Is This the New Norm?
Is Meibomian Gland Expression the New Norm?
BY MILE BRUJIC, OD, FAAO, & DAVID L. KADING, OD, FAAO
Dry eye comes in many different forms and often sneaks in the door. For many, it starts as a slight irritant that decreases comfortable lens wearing time. In many cases, the disease progresses to a serious problem that affects our patients’ quality of life. As our practices have grown, we have seen this patient base become a substantial sector of those that we see everyday. And, many of these patients are “silent sufferers,” thinking this is a condition that is normal or usual. Instead of bringing it up to us, consumers are spending millions of dollars each year on eye drops. In fact, the economics indicate that average moderate dry eye patients spend around $2,800 on dry eye treatments yearly (Yu et al, 2011).
This has brought up a whole new question about our method of evaluating patients. Is there a way that we can identify and treat patients who are on their way toward dry eye disease before they even have symptoms?
Eyecare practitioners (ECPs) have embraced the preventive model for patients who have ocular hypertension, but often ignore the anterior segment and ways to prevent future dry eye disease.
Diagnosing Early Dry Eye
In our practices, we have enacted a new normal. ECPs typically look at the eye lashes and lid margins first. Then, if all appears healthy, they move on to the bulbar tissue. But a condition has continued to elude us as practitioners: nonobvious meibomian gland dysfunction (NO-MGD) (Blackie et al, 2010). This condition has hallmark signs of perfect-looking lid margins without inflammation and/or any signs of telangiecstasia. Upon careful observation and manual gland expression, NO-MGD patients show plugged glands that do not flow. These patients may be symptomatic or asymptomatic of dry eye, but their glands are plugged and they are moving in the direction of dry eye. If acted upon while these patients are in their early disease states, we may be able to save them from contact lens discomfort or a more advanced dry eye state.
As such, we have begun to express the glands in all of our patients. This procedure can be done in two ways: 1) A thumb is pushed against the globe—with a mild amount of pressure, you should be able to see meibum expressed that appears like olive oil. 2) Use an instrument called a meibomian gland expressor (MGE), which exerts 1.2g/mm2 (Greiner, 2012)—upon forced blink, upper lids exert between 1 to 2 pounds of pressure to release meibum from the glands.
Although the MGE is more accurate, we suggest using either method to exert pressure onto the lid margin. Multiply the total glands that are expressing meibum by the quality of the meibum coming out of the glands (3 for olive oil to 0 for completely plugged) to get a total gland score. We feel that a gland score of either of the lower lids that is less than 12 needs to be treated.
We feel that preventive medicine is and should be the new norm in our practices. As such, we have added gland expression as part of our normal slit lamp examination. We would suggest that you give it a try. CLS
For references, please visit www.clspectrum.com/references and click on document #225.
Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, Allergan, B+L, Optovue, Nicox, Paragon, SpecialEyes, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision, VSP, and ZeaVision. Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle, Wash. He is the co-owner of Optometric Insights with Dr. Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon Laboratories, Allergan, Bausch + Lomb, Biotissue, Contamac, Essilor, Nicox, Oculus, RPS Detectors, TearScience, Valley Contax, and ZeaVision. Follow him on Twitter @davekading.