The most important objective in treating patients with dry eye symptoms (ie, dryness, redness, burning, itching, rebound tearing, foreign body sensation, pain) is to save the meibomian glands and attempt to restore their function. It is essential also to save and restore any damaged tissue in the lacrimal gland and conjunctival goblet cells, but this is the next generation of treatment options as we do not have an easy way to evaluate and follow these layers.
There are really only 3 ways to save Meibomian Glands:
1. Warm/hot compresses (without hurting skin) & expression
2. FDA approved Thermopulsation:
-I found Lipiflow to be much less painful than iLux or more effective than MiboThermaflow when I had each done on my eyelids last year.
-These methods are FDA approved to save meibomian gland loss over time but do not necessarily relief 100% of a patient’s symptoms.
-It is not painful but not pleasant. I have had many patients that say the found it pleasant, “like a massage.” I found the insertion of the applicator to be very uncomfortable but not painful. No one has yet to say it is worse than a dentist visit. But there is always a first. Still I get a Lipiflow 2 times per year as I often do not have time to apply the warm compresses 15 minutes 2x per day: and I know that is really needed.
-It is not covered by insurance.
-These do not restore meibomian gland function.
-These do little to help patients’ symptoms who have stage 4 gland loss except to save the remaining remnants of meibomian glands which is crucial but may not relieve symptoms.
-The only risk reported is a stye: this can form after any procedure that stimulates oil production in the meibomian gland: if the orifice gets clogged with debris, Demodex, makeup, a stye can form. It is very rare to get a stye and I have not seen one that has to be surgical removed after Lipiflow. Still we do not want a stye: applying warm/hot compresses (without burning the skin multiple times [100-200x per day] & massaging immediately helps open the orifice and resolve the stye. A prescription steroid-antibiotic ointment helps as well if not resolving with just warm compresses/massaging.
3. The Non-FDA approved options:
A. IPL: Intense Pulse Light applied to lower and upper lids with Expression
It works to relieve symptoms in about 90% of patients. We have had hundreds of patients who feel significant improvement after a series of 6-8 sessions initially. However, it is not a cure. It often needs to be repeated over time, In patients who have an autoimmune disease, IPL sometimes needs to be repeated every few weeks to months. Some patients without any underlying systemic issue feel relief for years.
-Meibomian Gland Expression of all 4 eyelids after IPL is critical and should be videotaped so the patient can follow the progress in the quality and quantity of oil expressed from each meibomian gland’s orifice.
-Very dark-skinned patients cannot have IPL due to risk of skin discoloration
-It is not covered by insurance.
-There is 1 case published of uveitis (internal eye inflammation) in a patient who did not have metal covers over the eyeballs during treatment). We always use a metal protector and have had no side effects to date. The other risk is the formation of a stye which is possible in any procedure that stimulates oil production in the meibomian gland: if the orifice gets clogged with debris, Demodex, makeup, a stye can form.
B. Meibomian Gland Probing with Expression (MGP)
Developed by Dr. Steven Maskin in Florida, MGP works very well to break open scar tissue at the meibomian gland orifice or deep within the gland. I was skeptical at first, but I have found this to be very helpful in patients who have not had any symptom relief with Lipiflow or IPL.
-it is painful
-it is not covered by insurance and is expensive
-no complications have been reported yet with this, but the formation of a stye is possible in any procedure that stimulates oil production in the meibomian gland: if the orifice gets clogged with debris, Demodex, makeup, a stye can form. I have used IPL and MGP to treat acute styes which have saved the meibomian gland.
More recently, we have seen very good results using IPL combined with Meibomian Gland Probing with Expression over the last year.
The best results have been for patients who have IPL with 4 lid expression (we videotape our expressions so patients can see the quality of the oil) first. If there is little to no oil expressed or some meibomian glands producing little to no oil, we then do Probing with Expression. Insertion of the patient’s own Platelet Rich Plasma (PRP) or Cord Blood Serum has yielded the best results in the amount of oil that is expressed on the next visit but some patients do well with just probing. Thus we usually start with Probing with Expression alone.
A week or two later, we repeat the IPL. The IPL is repeated every 1-2 weeks until the oil comes out like “olive oil.” Once the oil comes out like olive oil, 98% of patient have less then 3 out of 10 pain scores. 90% have 0-1 out of 10 pain. The key is getting the meibum to easily come out of the meibomian gland like olive oil with minimal pressure—like the force in the blink of an eye.
The paper below shows the benefit of the combined use of IPL and probing. Thank you to our wonderful patient who sent this to me!
There are issues with the paper listed below under **.
Still it does try to demonstrate in a randomized controlled study the benefit of IPL with Probing compared to just IPL or Probing alone.