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Topics
 Many patients present for routine eye care with nonspecific
complaints of ocular discomfort. By examining the lid margin and tarsal plate,
you may often explain or identify the root cause of a patient’s comfort issues.
Meibomian gland dysfunction (MGD) can lead to inflammation
of the meibomian glands (meibomianitis) and excess oil in the tear film.
Bacteria and other substances often accompany the oil, which causes a myriad of
ocular surface complaints and signs.
Here, we review the common causes of and treatments for
meibomian gland dysfunction to help you to diagnose and treat this common
condition.
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On this patient’s superior eyelid, dilated and inspissated
meibomian glands are visible—note the multiple glands that are affected
(above). Large, isolated inspissated glands and thickened lid margins are
apparent.
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The Meibomian Glands
Meibomian glands are modified sebaceous glands that are
arranged vertically within the tarsal plate. The interactive force of an eyelid
blink causes meibum to be excreted onto the posterior lid margin. This oil
protects the eyelids from maceration and creates a seal when the eyes are
closed. As meibum interacts with the tear film, it reduces surface tension and
enhances the tears by spreading them evenly, creating a smooth refractive
surface and maintaining a consistent quality of vision.
In a patient with MGD, vision is affected because there is
too much or too little oil in the tear film. This imbalance causes tear film instability, reduced tear
film break-up time (TBUT) and evaporative dry eye.
Meibomian Gland Dysfunction
MGD, also termed posterior blepharitis, is the most common
form of lid margin disease (LMD); nearly 40% of routine eye care patients and
50% of contact lens wearers are affected.1,2 In the early stages, patients are
often asymptomatic, but if left unmanaged, MGD will either cause or exacerbate
dry eye-like symptoms. Dryness, burning, itching, stickiness, foreign body
sensation, watering, photophobia and intermittent blurred vision are frequently
seen in cases of MGD.
Meibomian gland dysfunction can exist alone, or it can be
associated with anterior blepharitis or seborrheic dermatitis.
• Primary meibomianitis. Also known as obstructive MGD,
primary meibomianitis is a generalized dysfunction of the sebaceous glands. It
is commonly associated with acne rosacea, acne vulgaris and seborrheic
dermatitis. The anterior lid margin typically appears normal in those with
primary meibomianitis, but the meibomian glands are dilated and blocked with
inspissated secretions that are sluggish or stagnant upon expression.
• Anterior blepharitis. This can lead to secondary
inflammation of adjacent meibomian glands. In addition to the typical signs of
anterior blepharitis, focal patches of inflamed or plugged meibomian glands are
evident. It is unclear if bacteria cause the glands’ secretions to become
thickened (i.e., inspissated), or if they simply exacerbate the condition by
causing inflammation. But, it is known that gram-positive bacteria, such as S.
epidermidis and S. aureus, release lipases that hydrolyze sebaceous gland
lipids. These enzymes produce free fatty acids and other byproducts that
irritate the eyes and cause tear film instability.3
• Seborrheic dermatitis. Patients with seborrheic dermatitis
(a skin condition that affects the sebaceous glands of the scalp, face and/or
trunk) often have greasy flakes in the lashes and inflamed or infected lid
margins. These patients may simply have increased meibomian secretions, or
meibomian seborrhea. Along with the greasy scales seen in the lashes, excess
meibomian oil is usually evident on the lid margins and in the pre-corneal tear
film. The meibomian glands are dilated and full of meibum that can be easily
expressed.
Frequently, soapy-looking bubbles are seen along the
inferior lid margin. This saponification occurs when excess lipid secretions
react with protein in the tears. It’s not surprising that patients with
meibomian seborrhea frequently complain of burning upon awakening—it’s like
getting soap in their eyes! Inflammation is usually minimal in cases of
meibomian seborrhea, so patient symptoms are often worse than observed signs.
The localized inflammatory response that results from
meibomian stasis can lead to permanent keratinization and scarification of the
gland. Such an advanced condition affects the lid margin contour and gland
placement. Due to a lack of oil in the tear film, these patients typically have
a reduced TBUT and increased evaporative rates.
Early Signs of MGD
Do not dismiss the subtle signs of early MGD. Look for oily
lid margins, excess oil in the tear film, dilated meibomian glands, mild
injection and the occasional inspissated gland. Even if patients are
asymptomatic, it’s not too early to start educating them about lid hygiene, the
chronicity of the condition, and possible sequelae if left untreated.
In cases of longstanding disease, signs include thickened
(tylotic) eyelid margins, telangiectatic vessels, loss of lashes (madarosis),
poliosis, trichiasis and notching of the lid margin. Chronically inspissated
glands eventually become keratinized and “drop out,” leaving a divot in the lid
margin. This causes a shift in the meibomian glands, and they become unable to
secrete oil onto the proper location of the lid, which results in permanent
changes in the tear film composition and ocular environment, and significant
dry eye symptoms.
Kits for Ocular Hygiene and Therapy
Kits that combine oral tetracyclines and lid hygiene
products are now available by prescription. Packaging these products together should help patients
understand that lid hygiene and oral antibiotics together are important for
management.
• The Cleeravue-M Kit (StoneBridge Pharma) combines a
regimen of 50mg of minocycline with SteriLid.
• The Alodox Convenience
Kit combines a 20mg regimen of Alodox (doxycycline hyclate) with OcuSoft Lid
Scrub pads for acute treatment and OcuSoft Lid Scrub Original Foaming Formula
for maintenance. It also includes Tranquileyes Moist Heat Therapy Goggles.
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Care for MGD Patients
A happy patient who sees well is the goal of any eye care
professional. In MGD patients, the reduction of symptoms is important, and the
prevention of permanent damage that can affect the eye’s ability to maintain a
balanced environment is paramount. Many effective treatments for MGD are
available, so therapeutic care can be tailored to each patient.
Patients should be made and kept aware of the signs and
symptoms of meibomian gland dysfunction. They need to understand that MGD is a
chronic condition and that it requires a regular, if not daily, lid hygiene
regimen.
Treatment should incorporate lid hygiene techniques with expression,
if possible. Reserve medications for acute or recalcitrant cases. Omega fatty
acids found in fish oils and flaxseed are also commonly recommended to patients
with dry eye and/or MGD.4
Because of the common comorbidity of MGD and dry eye,
pa-tients are often on dry eye therapy while on MGD treatment. Prescribing
Restasis (cyclosporine 0.05%, Allergan) may be especially beneficial for those
who suffer from aqueous deficient or inflammatory dry eye. A recent study found
that dry eye patients on Restasis had fewer meibomian gland inclusions and less
lid margin injection.5 Restasis is also especially effective in those with acne
rosacea and meibomian gland dysfunction.6 As with any chronic disease,
continued compliance is a challenge for patients and doctors alike. Luckily,
most of the following treatments are not difficult to perform or explain.
• Warm compresses. A study out of Oxford University found
that heating the lids about 9ºF significantly increased meibomian oil
production.7 Using warm compresses, heat should be applied to the eyes for two
to 10 minutes. This warms the meibum, allowing it to flow more freely, and
helps soften lash debris. May recommend patients perform compress therapy with
a wet washcloth towards the end of a hot shower. This should encourage
compliance by helping incorporate lid hygiene into the daily routine—may also
enhance the therapeutic effect since meibomian glands and skin pores open in a
hot shower.
Other warm compresses are a microwaved sock filled with dry
rice, hot hard-boiled eggs in a damp sock, and gel-filled masks. After the
application of warm compresses, patients with all forms of posterior
blepharitis should massage their lids to help express meibum from deep within
the glands.
• Lid scrubs. These help to remove oil, bacteria and debris,
as well as to stimulate the meibomian glands. Baby shampoo or mild soap have
historically been recommended to patients with seborrheic forms of lid disease.
Note that some patient’s eyes are sensitive and become chemotic and injected
due to the detergent. OcuSoft (OcuSoft) and SteriLid (Advanced Vision Research)
are bactericidal products available commercially. These products may be less
irritating to the conjunctiva than shampoo or soap. Lid scrubs may be
prescribed at different steps within the lid hygiene regimen. In patients with
anterior blepharitis, lid scrubs should be performed before massage so the
lashes are cleared of bacteria and debris prior. In patients with posterior
blepharitis, one may opt to first express meibum from deep within the lids,
then perform lid scrubs to remove excess oil.
• Massage. Lid massage can dramatically improve symptoms by
helping re-establish tear film stability. Research has demonstrated that, after
gland expression, TBUTs return to normal, and in some cases, super-normal
levels.8 The technique: Extend finger and apply light pressure. Roll the finger
upward on the lower lid two times while in upgaze, then roll the finger
downward on the upper lid two times while in downgaze.
Excessive manipulation of the lids can cause additional
irritation, so lid massage and scrubs should be performed twice a day during
the acute stage, and once daily during maintenance. Follow-up care is important
in these cases, so that treatments can be assessed and modified.
After regular lid hygiene, have patients instill an
artificial tear. This helps to rinse away the extra oil from gland expression
and/or any residue from the lid scrub. MGD patients also typically have dry
eye, so tears are often recommended between two and four times per day.
• Tetracycline. For ongoing management of MGD, tetracyclines
are effective and useful. Oral tetracyclines—e.g., doxycycline and
minocycline—appear to inhibit bacterial lipase production. This reduces free
fatty acids, which helps to lessen inflammation and symptoms of irritation.
Tetracyclines also help inhibit keratinization of the meibomian glands, and
have been shown to reduce the number of Staphylococcus organisms.9,10 Ocular
hygiene kits that package tetracyclines and hygiene tools together for patients
are now available for prescription.
The current modality is to decrease doxycycline dosage from
the typical dose (100mg b.i.d.) to 20mg to 50mg b.i.d. for a two-month course.
In a study comparing low- vs. high-dose doxycycline, patient symptoms were
equally improved in both dosage groups.11 Side effects can be kept at a minimum
with a decreased dose of doxycycline. Minocycline can be considered as well,
because it already carries a lower dosage (50mg), once-a-day treatment, and few
side effects (particularly with regards to sun exposure). Patients may be kept
on a maintenance dose as long as necessary.
In-Office Expression of Meibomian Glands
In-office expression of the meibomian glands can provide
significant relief because the backed-up glands can be painful.
To express the meibomian glands, instill topical anesthetic
and apply pressure between two cotton-tipped applicators in an upwards-rolling
motion (one applicator on either side of the eyelid).
Alternatively, use a
Mastrota paddle (OCuSOFT), developed by Katherine Mastrota, O.D., which is used
specifically for expressing the meibomian glands.
Upon expression, the secretions may be thickened, and they
may appear cheesy or toothpaste-like.
A topical antibiotic/steroid may be prescribed to reduce inflammation
after manual expression. As prophylaxis post-expression, one may choose to
prescribe any of a variety of generic antibiotic ointments, like bacitracin or
erthythromycin.
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The pressure of two cotton-tipped applicators will express
the meibomian glands. Upon expression, not only are nearly all glands stagnant,
but dry and scaly material (i.e., scurfs) is also found in the lashes.
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Additional Remedies
The latest trend in the treatment of MGD is the use of the
topical antibiotic AzaSite (azithromycin 1%, Inspire Pharmaceuticals). AzaSite
is gel-forming and lipophilic. It remains on the ocular surface longer than
conventional drops do, which allows for an increased drug concentration in the
eyelid and conjunctival tissue. Like other macrolides, azithromycin has an
anti-inflammatory effect. AzaSite is prescribed off-label to help control
posterior blepharitis—it is thought to expedite resolution of gland
inflammation.12
Patients may instill one drop after lid hygiene at bedtime
and rub the solution into their lashes. They follow this routine for two to
four weeks and are closely monitored.
Another potential treatment option for MGD is to begin a
regimen of nutraceuticals. A growing body of evidence links the dietary intake
of omega fatty acids with benefits for patients with dry eye conditions and
MGD.13,14 This family of essential fatty acids provides the building blocks for
the prostaglandins that modulate tissue inflammation.
Because of the benefit to vascular, cardiac and other
physiologic functions, most clinicians suggest 2g to 3g per day of high-quality
OTC fish oil capsules or flaxseed. Lovaza (GlaxoSmithKline) is a 4g dose of
super-purified omega-3 fatty acid ethyl esters that is currently available by
prescription.
If patients are educated about eyelid hygiene early in the
course of the disease, it is possible to prevent advanced signs. For milder
cases, lid hygiene alone may be enough to prevent symptoms. For patients who
are symptomatic, a variety of therapeutic options may be used in combination
with hygiene techniques. It is especially important to incorporate eyelid
massage into the hygiene regimen; this helps keep the oil flowing from the
meibomian glands and can improve symptoms quickly. Manual manipulation of the
lid is critical for a successful outcome.
Ultimately, we want to keep patients comfortable. The
challenge for any clinician managing a case of MGD is to offer patients a
practical solution that is not overly cumbersome and affords a reasonable
chance at continued compliance. Dr. Pitts is a Southern College of Optometry graduate and
Clinical Instructor. She works in the Ocular Disease and Primary Care clinics
at The Eye Center, and she is a regular attending staff doctor with the Student
Volunteer Optometric Services to Humanity.
Dr. Lievens is an Associate Professor and the Chief of
Primary Care at the Southern College of Optometry. He is also the Interim Chief
of Staff of The Eye Center. Dr. Lievens is the co-creator of the funduscopic
grading card.
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meibomian gland dysfunction. Optom Vis Sci. 1990 Sep;67(9):710-2.
2. Henriquez AS, Korb DR. Meibomian glands and contact lens
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3. McCulley JP, Shine WE. Changing concepts in the diagnosis
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4. Paranjpe DR, Foulks GN. Therapy for meibomian gland
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5. Perry HD, Donnenfeld ED. Topical 0.05% cyclosporine in
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6. Schechter BA, Katz RS, Friedman LS. Efficacy of topical
cyclosporine for the treatment of ocular rosacea. Adv Ther. 2009
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(3):367-70.
8. McCulley JP, Sciallis GF. Meibomian keratoconjunctivitis.
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9. Marks R, Davies MJ. The distribution in the skin of
systemically administered tetracycline. Br J Dermatol. 1969 Jun;81(6):448-51.
10. McCulley J. A combination therapy for blepharitis and
meibomianitis. Ophthalmol Manage. 2006 Sept. Available at:
www.ophmanagement.com/article.aspx?article=86674 (Accessed May 2009).
11. Yoo SE, Lee DC, Chang MH. The effect of low-dose
doxycycline therapy in chronic meibomian gland dysfunction. Korean J
Ophthalmol. 2005 Dec;19(4):258-63.
12. Ianaro A, Ialenti A, Maffia P, et al. Anti-inflammatory
activity of macrolide antibiotics. J Pharmacol Exp Ther. 2000
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13. Sullivan BD, Cermak JM, Sullivan RM, et al. Correlations
between nutrient intake and the polar lipid profiles of meibomian gland
secretions in women with Sjögren’s syndrome. Adv Exp Med Biol. 2002;506(Pt
A):441-7.
14. Boerner CF. Dry eye successfully treated with oral
flaxseed oil. Ocular Surgery News. 2000;10:147-8.
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