department of Ophthalmology, Sørlandet Hospital Arendal, Arendal, NorwayDepartment of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, NorwayDepartment of Medical Biochemistry, Oslo University Hospital, Oslo, NorwayDepartment of Ophthalmology, Sørlandet Hospital Arendal, Arendal, NorwayDepartment of Ophthalmology, Oslo University Hospital, Oslo, NorwayDepartment of Ophthalmology, Stavanger University Hospital, Oslo, NorwayDepartment of Ophthalmology, Vestre Viken Hospital Trust, Drammen, NorwayDepartment of Computer Science, Oslo Metropolitan University, Oslo, NorwayDepartment of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, NorwayDepartment of Quality and Health Technology, The Faculty of Health Sciences, University of Stavanger, Stavanger, NorwayDepartment of Oral Biology, Faculty of Dentistry, University of Oslo, Oslo, NorwayNational Centre for Optics, Vision and Eye Care, Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, Kongsberg, NorwayDepartment of Health and Nursing Science, The Faculty of Health and Sport Sciences, University of Agder, Grimstad, NorwayThe Norwegian Dry Eye Clinic, Oslo, Norway
Meibomian gland dysfunction (MGD) reduces quality-of-life and hinders work productivity of millions of patients, with high direct and indirect societal costs. Thickened meibum obstructs the glands and disrupts ocular surface health. Heating the eyelids to soften and express meibum from the glands can be beneficial. The most accessible method for eyelid warming uses heated, wet towels. However, the efficacy of this treatment is reliant on the methodology, and evidence-based best-practice recommendations are needed.
Purpose
To evaluate the literature on hot towels in MGD treatment and recommend a best-practice protocol for future research and patient treatment.
Methods
Studies were identified through PubMed on the May 28, 2021, with the search terms: (warm* OR heat* OR thermal* OR towel OR wet towel) AND (meibomian OR MGD OR eyelid OR “dry eye” OR DED). All relevant original articles with English full-text were included.
Results
The search yielded 903 results, of which 22 met the inclusion criteria. Across studies, hot towels were found to be effective at reducing ocular symptoms. However, without reheating, the temperature quickly fell below the therapeutic range, which was deemed to be between 40 °C and 47 °C. Towels heated to around 45 °C and reheated every-two minutes were most effective at increasing eyelid temperature, comparable or better than several commercially available eyelid warming devices. No adverse effects were reported in the studies.
Conclusion
Hot towel treatment effectively warms the eyelids and reduces ocular symptoms, but must be standardized, and towels reheated to achieve maximum benefit. Future research should assess patient satisfaction with different hot towel treatment methods that reheat or replace the towel at least every-two minutes, to establish which methods yield the greatest compliance. Guidelines or clinical recommendations that do not mention the need for regular reheating during hot towel compress treatment should be updated to include this.
]. MGD is hallmarked by increased tear evaporation, hyperosmolarity and symptoms of dry eye, including discomfort, visual disruption, and eyelid tenderness [
]. The healthy eye is protected by the tear film, which provides a physical and immunological barrier against microorganisms, pollutants, and other stressors [
]. The meibomian glands, located in the tarsal plates of the eyelids produce the meibum that makes up the outer lipid layer which stabilizes, reduces the surface tension of, and prevents the evaporation of the aqueous tear fluid [
The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland.
Fig. 1Schematic drawing of the anterior segment of the eye and ocular adnexa with the overlying tear film. The tear film is made up of two distinct layers, with three major components; mucin (1), aqueous tears (2), and lipids (3) secreted by the goblet cells, lacrimal gland, and meibomian glands, respectively. Illustration by Sara Nøland.
In MGD, the loss of healthy meibum production and function leads to lipid layer deterioration, which causes the tear film to become unstable, resulting in DED [
The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland.
]. This is low enough to keep the meibum mostly fluid during normal conditions, where the ocular surface and eyelids maintain a temperature of between 33 °C and 36 °C [
The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland.
]. In MGD, the increased viscosity, higher melting point of the meibum, and hyper-keratinization of the ductal epithelium together lead to the obstruction of the terminal ducts, which halts the secretion of healthy meibum [
]. Generally, the chemical structure of the meibum from patients suffering from MGD is more ordered than healthy meibum and has a hydrocarbon chain stiffness halfway between olive oil and butter [
]. To achieve the same level of disorder and liquidity as healthy meibum at 36 °C, meibum from patients with MGD requires a temperature of 38.5 °C on average [
]. This can be accomplished by delivering localized heat to warm the meibum beyond its melting point and applying pressure to express the softened meibum.
For warming of the eyelids, the application of a warm compress for five to fifteen minutes, followed by brief eyelid hygiene between once and four times daily is often recommended [
]. The most accessible method for warm compress treatment is the use of a wetted and heated towel that is placed over the eyelids to provide direct, moist heat to the eyelids [
]. Despite the long clinical tradition of recommending this treatment to patients, limited research has been performed to standardize this practice. Recently, several studies were published focusing on the ever-increasing number of alternative modalities for eyelid warming. These include commercially available dry-heat eyelid masks, steam-based systems, and in-office treatment systems [
Evaluation of a novel eyelid-warming device in meibomian gland dysfunction unresponsive to traditional warm compress treatment: an in vivo confocal study.
]. By critically reviewing the current literature on hot towel compresses in the treatment of MGD, this review aims to establish a best-practice for hot towel treatment and recommend a standard methodology for the application of hot towel treatment as a control in future studies. As hot towel compresses are the most widely available and affordable treatment option, a large number of patients worldwide are reliant on this treatment. Standardization of methodology could both help patients achieve the best possible results from treatment and improve the quality of research on eyelid warming devices, further advancing the field.
2. Methods
A search was conducted on PubMed on the 28th of May 2021 using the following search terms: (warm* OR heat* OR thermal* OR towel OR wet towel) AND (meibomian OR MGD OR eyelid OR “dry eye” OR DED). All search results were evaluated by a single author, first by title and later by abstract to ensure relevance to the topic and satisfaction of the inclusion criteria. The inclusion criteria for this review were: original, peer-reviewed studies with available English full text that investigated hot towel warm compresses to treat MGD. Only articles clearly describing the use of a towel/cloth-based method of warm compress treatment were included, studies on commercial devices or which did not describe the method of warm compress treatment were excluded. Further, case reports, review articles, and non-peer-reviewed literature were excluded. The methodology is illustrated in Fig. 2.
The search term (warm* OR heat* OR thermal* OR towel OR wet towel) AND (meibomian OR MGD OR eyelid OR “dry eye” OR DED) yielded 903 results, spanning from April 1948 to May 2021. Review article and case reports were filtered out, leaving 688 studies to be assessed for relevance by title and abstract. At this step, 623 articles were excluded, leaving 65 full-text articles to be evaluated. Of these, 22 articles were selected for this review based on the content of the full text. A majority of the 43 studies that were excluded in this last step either clearly stated the use of a commercially available eyelid warming device, not hot towels, or failed to provide any information on the type of warm compress used. One article was excluded as the group receiving hot towel treatment was pooled with other treatments and no clinical measures were reported separately for this group [
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Patients were given thermometers and asked to heat water to 60 °C. Towels were warmed in the water and applied while cooling. Used as control group for moist hot air device.
Towels were wetted and wrapped around a hot egg. Temperature was between 40 °C and 50 °C. Study included control groups with either unheated egg or hot egg not touching the eye.
Towels were wetted and microwaved to reach 45 °C. Group A had no reheating. In group B and C, the towel was replaced every 2 min, however group C aimed the compress towards the lower lid. All three groups treated only one eye, with the contralateral eye closed.
Towels were wetted and microwaved to reach 45 °C. Replaced every 2 min. Towel applied to one eye only, the closed, contralateral eye was used as control.
Towels were heated in “warm” water. Patients were encouraged to reheat when “they feel it get cooler”. Use of artificial tears and Blephagel was encouraged. Control group for EyeGiene and Blephasteam.
Follow-up on sub-population of Sim et al. Clinical performance deemed equivalent to Blephasteam and EyeGiene and tear lipidome analysis conducted on pooled data for all three groups.
Towels were wetted and microwaved on 500 W for 30 sec. Not reheated. The study compared single application of hot towels, Azuki no Chikara, Eye Hot R, Hot Eye Mask, and Memoto Este, and 2 weeks use of either hot towels or Azuki no Chikara.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Towels were warmed in “maximum comfortable” warm water. Patients were encouraged to keep a bowl of warm water and reheat when it began to cool. Control group for combination treatment that did not include lid warming.
Towels were warmed in tap water microwaved for 20 sec to reach 43 °C. Not reheated. Placed on a Styrofoam board. Compared with MGDRx, The Eye Doctor, MediBeads, Tranquileyes, and Eye-ssential.
Towels were wetted, bundled, and microwaved for 1.5 min to reach 47 °C. New towel unbundled and used every 2 min. Compared with MGDRx, MediBeads, Eye-ssential, Tranquileyes XR, EyeGiene, Blephasteam, and rice bag.
Towels were warmed in tap water that was microwaved for 20 sec to reach 39 °C. Not reheated. Compared with MGDRx, The Eye Doctor, MediBeads, Tranquileyes, and Eye-ssential.
Towels were heated in warm water to reach approximately 40 °C. Replaced every 20 sec, 2 min, or 5 min in different groups. Compared with Blephasteam and sauna.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Subjects were instructed to boil 200 ml of water and let it cool in an open bowl for 10 min. This aimed to produce a water temperature of between 39 °C and 50 °C. The towel was heated in the water and reheated every 2 min. Control for MGDRx and OPTASE compresses.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Participants were provided with a video demonstration. The subjects were instructed to use hot towel compresses for 5 min, then lid massage with baby shampoo. Control for LipiFlow combined with lid hygiene. Desired temperature, method of heating, or reheating schedule not described.
*Subjects receiving hot towels treatment as primary treatment, **Sub-population of Sim et al.
3.2 Thermal properties and efficacy of hot towel treatment
Studies varied in the types of towels used, method of heating, and desired temperature. As shown in Table 1, eight studies relied on microwaves to heat the towels [
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
]. The cotton facecloth was wetted in room-temperature water, folded three times, and heated for 20 s in a microwave oven. This yielded an initial temperature of around 43 °C, but fell below 40 °C after 2 min and the towel had a temperature of less than 30 °C after 10 min [
]. In this trial, Bitton et al. found that when applied over closed eyes, a cotton facecloth similarly folded three times would fall from 39.2 °C to below 35 °C after the first two minutes of application and fall further, to under 30 °C, by the end of the 12 min period [
Initial cloth temperature was 40 °C. The temperature fell quickly, but due to replacement of the towel, the applied compresses were above 38 °C for the duration of treatment.
Maximum inner eyelid temperature in A was 38.8 °C, B was 40.4 °C, and C was 40.8 °C. Both B and C achieved 40 °C within the first 6 min, and remained above 40 °C for the duration of treatment.
The outer eyelid temperature rose to 42.2 °C after 6 min and was maintained above 40 °C for the duration of the treatment. The cornea reached a maximum temperature of 39.4 °C after 8 min, but never exceeded 40 °C.
The inner lower eyelid temperature rose to about 40 °C. The bundle method gave a consistent and distributed temperature of about 40 °C at both the inner and outer eyelid surfaces.
Eyelid temperature increase was 3.2 °C when reheated every 20 s, 2.0 °C every 2 min, and 1.4 °C every 5 min, in healthy subjects. In patients with MGD, the increase was 2.7 °C when reheated every 2 min and 1.4 °C every 5 min.
The clinical effect of this rapid fall in temperature in the hot towels that were not reheated was shown in study by Pult et al., investigating the change in outer eyelid temperature with application of either hot towel compresses or Blephasteam [
]. This study found that upon application of the cotton cloth, folded three times, with an initial temperature of 41 °C, the outer eyelid temperature rose to 38 °C within the first minute but then steadily fell each minute after that, ending at 35 °C after ten minutes of application [
]. This shows that when the towels are not reheated, the temperature falls too quickly to provide enough heat for more than a couple of minutes, potentially preventing the heat from diffusing throughout the whole thickness of the eyelid to warm the meibum sufficiently [
The cooling rate found in these studies highlights the importance of reheating the towels to provide effective eyelid warming. As most of the heat loss from the towel is due to conduction and convection, Newton’s law of cooling can be used to describe the temperature function [
]. Simply stated, this means that the heat transfer from the object to its surroundings is proportional to the difference in temperature between the object and its environment [
]. This explains why a towel heated to 50 °C will have a much greater drop in temperature within the first two minutes than the same towel heated to 40 °C, all else being equal. Therefore, simply having a higher initial temperature of the towel is not sufficient to maintain an adequate temperature over time, and reheating is necessary. This theoretical principle is reflected in the temperature curves shown in Fig. 3a), which shows the temperatures of cotton towels reported in two studies that did not reheat the towels. Included in the graph is also the temperature range reported in a study where the cotton towel was heated to 40 °C and replaced every-two minutes [
Fig. 3Temperatures over time, interpolated from listed studies. The three graphs show the temperature of a) the physical towel used for treatment b) the outer eyelid, and c) the inner eyelid in studies with or without reheating of the compress during application. In the study by Olson et al. (a), towels were replaced every-two minutes with new preheated towels, thus the range represents the temperature range of the applied towels reported in the trial, not the temperature of any individual towel. For the studies labeled reheated, towels were replaced every-two minutes with either new preheated towels, or by applying a new towel from the bundle, effectively reheating the applied compress.
]. A towel warmed to 40 °C and replaced every-two minutes maintained an applied temperature range of between 38 °C and 40 °C for a full 30-minute application [
]. This is a major advantage over the towels that were not reheated, as the ability to provide steady heat over time is important for raising the inner eyelid temperature [
]. However, a limitation of these studies is the use of an already preheated towel to achieve reheating, which might not reflect the clinical setting where reheating of a single towel might be more likely.
The importance of reheating on eyelid temperature was demonstrated in several studies [
]. In 2008, Blackie et al., compared three different regimens of eyelid warming, one without reheating and two groups where the cotton towels were replaced every-two minutes [
]. The group without reheating reached peak inner eyelid temperature after only four minutes, and this subsequently fell for the duration of application [
]. In the two groups where the towels were reheated every-two minutes, the inner eyelid reached 40 °C within 6 min and plateaued at this temperature for the remainder of the 30 min [
]. The same was shown for the outer eyelid temperature in a later trial by the same authors, where the outer eyelid temperature plateaued quickly and remained virtually unchanged during application [
]. Furthermore, a towel warmed to 40 °C increased eyelid temperature by 1.4 °C if changed every 5 min, 2.0 °C if changed every 2 min, and 3.2 °C if changed every 20 s in healthy subjects [
]. No adverse effects related to heating or thermal injuries were noted in any of the studies.
Collectively, these findings indicate that reheating of the towel every 2 min is essential in providing safe, effective, and practical heating of the eyelid.
3.3 Efficacy of hot towel therapy over time
Eleven articles described eight studies with follow-up on patients undergoing hot towel compress treatment [
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
]. Important outcomes of the initial studies are summarized in Table 3. In many of these studies, hot towel compresses were used as controls to other treatments, and the application method was not well-described [
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
]. Across studies, the most frequently used treatment regime consisted of twice-daily, ten-minute treatment with a warm cotton towel that was either reheated when cooled, or not reheated. Most studies offered only a subjective description of the towel preparation and application method, such as the temperature of the towel being “warm” [
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
]. However, beyond the application time being 5 min, no further information regarding technique was provided. An additional limitation was that three of the seven comparative studies were open label [
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
]. Symptom scores improved in all eight from baseline compared to the last follow-up for those receiving hot towel compresses. One study used three separate measures of symptoms: the Ocular Surface Disease Index (OSDI) and Standard Patient Evaluation of Eye Dryness (SPEED) at baseline and follow-up, and a daily assessment of dry eye severity using a visual analog scale (VAS) [
]. The authors noted improvement in the daily symptom burden using VAS, while OSDI and SPEED scores were not significantly different from baseline at follow-up [
]. Korb et al. used both the Standard Patient Evaluation of Eye Dryness (SPEED) and the OSDI questionnaire and found significant improvements in both scores at the 1-, 2-, and 3-month follow-ups [
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
]. In these six studies, hot towel compresses were used as the control intervention for other eyelid warming devices, either commercially available or under development [
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
]. Further clinical measurements such as Schirmer I and meibomian gland scores and gradings were also reported in a smaller number of trials. None of the four studies measuring Schirmer I found any change from baseline at follow-up [
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
]. Korb et al. explored the number of meibomian glands yielding liquid secretion and found no significant increase in the group receiving warm compress treatment [
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Across studies, although differing methods and study populations, hot towel compress treatment was consistently shown to effectively reduce symptoms of MGD, but the effect on clinical signs of MGD was more varied.
3.4 Safety assessment and adverse effects
In two of the studies without extended follow-up, there was a significant drop in visual acuity and increased in subjective blur immediately after hot towel compress treatment [
]. Solomon et al. also noted the presence of a Fischer-Schweitzer polygonal reflex in patients after a 30-minute hot-towel treatment and linked this to the reduced visual acuity [
]. Another study found that the pressing force negatively affected the corneal topography, when the hot towel was wrapped around an egg to increase the heat capacity [
]. One study by Blackie et al. also raised the issue of elevated corneal temperature as a possible adverse outcome, as 30 min of 45 °C hot towel increased the central corneal temperature to near 40 °C, the level they deemed to be the safe upper limit [
]. Due to these findings, three of the studies with a follow-up period included measures of visual acuity, with one of these also measuring corneal topography [
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
Effect of using a combination of lid wipes, eye drops, and omega-3 supplements on Meibomian gland functionality in patients with lipid deficient/evaporative dry eye.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
Murphy O, V OD, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis. Curr Eye Res 2020;45(5):563-75. doi:10.1080/02713683.2019.1686153.
The efficacy between conventional lid hygiene and additional thermal pulsatile system in Meibomian gland dysfunction patients treated with long-term anti-glaucoma medications in a randomized controlled trial.
]. None of the studies reported any form of thermal injuries or patient complaints about the towels being too hot.
In summation, the adverse effects noted in the trials without follow-up, were not found in the studies with follow-up. Long-term treatment with hot towels therefore appears safe as long as the towels are not heated beyond safe limits or applied with excessive force.
3.5 Comparative studies and outcomes
The single-visit studies that did not reheat the wet towels found that the heat retention and eyelid warming effect of hot towels were inferior to the commercially available alternatives [
]. Murakami et al. found that of the eight devices tested (the bundle method, EyeGiene, MediBeads, Eye-ssential, MGDRx Eyebag, a rice bag, Tranquileyes XR, and Blephasteam), the bundle method of hot towel treatment was the only method capable of heating the eyelids above 40 °C. Moreover, the bundle method provided consistent heat to both the outer and inner eyelid surface [
]. In short, the bundle method consists of wrapping five or six wetted and folded microfiber towels in a bundle and microwaving the bundle in a covered dish for about 1.5 min. The temperature of the outer towel should then be measured, with the targeted temperature being 47 °C, as described elsewhere [
]. It is important to note, however, that the temperature should not exceed 48–49 °C and the patient should be advised to wait before application if the towels are to
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