Dry eye is multifactorial disease caused by a loss of hemostasis of the tear film from instability, ocular surface inflammation and damage including neurological and morphology changes. Meibomian gland dysfunction or “MGD” is a chronic abnormality of the oil producing glands of the eye. MGD occurs when the oil glands are clogged and meibum cannot be released with each blink like it should be; this reduces the volume they produce and creates chemical changes in secretions. MGD is exacerbated by periocular rosacea, more on that in a minute.
Regardless of how much of the water component of your tears you produce (it makes up ~90% of the volume normally), without an oily layer on the surface of your eye, the tear film will evaporate quicker than a normal blink occurs; this instability leads to inflammation and mild damage. Without fixing the source of the problem, over time this negative feedback loop leads from mild symptoms, like intermittent blur to devastatingly severe symptoms of constant ocular discomfort, redness and irritation (burning, stinging, foreign body sensation). The earlier in this chronic process we treat the underlying cause, the better the outcomes and the less involved your treatments need to be.
MGD is not only the leading cause of evaporative dry eye and also makes up the majority of dry eye cases overall. Regardless of how much of the water component of your tears you produce (it makes up ~90% of the volume normally), without an oily layer on the surface of your eye, the tear film will evaporate quicker than a normal blink occurs; this instability leads to inflammation and mild damage. Without fixing the source of the problem, over time this negative feedback loop leads from mild symptoms, like intermittent blur to devastatingly severe symptoms of constant ocular discomfort, redness and irritation (burning, stinging, foreign body sensation). The earlier in this chronic process we treat the underlying cause, the better the outcomes and the less involved your treatments need to be.
One of the first things we recommend to improve the MG secretions is what is considered “conservative” treatment because it’s only effective when the disease is very mild, often before many people notice symptoms. These treatments include using hot compresses and introducing an increased amount of Omega 3s into the diet. Both of these aim to increase meibum volume, Omega 3s help increase volume by providing the proper building blocks to create meibom (namely DHA) and hot compresses express the oil near the gland’s opening removing any obstructing that might be beginning to form.
The Meibomian Gland Game Changer
When inflammation is limited to the meibomian glands and ocular surface, medications that treat inflammation help significantly restore a healthy tear film. Things like cyclosporine (Restasis) or lifitegrast (Xiidra) address this, but not everyone benefits from these medications nor does everyone want to be a medication indefinitely. For many people who have cloudy meibum (a chemical change from translucent olive-oil color to a milky white one), these options don’t help much, as inflammation from outside the eye needs to be stopped before a the tear film can reestablish a homeostatic ocular surface environment.
Inflammation of the peri-ocular region (aka the skin around the eyes, including the cheeks, upper and lower eye lids and brows), can leech through the thin skin of the lids and affect the function of the meibomian glands. The most common sign we see around the lids are dilated blood vessels call telangiectasia. Those with facial rosacea know this effect well as it’s the reason for the red patches on their cheeks, nose or other areas of their face.
These superficial blood vessels not only look bad (cosmetically), but they are poor quality and leaky. The slow leeching of inflammatory irritants into the skin leads to poor function of the skin barrier and oil glands, leading to dry skin that thickens over time. This same thing happens to the eye lid. Not only do meibomian glands produce poorer quality oil, these leaky vessels also thicken the tissue along the lid margin making what they do produce a challenge to get out of the pore when you blink. (I think of this like a pimple you picked on and can’t get to pop: the skin is swollen and nothing can come out until the inflammation quiets down.)
The best way to improve function to these glands is to treat the source of the problem: the superficial blood vessels. A light therapy was developed many years ago for use on the face to treat rosacea, but it’s only been applied to dry eye treatment for a few years. IPL or intense pulse light therapy was just approved in early 2021 for treatment of these vessels around the eye and results have been striking.
One study found when comparing Meibomian gland expression* alone and with IPL treatment:
- Patient’s subjective symptoms improved more when adding IPL compared to expression alone (all patients started around with moderate dry eye score of ~13-15, and improved by 9 points w/ IPL vs 3.5 with expression alone about 3 months since last treatment)
- Tear break up time (TBUT) or the measure of how quickly the tear film evaporates was significantly and consistently improved over the expression alone
- Superficial vascularity improved significantly after a few treatments and results remained for at least 3 months after last treatment (expressing miebomian glands doesn’t impact this one way or the other)
- There is improved conjunctival staining and plugging of MG, signs that high levels of inflammation are present and the benefit remained unchanged for at least 3 months after last treatment. These improved slightly with expression, but not near as much
- IPL makes the expression procedure more comfortable by softening the meibom through the thin lid skin
- 66% of patients saw improvements in signs and symptoms after 4 treatments and over 90% of patients saw improvement after 8 treatments; this improvement remained unchanged through the end of the study about 3 months after last treatment.
- Symptoms start to improve after only 2 treatments!
*Meibomian gland expression or thermal pulsation is when heat is used to clear the glands of thickened secretion; examples of this treatment are LipiFlow, iLux and to a lesser extent, hot compresses.
IPL is a game changer. Studies have shown over and over that IPL is a treatment amplifier: It more then doubled the effect of the meibomian gland expression alone.
There are several ways researchers think ILP helps MGD: IPL warms the MG through the thin eyelid skin and melts the secretions within the glands; IPL emits energy that is absorbed by chromophores in the hemoglobin and closes abnormal vessels in the lid margin and adjacent conjunctiva, this prevents release of inflammatory factors into the tears; ILP may relieve inflammatory or neurogenic pain; IPL results in an immediate reduction in bacterial load at the lid margin and surrounding skin, a external source of inflammation.
The exact reason may not be known for a while, but results of using this technology for the last 5 years have been exceedingly positive and without the negatives of daily medications, drops, or other routine. No other treatment for meibomian gland dysfunction treats the root of the problem like IPL and is effective at halting the disease process, unlike our go to treatments in the past Restasis or Xiidra which only make you less susceptible to the inflammatory irritants floating in your tears.
If you think you have meibomian gland dysfunction (it makes up 85% of dry eye sufferers), please call or text 816-524-8900 today and ask to be scheduled with our dry eye specialist Dr. Alyssa Sherwood. Ask about our introductory pricing for the rest of 2021 as we want all our loyal patients who suffer this an opportunity to feel the benefits themselves.
Posted July 2021 by Laura Nennig, OD; she specializes in contact lens fittings, with advanced training with scleral lenses including those used for dry eye treatment. She works closely with our resident dry eye specialist, Alyssa Sherwood, OD.