Aggressive treatments developed for meibomian gland dysfunction

Primary Care Optometry News, November 2009
Stephanie Vasta

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 patients.

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, he said.

“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, you’ll 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.”

Practitioners’ techniques

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 certain cases.

“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. It’s more of a procedure for true chronic meibomian gland dysfunction or what we call posterior blepharitis or meibomianitis,” he said.

Dr. Gutierrez often uses a binocular indirect ophthalmoscope
Dr. Gutierrez often uses a binocular indirect ophthalmoscope to get a slightly magnified view of the lids when using the MG Expressor Kit.

Image: Gutierrez M
Penetration of the Maskin Meibomian Gland Intraductal Probe
Penetration of 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 treated.

“If a patient returns with recurrent lid tenderness, then we’ll 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 there’s 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 I’ll 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 that’s 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 applications

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 didn’t work then we would inject with a needle into the persistent oil gland blockage.

“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. “It’s much more comfortable for the patient and a much better back-up treatment if the probing alone doesn’t 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. “It’s 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; e-mail: drmaskin@tampabay.rr.com; 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: margueritemcdmd@aol.com. Dr. 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: mjlaserdoc@msn.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: mariogut@flash.net. 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: drdan210@hotmail.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) 637-4346; www.rheinmedical.com.
  • The MG Expressor Kit is available from Gulden Ophthalmics, 225 Cadwalader Ave., Elkins Park, PA 19027-2020; (215) 884-8105; www.guldenophthalmics.com.

References:

  • 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.

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 patients.

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, he said.

“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, you’ll 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.”

Practitioners’ techniques

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 certain cases.

“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. It’s more of a procedure for true chronic meibomian gland dysfunction or what we call posterior blepharitis or meibomianitis,” he said.

Dr. Gutierrez often uses a binocular indirect ophthalmoscope
Dr. Gutierrez often uses a binocular indirect ophthalmoscope to get a slightly magnified view of the lids when using the MG Expressor Kit.

Image: Gutierrez M
Penetration of the Maskin Meibomian Gland Intraductal Probe
Penetration of 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 treated.

“If a patient returns with recurrent lid tenderness, then we’ll 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 there’s 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 I’ll 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 that’s 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 applications

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 didn’t work then we would inject with a needle into the persistent oil gland blockage.

“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. “It’s much more comfortable for the patient and a much better back-up treatment if the probing alone doesn’t 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. “It’s 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; e-mail: drmaskin@tampabay.rr.com; 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: margueritemcdmd@aol.com. Dr. 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: mjlaserdoc@msn.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: mariogut@flash.net. 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: drdan210@hotmail.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) 637-4346; www.rheinmedical.com.
  • The MG Expressor Kit is available from Gulden Ophthalmics, 225 Cadwalader Ave., Elkins Park, PA 19027-2020; (215) 884-8105; www.guldenophthalmics.com.

References:

  • 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.