Services

Intraductal Meibomian Gland Probing
Relieves Symptoms Of Obstructive
Meibomian Gland Dysfunction

Steven L. Maskin, MD

Disclosure: patent pending.
Commercial relationship: Rhein Medical

Background:

Meibomian Gland Disease is arguably the most common cause of dry eye and has certainly been the most challenging to treat. Traditional therapies have failed to consistently provide effective results leading to ongoing suffering and frustration for patients and physicians alike.

Purpose:

We have taken a retrospective look at the efficacy of a new invasive approach to treat symptomatic obstructive MGD.

Methods:

A patent pending method and disposable instrument with stainless steel tip were used to perform intraductal probing of 25 consecutive patients with obstructive MGD.

Results:

20 of 25 patients complained of pre-treatment lid tenderness or soreness which was immediately relieved with probing. At one month post procedure each (100%) of these 20 patients continued to have decreased tenderness or soreness.

Findings:

Suggestion of intraductal fibrotic and neovascular membranes were frequently identified. These were able to be opened up by probing allowing sequestered plug of meibum to escape.

Technique:

We have 2, 4, and 6 mm stainless steel sterile solid wire probe cannulas available with attachable ergonomic handle.

The lid margin and glands are examined with and without transillumination to evaluate patency of orifice and status of the glands, specifically looking at gland proximal and distal atrophy, length of glands and signs of ductal dilation suggestive of proximal obstruction. Palpate glands individually for gland tenderness seen with inflammation and obstruction.

With transillumination.

Without transillumination.

Begin by passing the 2 mm probe through the orifice. A fine router movement may be needed to find the opening, especially in setting of orifice metaplasia. After penetrating the orifice with the 2 mm, the 4 or 6 mm probe is used depending on the length of the gland to achieve complete patency of the ductal highway.

Resistance may be encountered. Respecting the length of the gland will prevent extending the probing too far. Therefore, if resistance is obtained, the probe may be up against a fibrotic band. Check to ensure the probe is co-linear to the gland, then provide additional force to pop through the intraductal scar.

Penetration with a 2mm probe. Note heme at orifice of adjacent gland.

4mm probe with transillumination.

At times a drop of heme will be noticed at an orifice. (see photo above) this may occur as the probe passes through a fibrotic neovascular scar or simply a neovascular membrane.

A plug of Sequestered meibum.

Photo above is an example of a plug of meibum freed up from behind a neovascular membrane. Notice the meibum being released adherent to the probe and a drop of heme at the orifice.

DR1 lipid interferometry:

Below is a DR1 lipid interferometry courtesy of Dr. Scheffer Tseng showing views before and after probing. Note the dramatic increase in tear film brown and blue lipid after probing.

Lipid interferometry- before

Lipid interferometry- after

Clinical photos:

Below is a before and after photo showing less deep lid margin redness, less prominent superficial vessels and reduced orifice pouting. Together these findings suggest reduced congestion correlating with the immediate and dramatic reduction in tenderness.

Conclusions:

Intraductal fibrotic and neovascular changes may explain the persistence of obstructive mgd despite exhaustive therapies directed at the lid margin and orifice and the inconsistent effect of warm compresses and lid massage. Intraductal meibomian gland probing appears highly effective in quickly relieving inflammatory symptoms of obstructive MGD.

Dry Eye and Eye Surface Disease

Over 30 million Americans have dry eye. And if you include the number of persons who live with or socialize with a person with dry eye, the number of affected Americans easily surpasses 75 million. This is pertinent because significant others must respect the needs of their spouse/friend/relative with dry eye and help create a dry eye friendly environment.

There have been significant advances in the understanding of dry eye and eye surface disorders over the past several years. These advances have increased our ability to successfully diagnose and treat common and rare eye surface disorders. For common eye surface disorders such as dry eye, irritated eye, red eye, as well as contact lens intolerance and eye infections, new medical therapies and approaches to treatment can restore a comfortable, healthy eye with improved vision.

In some cases medical therapy alone is insufficient to relieve symptoms. In what has become an exciting breakthrough in therapy for intractable eye surface disease, placenta tissue, or amniotic membrane, obtained at elective Cesarean section, is used to resurface the eye. Amniotic membrane surgery has elevated the standard of care for eye surface diseases to a whole new level. Importantly, the tissue contains no viable cells and, therefore, cannot be rejected.

Eye resurfacing surgery is a day surgery performed under local anesthesia with sedation.

Cornea Transplant Surgery

The cornea is a dime sized clear tissue that is the front of the eyeball. It allows light to pass through it to reach the back of the eye, where photochemical signals relay the visual message to the brain.

An unhealthy cornea prevents light from entering the eye thus, blurring or in advanced cases, blinding an individual. This occurs, for example, when the cornea is swollen, or scarred, or irregular as in the disorder known as Keratoconus.

Cornea transplantation can successfully replace these unhealthy corneas with a healthy new one, thereby, restoring vision. Cornea transplants have been performed for several decades and approximately 40,000 are done in the USA yearly. New understandings and therapies of eye surface disease in tandem with advances in cornea transplantation have allowed for greater cornea transplant success than ever before.

What is DSAEK?

DSAEK is a cornea transplant technique where the unhealthy, diseased, posterior portion of a patient's cornea is removed and replaced with healthy donor tissue obtained from the eye bank. Unlike conventional cornea transplant surgery known as penetrating keratoplasty (PKP), the DSAEK procedure utilizes a much smaller surgical incision and requires no cornea sutures. This usually results in more rapid visual rehabilitation for the DSAEK patient (weeks rather than years) and also reduces the risk of sight threatening complications that may occur with the PKP procedure such as intraoperative expulsive hemorrhage or post operative traumatic wound rupture.

Who is a candidate?

DSAEK is indicated for those patients who have cornea pathology located on the posterior aspect of their cornea known as the endothelial layer. The endothelial layer of the cornea is a monolayer of cells attached to a basement membrane called Descemet's membrane. A healthy endothelial layer consists of small, hexagonally shaped cells with a density of 2500 to 3000 cells/mm2.

When endothelial cells are healthy, they function as a "pump-leak system" to provide nourishment for the cornea. In other words these cells allow nourishing fluid from inside the eye (aqueous humor) to leak into the cornea. After the cornea cells have been nourished, the cells pump the fluid out of the cornea. If the endothelial pump is compromised for any reason the cornea will over hydrate and become cloudy. This most commonly occurs in patients who have sustained trauma to the endothelial layer during complicated cataract surgery or patients who have an inherited disease of the cornea endothelium known as Fuchs' Endothelial Dystrophy.

When the cornea endothelium is stressed, the endothelial cells become larger and more sparse. As endothelial cell density falls between 500 to 1000 cells/mm, the pump mechanism can no longer maintain a clear cornea. In the case of Fuchs' dystrophy the endothelial cells also start secreting material that makes Descemet's layer thicker and more opaque. Vision eventually deteriorates to a point where these patients feel like they are looking through wax paper. Such patients are good candidates for the DSAEK procedure.

Cornea transplantation is a day surgery and can be done either with local, or general anesthesia (for the young or anxious patient).

Pterygium Surgery

Pterygiums are growths on the surface of the eye. They grow toward the middle of the eye over the colored part of the eye. Ptergiums can cause redness, decreased vision, double vision and can rarely become malignant. Removed inadequately, they can recur in at least 50% of cases. With our surgical technique, we have not had a recurrence in over 20 years managing these cases.

Pterygium surgery is a day surgery under local anesthesia with sedation.

Eye Surface Cancer

There are different types of eye surface cancers and pre-cancer. The most common is called Squamous Neoplasia. These can present with a focal area of redness at the junction of the white and colored part of the eye, or as a translucent sheet growing onto the cornea.

Dr. Maskin has discovered and published a cure in the Peer Review Literature in 1994 for this type of neoplasia. This landmark contribution to Ophthalmology was printed in the Chinese and Spanish editions of Archives of Ophthalmology.

Ocular Surface Research & Education Foundation, Inc.(OSREF)

OSREF is a tax exempt non-profit foundation whose mission is to conduct research and to develop therapies to relieve the suffering of patients with ocular surface and tear disorders. Dr. Maskin serves on the board of directors and is co-researcher.