Dr David Kading presents a case of MGD associated with extreme inflammatory reaction.
Hi, my name is David Kading, I’m the owner of Specialty Eye in Seattle, Washington. I’m excited to share some insights from a recent Optometry Times roundtable that I [was] part of. We discussed 2 patient cases of meibomian gland dysfunction [MGD] and its management. I hope you’re able to take something away from our roundtable discussion. So let’s dive into case number 1.
This was a 66-year-old [man who] presented to the office [with] first-time dry evaluation; [he] has had dry eye problems since the early 2000s when he became less tolerant to his contact lenses. [He] has had to reduce his contact lens wear, states that there’s fluctuation in vision, especially more so lately, [and has] burning and drying and irritation. You can see his reduced visual acuity here, and everything is unremarkable in the posterior segment. [There are] no other findings that would point toward the reduced vision. He has been [taking] Restasis and Lotemax, [and he] uses warm compresses occasionally.
In evaluating the patient, we were able to see that he had a reduced lipid layer thickness. Partial blink was pretty substantial [and] had strong inflammatory components; [he] wasn’t closing his eyes all the way, had some corneal staining, and then circumlimbal conjunctival staining indicated that there was a goblet cell reduction line of marks, which indicates a hyper amount of keratinization and had some [eye]lid wiper epitheliopathy. And then the biggest finding for me was that the meibomian glands yielding liquid secretions were 5 or fewer. What we know from this is if the glands are reduced in their flow for a long period of time, then the glands will become less functional and will begin to atrophy, which we noticed with his atrophy on his meibography.
So looking at this, there’s a lot going on here, but from the perspective of the MGD, we wanted to really handle that to keep things stable. We continued him on Restasis, believing that that would reduce the progression of his overall dry eye disease. We wanted to improve the quality of the meibum, so we started [him with] omega-3 that would also reduce some inflammatory components. Blinking exercises are a really important part because we’re not expressing those oil glands like we should be throughout the day. We recommended he continue to do warm compresses throughout the night, which [has] never been shown to take a gland that is clogged to open, but it has done a great job of helping to keep glands that are flowing to continue to flow. [We also recommended a] sleep mask, [eye]lid exfoliation to clean up that keratinization along the lid margin, and we recommended LipiFlow because we wanted to get the glands to go from no flow to more flow, less flow to more flow, and that’s our real objective here. If we can reduce the evaporation that is happening for this patient, we’ll be far more successful.
[Here are] just some of the findings that we saw at that follow-up visit. We want to do 6 to 8 weeks because we know the glands won’t be robust enough at 1 or 2 or 3 or 4 weeks. We need to see where it is at. Five, 6, 7 to 8 weeks is where we’re looking. You can see the improvement already here, and the things that really are sticking out to me with this is that we’re starting to see the number of glands that are flowing to be flowing even better. Now, we continue to see that improve all the way out to 6 to 9 months for oil-secreting glands, and you can see here at his second follow-up, his SPEED [Standard Patient Evaluation of Eye Dryness Questionnaire] score, which is his symptomatic [score], had gone from an 8 to a 13 to a 21 from a symptomatic standpoint. He’s noticing that his vision is getting better and better, his inflammation is going down, osmolarity is improving, and most importantly, the number of meibomian glands that are yielding liquid secretion are becoming more robust. As a result of that, the inflammation and the friction that’s happening on the [eye]lid wiper region is improving for him. His lid wiper region [has] cleaned up a lot. There’s less keratinization there, and at this point, we know we have helped to stabilize the patient a lot. He needs ongoing therapy. He needs ongoing treatment with omegas, ongoing treatment with warm compresses. [He] likely may need another treatment with a thermal pulsation procedure in another 6 months or so, maybe even a year. But ultimately what we [have] done during this case is taken a patient who was in an extreme inflammatory reaction [and] been able to bring that inflammation down by continuing the current treatments, adding omega-3s. But most importantly, we brought about a level of increased oil and lipid layers, which is going to reduce the desiccating stress damage that is occurring on the surface of his eyes. This is a great example of a great case [of how] with patience and time, we can get the glands to flow even better and make our patients better.
Transcript is AI-generated and edited for clarity and readability.