Over the past few years, there seems to be an explosion of attention given to meibomian gland dysfunction/disease (MGD). First described by Dr. Donald Korb and associates (what’s new? He has brought us GPC, lid wiper epitheliopathy, and a host of contact lens designs and ophthalmic instruments and products over the years), MGD has been suggested to be the main cause of dry eye that we see in clinical practice on a daily basis. Primary eye care practitioners have been bombarded with eye drops, pharmaceutical options, home therapies and in-office treatments for MGD. It is no wonder that ECPs often experience “deer in the headlights” syndrome regarding the best way to approach MGD. What treatment is most effective? What order of intervention should I take? Is there an algorithm that I can follow? How much of what is out there is evidence-based with solid science behind it?
What’s out there for treatment of MGD?
OTC Agents: A mainstay treatment for at least managing the symptoms of MGD (which relate to evaporative dry eye) would be the use of tear film stabilizing agents. There are many of these out there including Oasis Tears Plus, MGD Retaine, Soothe XP, Systane Balance and the new Systane Complete (among others). These agents surely have an important place in MGD management and can provide some degree of almost immediate relief of symptoms. Some agents are not approved to be used with contact lenses and others are, however, we have found that placing a drop in the eyes prior to contact lens insertion surely can extend comfortable wearing time.
Pharmaceutical Agents: the role of pharmaceutical agents in the treatment of MGD has been controversial, especially the use of topical antibiotic agents. MGD is thought to be an inflammatory disease and not typically an infectious disease. However, things are not always cut and dry since MGD is often also associated with infectious blepharitis (either staph or often demodex). Appropriate management with topical anti-infective agents in these cases would be in order. Oral tetracycline derivatives are often highly effective in the management of MGD but not due to their anti-infective action. It is their anti-inflammatory effects that make them so helpful. The most commonly used agent is oral doxycycline. Depending on the severity of the case, we often start with higher doses (such as 100mg BID PO) and then gradually reduce to a maintenance dose (commonly 25mg QD PO). Always keeping in mind contraindications and potential side effects. Finally, the use of topical steroids seems to play a role when significant lid margin inflammation is evident.
Home Based Therapies: The advent of a number of home-based treatments for MGD has had a significant impact on patients. The most commonly employed would be the use of home lid heat therapy. For the most part, gone are the days of heating up a washcloth. Today there are many companies the manufacture home use heat masks that are heated up in microwaves and strapped over the eyes for a few minutes. These products retain their heat longer than the washcloth method and are easy to use. Our patients often say it is quite soothing and like a bit of a home spa treatment of their eyelids! A recently introduced home therapy is targeted more for anterior blepharitis and is used to remove debris/build up. Called the NuLids system from NuSight Medical, this device is prescribed by the ECP for the patient to use as a maintenance device at home. NuLids Pro is also available as an in-office treatment.
In-Office Treatments: Now here is where the rubber meets the road! We now have a number of in-office treatments for MGD. The goal of these treatments is to improve flow of normal meibum from the glands. This is achieved by a combination of deep heating of the glands and also by expression of the glands (either simultaneously or subsequently). The most well-known system and the one with the longest track record and amount of evidence base is the Lipiflow system by Tear Science (now part of Johnson and Johnson). Lipiflow performs simultaneous deep heating and gland expression. Heating is conducted both on the internal and external lid surface via the disposable portion of the instrument. Initially, the cost of this treatment significantly limited its use, however, purchase price and disposable costs have come down quite a bit. I expect that with the involvement of J&J that we will see this trend continue. The Mibo Thermoflow system by Mibo Medical is a treatment that deep heats the eyelids from the external surface through a topical gel. There is no gland expression with this system and no disposable elements. Most recently the ILux system by Tear Film Innovations has come to market. This system also provides deep heating of both the anterior and posterior lid surfaces along with simultaneous gland expression. This is a hand-held unit and treatments can be performed within 10 to 15 minutes. The ILux unit does have a disposable tip that is used to treat both eyes prior to disposing. Acquisition cost of ILux and disposable costs are significantly lower than Lipiflow. In order to obtain FDA approval, ILux conducted a study that demonstrated clinical equivalency to Lipifow (which served as the control treatment), however, there are no long-term studies published to date although plans for such are underway (as stated by the company).
Another system is awaiting final FDA approval and involves a two-step process. Initial deep heating of the lids via external disposable eyelid pads is followed by manual expression with a hand-held meibomian gland expressor. This system is called TearCare by Sight Sciences.
So, after a review of the many ways we can treat the commonly encountered MGD we realize that it is not a lack of treatment options that is holding us back. It is simply that we have not come to a consensus regarding the appropriate treatment algorithms that are based on solid science. So many “dry eye experts” are out there lecturing and speaking at various meetings. Each of them seems to have their individual secret sauce, but often it is not shared with the rest of us. I urge our professions to try to come to a critically important consensus for MGD treatment. It will benefit all of us, but most importantly our patients.