MGD’s Multimodal Treatment

In-office procedures and long-term therapies are a successful pairing for managing this chronic disease

Eye care professionals have many treatment choices, including in-office approaches and at-home therapies. Let’s begin by discussing in-office treatments. Do any of you use thermal pulsation treatment?

Alice T. Epitropoulos, MD, FACS: MGD is a chronic, progressive disease. Untreated, it can lead to glandular atrophy and loss of function. If we start treating patients at an early stage of the disease, before they have severe damage, they are more likely to respond more favorably than if we wait until the glands are atrophied and nonfunctional. With this in mind, I use thermal pulsation treatment (LipiFlow, TearScience) in combination with standard long-term therapies. Thermal pulsation provides a long-term effect, but it is not a cure. According to TearScience, the treatment may be effective for 9 to 15 months, and we can repeat it to relieve obstruction and maintain the health of the glands.

In addition to taking re-esterified omega-3 supplementation, my patients receiving thermal pulsation use Avenova (pure 0.01% hypochlorous acid, NovaBay) lid cleanser, the first prescription daily lid hygiene product used twice a day to help to control bacterial overgrowth and help relieve symptoms of lid margin disease. Patients also perform blinking exercises and use hot masks.

Arthur B. Epstein, OD, FAAO: I also use LipiFlow thermal pulsation treatment for patients who have obstructive MGD and require expression, and I have had excellent results. Post treatment, patients need to continue on the long-term management regimen for MGD, particularly use of Avenova, a triglyceride-based omega-3 supplement such as PRN Dry Eye Omega Benefits (Physician Recommended Nutriceuticals), and blinking exercises. This approach has been incredibly effective for a large majority of my patients.

Do you find that intense pulsed light (IPL) therapy is an effective option?

Ivan Mac, MD, MBA: In our clinic, we employ IPL therapy for severe MGD-associated dry eye. IPL uses a xenon flash bulb to emit wavelengths of light of approximately 500 nm directly to the eyelid margin. Potentially, IPL near the lid closes the abnormal blood vessels secreting inflammatory mediators and decreases bacterial overgrowth at the lid margin. We typically apply this therapy once a month for 4 months.

For severe cases of MGD-associated dry eye disease, many of our patients follow the initial treatment period with maintenance treatments to continue the therapy’s effects. We have found that Avenova is one of the most important tools to maintain the effectiveness of IPL, and it can lead to an increase in time between the maintenance treatments. We were treating patients every 6 months, but now we can stretch it out to once a year.

We use Avenova in combination with other therapies to treat more severe cases of MGD, and it is our treatment of choice for earlier and mild stages of the disease as well.

Ivan Mac, MD, MBA

What additional steps do you take to treat MGD in your office?

Melissa Barnett, OD, FAAO: We have several options, including applying warm compresses, debriding the line of Marx, and expressing the meibomian glands.

BlephEx (Rysurg) is another debridement method to use prior to expression. Meibomian gland expression can be done with a Mastrota meibomian paddle (Ocusoft), Leduc meibomian forceps (Ocusoft), Korb Meibomian Gland Evaluator (TearScience), Meibomian Gland Expression Lid Plate (Gulden), or even two applicators.

Dr. Epstein: Conservative treatment works well for many patients — particularly those in the early stages of MGD — but some patients with more advanced disease require clearing of the glands through expression. I debride the lid margins, usually using a BlephEx device or golf-club spud, and then express the meibomian glands using LipiFlow. I prefer this approach over manual expression. I find it only marginally effective for many patients, and it must be repeated every 3 to 4 months.

When it comes to long-term, at-home therapies, successful treatment hinges on compliance. How do you prepare patients for the lifetime habit of treating MGD?

Steven I. Rosenfeld, MD, FACS: I counsel my patients so they understand that MGD is a chronic condition that requires long-term treatment and vigilance. If they stop their lid hygiene and other treatments, their condition is very likely to recur.

Dr. Mac: At the beginning of treatment for patients with MGD, we stress to them that this is a chronic condition that requires lifelong treatment. Many patients will get better from the therapies that we institute, but if stopped, the disorder always causes symptoms to recur. The treatment regimen that we employ is designed to be safe and effective for long-term usage, as well as patient-friendly.

Even when patients have mild MGD and without typical clinical symptoms of ocular discomfort, itching, or photophobia, it is pertinent to explain the disease and how it develops. We discuss the potential impact of diet, the effect of work and home environments on tear evaporation, and the possible drying effect of certain systemic medications.

What hygiene practices and compresses do you recommend?

Dr. Mac: Although warm compresses and lid massage can be helpful, in our practice we have found that it is hard for patients to accomplish. Avenova is easier to use, so it has a rate of high compliance. Avenova is a pure form of hypochlorous acid that, when used as directed, helps to reduce the lid margin bacterial load.

We use Avenova in combination with other therapies to treat more severe cases of MGD, and it is our treatment of choice for earlier and mild stages of the disease as well. Patients in our clinic usually notice that their eyes feel cleaner and more comfortable after 2 to 4 weeks of treatment.

Dr. Epstein: I recommend heat masks (EyeEco) and blink exercises, as well as artificial tears when necessary. I also prescribe Avenova twice a day for every patient. Patients absolutely love it.

Hypochlorous acid is naturally produced by white cells within the body; it kills bacteria, blocks bacterial toxins, and deactivates bacterial enzymes, such as lipase. As I caution my colleagues, hypochlorous acid products that contain substantial amounts of sodium hypochlorite (bleach) are not the same as Avenova.

I counsel my patients that MGD is a chronic condition that requires long-term treatment and vigilance. If they stop their lid hygiene and other treatments, their condition is very likely to recur.

Steven I. Rosenfeld, MD, FACS

Christine W. Sindt, OD, FAAO: I start patients on coconut oil lid scrubs to remove any scurf, as opposed to hot, wet compresses that increase evaporation off the skin and have poor compliance because they are uncomfortable. My patients apply coconut oil, wait 15 to 20 minutes, and then wipe it off with a dry washcloth. Finally, they use Avenova lid cleanser as directed to reduce bioload.

Dr. Barnett: I recommend patients perform an eyelid hygiene regimen each night, including warm compresses with gentle wiping across a closed eyelid margin to remove keratin debris. Using effective warm compresses for at least 10 minutes daily is beneficial to control MGD. Patients can use a Bruder mask or moisture goggles with heated pads, or they can heat and reheat a warm cloth for 10 minutes.

Avenova is an effective treatment in my practice. Lab testing shows it exhibits anti-microbial activity in solution similar to povidone-iodine with 1,000x less toxicity. Avenova is an effective cleanser for patients with multiple conditions, including blepharitis, MGD, demodex, and dry eye. Proper hygiene improves the appearance of the meibomian glands and promotes a healthy tear film.

Dr. Rosenfeld: My basic treatment regimen often includes warm compresses to soften the meibomian gland lipid secretions and open the orifices, as well as Avenova twice a day. One of the strong points for Avenova is how gentle, yet effective, it is on the lid margin even when used chronically. Laboratory testing has shown that in solution, the hypochlorous acid effectively kills the Staph bacteria that secrete lipases that degrade the meibomian gland’s lipid composition, reducing ocular discomfort and helping to stabilize the tear film. Avenova does not cause antibiotic resistance with long-term use, and it is not cytotoxic to the eyelid and conjunctival cells.

What medications and supplements do you prescribe for your patients with MGD?

Dr. Mac: Short courses of tetracycline antibiotics or pulsed steroids can be helpful, but, often, ocular and systemic side effects can occur. Artificial tears can be helpful as well at all stages of the disorder, as can lubricant ointment at bedtime.

I generally try to avoid using topical corticosteroids for long periods, based on concerns about ocular side effects, such as glaucoma or cataracts. Systemic medications, such as doxycycline, can have undesirable gastrointestinal side effects, so I try to stay away from them as well.

Dr. Rosenfeld: Along with my hygiene recommendations, including Avenova, I often order oral doxycycline (50 to 100 mg daily) for acute cases, as well as a steroid or combination antibiotic-steroid ointment applied to the lid margins at bedtime, a topical steroid or combination steroid-antibiotic drops and frequent artificial tears for comfort. For long-term maintenance, I favor doxycycline 50 mg orally each day, Avenova daily, warm compresses twice a day, oral omega-3 fatty acid supplements, and artificial tears. I particularly like omega-3 fatty acid preparations specifically formulated for ophthalmic use, such as HydroEye (ScienceBased Health) or Dry Eye Omega Benefits (PRN).

Dr. Epstein: I put all patients on a triglyceride-based omega-3 supplement. PRN Dry Eye Omega Benefits works very well for our patients. It is important that patients understand that a triglyceride-based product is not the same as a more commonly available ethyl ester form, which is largely ineffective at tolerable doses.

Dr. Barnett: Oral omega-3 fatty acids are anti-inflammatory and helpful to reduce inflammation and, thus, improve MGD. Specifically, we use HydroEye, which contains gamma linolenic acid, an omega that is very effective for treating dry eye and MGD.

Other treatments include topical azithromycin, oral doxycycline, and oral azithromycin. Topical cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) is beneficial to control the inflammatory load of MGD. Inflammatory cytokines found as hyperkeratinization on the posterior lid margin under the tear meniscus/Marx’s line respond well to this treatment. ■

	Melissa Barnett, OD, FAAO, is a principal optometrist at the UC Davis Eye Center in Sacramento and President of The Scleral Lens Education Society.
	Alice T. Epitropoulos, MD, FACS, practices at Ophthalmic Surgeons and Consultants of Ohio at The Eye Center in Columbus, Ohio, and is a clinical assistant professor at The Ohio State University.
	Arthur B. Epstein, OD, FAAO, is the director of cornea external disease and clinical research at Dry Eye Center of Arizona in Phoenix.
	Ivan Mac, MD, MBA, is medical director and CEO at Metrolina Eye Associates in Charlotte, N.C.
	Steven I. Rosenfeld, MD, FACS, is in private practice at Delray Eye Associates in Delray Beach, Fla., and is a voluntary clinical professor at the Bascom Palmer Eye Institute, University of Miami School of Medicine.
	Christine W. Sindt, OD, FAAO, is the director of the Contact Lens Service and a clinical associate professor at the University of Iowa, Department of Ophthalmology and Visual Sciences.