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Combination of treatments may be most effective for MGD
Variations of the Maskin procedure and eyelid expression together may speed resolution.
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Previous treatments for meibomian gland disease, such as application of hot compresses, oral supplementation with omega-3 fatty acids, oral low-dose doxycycline and lid scrubs, have not always been enough to control this condition because of cost, adverse drug reactions, compliance or efficacy.
One old and two new surgical techniques are proving to be useful in the evolving treatment of meibomian gland dysfunction (MGD): meibomian gland probing (the Maskin Procedure), intraductal medication injection and eyelid expression. In combination with these other therapies, these three may speed resolution or control of MGD.
Mark R. Flora
Meibomian gland probing, lid expression
Steven Maskin, MD, developed the instruments and technique for meibomian gland probing for dry eye disease in 2009, and it has evolved into an effective method of treatment for the primary disease as well as another new indication: early chalazia.
This ingenious technique mechanically opens the duct orifice, breaks up inspissated secretions filling the duct and allows easier, more complete expression of the inflammatory debris from single or multiple glands. The instruments consist of 70-micron diameter probes with varying lengths of 2 mm, 4 mm and 6 mm on a syringe-attachable cap, as well as a 104-micron diameter flexible plastic cannula 1 mm in length and are available from Rhein Medical (Tampa, Fla.).
As with any new surgical procedure there is a learning curve, although relatively “flat,” and there have been some key innovative variations.
Topical drop anesthesia is inadequate for most patients; 8% lidocaine ointment can be formulated for ophthalmic application and allows much longer contact time with the transitional epithelium of the lid margin as well as deeper structures of the eyelid. After applying a generous amount to the lid margin to be probed, have the patient gently close the eye and allow 15 minutes for deepest anesthesia before probing.
Maskin 4-mm probe, 70-micron diameter.
Images: Flora MR
Maskin cannula, 1-mm length, 104-micron diameter
Lid expression.
While the patient is waiting, apply a hot compress or mask (CPT 97010) for 15 minutes, as this will facilitate softening/liquefaction of the secretions inside the glands, making probing and expression more effective.
Because these patients usually have an increased bacterial load on the ocular surface and lids or concomitant blepharitis, the physician should wear nonsterile gloves during the procedures.
A recent suggestion has been to immerse the probe into a steroid, steroid-antibiotic combination or nonsteroidal anti-inflammatory drug to coat it with the drug before insertion into each duct, thereby administering a small amount of the medication to the interior of the gland. It is not particularly elegant, but potentially effective and would constitute an off-label use for any drug selected.
Probe immersion into a drug before insertion.
Blocked meibomian gland orifice associated with an early chalazion in the lid above, which is not shown in the photo.
After probing, the lid should be expressed (CPT code 68040) using a lid expressor. Lid expression has been available for many years, although it is probably underutilized. The accumulated debris may be washed out of the cul-de-sac using sterile saline or wiped out using a surgical sponge.
Typical postoperative treatment includes prescription of a steroid-antibiotic combination drop followed with hot compresses for several days and regular follow-up as required. Probing may be repeated cautiously, usually after 3 to 6 months or earlier if the situation warrants. Excessive probing could scar the duct lining, permanently damaging the gland. At this point, we do not know how many times a duct can be probed before damage might occur.
It is not advisable to wait for moderate or severe MGD, as some have suggested, to probe. In fact early probing may “jump start” other therapies and provide earlier relief of symptoms as well as earlier control of the disease.
There is no current CPT code for intraductal probing, but some doctors are using 68020: conjunctival cyst incision and drainage.
Intraductal medication injection
Maskin had the foresight to develop a cannula small enough with which to inject medication into individual meibomian glands (intraductal injection). It is plastic and, therefore, flexible, 1 mm in length and 104 microns in diameter. When attached to a 3-cc syringe, very small amounts (less than 0.10 mL) of medication, such as a steroid, steroid–antibiotic combination or NSAID ophthalmic medication, can be injected directly into individual meibomian gland ducts. Again, this use would be off-label. Intralesional injection, CPT 11900, may be used to report this procedure.
Because ophthalmic steroid drugs are suspensions, and newer ophthalmic antibiotics are in much thicker vehicles, it can be difficult to push the drug through the 90-micron diameter cannula. It is also difficult to hold the cannula tip inside the duct and at the same time compress the syringe plunger, but it can be done. Even such small amounts of medication can be enough to halt ongoing inflammation inside a single meibomian gland, such as with an early chalazion.
Case report
The patient shown presented 1 week after developing a 3-mm hard, tender nodule located in the lid about 8 mm above the upper lid margin. In the photo one can see the “pouting,” swollen, meibomian gland orifice associated with the chalazia (higher up in the lid) exuding inflammatory debris.
This patient received an intraductal steroid injection, and at the 7-day follow-up the lesion had resolved completely with no other treatment. There was no palpable lesion in that lid where the small chalazion had been, a remarkably shortened course for this disease.
Intraductal medication injection could have a significant impact on the treatment of chalazia by avoiding percutaneous steroid injection and its attendant potential for skin depigmentation in African Americans, avoiding incisional surgery, shortening the course of the disease and reducing costs.
Maskin’s innovations illustrate how thinking outside the box can lead to new technologies and procedures that can significantly affect diseases such as dry eye, meibomian gland dysfunction and chalazia; surely they deserve his name.
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Disclosures: Flora is a paid consultant for Ambler Surgical, but has no financial interest in Rhein Medical.