September 15, 2011
Meibomian gland disease (MGD) (Evaporative dry eyes)
Read this 170 page PDF file first
Anatomy
Meibomian glands are the oil-producing glands located in both the upper and lower eyelids. They number about 25 to 30 (each: a total of about 100) and normally slowly release oil into the tear film. This oil helps to stop the water in the tears from evaporating, thus helping to prevent dry eyes. Detailed anatomy here.
The meibomian glands (3 Fig above) of the tarsal plate produce the lipid that will line the layer of the tear film. The Meibomian lids empty into ducts that dot the marginal surface of the eyelid and can be seen emanating droplets of oil for the tears.
Normal glands:
Healthy
meibum is a transparent, free-flowing, yellow oil that when expressed resembles a light cooking oil. In a healthy eye, gentle pressure with a finger or cotton swab for as little as 15 seconds in the central portion of each lower lid should produce a small amount of meibum from one or more of the glands in each lid. If no oil is produced, or if a thickened or opaque oily substance issues from the glands, the diagnosis is MGD and appropriate treatment should ensue [Source]
Details on how long it takes for a gland to regenerate its liquids after it has been expressed: http://www.ncbi.nlm.nih.gov/pubmed/19387230
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The cure for eye strain/ dry eyes (for most cases of dry eye) |
Over time, some of these glands die or otherwise atrophy. See this. Hyperkeratinization of ductal epithelium and atrophy of acinar cells may cause meibomian gland dysfunction.
the natural history of MGD starts with hyperkeratinization of the duct epithelium leading to duct occlusion. This is seen as pouting or plugging of the gland orifices and production of keratin rich expressed material. This plugging causes damming back of the gland secretions that leads to disuse atrophy of the acini. In the advanced stages periductal scaring occurs, it is seen as an exaggerated opaque ring shaped opacity around the ducts or a focal absorption of the gland orifices that ends in total damage and gland loss [Source]
MGD as a MAJOR CAUSE OF DRY EYES (Evaporative dry eyes)
Many people who have dry eye symptoms are treated as though the cause is aqueous deficiency (artificial tear supplementation and punctal plugs), when in fact their primary problem is meibomian gland dysfunction MGD. Some researchers believe that up to 70% of chronic dry eye may actually be MGD, not "classic" dry eye. More broadly, nearly half of the subjects with dry eyes have MGD [Academic paper].
Posterior blepharitis is often called meibomitis or meibomian gland dysfunction [Source]. Meibomian gland dysfunction is quite common and unfortunately it often goes undiagnosed. Even when diagnosed is often not treated or is not treated effectively until it has become chronic or severe.
MGD may be inflammatory (often as a result of blepharitis) or atrophic.
Blockage
Severe blockage can lead to much enlarged glands (a cyst) or even infection. It is therefore important to firstly, unclog the glands which are blocked and secondly to prevent them from blocking up again as much as possible
Thickening of oil
The oil is supposed to be nice and warm and runny, but sometimes it can get thick and gets stuck. This leads to blockage of the narrow duct which takes the oil from the gland to the tear film. The oil continues to be made and this can lead to filling and swelling of the glands.
Vicious cycle: bacterial infection as a result of MGD
MGD causes reduced lipid production for the ocular surface, leading to tear evaporation and dry eye. Decreased tear production reduces the eye’s ability to flush bacteria from the lid margins, enabling bacteria to infect the meibomian glands and eyelash follicles, in turn further degrading the tear film. In addition to aqueous deficiency dry eye, MGD contributes significantly to ocular surface disease. Since it is not always easy to distinguish the clinical signs and symptoms of MGD from dry eye disease or ocular allergy, the MGD may go untreated. [Source]
Anterior blepharitis is not uncommonly seen in association with MGD due to the abnormal keratinization found mainly with seborrheic blepharitis E161.However it is still unclear whether the keratinization and gland drop out are primary or secondary phenomena [Source]
Anterior blepharitis is commonly found among patients and it was hypothesized that it might play a role in the progression of the disease. [Source]
Age related cause
A neurotransmitter called vasoactive intestinal polypeptide and the hormone androgen control meibum secretion.2 Women's androgen levels drop during and after menopause, and post-menopausal women have an increased prevalence of MGD, so this may indicate a hormonal connection.3 As further proof, topical antiandrogen treatments reduce meibum levels, while topical use of the androgen precursor dehydroepiandrosterone increases meibum levels.4 [Source]
As the natural history of meibomitis advances, the meibomian gland orifices progress from open to stenosed to closed (Figure below). [Source]
Natural history of meibomitis. Meibomian gland inflammation leads first to stenosis and then closure of the meibomian gland orifice.
Symptoms
The clinical presentation of MGD includes, capped meibomian glands and the pathognomonic foamy tear. Expression of the meibomian glands may be difficult. The secretions of the meibomian glands can become extremely thickened and have the appearance of tooth-paste. The plugged glands can become infected and the patient may complain of recurrent styes. The dysfunctional lipid layer that occurs in MGD leads to a rapid tear film breakup and evaporative loss of tears resulting in secondary aqueous tear layer insufficiency. [Source]
Symptoms of MGD include redness on the lid margin, flaky debris or mattering, fluctuating vision, burning and stinging. [Source]
Cure
1. Unblock the glands
Lid therapy – particularly heat treatment – helps deal with this by first kind of melting the stuff that’s thickened up, then gently squeezing it out.
The first part of unblocking the glands is to liquefy the thickened oil in the glands. This is achieved by running a face cloth under the hot tap until it is warm, but not hot. (From here)
- Hold this against the closed eye for about one minute or so (see figure One).
- Then, having liquefied the oils with this warming, press with one finger firmly on your cheek.
- Next, with the first-finger, press firmly on the lower lid, pushing upward to push the oil up into the tear film (see figure Two).
- Do this a few times over the entire lower eyelid, and then repeat for the upper eyelid.
- Repeat the entire procedure for the other eye.
- Do this initially once per day for one week. This will help to unclog the blocked glands.
- After the first week, doing this once or twice per week should help prevent the glands from becoming reblocked.
2. Kill any bacteria that have collected
Oral antibiotics such as doxycycline 50mg twice a day for one month then once a day for another two months [Source]. And take preservative free artificial tears. Make sure you use warm compressors on daily basis to help disease stability.
3. Increase the production of lipids
Some nutritional supplements such as flaxseed oil may be useful as well
New treatment -LIPIFLOW
Providers have historically considered MGD one of the most difficult diseases to treat because we have lacked a simple, effective therapy. The challenge with “mechanical” therapies (cleansing, hot compresses, massage) is adherence; the challenge with topical antibiotic drops and ointments is efficacy—they do not penetrate the lid margin well, and most lack the needed antiinflammatory effect. While more effective, oral tetracyclines often have unpleasant gastrointestinal side effects. [Source]
TearScience has received FDA clearance for its LipiFlow Thermal Pulsation System that works on meibomian glands to promote the release of lipids to the tear film.
The procedure is performed at the doctor’s office and takes about 12 minutes for each eye. LipiFlow delivers heat to the inner eyelid and massage to the outside, which helps unblock the flow of lipids from the cystic meibomian glands. [Source]
[See video below]
Addendum
Obstructive meibomian gland dysfunction (MGD) is a common source of complaint among patients with dry eye syndrome and its prevalence increases with age. The principal clinical consequence of obstructive MGD is evaporative dry eye syndrome. Moreover, chronic obstruction of the meibomian glands may also result in degeneration of the secretory gland tissue that can lead to a secondary hypo-secretion even if the primary obstruction is later resolved by therapeutic approaches. Risk factors in the pathogenesis of obstructive MGD include age, hormonal disturbances and environmental influences (e.g., contact lenses). Furthermore, qualitative alterations in the composition of the meibum may lead to hyper-keratinization of the ductal epithelium and increased viscosity of the meibum. This can result in obstruction of the duct and orifice leading to a lack of meibum on the eyelid margin and tear film with downstream hyper-evaporative dry eye syndrome. At the same time, obstruction leads to a stasis of meibum inside the meibomian gland with increased pressure and resulting dilatation of the ducts and in atrophy of the acini with rarefaction of the secretory meibocytes and gland dropout. Stasis can also increase the growth of commensal bacteria, their production of oil degrading enzymes and release of toxic mediators. These factors can act as self-enforcing feedback loops that aggravate the primary hyper-keratinization and compositional disturbance of meibum and can hence lead to a progressive MGD (Knop and Knop, 2009b). [Source]
CONSENSUS FINDINGS
The first global consensus report on meibomian gland dysfunction — a major cause of lid disease and evaporative dry eye — has been published in a special issue of the Investigative Ophthalmology & Visual Science (IOVS) journal. The report is the result of findings from a two-year-long workshop composed of more than 50 leading clinical and basic research experts from around the world.
The workshop participants used an evidence-based approach to develop a worldwide definition: meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.
Using the same methodology, the participants developed a universal classification system — based on pathophysiology, rather than anatomical changes or the severity of disease — to meet the needs of clinicians and researchers alike. The consensus paper further proposes recommendations for diagnosing MGD and MGD-related disorders and presents a sequence of diagnostic tests to be performed in an order that will minimize the extent to which one test influences those that follow.
Also included in the report are recommendations for the evaluation and grading of the severity of MGD, management of and therapy for the disease and norms for clinical trials designed to evaluate pharmaceutical interventions for treatment.
The International Workshop on Meibomian Gland Dysfunction was conducted by the Tear Film & Ocular Surface Society (TFOS). While the breadth and depth of the consensus findings are expected to have a far-reaching impact on the clinical care of patients, the group of experts concur that additional research be conducted to further study other aspects of MGD. These include its association with dry eye disease and standardized and validated ways to identify symptoms and signs of MGD.
"IOVS publishes consensus findings on meibomian gland dysfunction." PHYSorg.com. 31 Mar 2011.
http://www.physorg.com/news/2011-03-iovs-publishes-consensus-meibomian-gland.html
In particular read this: http://www.iovs.org/content/52/4/1922.full.pdf
The diagrams below are from: http://www.iovs.org/content/52/4/1930.full.pdf
The new classi?cation system proposed by the International Workshop on MGD distinguishes among the subgroups of MGD on the basis of the level of secretions and further subdivides those categories by potential consequences and manifestations. On the basis of these proposed classi?cations, obstructive MGD is the most pervasive.
Ophthalmology. 1993 Mar;100(3):347-51.
Ocular evaporation in meibomian gland dysfunction and dry eye.
Source
Department of Ophthalmology, University of Iowa Hospitals, Iowa City 52242.
Abstract
BACKGROUND:
Secretions from the meibomian gland are believed to be important in reducing ocular surface water evaporation and preventing dry eye. Patients with blepharitis frequently have meibomian gland dysfunction with loss of meibomian glands (drop out). The authors hypothesized that dry eye that often occurs in patients with chronic blepharitis is secondary to increased evaporation associated with gland loss.
METHODS:
The authors measured the ocular surface water evaporation and tear osmolarity of patients with meibomian gland drop out and patients with gland drop out with a low Schirmer test. These findings were compared with those of a control group.
RESULTS:
The authors found that eyes with meibomian gland drop out and those with drop out and a low Schirmer test had a significantly higher evaporative rate at 30% relative humidity (average, 49.9 +/- 21 x 10(-7) g/cm2/second, or 0.49 +/- 0.29 microliters/minute evaporative loss per eye, and 59.1 +/- 28 x 10(-7) g/cm2/second, or 0.58 +/- 0.23 microliters/minute, respectively) when compared with those in the control group (average, 14.8 +/- 6 x 10(-7) g/cm2/second, or 0.15 +/- 0.07 microliters/minute [P < 0.05]). There was a significant correlation between evaporative rate and gland drop out (r = 0.522).
CONCLUSION:
Patients with meibomian gland drop out, and especially those with low tear production by Schirmer test, have an increased risk of dry eye developing through increased evaporation.
- PMID:
- 8460004
- [PubMed – indexed for MEDLINE]
I suffer from dry eye and the eye specialist prescribed blephamide ointment to help with my blocked oil glands which resulted in my getting styes on my lids, this oint was to be used for 5 straight days once every month but my own eye doctor said that too much blephamide oint is not good, I would be interested to know what your thoughts are.
Thanks, but my doctors wrongly diagnosed dry eye. My issue was severe eyestrain which I’ve resolved through eye exercises I’ve discovered on my own and documented on the main page of this blog. So I’m afraid I’ve not further researched dry eye. Please read up the latest journals on this topic. I’m sorry but I’m not going to be researching this topic further at the moment.
Hello,
My 21 year old brother has had an eye oil gland issue for several years now. He is in severe pain if he is in a room with circulated air, if wind blows in his eyes, when he looks at the television or any flashing lights, and/or he is anywhere where exposed air comes in contact with his eyes. He has tried every drop under the sun, including some homopathic remedies involving cayenne pepper. He has had the oil glands pierced numerous times and recently underwent an extremely painful procedure where his oil glands were heated with a machine which actually caused his oil production to worsen. Does anyone know of anyone who has experienced this debilitating problem? He is pretty much home bound as he is in pain wherever he goes. We are desperate for any info anyone can give to help out with this. Thanks!
Hi andrea, my husband is 30 years old and have the exact same problems with his eyes. Especially the glands making no oil, the dry eye symptoms and severe pain all day every day. He tried most meds and remedies. And were at lots of different specialist . Have you found any cure for your brother as yet? Any treatment or remedy that work for him? A reply would be greatly appreciated. Sonnike
Hi,
Could you please tell me what the machine was that you feel made his eyes worse, was this Lipiflow or IPL? I suffer from the same condition, I was thinking of getting Lipiflow but after reading your comment, interested to know what treatment he had. Both these treatments are meant to be pain free.
Thanks
I am in the same boat… I can’t do anything (sigh)
I've had this disease for a long time @ times it is extremely bad. I was told by Doctors to wash my eyes at least twice a day with baby shampoo the no tear formula, then use aquaphor healing ointment, to always use white washcloths, & two to three times a day use a dry towel heated by a microwave or etc to warmed only & put on eyelids, press lightly into eyelashes for 5 10 mins this will loosen trap'd oil in glands, & ease pain. Then use aquaphor ointment. Different times I get an infection & I'm given an eye drop antibiotic. For allergy relief I'm told to use cortizone 10 Ointment maximum strength, it can be rubbed in & around the eyes. It's a lot to do but it's a life long problem but these bring great relief. Remember the towel you use must be dry / No water No moisture & use warm only. I spent many many years with the wrong Dx, & Dr after Dr researching all I could & @ 61 I've found some relief. I experienced everything All of You are going through now, but have heart talk it over with your Dr's & family it's not drastic & everything don't cost sooo much & a very little of each goes a long way. I pray each of you find relief & I hope this help.
Try castor oil on eyelids twice a day after cleaning and massage stops eyes from drying and seems to help with clogging of the glands…
Hi
If the oil glands are blocked severely then the try to do warm compresses everyday and contact doctor steven maskin. he is the best doctor for treating these kind of diseases.
I just got diagnosed this week with this disease and I have been complaining about the itching dry eyes and sometimes sore for years. why can the heated towel be only warm and not hot. wouldn’t hot do a better job to loosen trapped oil in the glands. regards BJ
I use retaine eye drops, they are the only eye drops I have found worked for meibomian gland dysfunction. They don’t stop my eyes from getting red at work but definitely stop the pain. Heating my eyelids actually makes things worse. The only thing that has helped is the retaine drops, doxycycline, increasing water intake, taking omega 3’s, avoiding an inflammatory diet, using baby shampoo to clean eyelids, I also clean my pillow case twice a week. Intense exercise has also been found to make my meibomian gland dysfunction worse.
I was diagnosed with severe dry eye disease as well as MGD and eye mites which everyone has but mites are way worse for all MGD sufferers. Eye doctor has prescribed a lot of different things for me to do and I added a little bit myself. I had about a 3-4 second tear film evaporation time when I first went in. It’s been 3 months and last he checked one eye was 8 seconds and the other was 10 seconds and I’m still improving. Here are my steps.
Things to stop doing immediately- Do not smoke period. Weed or cigarettes will only worsen your disease!! Stop both immediately! Do not use red eye eye drops vasoconstrictors they make your eyes more red and dry after the affects wear off! Cut way back on drinking alcohol as this thickens your meibomian oil. I dropped all dark liquors and dark beers. Vodka drinks and light colored beers did not bother me nearly as much but I still cut way back on drinking in general!
Step 1. Use a heat compress for 10 minutes at least twice a day. I try to do it 3 times a day. I bought one of those bead filled eye masks you microwave for 20-25 seconds at Walgreens. A warm wash cloth works and can be put under the warm/hot water multiple times to keep it very warm. Don’t go so hot that you burn your eyelids but make sure it’s hot.
Step 2. I was prescribed Restasis which I use twice a day immediately after the heat compress. This helps restasis enter the glands as they were emptied when heat compress was applied. Be very patient with Restasis it takes months and ignore the burn if you get it. The burn is not a big deal so just deal with it and it goes away about 30 minutes after you put in the drops. Closing your eyes for a minute after putting them in helps the burn.
Step 3 (Very Important) Tea Tree Oil Foaming Face wash. You can find it online. Close your eyes and with clean hands wash your eyelids for 1 minute. Let sit on eyes for another minute then rinse your face. I do this 3 times a day 2 times a day at the minimum. This can slightly burn especially if your eyelids aren’t closed all the way but Tea Tree Oil face wash will not hurt you! This is very important as it slowly kills the eye mite bugs and causes eyes to water a little. I notice whiter healthier looking eyes immediately! We all have eye mites everyone does but it affects unhealthy glands more than healthy glands so we need to have better hygiene then the average person!!
Step 4. Blink eyes hard often and make complete blinks. Look away from electronics every 20 minutes for at least 10 seconds at a time. Keep blinking on your mind all the time!
Step 5. Use preservative free artificial tears multiple times a day. I like preservative free blink tears but they are a bit hard to find where I live. There’s a Ghetto Pharmacy I found that carries them and they are cheaper than anywhere online. $10 for 25 vials. Once a vial is open keep it in the fridge or a dark place like an eyeglass case. This helps stop bacteria from getting in the drops. Discard each vial within 16 hours of opening and keep in cool temperatures.
Step 6. Supplements. Fish Oil that’s very high in EPA and DHA. 2000mg minimum a day. Maquibright 60mg supplements once a day. I bought on Amazon. The maquiberry in maquibright is all natural like a raspberry or blueberry but it is by far the most potent strongest natural anti-inflammatory antioxidant ever found in the entire world! I don’t know if it’s helping but it’s a berry so it isn’t going to make it any worse :-).
I started a new treatment suggested by eye doctor but it’s only been about a week. It sounds weird but it makes sense and should help the yellowing of my eyes and the red veins over time. Autologous Serum Eye Drops. This is created from the white cells/serum in your blood. I’ve been prescribed 20% strength. The composition of this drop is very close to your natural tears. There are so many healing properties in your own blood and since it is your own blood your eyes won’t reject it unless the preparation company/pharmacy doesn’t make it properly! It’s not cheap but it wasn’t to bad for me either. It was $155 for 10 to 12 3ml bottles and it depends on the serum quantity in your blood when it’s been drawn by the pharmacy. They don’t say this but I’d stay away from alcohol a few days before the draw since it gets in your blood serum. They are a bit of a pain to carry around though since the bottle you are using must be refrigerated at all times! The others stay in the freezer. It only takes 2 hours to thaw a bottle in the fridge. I only got 10 bottles but it should last me for at least 3 months using 4 times a day sometimes more if I want. I bought a 12oz vacuum sealed food jar and bought the fake ice cube things you put in the freezer that have water inside that can be reused over and over again. I put 5-7 of those ice things in the jar and an empty open pill bottle where I drop the bottle of eye drops in and screw the lid closed on the food jar. It lasts 12-14 hours in the vacuum sealed metal food jar.
I am seeing drastic improvements but patience is key to all of this. It didn’t take a day for you to develop the disease and it won’t take a day to get rid of it either. I’m excited for what has started and am hoping it only will get better and better as I continue these treatments. It takes a lot of hard time consuming work but it’s better than looking in the mirror and getting anxiety and being embarrassed in public constantly. Im very young only 30 years old but I’m excited about the future and finally I have a smile on my face. I hope these steps can help many of you as well.
Correction to food jar serum drops. It stays cold for 12-14 hours in food jar. The drops last a few weeks when refridgerated.