OD shares drug-free approach to treating meibomian gland dysfunction
We talk about dry eye all the time to patients, but are we diagnosing dry eye correctly?
I will share my protocol for treating evaporative dry eye associated with meibomian gland dysfunction (MGD) or posterior blepharitis, which I have refined over the course of 10 years.
Most optometrists treat dry eye with artificial tears, indicating that they believe most dry eye is due to an aqueous deficiency. I have found that about 80% of my patients with dry eye complaints have an evaporative component (meibomianitis) and many have a combination of evaporative and aqueous deficiency. However, if you treat the MGD first, the artificial tears work much better because the patient will have a sufficient lipid layer to prevent evaporation of the tears.
Determining type of dry eye
Image: Lee J
Patients have a variety of subjective complaints when the eyes are dry. Based on the symptoms, the doctor can easily predict which type of dry eye a patient has before clinical testing is performed. The accompanying table shows the common symptoms associated with each dry eye deficiency.
When a patient has MGD, the pores are moderately to severely blocked and can also have an oil deficiency. Various factors such as dust, make-up, pollen, blepharitis scales or wearing contact lenses can block these pores. No matter what factor caused the pores to be blocked, opening them can greatly reduce the dry eye symptoms.
Biochemical changes in the body due to hormonal changes, medications or stress can cause an oil deficiency. The quality of oils secreted becomes thicker and the quantity can be affected. Oil deficiency is addressed through nutritional supplements. I recommend ProOmega capsules from Nordic Naturals.
How to assess MGD
When diagnosing MGD, first assess the lids and look at the lid margins to note redness, inflammation or fatty acid build-up. The most important component of the dry eye exam is the manual expression of the meibomian glands.
Place the thumb against the lid margin and press firmly against the eyeball to determine the percentage of meibomian pores that are blocked. This assessment is performed on both the upper and lower lid of each eye. Refer to the accompanying table to grade the MGD. Normally, the meibomian secretions are easily expressed and are thin and clear in consistency. Lipid secretions become more milky and thicker as more pores are blocked.
First treatment phase: open meibomian pores
There are two phases of treatment: Open up the meibomian pores and recommend daily use of nutritional supplements.
The key to my success of this dry eye treatment was finding a heat pad that sustained its temperature for about 15 minutes. I use the heat pads made by Quantum Heat. Warm compresses cannot work without massage therapy of the lids to release the blocked contents. For patients to have minimum dry eye complaints, the pores must be 65% open on both upper and lower lids. My goal is to get the pores more than 80% open so patients can remain asymptomatic without repeating this dry eye treatment. I have set this goal as a result of fine-tunning my treatment plan for nearly 10 years.
Use two heat pads, one for each eye, with the lids closed for a minimum of 15 minutes. The more heat the lid can take, the more the pores open up and the more the blockages dissolve.
Remove the heat pads and immediately massage each eye (upper and lower lid) for 5 minutes. Place the index finger against the edge of the lid margin. Massage in a circular motion and begin on the nasal side and then move across the lid to the temporal side. Repeat this again, but go from the temporal side to the nasal side. The patient may experience temporary blurred vision due to the blocked oils being released into the eye.
Clean the base of the lids and lashes with lid scrubs, preferably pre-moistened pads. I use OcuSoft Lid Scrub Premoistened Pads. This prevents all the debris and expressed contents from re-blocking the meibomian glands.
The patient should perform these steps before bedtime for up to 6 weeks.
Patient understanding and recognition that they have dry eye is vital to the success of the dry eye program. Patients with grade 1 MGD are generally asymptomatic and will not acknowledge that they have dry eye even if clinical findings determine otherwise. However, those with grades 2 to 4 of MGD will greatly benefit from the treatment.
Perform medical visits every 2 weeks to reassess the percentage of blocked or open pores. Patients cannot tell if they are massaging correctly, but the doctor can guide the patient during theses visits. If patients perform this treatment daily and correctly, they will complete the regimen within 6 weeks by reaching more than 65% opening of the meibomian gland pores. For maintenance, patients should continue with massaging the lids (without heat pads) daily in the shower to keep the pores unblocked.
Second treatment phase: nutritional supplements
Research has shown that essential fatty acid supplements, omega-3 and omega-6, aid in the treatment of dry eye. I recommend front-loading the first month with omega-3 fatty acid supplements (one capsule = 1,000 mg), two capsules twice daily for the first month, then one capsule twice daily continually. This greatly enhances the quality and quantity of the lipid layer. Before beginning treatment, make sure this supplement does not interfere with patients’ medication.
Completion of the two-phase treatment will heal most patients’ dry eye symptoms. If needed, patients may require more dry eye treatment. It is amazing how patients can have dry eye problems most of their life, but this simple drug-free treatment can cure this problem within a few weeks.
For more information:
Jeanette Lee, OD, can be reached at 20/20 Optometry of Silicon Valley, 2555 North First Street, San Jose, CA 95131; (408) 433-0800; fax: (408) 577-0849; e-mail: email@example.com.
Heat pads are available from Quantum Heat, (760) 429-3380; Web site: www.quantumheat.net.
OcuSoft Lid Scrub Premoistened Pads are available from Cynacon/OcuSoft, P.O. Box 429, Richmond, TX 77406-0429; (800) 233-5469; fax: (281) 232-6015; Web site: www.ocusoft.com.
ProOmega is available from Nordic Naturals, 94 Hangar Way, Watsonville, CA 95076; (800) 662-2544, ext. 1; (831) 724-6200, ext. 1; fax: (831) 724-5263; e-mail: firstname.lastname@example.org; Web site: www.nordicnaturals.com.