Do most optometrists think to look at and evaluate the meibomian glands in everyday practice?
With the majority of treatments, both over-the-counter and prescription, focusing on tear supplements and the increase of the natural tear, there may not have been a shift in focus or thinking by most practitioners.
Undoubtedly, poor aqueous production will result in a compromised tear film and ultimately ocular surface disease. However, with a poor lipid component in the tear film, evaporation of the tears will surely cause a breakdown of the ocular surface and cause symptoms to occur.
Meibomian gland dysfunction and its role in ocular surface disease is an increasingly common topic. In fact, the Tear Film & Ocular Surface Society formed a subcommittee whose sole purpose was to evaluate the meibomian glands.1
Examining the blink
Blinking occurs about once every three to four seconds in most patients.2 However, when one uses a digital device or reads, blink rates slow to 4.5 per minute,2 or once every 13.5 seconds.
If a slowed blink rate is then combined with other factors that may affect eyelid mobility (such as lagopthalmos, scarring, ectropion, etc.), that patient is at serious risk for meibomian gland atrophy and ultimately chronic ocular surface disease.1
Early detection is important when it comes to meibomian gland dysfunction prevention. While we know that dry eye disease is more prevalent with increasing age,3 it’s likely that many meibomian gland problems may be occurring much earlier in life.4,5
Related: Diagnosing and treating lagopthalmos
Having had a shift in thinking myself, I have begun to screen patients for dry eye at a much younger age than I had previously.
Typically anyone over age 18 is treated as an adult in our practice. The patient completes a small dry eye questionnaire and her glands are expressed and viewed during examination.
However, because more children are using digital devices, it may become necessary to screen those patients as well. If nothing else, asking them how their eyes feel may not be a bad place to start.
As more patients are identified as having meibomian gland changes, whether in terms of structure, function or both, the question becomes what methods are available to practitioners to help those patients. Is simply reminding them to blink enough?
Blinking has a significant role in the secretion of meibum into the tear film.1 If the blink rate is slowed or blinks are incomplete, meibomian glands will be used less over time. This could lead to meibomian gland atrophy if unidentified.1
For patients who are less symptomatic but are at risk of developing a problem with their meibomian glands, I prescribe blinking exercises. Younger females are more likely to show early signs of meibomian gland atrophy than males.4
Related: How to know when it isn’t dry eye
There isn’t a set of rules for how to tell your patients to blink. I tell patients to do 10 good blinks—meaning eyes fully closed for two seconds, then squeezed for another two seconds—for every hour of digital device use.
I encourage patients to download a blinking app created by Donald S. Korb, OD, FAAO. It is available for iOS for free in the App Store. Patients can set their own blinking reminders for their desired frequency.
Typically I will encourage awareness of blinking and completion of the blinking exercises for one month, then see the patient for a brief follow-up visit. My hope is that my wanting to see them in a month’s time will help ensure compliance and, in that time frame, may also allow the patient to experience some benefit from the exercises.
In many cases, blinking exercises may not be enough, particularly when atrophy has already occurred in the meibomian glands and patients are already feeling the results of evaporative stress on their ocular surface.
In those cases, the use of heated eye masks are a good treatment option. Heat therapies for MGD are effective only if the glands are consistently heated to at least 45° C (113° F).6
To ensure compliance with treatment, offering devices, such as a Bruder eye mask, for sale in your office is the best course of action.
Again, when I use this as a method for treatment, I will schedule a quick follow-up visit after one month of daily use to ensure a patient has been compliant and to address any further symptoms she may be experiencing.
Beyond blinking, heat masks
Clearly not every patient you encounter is going to respond well to blinking exercises and daily heat treatments. Some patients are unable or unwilling to comply, and some have progressed to far in their disease. In those cases, there are other treatments available.
The most common adjunctive therapy still used for treatment of meibomian gland lid disease is low-dose oral doxycycline. The properties of doxycylcine help to reduce inflammation in the eyelid tissue and ultimately assist the gland’s function over time.7
However, the drug is sometimes not tolerated by patients7 and isn’t encouraged for use in younger patients. As we screen for and see MGD at a younger age, it may not be a great treatment method for proactive practitioners.
For patients who struggle with compliance or who have been suffering from meibomian gland-related dry eye disease for extended periods of time, more advanced methods of treatment are available.
TearScience LipiFlow thermo-pulsation is one such treatment. One study showed that one treatment of LipiFlow was as effective as three months of twice-daily lid warming and massage.8 For a non-compliant patient or someone looking for more immediate relief, LipiFlow may be a great option.
Unfortunately the cost of a single LipiFlow treatment is about 35 times more expensive than purchasing and using a heat mask. The cost may be a major deterrent to some patients.
MiBoFlo Thermoflo (MiBo Medical Group) is also a thermal device designed to distribute sustained, therapeutic heat to the outside of the eyelid in order to generate better meibum flow from the glands. The cost of this in-office treatment is significantly less than LipiFlow, though more frequent treatments may be necessary.
Two other less common but interesting meibomian gland aiding treatments is intense pulsed light (IPL) and ductal probing.
A study comparing the use of IPL on one eye showed improvement of lipid level in the tear film as well as improvement in symptoms in the eye that was treated.9
Meibomian gland ductal probing is not something that’s been commonly performed in clinical practice; however, there’s strong evidence to suggest that gland orifice obstruction plays a role in meibomian gland disease.1 Thus, probing the glands makes sense clinically. One in-office study showed that 100 percent of patients who had duct probing reported relief of symptoms four weeks after treatment; additionally 80 percent of patients needed only one treatment to feel continued relief.10
Cost of these procedures as well as billing capabilities may be downsides with these treatments, not to mention potential grey areas in terms of scope within optometry.
Importance of glands
The more we learn about meibomian glands and their role in the progression of ocular surface disease, the more we realize that early detection of gland problems is paramount.
Poor blinking needs to be addressed and evaluated by practitioners to assess risk of patients and possibly prescribed as an exercise in order to prevent disease development.
As more treatments become available for patients already suffering from meibomian gland dysfunction, the implementation of treatment early in the disease process becomes important. I encourage all optometrists to keep gland function as part of their primary evaluation of patients and to implement treatment and preventative measures where necessary.
1. Nichols KK, Foulks GN, Bron AJ, Glasgow BJ, Dogru M, Tsubota K, Lemp MA, Sullivan DA. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1922-9.
2. Bentivoglio AR, Bressman SB, Cassetta E, Carretta D, Tonali P, Albanese A.
Analysis of blink rate patterns in normal subjects. Mov Disord. 1997 Nov;12(6):1028-34.
3. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003 Aug;136(2):318-26.
4. Schachter SS, Schachter A, Kwan JT, Hom MM. Gender Differences of Meibomian Gland Atrophy in a Younger Population. Paper Presented at American Academy of Optometry annual meeting: Anaheim, CA. 2016 Nov. 8-11.
5. Xiu W Xiaoxiao L ,Yun Y, Ruihua W, Liyuan Y, Shaozhen Z, Xilian W. Evaluation of Dry Eye and Meibomian Gland Dysfunction in Teenagers with Myopia through Noninvasive Keratograph. J Ophthalmol. 2015 Nov. Vol 2016: 5 pages.
6. Blackie CA, Solomon JD, Greiner JV, Holmes M, Korb DR. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008 Aug;85(8):675-83.
7. Yoo SE, Lee DC, Chang MH. The effect of low-dose doxycycline therapy in chronic meibomian gland dysfunction. Korean J Ophthalmol. 2005 Dec;19(4):258-63.
8. Finis D, Hayajneh J, König C, Borrelli 2, Schrader S, Geerling G. Evaluation of an automated thermodynamic treatment (LipiFlow) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial. Ocul Surf. 2014 Apr;12(2):146-54.
9. Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015 Feb 12;56(3):1965-70.
10. Maskin SL. Intraductal meibomian gland probing relieves symptoms of obstructive meibomian gland dysfunction. Cornea. 2010 Oct;29(10):1145-52.