Two new treatment options are helping clinicians experience better
outcomes when dealing with meibomian gland dysfunction.
The Maskin Meibomian Gland Intraductal Probe (Rhein Medical), developed
by Steven L. Maskin, MD, helps remove obstructions within the duct. Dr. Maskin
told Primary Care Optometry News that clinicians can enter the meibomian
gland with the probe and provide dramatic and immediate relief to
Blockages within the gland may be caused by fibrovascular tissue that
grows into the duct with new blood vessel formation as well as an abnormal
hyperplastic keratinized ductal epithelium or scarring in or over the orifice,
What I found when I entered the meibomian gland was that there was
frequently some resistance deeper inside, within the duct, which was able to be
relieved with mild pressure, Dr. Maskin said. When you apply that
pressure, youll be able to penetrate through that and there will be a
pop characteristic of a fibrovascular membrane. You can create a
patent open duct from orifice to the deeper duct. Patients lid tenderness
dramatically and immediately improves.
Marguerite McDonald, MD, shared her protocol with PCON. She first holds
lidocaine gel against the lid margin to anesthetize the area where the probe
will be inserted. Afterward, she prescribes a combination of topical and
sometimes oral medications to treat the disease.
For patients with moderate to severe meibomian gland disease, I
place them on soaks and scrubs twice daily, as well as on AzaSite
(azithromycin 1%, Inspire), one drop in both eyes twice daily for 2 days
followed by one drop daily for at least a month, she said. Some
severe patients stay on AzaSite indefinitely.
I ask the patients to rub the drop into the base of their lashes
for a few seconds while their lids are gently closed, immediately after
instilling the drop, she continued. In addition, many patients are
placed on oral doxycycline (100 mg) twice daily for a week to 10 days, then 20
mg once daily for a few months, if not indefinitely.
According to Mitchell A. Jackson, MD, the probe may not be indicated in
This is not a good procedure to use for scarring from conditions
such as ocular cicatricial pemphigoid, symblepharon type conditions or for
systemic diseases where you get scar tissue from the conjunctiva to the lid
margin. Its more of a procedure for true chronic meibomian gland
dysfunction or what we call posterior blepharitis or meibomianitis, he
often uses a binocular indirect ophthalmoscope to get a slightly magnified
view of the lids when using the MG Expressor Kit. |
Image: Gutierrez M
the Maskin Meibomian Gland Intraductal Probe into the orifice.
Image: Radice R
Consider co-morbid conditions
A study presented by Dr. Maskin during the Association for Research and
Vision in Ophthalmology meeting found that 80% of patients studied, or 20
patients, had decreased symptoms of lid tenderness and soreness and did not
require retreatment after probing. The five remaining individuals who returned
for retreatment at 4.6 months had an increase in symptoms, which responded to
repeat probing. In a separate study, Dr. Maskin found that different co-morbid
diseases were responsible for aggravating the patients meibomian gland
dysfunction after successful probing, and the symptoms were reversible when
If a patient returns with recurrent lid tenderness, then
well probe them again, but we also look for any other signs of co-morbid
disease, Dr. Maskin said. The collagen in the tarsus gets denser
the closer it is to the meibomian gland, and if theres edema or swelling
in the tarsal plate, the meibomian gland central duct could effectively
collapse on itself and have a functional blockage, even though there may not be
a mechanical blockage.
He noted that those patients who returned with increased symptoms also
had anterior blepharitis, topical toxicity from a glaucoma drop or allergy.
When those problems were addressed, the meibomian gland symptoms resolved
without re-probing, he said.
New expressor kit
For less severe cases of meibomian gland dysfunction, Mario Gutierrez,
OD, FAAO, has developed the MG Expressor Kit (Gulden Ophthalmics), which
combines the traditional therapies of warm compresses and massage, though in a
more rigorous form. The kit includes a gel mask that can be warmed, the
expressor tool and sanitary caps that can be placed over the roller. Dr.
Gutierrez described the technique.
Once the lids are warm, it liquefies the contents of the meibomian
glands, he told PCON. Then, we basically roll the tool on
the eyelid near the eyelid margin, and that helps express the liquefied
meibomian gland content.
I typically warm up the eyelids, use the roller, really work the
nasal eyelids the glands a little bit more, he continued.
This seems to help the patient become less symptomatic if we can get the
nasal meibomian glands working well. Then Ill go back and warm the lids a
little bit more, maybe for a minute or two more, and then go back and roll it
one more time to try and liberate as much of the expressions as possible.
According to Daniel Adams, OD, the expressor is best used at a
horizontal angle, working from the lash line upwards.
The gel pack should only be used for 3 minutes to warm the glands,
and then the expressor tool should be rolled horizontally not vertically
over the eyelid, forcing the meibum upwards, Dr. Adams said in an
interview. You want to soften the oil thats congealed in the gland,
and once you are able to get it to a soft butter stage, roll the
glands and try to express it out.
Pharmaceutical agents will be more effective once the glands are
cleared, offering quicker relief from pain and inflammation.
By decongesting the eyelids and emptying out the contents of the
meibomian glands, the medication has a better chance of getting into the glands
to help alleviate some of the inflammation that might be contributing to the
dysfunction, Dr. Gutierrez said.
A separate tool sold by Rhein Medical allows for a drug to be injected
into the meibomian gland, speeding the delivery and concentration of the drug
to where it is most needed.
Also developed by Dr. Maskin is a cannula for an intraductal
cannula delivery system, Dr. Jackson said. Traditionally we would
lance the meibomian gland open, get it to drain, inject anesthetic, and if that
didnt work then we would inject with a needle into the persistent oil
Now we can actually deliver everything right into the gland
to the specific, individual gland instead of a generalized injection
through the whole area, he continued. Its much more
comfortable for the patient and a much better back-up treatment if the probing
alone doesnt work.
Treating the cause of dysfunction
According to Dr. Maskin, entering the meibomian gland will change the
way doctors approach this disease. Instead of only treating symptoms
externally, practitioners are now able to address the cause of dysfunction from
within the gland itself and will be able to begin taking samples from within
the gland to understand the pathophysiology behind this disease.
If you have a 10-car pileup on a highway blocking traffic, and all
you do is sweep up glass and debris but leave the cars on the road, not much is
going to flow through there, he said. Its the same idea with
the meibomian gland ductal system. To optimize treatment, we need to establish
patency. Because we are now inside of this gland, we can look to a future where
we can unravel this disease process and develop new therapies through which we
can control this disease. In so doing, we will be able to comfort our patients
and prevent suffering and loss of sight through dry eye disease.
For more information:
- Steve L. Maskin, MD can be reached at the Dry Eye and Cornea
Treatment Center, 3001 West Swann Avenue, Tampa, FL 33609; (813) 875-0000;
Web site: www.drmaskin.com.
Dr. Maskin has a direct financial interest in Meibomian Gland Intraductal
Probes and Tubes.
- Marguerite McDonald, MD, can be reached at OCLI, 360 Merrick Road,
Lynbrook, NY 11563; (516) 593-7709; e-mail:
McDonald is a paid consultant for Inspire.
- Mitchell A. Jackson, MD, can be reached at 300 N. Milwaukee Avenue,
Lake Villa, IL 60046; (847) 356-0700; e-mail:
email@example.com. Dr. Jackson has no
direct financial interest in the products mentioned in this article, nor is he
a paid consultant for any companies mentioned.
- Mario Gutierrez, OD, FAAO, can be reached at 5212 Broadway, San
Antonio, TX 78209; (210) 829-8083, fax: (210) 822-4011; e-mail:
firstname.lastname@example.org. Dr. Gutierrez has a
direct financial interest in the MG Expressor but donates all royalties to
Optometry Giving Sight.
- Daniel Adams, OD, can be reached at SVS Vision, 2350 Tittabawassee,
Saginaw, MI 48604; (989) 791-1044; e-mail:
email@example.com. Dr. Adams has
no direct financial interest in the products mentioned in this article, nor is
he a paid consultant for any companies mentioned.
- The Maskin Meibomian Gland Intraductal Probe is available from
Rhein Medical Inc., 3360 Scherer Dr., Suite B, St. Petersburg, FL 33716; (800)
- The MG Expressor Kit is available from Gulden Ophthalmics, 225
Cadwalader Ave., Elkins Park, PA 19027-2020; (215) 884-8105;
- Maskin SL. Intraductal meibomian gland probing relieves symptoms of
obstructive meibomian gland dysfunction. Association for Research and Vision in
Ophthalmology; March 2009; Fort Lauderdale, FL.