How to treat meibomian gland dysfunction

EP: 1.Introduction and overview

EP: 2.Consequences and epidemiology of untreated dry eye

EP: 3.Diagnosis and overlooking asymptomatic patients with DED

EP: 4.Standard testing and assessment for DED

EP: 5.General Principles of Treatment of DED

EP: 6.OD and MD communication for optimal care

EP: 7.Review of artificial tears for DED

EP: 8.Corticosteroids and Immunomodulators for the treatment of dry eye

EP: 9.The role of nutritional supplements and antibiotics in DED

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EP: 10.How to treat meibomian gland dysfunction

EP: 11.In-office procedures and patient resistance for DED treatments

EP: 12.Treatments for aqueous dry eye

EP: 13.Challenges in the management of DED

EP: 14.Counseling and formulary concerns for DED therapies

EP: 15.Overlapping diseases and COVID-19's impact

EP: 16.Agents in the pipeline for DED

EP: 17.Novel agents in the pipeline for DED

Marguerite McDonald, MD: Crystal, let’s talk about your preferred methods for treating meibomian gland dysfunction, and let’s start with what do you think of at-home lid hygiene? Does it work?

Crystal Brimer, OD, FAAO: It has limitations. Depends on if we’re talking about cleaning or ….., they both have limitations. The lid was made to ….. away from the cornea to protect it. So here we are trying to put a mask on and ….. go through the lid. What I’ve found is, my overall theme when it comes to MGD [meibomian gland dysfunction] is thin it out and keep it moving. It’s a 2-fold treatment. It’s not just about cleaning the lid or the heat therapy. It’s really about, like what Eric has been talking about, nutrition and nutraceuticals, things like that, and anti-inflammatories, on thinning out what we’re making. Then as far as keeping it moving, then we talk about the heat. I believe there’s a big difference in nutraceuticals, I believe there’s a big difference in heat therapy.

As far as my preferred treatments, I’m a big fan of the Eye Eco ….., which has the foam outer ring, so it traps the heat in there and it penetrates better, but the patient needs to commit to 20 minutes. Now, most of my patients are severe, so they will. If they won’t, then I’m going to lead them towards the new lid device, because not only is it going to clean the lid exponentially better than a scrub would, it’s going to also help with the circulation—blood circulation, distribution of fluid, but also help motivate those meibomian glands to move and to work better. They can do that in a minute versus the 20 minutes on a warm compress. I think they’re both very effective and it depends how much intervention I need for the patient and how willing they are to do the at-home treatments.

Eric Donnenfeld, MD: Crystal, you mentioned that you think there’s a big difference in nutraceuticals. Can you expand on that? I’d like to hear what you have to think, because I agree with you. What do you think is important about omega-3s?

Crystal Brimer, OD, FAAO: Omega-3 specifically, I believe honestly, it’s got to be triglyceride form. We need the alcohol out of there so that we can get better absorption and better tolerability, because if I want them to do more than 2,000 milligrams a day, I need them not to have fish burps and GI [gastrointestinal] issues with it. I need the absorption, but also, I believe there’s a little bit of magic to the 3:1 ratio of EPA [eicosapentaenoic acid] to DHA [docosahexaenoic acid]. I’ve trialed a lot of different formulations and that seems to be a very effective portion. Even in the same brand where it was not a three-to-one, it wasn’t effective among my patients.

Now, in addition ….., I appreciate the benefit of science-based ….. with their omega-6. I think they work very, very well together. So a lot of times I’m looking at the patient going, OK, how much systemic inflammation of disease do they have? How good is their diet? ….. deficient do I think they are in omega-3s, and a lot of ….. pull out the omega-6 as my first defense. But, no matter what I’ve started them on, every single visit, I’m going to ….. do just an ….. expression to see what’s coming out, and they know it. They’re expecting it. It’s kind of like wanting to know what their pressure is or what their osmolarity is. They want to know, alright, what have we got. So that’s going to determine is our dosing right. Am I going to ask you to do more pills a day or to combine 2 different mechanisms of action, or am I going to finally tell you it looks awesome and you can back off now?