OD shares drug-free approach to treating

meibomian gland dysfunction

Primary Care Optometry News, November 2009
Jeanette Lee, OD

COMMENT ON THIS ARTICLE

EMAIL

PRINT

SAVE

We talk about dry eye all the time to patients, but are we diagnosing dry eye
correctly?
See Also

Dry eye treatment: the whole picture

Herantis Pharma pursues phase 2 study for dry eye treatment ...

Begin treating dry eye before referring cataract patients for ...

Featured

VEW 2014

AOA

ARVO

Highlights from EGS

Highlights from Vision Expo East

Highlights from SECO

Highlights from AAO

I will share my protocol for treating evaporative dry eye associated with meibomian gland
dysfunction (MGD) or posterior blepharitis, which I have refined over the course of 10 years.
Most optometrists treat dry eye with artificial tears, indicating that they believe most dry eye is
due to an aqueous deficiency. I have found that about 80% of my patients with dry eye
complaints have an evaporative component (meibomianitis) and many have a combination of
evaporative and aqueous deficiency. However, if you treat the
MGD first, the artificial tears work much better because the
patient will have a sufficient lipid layer to prevent evaporation
of the tears.
Determining type of dry eye
Patients have a variety of subjective complaints when the eyes
are dry. Based on the symptoms, the doctor can easily predict
which type of dry eye a patient has before clinical testing is
performed. The accompanying table shows the common
symptoms associated with each dry eye deficiency.

Warm compresses by
Quantum Heat are applied
with the lids closed for at least
15 minutes.
Image: Lee J

When a patient has MGD, the pores are moderately to

severely blocked and can also have an oil deficiency. Various
factors such as dust, make-up, pollen, blepharitis scales or
wearing contact lenses can block these pores. No matter what factor caused the pores to be
blocked, opening them can greatly reduce the dry eye symptoms.

Biochemical changes in the body due to hormonal changes, medications or stress can cause an
oil deficiency. The quality of oils secreted becomes thicker and the quantity can be affected. Oil
deficiency is addressed through nutritional supplements. I recommend ProOmega capsules from
Nordic Naturals.
How to assess MGD
When diagnosing MGD, first assess the lids and look at the lid margins to note redness,
inflammation or fatty acid build-up. The most important component of the dry eye exam is the
manual expression of the meibomian glands.
Place the thumb against the lid margin and press firmly against the eyeball to determine the
percentage of meibomian pores that are blocked. This assessment is performed on both the upper
and lower lid of each eye. Refer to the accompanying table to grade the MGD. Normally, the
meibomian secretions are easily expressed and are thin and clear in consistency. Lipid secretions
become more milky and thicker as more pores are blocked.
First treatment phase: open meibomian pores
There are two phases of treatment: Open up the meibomian pores and recommend daily use of
nutritional supplements.

The key to my success of this dry eye treatment was finding a heat pad that sustained its
temperature for about 15 minutes. I use the heat pads made by Quantum Heat. Warm compresses
cannot work without massage therapy of the lids to release the blocked contents. For patients to
have minimum dry eye complaints, the pores must be 65% open on both upper and lower lids.
My goal is to get the pores more than 80% open so patients can remain asymptomatic without
repeating this dry eye treatment. I have set this goal as a result of fine-tunning my treatment plan
for nearly 10 years.

Use two heat pads, one for each eye, with the lids closed for a minimum of 15 minutes. The more
heat the lid can take, the more the pores open up and the more the blockages dissolve.
Remove the heat pads and immediately massage each eye (upper and lower lid) for 5 minutes.
Place the index finger against the edge of the lid margin. Massage in a circular motion and begin
on the nasal side and then move across the lid to the temporal side. Repeat this again, but go
from the temporal side to the nasal side. The patient may experience temporary blurred vision
due to the blocked oils being released into the eye.
Clean the base of the lids and lashes with lid scrubs, preferably pre-moistened pads. I use
OcuSoft Lid Scrub Premoistened Pads. This prevents all the debris and expressed contents from
re-blocking the meibomian glands.
The patient should perform these steps before bedtime for up to 6 weeks.

Patient understanding and recognition that they have dry eye is vital to the success of the dry eye
program. Patients with grade 1 MGD are generally asymptomatic and will not acknowledge that
they have dry eye even if clinical findings determine otherwise. However, those with grades 2 to
4 of MGD will greatly benefit from the treatment.
Perform medical visits every 2 weeks to reassess the percentage of blocked or open pores.
Patients cannot tell if they are massaging correctly, but the doctor can guide the patient during
theses visits. If patients perform this treatment daily and correctly, they will complete the
regimen within 6 weeks by reaching more than 65% opening of the meibomian gland pores. For
maintenance, patients should continue with massaging the lids (without heat pads) daily in the
shower to keep the pores unblocked.
Second treatment phase: nutritional supplements
Research has shown that essential fatty acid supplements, omega-3 and omega-6, aid in the
treatment of dry eye. I recommend front-loading the first month with omega-3 fatty acid
supplements (one capsule = 1,000 mg), two capsules twice daily for the first month, then one
capsule twice daily continually. This greatly enhances the quality and quantity of the lipid layer.
Before beginning treatment, make sure this supplement does not interfere with patients
medication.
Completion of the two-phase treatment will heal most patients dry eye symptoms. If needed,
patients may require more dry eye treatment. It is amazing how patients can have dry eye
problems most of their life, but this simple drug-free treatment can cure this problem within a
few weeks
http://www.healio.com/optometry/cornea-external-disease/news/print/primary-careoptometry-news/%7Bf72f71ed-ec25-421a-8731-97cdafd0766c%7D/od-shares-drugfree-approach-to-treating-meibomian-gland-dysfunction

The Experts Open Up on Meibomian

Dysfunction
When youre facing a condition with signs and symptoms as varied as those in meibomian gland dysfunction,
it pays to be thorough.

Walter Bethke, Managing Editor

11/16/2010
When a patient presents with an irritated eye and/or dry-eye symptoms, meibomian
gland dysfunction is high on the clinician's differential-diagnosis list. Different from
an aqueous-deficient state, MGD can cause dry eye by either hindering the body's
ability to produce natural oils that keep tears on the eye, or by altering the quality

of the oils so much that they can't do the job properly. In this article, ocular surface
experts share their tips for rooting out MGD as the cause of patients' complaints and
discuss the treatment approaches that work best.

Classifying MGD
MGD is also sometimes referred to as posterior blepharitis, and Kansas City, Mo.,
corneal specialist Joseph Tauber says he's amazed at how common it is. "I'm always
treating a lot of patients with ocular surface disease, and I'm struck by how high the
incidence of MGD is in my patients," he says. "The coincidence of meibomian gland
dysfunction and dry eye is probably between 50 and 75 percent, depending on the
type of practice you're looking at. Every study I know of that's looked at the
incidence of meibomitis has reported an incidence of 50 percent or greater in
patients coming in for cataract surgery, retinal surgery or even in general
ophthalmic practice.
"The traditional division in the classification of dry eye is aqueous-deficient and
evaporative," Dr. Tauber continues. "Though there are some causes of evaporative
dry eye unrelated to blepharitis, such as anatomical problems with the lids like
issues with exposure, the overwhelming cause of evaporative dry eye is related to
dysfunction of the meibomian gland. Also, severity escalates from individuals with
abnormal secretions from the meibomian gland but no symptoms to individuals with
lid problems. There are also those a little further along with problems on the corneal
surface that are directly related to the abnormal functioning of the gland and/or
problems from the gland's effects on the tear film."
Ottawa
ophthalmologist Bruce
Jackson says
dysfunction of the
meibomian glands
occurs over a wide
range. "For me, the
abnormal functioning
of the glands means
that they're

oversecreting, undersecreting or blocked, with underlying changes to the eye," he

says.

Diagnostic Signs and Symptoms

Though every ophthalmologist will approach a patient a little differently than his
colleagues, here are thoughts to keep in mind from physicians constantly dealing
with MGD.
Symptoms. Physicians say it can be hard to pinpoint MGD from a patient's chief
complaint alone. "The symptoms of meibomian gland dysfunction occupy, I find, a
wide range," says Robert Latkany, MD, founder of New York Eye and Ear Infirmary's
Dry Eye Clinic. "They can be as simple as asymptomatic, or they can be burning
which is high on the listdryness, irritation, tearing, redness, a foreign body
sensation or intermittent blurry vision. Those are the key complaints. However,
sometimes there can be pain in the form of a pinprick sensation. So, no one
symptom points directly to this condition, though some specialists disagree with
that notion."
Look at the whole patient. The experts note that, in cases of MGD, it can be
a mistake to instantly dim the room lights and go to the slit lamp, as that approach
can actually make your diagnostic process harder. "Everyone needs to stand back
and look at the patient as a whole," says Dr. Jackson. "We should quickly assess
such aspects as whether or not he has rosacea or other skin problems around the
face, as MGD is associated with rosacea. Rosacea cases are frequently missed,
especially when associated with dry eye." It's at this time that you can also notice
chalazia. "If the patient has a chalazion you can see or has a history of multiple or
recurrent chalazia, that's diagnostic of MGD," says Knoxville, Tenn., corneal
specialist David Harris. "It implies that there's already been obstruction of the
meibomian glands and chalazia have formed."
The patient's history. It's also important to take a good history, especially
with regard to the medications the patient may have taken. "A complete history is
of great value," says Dr. Tauber. "In patients with a history of breast cancer, the
chemotherapy drug Taxotere is infamous for causing pretty severe meibomian gland
dysfunction, in my experience. The same is true for Accutane, not that you can
reverse its effects easily.
Still, knowledge of a patient's use of these drugs has prognostic value, as you can

tell the patient to buckle up for the long haul in terms of treatment." Dr. Jackson
also lists topical antibiotics, especially aminoglycocides, as possible inciting factors
behind MGD, due to their possible toxic effects.
Dr. Latkany tries to get a
sense of the diurnal
fluctuations in symptoms.
"I find that meibomian
gland dysfunction is more
bothersome for these
patients early in the
morning or near the end
of the day," he says.
Detailed diagnostic
tips. If there aren't
obvious signs of rosacea
or chalazia that help
clinch the diagnosis
quickly, take a detailed
look at the eye. "Look at
the quality of the tear
film," says Dr. Harris. "Are
there oily debris floating
in it that could point to
MGD?
Also, look at the tear-film breakup time. Sometimes, there's no oily debris in the tear
film but a rapid tear breakup that can be a clue that MGD is present. Punctate
keratopathy can be a sign of dry eye, MGD or both. And look at the meibomian
gland orifices to see if they're present or scarred down by previous inflammation or
plugged with a whitish material. Also, you can transilluminate the tarsal plate to
look for evidence of atrophy, loss or degeneration of the meibomian glands, all of
which would contribute to the diagnosis of MGD."
Doctors say expression of the glands is telling, as well. "The eye exam isn't
complete until you look at the lid margin at the slit lamp and express the glands
with a cotton-tip applicator or your finger," says Dr. Latkany. "Observe how easily
the contents of the meibomian glands come out and note their consistency. In a
healthy patient without evidence of blepharitis, a gentle compression of the lid
margin will yield a clear, oily substance from the meibomian glands. You don't have
to push that hard to get it out.

The harder you have to push, the less likely it's coming out with a natural blink. And,
if it's not coming out with a natural blink, chances are the oils aren't serving their
purpose.
Use that as your baseline. In patients with meibomian gland dysfunction or posterior
blepharitis, it won't be normal. I use a grading system of 0 to 4+ for meibomian
gland secretions. 1+ is a slightly thicker and slightly discolored expression, while at
4+ you might not be able to get anything out of a gland. There's also the toothpaste
sign in which, if you squeeze hard enough, you get a secretion that has the
appearance of toothpaste squeezed from a tubea white ribbon. That's also on the
severe end of meibomian gland dysfunction."
Dr. Latkany also uses the tear-film normalization test on these patients to look for
the presence of dry eye, since they often experience intermittent blurry vision. For
the test, he checks the patient's vision with the Snellen chart until he gets to a line
that looks fuzzy to the patient. At that point, Dr. Latkany instills a drop of watery
tears in the patient's eyes, such as a Refresh or a Blink tear. If the line becomes
clear within five to 10 seconds, he knows the patient has dry eyes, and, in his
experience, it's typically from MGD. "If the vision doesn't improve, his level of
dryness isn't that severe, or is possibly non-existent," he says.
Dr. Harris also notes to watch for saponification. "Another indication of meibomian
gland dysfunction is foaming in the tear lake consisting of soapy molecules," he
says. "Bacterial oxidation has begun to convert the meibomian lipids into soapy
molecules in the tear film, which cause the symptoms of irritation patients may
complain of." Physicians also say bad atopic patients can have both anterior and
posterior blepharitis, and often present with red, puffy eyes.

Treating MGD
When approaching treatment for MGD, the experts usually try the simple
treatments first.
Traditional approaches. "Highest on the list is getting the patient to play an
active role expressing his glands on a daily basis, similar to flossing his teeth," says
Dr. Latkany. "He can do it at home with a Q-tip. Also, addressing the source of any
inflammation is key. If the patient is highly allergic, find out what he's allergic to and
avoid it, or have him take some anti-allergy medication. If he has rosacea, identify

the triggers and avoid them. If it's a medication issue, see if you can go to an
alternative. Anything that triggers inflammation can certainly impact the flow of the
meibomian glands."
Dr. Tauber describes his treatment approach to patients with the phrase,
"Normalize, mobilize and neutralize." "Ideally, first we would normalize the
secretion," Dr. Tauber says. "I think doxycycline and omega-3 supplements are our
best strategies to do that at the moment. There's good evidence that systemic
tetracyclines like doxycycline, by virtue of their anti-inflammatory effect and the
way in which they change the nature of the lipids produced by the meibomian
glands, can relieve symptoms.
"Next, we mobilize," Dr.
Tauber says. "This means
getting the oils out of the
lids where you don't want
them and onto the eye
where you do want them.
We achieve this through
the use of lid compresses,
which are believed to melt
plugs composed of dried
secretions blocking the
gland orifice; lid hygiene
measures and/or the new
approach of probing.
Finally, we neutralize. By
this I mean the use of
artificial tears for their
rinsing effect in an attempt to balance the ill effects that are caused by the
secretions on the ocular surface." For the use of tetracyclines, a common regimen is
doxycycline 100 mg b.i.d. for four to six weeks, according to Dr. Latkany, who
mainly reserves it for patients with an inflamed facial presentation.
"Along the same lines as the tetracyclines, azithromycin [AzaSite] is an option,"
adds Dr. Latkany. "I haven't determined the type of patient for whom it works best,
though, since it doesn't work best for every case of MGD. There's no one medication
that treats all cases 100 percent of the time. To try it in a patient, I'd use it b.i.d. for
five days along the lid margin, and then q.d. for three more weeks. Here, you're
trying to attack the posterior blepharitis with the drug's anti-inflammatory
properties in what amounts to an off-label use. I'd also potentially use Restasis for
addressing dry eye, as I find it's sometimes helpful for patients with posterior

blepharitis/MGD. If I am going to use it, I recommend they refrigerate it and use it

b.i.d. or t.i.d. indefinitely.
"For patients who aren't responding to day expression or the subsequent
medications, we have steroids and non-steroidal anti-inflammatories, which can
certainly be beneficial," Dr. Latkany continues. "You have to be cautious if their use
becomes chronic, but, as long as you follow them closely, this is an option. If
needed, I'll use Alrex or FML b.i.d. or q.d. for a month or so, then reassess the eye.
For some of the severe cases, I might go to a stronger steroid if need be, but I never
use it more than t.i.d. I'd then reassess the eye and check the pressure, seeing what
the response is in a shorter time frame." Dr. Latkany says it's important for patients
who are using more viscous drops or thick ointments to wipe those ointments from
their eyes each morning, because the accumulation can potentially obstruct the
flow of the glands. Dr. Harris notes that the recently introduced drop Systane
Balance (Alcon) may be useful in these patients, as well, since it's designed for
patients with MGD. Alcon says Systane Balance's LipiTech system works with the
drop's other ingredients in an effort to restore the tear film's lipid layer.
Experimental treatments. Physicians are working with novel therapies for
MGD, including gland probing, intense pulsed light and hormone therapies.
Probing consists of anesthetizing the lid, then inserting a thin, stainless steel probe
into blocked glands in the hope of unblocking them. It was first proposed by Tampa,
Fla., dry-eye specialist Steven Maskin. Dr. Tauber has done just over 200 cases with
probing and says he's improved his anesthetic approach as he's gone along. He's
currently gathering his results for a study evaluating objective signs of meibomitis
as well as patient symptoms. Because patients complain of varied symptoms, Dr.
Tauber is evaluating the treatment's effect on the worst symptom, as described by
each patient. He says the single initial word patients use to describe their worst
symptom is usually "dryness," "blurring" or "burning." Dr. Tauber's probing approach
is different from Dr. Maskin's in that Dr. Tauber treats every gland he can during a
treatment session, while Dr. Maskin treats a select number based on a patient's
report of tenderness. "At this point in my experience, with an average follow-up of
9.5 months, I'm seeing overall positive response rates in between 66 and 75
percent of patients, with an average of 50 to 60 percent relief of their worst
symptom," Dr. Tauber says. The probes are sold by Rhein Medical (Tampa, Fla.).
Another experimental treatment is Intense Pulsed Light, championed by Memphis
surgeon Rolando Toyos. The treatment uses heat from a special flashlamp to melt
the plugs in the gland orifices. (For a detailed look at IPL, see this month's
Technology Update).

Finally, some physicians are turning to compounding pharmacies to mix up topical

hormone therapies for MGD patients. "For tough cases, you have to think outside
the box," says Dr. Latkany. "Hormone therapy can be testosterone or a combination
of testosterone and progesterone. Leiter's Compounding Pharmacy in California has
several hormone options, and I've used them with varying degrees of success."
Though ophthalmologists can successfully treat many MGD patients, they say their
understanding of the disease is only just beginning, and they look forward to the
upcoming release of the findings of the International Workshop on Meibomian Gland
Dysfunction, which are to be published in Investigative Ophthalmology and Visual
Science. "With the publishing of the workshop's findings, we're going to find out that
there's so much crossover," says Dr. Jackson. "You can have anterior and posterior
blepharitis together. Also, we don't yet know the roles of cytokines and chemokines
in blepharitis, for example. We're not nearly as far along in our understanding of lid
disease as we are in our understanding of dry eye."
- See more at:
http://www.reviewofophthalmology.com/content/i/1353/c/25863/#sthash.9E30zg55.
dpuf
http://www.reviewofophthalmology.com/content/i/1353/c/25863/