Looking at the meibomian glands during an exam for dry eye, most of us are surprised to find that 70% of patients with dry eye symptoms have signs of meibomian gland disease. Unfortunately, finding relief for these patients is much more difficult than identifying the cause.
First, let’s put a nail in the coffin of warm compresses. As a rule, patients don’t do them — at least not long enough to consider them a meaningful solution. Most will give a few tries, find temporary relief, and soon forget about them. Docs who recommend baby shampoo scrubs will find even faster attrition of compliance. Detergents like baby shampoo sting.
However effective these age-old treatments, they become irrelevant for most patients.
Another approach is surgical meibomian gland expression performed in the office. Using two cotton-tip applicators, the examiner can apply bimanual pressure to the glands of the lower lid, expressing the opaque, inspissated, staph-laden material. (Upper lids can be expressed also but it leads to greater patient discomfort.) If you’ve ever performed this lipid catharsis, you know from somewhat grotesque personal experience the sheer amount of “gunk” that can be painstakingly (and painfully) removed with proper technique. The masochistic patients who return periodically for this time-consuming procedure do seem to experience true and prolonged relief. Why else would they ask for this procedure again?
In my own experience with this procedure, most patients experience discomfort for about 24 hours afterwards, with extensive pus production and stinging of the lids. This can be treated by the patient regularly irrigating the lids with eye wash for the first day and applying a topical antibiotic/steroid for 72 hours. It is worthwhile to clearly warn patients about this postoperative ordeal prior to the procedure.
A new device from Tear Science is designed to detect patients in whom meibomian gland expression might be most helpful and will soon be on the market. The company hopes to pair with it a device (not yet approved) that automates the process of gland expression. The gland expression device, which first heats then gently squeezes a patient’s tarsal plates in about a 12-minute procedure, already has been shown to provide symptomatic relief of meibomian gland disease for 10 to 18 months. I am eager to see how it performs after FDA approval.
How about meibomian gland probing, as taught by Steven Maskin, MD? The tiny wire probes available from Rhein Medical are used surgically to explore the meibomian glands. Many glands become “capped” externally with keratin or plugged internally with meibum. These glands often lead to acute chalazia or chronic tenderness and swelling. Simply opening these caps can restore flow and provide meaningful, symptomatic relief. This procedure too is painstaking for the surgeon and somewhat uncomfortable for the patient. However, it is the only way we currently have to get inside those blocked glands and restore flow. Its ultimate success, in my personal experience really depends on fully treating the underlying meibomian gland disease with all the tools in our arsenal