Contact Lens Practice Pearls
The Importance of Meibomian Gland Expression
BY GREGORY J. NIXON, OD, FAAO
The release of the Tear Film and Ocular Surface Society’s (TFOS) report of the International Workshop on Meibomian Gland Dysfunction (MGD) in 2011 highlighted the important role of the meibomian gland in dry eye and ocular surface disease. MGD is not only a leading cause of evaporative dry eye, it is also the likely leading cause of dry eye disease itself (Nichols et al, 2011). As dryness is a prevalent symptom among lens wearers, it is increasingly important for practitioners to address meibomian gland health during a contact lens exam.
The MGD workshop defined and categorized all aspects of the condition and concluded that the main cause of MGD is obstruction of the terminal ducts with thickened opaque meibum (Nichols et al, 2011). This leads to a lack of a proper liquid oil component within the tear film, causing greater tear evaporation, tear hyperosmolarity, and ocular surface inflammation. Consequently, expression of the meibomian glands is now a key element in aiding diagnostic workups of patients complaining of ocular surface irritation (Tomlinson et al, 2011). Typically, an examiner uses a finger to apply pressure for 10 to 15 seconds to the outside of the central lower lid while the patient looks in upgaze. Only gentle pressure is recommended to approximate the same force exerted during normal blinking. Grade the expressibility of the glands themselves (how many express meibum) and the quality of the expressed lipid (clear, cloudy, granular, inspissated). Consult the TFOS report for details of recommended grading scales.
Figure 1. Therapeutic expression technique.
Patients who have significantly thickened meibum secretions may benefit from more aggressive meibomian gland expression. This will help clear the obstructed duct, remove stagnant meibum, and restore the normal expression of liquid meibum. This requires significantly greater amounts of pressure applied to the lid. Apply topical anesthetic and use a wetted cotton tip applicator or Mastrota paddle (Figure 1) behind the lid to provide some leverage in applying pressure. Either technique can be performed swiftly as an in-office procedure. LipiFlow by TearScience is a more elaborate therapeutic expression device involving a scleral shell that supplies heat to the inner aspect of the lid along with an intermittent pulsatile pressure applied to the outside of the lids. Following therapeutic expression, advise patients to continue regular warming and digital lid massage to maintain gland functioning for long-term comfort.
Provide Complete Care for Your Patients
Complaints of dryness and ocular discomfort are common among contact lens patients. Before hastily changing lens materials or care solutions, we must perform a systematic evaluation to properly determine their root cause. Detailed meibomian gland expression can help diagnose MGD and also can provide therapeutic relief. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #212.
Dr. Nixon is a professor of clinical optometry and director of extern programs at The Ohio State University College of Optometry. He is also in a group private practice in Westerville, Ohio. He is on the Allergan Academic Advisory Board, the B+L Advisory Board, the Alcon Glaucoma Advisory Board, and the Alcon Speakers Bureau. You can reach him at email@example.com.