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Treatment Approaches for MGD


Dr David Kading explores various treatment options for MGD, including thermal pulsation and light-based therapies such as low-level and intense pulsed light (IPL).

When it comes to deciding upon the treatment, really what we’re looking for, and it’s very simple, [are] treatments that take a patient from no flow to flow, or from low flow to more flow. And that’s what we look for. So we can look at the literature to find out whether that’s the case. And…when it comes to MGD, there are really only a couple of treatments. There’s some sort of a thermal pulsation and evacuation type of procedure; [for example,] LipiFlow or iLux or the TearCare type of devices. And their goal is to heat up and then express the glands so that they’ll flow more. We know that they worked if the glands go from less or no to more flow. When it comes to pharmaceuticals, we do have treatments like the Miebo treatment, which is from Bausch + Lomb, which gives a more robust oil layer. It doesn’t show that the glands get better at flowing themselves, but we can do a treatment like a thermal pulsation and then have the patient [receive] that pharmaceutical treatment and they’re going to have a thicker lipid layer while their eyes are getting better and the oil glands are flowing better. But we haven’t seen any pharmaceutical agents that actually take a patient from nowhere low to more flow. With regards to combining the 2, I think that’s a really good way for us to consider it.

One of the other questions people are bringing up is what has our experience been with thermal pulsation treatment. And as I shared in the case example here, a lot of patients don’t necessarily feel immediate results from this treatment. You know, they’re thinking that it’s a magic drop that makes their eyes feel better. The reality is we’re not in the business of treating symptoms. As physicians, we’re in the business of treating the body to function better. So if we get meibomian glands to go from less or no to more flow, our objective has been met. From a symptomatic standpoint, we then most often have reduced the desiccating stress. The ocular surface should feel better [and] about 91% of the time it does, according to [data from] studies. But beyond that, it’s probably the [case that] patient has some other issue, some sort of desiccating stress that is more robust because of a lacrimal functional unit disruption or dry eye disease that is causing those issues. And that’s an additional treatment, which is a whole other discussion.

But from the perspective of getting the glands to go from less to more flow, we know that with [the] thermal pulsation procedure, both from clinical practice as well as the research, we can get a 2 to 3 times increase in the number of glands that we’re flowing. Now, if their glands are completely clogged, that doesn’t mean we shouldn’t treat them. It just may mean that it’s going to take a little longer for those glands to really get up and go and start really flaring up and be excited. Which brings us to some great research [findings] that we’ve had in the arena of light-based therapy. That would include low-level light treatment as well as IPL [intense pulsed light]treatment. And what these treatments have been shown to do is not a great job at helping to thermal pulsate and evacuate the glands. Some practitioners do that where they do an IPL procedure and then they do manual expression. But that treatment, even in the literature, has not been shown to be as effective as thermal pulsation to get glands to go from less or no to more flow. So how we utilize it in our practice is we combine the 2. We do that thermal pulsation treatment and IPL at the same time, or low-level light therapy, because the photobiomodulation––which is a fantastic word––the light-based modulation to the gland helps to signal it to become more active. And what we’re seeing is that the glands become more excited. They become more active. You know, we’ve depressed them because they’re clogged. And as I shared, it takes 6 to 8 weeks for them to flow again. What we’re trying to do with light-based therapy is…2-fold. Number 1, we’re trying to get the glands and the treatment of the tears to be more active quicker. But [number 2,] on the other side of dry eye disease, it’s reducing the inflammatory component that’s targeting those glands, but also reducing the inflammatory component on the ocular surface. It makes the tears less inflamed. So the combination of those treatments, when a patient has evidence of inflammation, and telangiectasia, are really a…good marriage….

For years, we just had thermal pulsation in our practice. And for years, we’ve read research [results] about IPL type of treatment, low-level light treatment, and all of them are really good. But when we can marry those 2 treatments together, we’re getting a very, very good effect. And…it’s a challenge for practices to…say, “I’m appropriately treating my patients,” when they don’t have those types of treatments. That’s a challenge, right? What do you do? Well, there are 2 approaches here. Number one is you just do the best that you can…with the things that you have in your office…. And what you’re looking for to know that your treatment was successful is that patients go from low or no flow. When you’ve treated them, now they have more flow. If you don’t have that outcome, even if the patient feels better with what you did––for example, warm compresses make patients feel better, but they don’t necessarily increase the number of glands that are flowing––…atrophy may continue to occur for the patient. You may feel like you’re doing something good for them, but their eyes are getting worse. A really key component is if you’re not getting a successful treatment [for] reducing inflammation and getting those things down, you must send that patient to someone else if you…aren’t bringing in those treatments because the patient will continue to get worse and we certainly wouldn’t want that.

So either…consider bringing those treatments in––that’s a whole practice management discussion as to how…you go about that––[because] patients will pay for these treatments, in low- or high-income areas,…so that their eyes can get better. [Alternatively,] look to have somebody who you can partner with in your area and maybe they [will] send patients to you or you send patients to them. You team up on buying a device and then you work together to get those patients adequately treated.

Ultimately, we’re in this for the success of our patients. But there certainly are things that we can do from a clinical satisfaction [standpoint] where we…are actually getting patients treated with the underlying cause to make ourselves feel better that we’re doing the right thing for patients. And on the financial end, we certainly want to make sure that we’re doing things that are going to sustain and grow our practices so they can continue to be better. Again, we know success when we’re going from less or no to more flow and we see that [is] really effective when we can use an adequate thermal pulsation type of procedure activated by an intense pulse light or a low-level light therapy.

Thanks for [listening to] this conversation. I hope you enjoyed it as much as I did around meibomian gland dysfunction and our diagnosis and our treatments.

Transcript is AI-generated and edited for clarity and readability.

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