Dry Eye: Meibomian Gland Dysfunction
What is Meibomian Gland Dysfunction?
Meibomian Gland Dysfunction, or MGD is by far the most common form of dry eye I see in patients. It appears to be highly correlated with computer time, is usually worse in the winter, and most people are using the wrong treatment strategies.
Common Symptoms:
Intermittent blur, closer to end of day
Watery eyes for no reason, but especially common in cold weather
Burning, irritated, acidic-feeling eyes
What is the problem here?
In everyone’s eyes, we have about 20 glands on the top of the lids, and about 40 on each lower lid. They are supposed to be making oils (meibum) that cover the tears in a uniform film, preventing evaporation. With every blink, they are stimulated to release the oil, and make more to fill up for the next blink.
Here’s the thing - when we use the computer, or many screens, we tend to stare. When we stare, we blink far less frequently, and twice as many blinks are not complete, so the glands are not even signaled to release the oils in those cases.
If the glands don’t receive a regular signal to produce oil, eventually they degenerate, easily visualized and tracked on eye tests, called meibography. The fewer glands present, the less oil we can expect to protect the tears from evaporation.
To explain these common symptoms, when the tear film is unstable, this non-uniform surface you have to look through causes moderate blur. Once you blink, a new surface is created. Depending on the severity, the tears will become scattered at different times - generally I like to see the tears stable for 7-10 seconds, but in severe MGD, it can be instantly blurry. Once this protective barrier is broken, the tears are exposed to the environment, and quickly evaporate. As a reflex, we make more watery tears (without oil) that tend to be over-produced, and roll off the eyes, down the face. In the cases where patients do not make revlex tears, the evaporation of the watery component causes concentrated inflammatory factors and salts, and can cause burning or irritation.
So What Do We Do?
At Home Treatments
Warm Compress and Lid Massage
The purpose of this treatment is to heat the hardened, buttery substance in the glands, turning them to oil. Immediately after, pressure is applied on the lower lids to push it out onto the eye surface. This stimulates the oil glands to keep on producing oil, and keep the glands alive. It does take time out of every day, so regular treatment at home requires dedication and planning.
Omega - 3 Fish Oils
A standard dose of Omega 3 Fish Oil, and to a slightly lesser degree, Flax seed oil helps to get in the clogged glands and naturally soften the hardened oil into fluid so it can be more easily released. This works well in conjunction with the warm compresses and lid massage above.
Artificial Tears
There are many artificial tear brands out there, and a small proportion of them actually treat this common type of dry eye. What to look for is a drop that contains the missing oils in them. These tend to be milky or cloudy, and are often labeled with MGD. Clear drops just put the watery component back in the eye, and evaporate or roll off the face like the rest of those tears, so they only last minutes.
The ones I most commonly recommend to my patients are:
Systane Complete
Retaine MGD (also comes as preservative free)
Refresh Digital
FreshKote
These milky-emulsion tears usually stick on the eye for hours, but depend on the severity of the dry eye and the patient.
Tea Tree Oil and Hypochlorous Acid
Certain chemicals can be used at home as an eyelid treatment. Some stronger concentrations may be used in office as well. These are all-natural antimicrobial agents that kill bacteria and neutralize toxins. They are broken down very quickly, so they are very gentle on the eye surface.
Pharmaceuticals
Occasionally for severe cases I will prescribe oral or topical antibiotics, as well as steroid or immunosuppressant eyedrops, but there are risks and side effects involved, so these cases are closely monitored. Do not do either of these without close supervision.
In-office treatments
Heat and Expression (thermal pulsation)
There are several medical devices that are specifically made to heat the lids to the right temperature and then mechanically evacuate the glands. This procedure does a great job, but needs to be repeated usually 1-2x per year, and can be costly.
Lid Debridement, blepharo-exfoliation, intraductal probing
Removes built-up biofilms on the lids (right on top of the meibomian glands). These biofilms cause inflammation, decreased blood flow, and can be a major factor in MGD.
Intense Pulsed Light Therapy
Widely used in dermatology for skin (rosacea, acne, skin lesions), this therapy has been recently introduced into he optometric practice for MGD treatment. High energy light is pulsed on the skin to be absorbed, ablating blood vessels in the area, which normally release inflammatory factors that contribute to MGD. This also causes the hardened oils (meibum) to liquify by raising the temperature of the skin. It is also thought to extend the life of skin cells, preventing dead cells from clogging the glands. There are also more scientific-based theories on why this helps - ask Dr. Mark at your next exam!
The bottom line is, meibomian gland dysfunction is very common, especially now with the amount of screen time we all have. Older treatments tend to be short-term, and need to be repeated often. newer treatments are performed in office and encourage long-term health of the glands that cause blur, watery eyes, and irritation. Early management could greatly improve the long-term health of your eyes.
Come in and have a chat with Dr. Mark about this, or feel free to reach out via email!