Dry Eye Dx and Tx
Therapeutic Meibomian Gland Expression: Squeeze to Please
By Amber Gaume Giannoni, OD, FAAO
A number of patients in my dry eye practice come in of their own accord requesting in-office meibomian gland (MG) expression (Figure 1). They actually look forward to the procedure because they know that they will feel relief afterward (or perhaps it just feels so good when it stops).
Thickened, inflamed lids due to meibomian gland dysfunction (MGD) can result in a multitude of ocular symptoms, including overall soreness and redness as well as complaints of stickiness, burning, and variable vision. While MGD can be asymptomatic, if ignored it can lead to gland atrophy and the development of severe dry eye disease. Convincing an asymptomatic patient that therapy is necessary can be challenging, so mention these facts to encourage lid care compliance.
Although the most common form of dry eye disease is evaporative, and obstructive MGD is a likely culprit, many practitioners still do not perform therapeutic MG expression. This is possibly because full expression of both upper and lower lids can take up to 30 minutes. In addition, there is no current code for the procedure, leaving most of your efforts non-reimbursable by insurance. However, given that 40 percent of our patients have MGD (Gaume Giannoni et al, 2012), and many give up on warm compresses because benefits are delayed and improvement is sometimes minimal, in-office expression can go a long way in helping patients feel better quickly.
Expressing Meibomian Glands
To augment in-office gland expression and make it a more comfortable experience for all involved, have the patient perform at least 10 minutes of warm compresses and instill several drops of topical anesthetic before the procedure. Place a Mastrota paddle or cotton-tipped applicator on the palpebral side of the lower lid. This “backstop” allows for forceful expression without pushing on the globe. Use your thumb to apply pressure on the outer lid, directly in front of the paddle. Continue along the upper and lower lids until all of the glands are expressed.
Figure 1. MG expression.
We take frequent breaks during the procedure if necessary, and I educate patients that cool compresses for a day or two may provide relief of any residual lid swelling and discomfort. Rarely, topical steroid ointment can be prescribed if the patient is significantly uncomfortable. Patient education on continued lid care is important to maintain results.
The amount of digital pressure required for complete MG expression is likely more than you think. Korb et al (2011) conducted a study on subjects who had obstructive MGD and found that up to 40 pounds-per-square-inch (psi) of pressure is required to fully evacuate a gland, which may take up to two minutes. For perspective, a very forceful blink requires only 0.3 psi. Interestingly, only 7 percent of study subjects could tolerate the level of pain associated with full MG expression of the entire lower lid. While this may sound discouraging, partial gland expression can also provide significant symptom relief for patients without making the process intolerable. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #207.
Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and the Co-Director/Co-Founder of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.