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New technology helps diagnose, manage meibomian gland dysfunction
A thorough evaluation and proper identification of the condition can help patients receive earlier treatment.
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Ophthalmologists’ understanding of dry eye disease has dramatically changed over the past decade, and while aqueous deficiency dry eye is still significant and common, we have learned that meibomian gland dysfunction is a much more common finding and a more significant contributor to dry eye disease.
Research has shown that 86% of dry eye sufferers have meibomian gland dysfunction (MGD). For that reason, the management of MGD in patients with dry eye disease is paramount to improving patients’ quality of vision and resolving dry eye symptoms. Although I applaud the efforts clinicians have made, we now have better insight into managing both MGD and aqueous deficiency dry eye to achieve therapeutic resolution of significant dry eye disease as a whole.
Poor nutrition and age contribute to MGD
I am a firm believer that nutritional intake is a significant contributor to dry eye disease, specifically MGD. Over the past 50 years, the nutritional intake of most Americans has dramatically changed, as we consume significantly too many omega-6s and not enough omega-3s, such as fish oils (polyunsaturated oils) that melt at body temperature. As a result, MGD secretions are now solidified and do not melt at body temperature, causing cessation and a lack of quality lipid content in tear film secretions. Prevalence also increases with age, and as the baby boomer generation gets older, ophthalmic practices are seeing an influx of MGD patients. Rosacea and family history also play a role in MGD.
Proper identification and effective treatments
MGD is fairly easy to diagnose when we look at a patient’s eyelids and see the glands and thickened secretions, but we do not really know the impact of these changes on the patient’s ocular surface. With the advent of an ocular surface interferometer (LipiView, TearScience) and thermal pulsation system (LipiFlow, TearScience), we can obtain objective measurements of the tear film lipid layer and also document the blink rate in patients. For the first time, we can view the effect of MGD on the lipid layer in patients who have dry eye disease. That allows us to make a more thorough and accurate diagnosis and gives us more insight into initiating therapy.
Eric D. Donnenfeld
As a cataract and refractive surgeon, I understand the importance of a healthy tear film in improving surgical outcomes, and we work with our patients to improve the quality of the tear film with traditional therapy, such as hot compresses, lid hygiene tears and oral fish oil supplements. However, two things most clinicians are not aware of in regard to hot compresses are, first, most patients do not use them, and second, the meibomian glands that secrete the oils and lipids responsible for the quality of the tear film are found in the tarsal plate, just underneath the conjunctiva. When heat is applied to the external lid, the blood flow in the lids dissipates the heat, and very little heat actually gets to the meibomian glands themselves. As a result, patients are highly frustrated with hot compresses because they may not work at all. Commonly, we reach a dead end in which the patient has not gotten any therapeutic relief.
With the thermal pulsation system, heat is applied to the tarsal conjunctiva directly adjacent to the meibomian glands, so there is an effective application of heat to the area that matters most. The glands are heated and then massaged out onto the tear film, opening them up. It offers a therapeutic advantage that provides long-term significant relief for a chronic problem that has been affecting the patient’s quality of life, and it can move the patient in a positive direction.
How to assess for MGD
When a dry eye patient presents to my practice, I start by taking a patient history and asking the patient about symptoms. Symptoms of MGD are different from those of aqueous deficiency dry eye in that MGD symptoms generally occur in the morning and aqueous deficiency dry eye symptoms occur in the evening. MGD tends to have more burning and visual fluctuation, and aqueous deficiency dry eye tends to have more irritation and foreign body sensation. I then examine the patient’s skin for signs of rosacea, starting with the eyelids, which is a common thread that we often overlook.
By assessing the meibomian glands, the size of the lids and the appearance of the secretions, I commonly find this toothpaste-like material coming out of the glands, and that is a pathognomonic sign of MGD. I also look for foam in the tear film, which is another common sign of MGD. I then use the ocular surface interferometer to look at the difference between the two eyes, which I find to be most effective. In more severe disease states, the glands will be scarred over and closed, which is an indication that MGD is a progressive disease. Once the glands are scarred and closed, they cannot be restored, so we need to treat patients as early in the disease state as possible.
MGD is a common, chronic and potentially debilitating disease, and we now have new diagnostic agents and treatment options that have not been available before. Furthermore, by better serving dry eye patients, we can retain patients and gain referrals to grow our practices.