There are only 4 Ways to Save Meibomian Glands: What is the best way to treat dry eyes? How can you save meibomian glands?

Meibomian gland loss/atrophy increases usually with age. Staring at the computer with its inherent decreased blink rates can increase meibomian gland loss even more. So can chronic allergy, chronic blepharitis (demodex mites clogging glands), Accutane (isotretinoin) use, chemotherapy, radiation, Rheumatoid Arthritis, Sjogren's syndrome, Lupus, or any other Autoimmune diseases, and maybe even LASIK and PRK.

I believe there is a global epidemic of dry eye. I am receiving consults from patients in China, Italy, England, Iran, Pakistan and Canada for dry eye. Many of these locations have poor air quality which will exacerbate dry eye symptoms.

There is a race against time to save meibomian glands globally. 

There are only 4 ways to save Meibomian glands:1

1. Lid hygiene, warm compresses (which really should be done for 15 minutes at a time with pretty hot compresses without burning the skin 2-3 times per day: this is tough to do), 2000-4000mg Omega 3 intake, liposomal sprays, artificial tears.

2. LipiFlow: we know that a single treatment of LipiFlow can improve tear breakup time at nine months (see Reference 1)  and improves dry eye symptoms for at least 12 months (see Reference 2). This costs about $1000 and is not covered by insurance but can be submitted to Medical Spending Accounts.

3. Intense Pulsed Light (IPL):  a 3-6 session course of intense pulsed light can lead to significant improvements in lipid layer thickness and tear breakup times at 45 days (see Reference 3). IPL cannot be performed on dark skinned patients due to depigmentation risks. This is not covered by insurance but can be submitted to Medical Spending Accounts. 

4. Meibomian Gland Probing AND Expression (MGPE) (Reference 4): This is a procedure where we take a 1mm cannula or probe and enter as many meibomian glands as possible of the upper and lower lids as indicated to try to open up any scar tissue and try to stimulate more oil gland production. It does work. A one time session of all four lids can provide eye pain relief, in some cases instantaneously and permanently (usually these patients do not have an autoimmune disease). Some patients need probing multiple times. I have many Sjogren's patients who say MGPE is the only thing that provided eye pain relief (even after Lipiflow or IPL). Two of these patients come in every 2-3 months for probing. Dr. Maskin charges about $7000. We charge currently $2000. This is not covered by insurance but can be submitted to Medical Spending Accounts.

http://eyedoc2020.blogspot.com/2016/10/how-much-does-meibomian-gland-probing.html

That is it. Thus there is a race against time to save the Meibomian Glands from chronic screen use and other factors that destroy glands.

Patients ask me frequently of what is the best way clean the eyelids and apply warm compresses. 

The small study by optometrists (non-MDs) in New Zealand shows that using heating devices, liposomal sprays, and heated warm compresses increase lipid layer grades but that there was no difference between them in the effectiveness: future larger sample-size studies will determine if there is any difference among them.

Sandra Lora Cremers, MD, FACS

Reference:

1. J.V. Greiner

Thermal pulsation system treatment improves meibomian gland function and reduces dry eye symptoms for 9 months

Curr. Eye Res., 37 (2012), pp. 272-278

2. J.V. Greiner

Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment

Clin. Exp. Ophthalmol., 41 (2013), pp. 524-530,

3. J.P. Craig, Y.-H. Chen, P.R.K. Turnbull

Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction

Invest. Ophthalmol. Vis. Sci., 56 (2015), pp. 1965-1970

4. Br J Ophthalmol. 2017 Jun 7. pii: bjophthalmol-2016-310097. doi: 10.1136/bjophthalmol-2016-310097. [Epub ahead of print]

Growth of meibomian gland tissue after intraductal meibomian gland probing in patients with obstructive meibomian gland dysfunction.

Maskin SL1, Testa WR1.

Author information

1

Dry Eye and Cornea Treatment Center, Tampa, Florida, USA.

Abstract

PURPOSE:

To investigate the impact of meibomian gland probing (MGP) on meibomian gland (MG) area from the upper lids of patients with obstructive meibomian gland dysfunction (o-MGD).

METHODS:

Retrospective study comparing pre-MGP/post-MGP non-contact infrared meibography results in patients with o-MGD, viewing signs of MG growth within total measurement field.

RESULTS:

Post-MGP meibography of 34 lids (19 patients, ≥4.5 to ≤12 months' follow-up) showed 41.2% with MG growth. Ten lids had meibographies suitable for analysis, showing significant collective (116 glands) increase in mean individual glandular area (MIGA) of 4.87% (p=0.0145). Four of 10 lids independently showed significant increase in MIGA, ranging from 10.70% to 21.13% (p<0.0001, p=0.0277, p=0.0292, p=0.0345), while six did not.At >12 and <25 months' follow-up, 16 lids (9 additional patients) had follow-up showing 25% with signs of MG growth. Analysis of three lids showed a significant collective (33 glands) increase in MIGA of 11.19% (p=0.0004). Two of three lids independently showed significant increase in MIGA of 13.73% and 20.00% (p=0.0097, p=0.0001). Collectively, for all 13 analysed lids (149 glands), there was a significant increase of 6.38% in total glandular area (p=0.0447) and a significant increase of 6.23% in MIGA (p=0.0003).

CONCLUSION:

MGP was associated with increased MG tissue area and growth of atrophied MGs as viewed on meibography. MGP provides unequivocal physical proof of a patent meibum outflow tract through the natural orifice, and may promote glandular growth in part by direct mechanical establishment of a patent duct/orifice system.

Cont Lens Anterior Eye. 2017 Sep 30. pii: S1367-0484(17)30250-3. doi: 10.1016/j.clae.2017.09.004. [Epub ahead of print]

Comparison of treatment effect across varying severities of meibomian gland dropout.

Turnbull PRK1, Misra SL2, Craig JP3.

Author information

1

School of Optometry and Vision Science, New Zealand National Eye Centre, The University of Auckland, New Zealand.

2

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand.

3

Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand. Electronic address: jp.craig@auckland.ac.nz.

Abstract

PURPOSE:

Better understanding of the pathophysiology of meibomian gland dysfunction (MGD) has provided the opportunity to develop treatments which could be tailored for specific presentations of MGD. This study sought to directly compare treatment effectiveness for three current therapies across differing levels of MG dropout.

METHODS:

Subjects (n=81), grouped by infrared meibography dropout proportions, into either no (control), mild, or pronounced MG dropout, were randomised to receive treatment with a latent heat device (n=25), liposomal spray (n=28), or heated warm compress (n=28). A battery of tear film measures was performed, pre- and post-application of treatment, and compared by treatment type and MG severity.

RESULTS:

Symptoms correlated with MG dropout proportions (r=0.618, p<0.001). Following treatment, non-invasive tear breakup time improved (p=0.010), independent of treatment type (p=0.131). The improvement was significant only in the pronounced MGD group (+4.32 ±1.15s, p=0.008), however, following treatment, the mild group was no longer distinct from the control group (p=0.843). Lipid layer grade (LLG) also improved following treatment (p<0.009), but again was not specific to treatment type (p=0.349). All three severity groups showed an improvement in LLG, with 49.3% of participants showing an improvement of at least one grade, and none showing decreased LLG.

CONCLUSIONS:

Increased LLG across all three treatment groups suggests that all methods increase meibum outflow to the tear film, resulting in a thicker lipid layer after treatment. These results suggest that all three treatments are effective in improving tear film quality, independent of MGD severity based either on symptoms or based on gland dropout.