SPECIAL REPORT

Treatments for Meibomian Gland Dysfunction

By Ahmad Fahmy OD, FAAO, Scott G. Hauswirth, OD, FAAO and David R. Hardten, MD

Patients presenting with irritation, conjunctival inflammation and corneal epithelial compromise were often treated as aqueous deficient dry eye patients prior to pivotal clinical descriptions by the Meibomian Gland Disease (MGD) workshop. We now have a growing body of evidence corroborating MGD as a primary source of the dysfunction of the tear film in nearly 65% of cases.^1-4 Patients suffering from symptomatic ocular surface pathology comprise close to 37% of all visits to an ophthalmologist's office and 47% of visits to an optometrist's office.¹

In the past, when patients presented to the office with MGD and dysfunction of the tear film, we had them use home therapies consisting of warm compresses, eyelid scrubs and pharmaceuticals in an effort to alleviate symptoms and restore normal lipid layer uptake to the tear film. Occasionally, manual expression of the meibomian glands was performed in the office. We now have mutliple treatments available to treat MGD, using novel devices that provide a more focused and effective treatment.

What's New for Treating MGD?

As the meibum conformation and thermodynamic properties are altered, the gland is no longer able to provide the important role of tear film preservation. The meibomian secretions become more solid at body temperature and secretions from dysfunctional glands require higher melting points than healthy glands.⁶ It's a challenge when applying heat from an external source to reach an effective temperature range which will benefit the function of these glands. The highly vascularized anterior lid transfers heat away from ocular surfaces, making it difficult to achieve and maintain adequate temperatures with a warm compress.

The LipiFlow system (www.lipiflow.com) is a device that provides a 12-minute lid heating and massage. The system allows doctors to get more concentrated heat and massage treatment to the eyelids. It's similar to a large contact lens that is inserted over the globe and under the lids and heats up the posterior lid surface. Heat is applied to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands. At the same time, it applies directional pulse pressure onto the gland to express it. The pulsing increases heat transfer efficiency toward the distal gland orifice. The LipiFlow system is very effective in patients with normal lid anatomy and no scarring (Figure 1).

Figure 1. Dry eye patient receiving LipiFlow treatment.

It's important to perform diagnostic lid expression on the MGD patient. Evaluation of the meibomian gland anatomy and quality of the secretion is critical in determining the most appropriate treatment strategy. This can be done by breaking up the glands into sections and observing how many glands yield lipid, as well as examining the quality of the secretions in each section. If many glands are obstructed and not yielding meibum, another step to consider is to heat the lids and perform Maskin probing. If careful, non-aggressive distal probing yields some expression, these patients will most likely benefit from the Lipiflow treatment.

Prematurely treating a patient with LipiFlow may have minimal effect if there is severe stenosis or obliteration of the distal orifice.

In January 2012, we were one of 10 sites that had the LipiFlow system. Since then, many more practices using this novel treatment. We're learning from the patients we're treating. In our experience, most patients have systematic improvement 3-4 weeks after treatment. We've had no patients experience exacerbation of their condition after treatment.

Doctors with a special interest in ocular surface disorders (OSD) are gladly welcoming the application of this novel treatment, yet we are careful to appropriately choose the patient who might benefit. Not every patient with OSD is going to get a noticeable increase in lipid production.

Other Viable Options for Treating MGD

In our experience, patients undergoing LipiFlow treatment are also typically using additional daily treatments at home. This often includes topical azithromycin, omega 3 fatty acids, oral doxycycline and the occasional pulse dose of steroid. Often, patients with MGD also have ocular surface inflammation, and topical cyclosporine is a common and useful addition.

Intense Pulsed Light

Intense pulsed light (IPL) is another very effective method for heating the meibomian secretions at the same time as providing the added benefit of sealing telangiectatic vessels. This is especially useful for patients with ocular rosacea. IPL treatment settings were fine tuned by Dr. Rolando Toyos after noticing that patients returning from facial treatment for telangiectasia with associated telangiectasia of the lids reported improved ocular symptoms.

In our experience, LipiFlow is a more comfortable treatment than IPL. These two treatments can be used synergistically in patients and offer an excellent combination of intense pulsed light treatments as well as Lipiflow, which some patients describe as a more tolerable spa-like treatment.

Patients struggling with severe MGD often describe a quality of life that is significantly adversely affected by their symptoms. The societal economic impact of OSD measured in loss of productivity parallels these patients' complaints. We're now adding effective novel treatments which serve to help many of these patients to be more functional and in many cases, decreasing symptoms to a level that is much more tolerable. ■

References

1. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009;7(2 Suppl):S1-S14.
2. The Tear Film & Ocular Surface Society Newsletter, 2010.
3. Multi-Sponsor Surveys, Inc. The 2009 Gallup Study of Dry Eye Sufferers: Topline Findings Volume. July 2009:1-123.
4. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136:318-326.
5. Shimazaki J, Sakata M, Tsubota K. Ocular surface changes and discomfort in patients with meibomian gland dysfunction. Arch Ophthalmol. 1995; Oct;113(10):1266-1270.
6. Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;106:336-356.
7. Bron AJ, Tiffany JM, Gouveia SM, Yokoi N, Voon LW. Functional aspects of the tear film lipid layer. Exp Eye Res. 2004;78(3):347-360.