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Diagnostic and treatment options continue to expand for MGD patients
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Meibomian gland dysfunction is very common in our patients, and our understanding and diagnostic and treatment capabilities are expanding rapidly. Here are a few of my personal thoughts and insights. As always, I have much to learn, and many of my comments are open to debate. I would also like to disclose that I consult for several companies active in the field.
There are approximately 50 meibomian glands along the margin of the upper tarsus and 25 in the lower tarsus. Meibomian glands are in the class of sebaceous glands, but while sharing some characteristics, meibum is quite different in composition from sebum. Both are exocrine glands, meaning that the cells and their content are excreted together. Both contain a complex mixture of lipids, proteins and cytokines that are both proinflammatory and anti-inflammatory. The purpose of sebum is to lubricate and protect the skin and hair. Common maladies include seborrheic dermatitis, acne vulgaris, acne rosacea and sebaceous cysts. The purpose of meibum is to stabilize the ocular tear film, reduce evaporation and protect the ocular surface by serving a role in defense against infectious agents. Common maladies of the meibomian glands include meibomian gland dysfunction (MGD), posterior blepharitis, hordeola and chalazia.
The etiology of MGD is multifactorial, including as a primary cause natural aging of the glands. Inflammation plays a role, and our modern diet with an excess of proinflammatory omega-6 lipids also appears to be involved, as do diseases such as acne rosacea. Increased colonization with bacteria, especially Staphylococcus species and perhaps Propionobacterium acnes and even Demodex, also are implicated. Dry eye is a significant issue for every eye care practitioner, and MGD is a contributor in as many as 87% of dry eye patients, according to Michael Lemp, MD.
The diagnosis of MGD is usually readily apparent on slit lamp examination. A gentle expression of the gland can provide confirmatory evidence, but for me, this is rarely needed. I will grade the MGD plus 1 to plus 4, and in my cataract patients older than age 70 years, plus 1 MGD is present in nearly 100%. The dilemma for me is who should I treat and how. If 100% of patients older than age 70 have some MGD, and it is likely a progressive disease process, one could argue that all patients should be treated. I am not there yet, but I have respected colleagues who are more aggressive than I in the indications for treatment. I personally treat only those MGD patients who have signs or symptoms that elicit a complaint.
The most common complaints are ocular irritation symptoms including burning, itching, excess morning matter, fluctuating vision and the classic dry eye symptoms of a gritty, scratchy, foreign body sensation or even pain and photophobia. Unlike aqueous-deficient dry eye, the symptoms are often worse in the morning rather than later in the day, but many patients have combined disease, and there is a lot of overlap. Some practices use the Ocular Surface Disease Index questions to screen for dry eye, but for me, this is overkill except in a clinical trial. I like the more simple UNC Dry Eye Management Scale developed by Richard Davis, MD.
In regard to signs, lid erythema, conjunctival hyperemia, lid debris, mattering, madarosis, distichiasis, hordeola and chalazia are common. A more rapid tear breakup time less than 5 seconds is the classic sign of evaporative dry eye secondary to MGD. I also find an elevated, asymmetric or variable tear film osmolarity quite helpful and use this test in monitoring response to treatment as well. Corneal staining with fluorescein, rose bengal or, for me, lissamine green is an important sign that treatment is indicated.
Let’s say I have a patient with burning and itching, red lids and conjunctiva, and some punctate epithelial staining. I am definitely going to treat this patient. At Minnesota Eye Consultants, we have all the technology, including simple treatments such as warming the lids with a Bruder mask and performing manual lid margin debridement, probing and expression, as well as those treatments that involve technology such as BlephEx lid margin treatment (BlephEx LLC), intense pulsed light (IPL) and LipiFlow (TearScience). My level 1 treatment is 2 g a day of PRN omega-3 supplements, Avenova lid hygiene (NovaBay), and a tear supplement such as Systane Balance (Alcon) or Soothe (Bausch + Lomb). This is adequate for 70%-plus of my patients. Those who do not respond in 2 to 3 months are treated with a course of antibiotic/steroid in drop and ointment form for 2 weeks, transitioning to AzaSite (azithromycin ophthalmic solution 1%, Akorn) or erythromycin ophthalmic ointment at night. If acne rosacea is present, I will use low-dose doxycycline at 20 mg to 50 mg per day. In some patients with combined aqueous-deficient and evaporative dry eye, I try Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), but I have few patients who stay on this treatment long term because of annoyance with the delivery system, high cost and poor efficacy from the patient’s perspective.
Repeated manual lid margin debridement, with or without BlephEx every 3 to 6 months, helps some patients in the more severe category and is part of my treatment algorithm. I rarely use punctal plugs, unless there is severe associated aqueous deficiency. In very severe MGD cases unresponsive to the simpler and cheaper treatments, I will offer LipiFlow, and I find it works well and patients like it. The problem is that it is just too expensive for most of my patients.
Finally, what about IPL? The main value to me is in treating patients with significant lid erythema, especially those with acne rosacea. This is also how it is primarily used by our dermatology colleagues. I am not convinced IPL heats meibum, and a simple application of a Bruder mask does this better in regard to enhancing meibomian gland expression. However, patients with significant lid margin erythema and telangiectasia like to see the redness reduced, and it is possible this also positively impacts the disease process. The treatment needs to be done properly, with the appropriate equipment and eye protection, and only on those with lighter skin (look up and understand the Fitzpatrick skin types).
At the same time one treats the meibomian glands, it makes sense to treat the surrounding sebaceous glands in the periocular skin, especially in the patient with acne rosacea. We always also perform lid margin debridement and meibomian gland expression along with post-IPL treatment. After IPL, we treat with antibiotic and steroids. It is somewhat difficult to separate out the impact of each component in such a combination of treatments, but it is the IPL absorbed by the oxyhemoglobin that coagulates the blood in the telangiectatic capillaries and vessels that primarily takes the red out, and patients like that outcome.
In my opinion, MGD deserves more attention from the practicing ophthalmologist. The good news is that we now have much better diagnostics and many more effective treatments. Compensation for these treatments is reasonable, and treated patients, many of whom were neglected for years, are appreciative.