How to Clean Your Eyelids & How Best to Clean Your Eyelids (Lid Hygiene): The Controversy



How to Clean Your Eyelids 
& 
How Best to Clean Your Eyelids: 
The Controversy



Sandra Lora Cremers, MD, FACS




For years, eyeMDs and optometrist have recommended cleaning the eyelids, also known as lid hygiene, as a way to keep bacteria and mites (now we know the latter to be a big issue for some patients) away from the eyelids and in particular the meibomian gland orifice. The hypothesis is that debris (ie, old cell, bacteria, mites, makeup) clog the meibomian gland orifice which then prevents the meibomian gland from pumping out its oil. This leads to a back up which can then lead to a stye (or sty) and eventually a chalazion in the eyelid: sometimes there are multiple ones of these. If not cleared quickly, this gland can scar permanently and never produce meibum (the precious oily part of the tear film) again. 


How best to clean the eyelids is actually very controversial. 

Some doctors recommend frequent lid cleaning, warm/hot compresses (without burning your skin) and eyelid massaging with attempts to express the oil from the eyelid margin.


Other doctors say things like the below by Dr. Brown: “Repeated expression can lead to the cells permanently adhering, causing obstructions deeper in the gland.”


The fact is that there is no randomized, controlled study to prove the later is true. I could not find any study supporting Dr. Brown’s statement: the full article is below. If you see a study to prove me wrong, please let me know. As far as I could see in the literature, we do not have molecular or even Lipiview proof to say that applying too much warm compresses is bad for your eyelids or leads to permanent damage. Clearly one should not apply so much heat as to chafe the skin


On the contrary, most MDs and ODs, including myself, feel the warmer the better, the longer the better, the more frequent massaging of the eyelids the better (in the form of blinking exercises and hard blinks after a warm/hot compress and gentle eyelid massages without feeling pain in the eyeball.)


This makes it very frustrating for patients that want a firm guideline on how to clean their eyelids.



Hopefully more studies like the ones below will begin to shed light on the following questions everyone has:
1. How hot should the compress be?
2. For how long should I put the compress on?
3. How exactly should I do the warm compresses?
4. How many times a day should I apply warm compresses?
5. Should I massage my eyelid margin?
6. How should I massage my eyelid margin?
7. Should I self-express my glands?
8. What drops should I use?
9. Is it ok to wear makeup?
10. Should I throw out my makeup?
11. How best should I dilute the Tea Tree Oil?
12. Is Avenova equivalent truly to Tea Tree Oil in getting rid of Demodex?








But there is some data to answer some of these questions:


1. How hot should the compress be? 
Dr. Korb and Dr. Blackie, who are excellent optometrists, have done the most research on this question that I could find thus far:

Reported melting temperatures of normal meibomian secretions vary significantly with the majority of reports ranging from 32 to 40°C; severely obstructed meibomian glands have considerably higher melting points. Only using mildly warm water may not be adequate to relieve the meibomian gland obstruction. Therefore, each degree of temperature increase over 40°C could be critical in melting severely obstructed material. However, increasing temperature without safety controls raises the issue of potential thermal damage to the cornea [though I have never seen this or read a case report of burning the cornea as one would usually have so much pain from burning the skin that it would not be possible to burn the cornea with just a hot compress]. Based on the most conservative safety thresholds in the literature, temperatures below 40°C will not result in thermal injury to the cornea or crystalline lens.(Reference 1 below)


They created the LIPIFLOW machine which provides steady state temperature of 42.5°C for 12 minutes at the eyelid margin. 


For daily cleaning, this means the water should be very warm but not hot enough to cause pain or burn the skin.

2. For how long should I put the compress on?
Dr. Korb says 15minutes is the best. But no one I know really has 15 minutes 2-3 times per day to do there warm compresses. Thus it may be better to do warm compresses more often (but not within 2 hours of each session–see below) 3 times a day instead of 2 times a day for as long as you can.


3. How exactly should I do the warm compresses?
The only good study I could find to say it was superior is called the Bundle Method. 

Again, the bundle methods sounds lovely, but most patients I know do not have time to do this. Thus any type of dry or wet heat helps. How much it will help for you depends on many factors: how many glands you have, is there any scaring in the glands, your age, your hormone status, what other meds are you on. 


4. How many times a day should I apply warm compresses?
Likely the best is at least 2-3 times per day. 
What we do know is from a study by Dr. Korb & Dr. Blackie: the below tells us, you need to apply some pressure (not too hard) on the eyelids for about 8-20 seconds 

“The results show that a single central meibomian gland can be drained of its liquid secretion in 8-20 seconds upon application of a constant force of 1 g/mm2. After a central optimally secreting gland has been drained of its liquid secretion, it takes a mean time of 2.17 ± 0.49 hours to again secrete liquid during waking hours, using the same amount of force to express the new liquid secretion. At that serial expression when liquid secretion is first observed, it then takes approximately half of the time required to drain the gland originally to redrain the gland, indicating a partial recovery. Furthermore, the minimal amount of liquid secretion obtained upon diagnostic reexpression after drainage suggests that a meibomian gland in this condition may contain inadequate liquid secretion to be available with habitual blinking, which applies a force less than 1 g/mm2.“ Reference 3,4 below.


5. Should I massage my eyelid margin?
Yes. Studies show massaging pumps out the oil, especially if the oil has been melted with warm compresses beforehand.


6. How should I massage my eyelid margin? And can I massage my eyelids too much?
This is a controversial one. I recommend massaging for 20 seconds with warm water applied to eyelids at same time (mostly to save time), or with a warm compress as noted below. The key thing to remember is that the warmer the better but do not burn your skin. I have not heard of massaging your eyelid too much if there are no skin issues. 


Both these options are good. I find the above one to be faster. If someone has a tremor or very long fingernails, I would avoid this bottom one to avoid a corneal abrasion.

7. Should I self-express my glands? 
It depends on what we mean by “self-express.” Some patients I know pinch their eyelid margin trying to push out the oil for relief. I could not find any studies to show this is dangerous, but my main concern would be a potential corneal abrasion from scratching the eye. Using an instrument to self express again would be a concern for potentially scratching the cornea. As long as this self expression is not done too aggressively, it makes does not seem to be dangerous. But again we do not have good studies to show it is dangerous that I could find. 


8. What drops should I use?
There are many that can be used. The best is a non-preserved tear. A ‘no-drug company money” study showed that Retaine is the best. I have a post on this which I will link up shortly. 


9. Is it ok to wear makeup?
Likely yes as long as you are taking off the make up completely. I could not find any study saying make up permanently clogs the glands if removed. Many of my severe dry eye patients, though, have stopped being able to use make up as they do feel it makes their eyes feel worse even if they remove it completely. 


10. Should I throw out my makeup?
When I was a resident, we used to recommend patients throw out their make up if we saw “Blepharitis”–the catch all phrase for bacteria and now Demodex mites seen on the microscope. We now know that the bacteria & mites will come back even if you get new make up. Likely it makes sense to throw out the make up every year or 2 but I do not have studies to back this up. 


11. How best should I dilute the Tea Tree Oil?
Different patients and their skin prefer different dilutions. 50% dilution with coconut oil, mineral oil, olive oil is likely best. I use pure tea tree oil “diluted” on a warm wet towel to clean my eyes. Likely it does not dilute very much as oil and water do not mix, but this works best for me. 


12. Is Avenova equivalent truly to Tea Tree Oil in getting rid of Demodex?
The Avenova company says they are but there are no head to head studies. I do use both and find both to work. I prefer Tea Tree Oil when my eyes feel particularly crusty or uncomfortable as one can feel it working. The Avenova feels like water but that is a good thing especially if you have very sensitive skin. My kids prefer Avenova!





1A.

 2015 Sep;92(9):e327-33. doi: 10.1097/OPX.0000000000000675.


All Warm Compresses Are Not Equally Efficacious.

Murakami DK1, Blackie CA, Korb DR.


Abstract


PURPOSE:

To investigate which warm compress (WC) methods used in a small case series are the most effective in providing heat to the inner eyelids for the supplemental treatment of meibomian gland dysfunction.


METHODS:

Inclusion criteria included the following: 18 years or older and willingness to participate in the study, no current ocular inflammation/disease, and no ocular surgery within the last 6 months. Five patients were fully consented and enrolled. Various forms of contact and noncontact WC heating methods (dry, wet/moist, and chemically activated dry heat) were tested. A paired contralateral design was used; each subject had a heated test eye and an unheated control eye. For both test and control eyes, the temperature of the external upper, external lower, and internal lower lids was measured at baseline and every 2 minutes for 10 minutes during application. Each participant underwent each of the eight treatments under study. Microwaved compresses were heated to 47 ± 1.0°C; two compresses were self-heating and thus not under investigator control.


RESULTS:

The mean (± SD) age of the patients was 42.2 (± 20.3) years. Out of the eight methods tested, the bundled wet/moist towel method was the only compress that elevated the temperature of all three lid surfaces (external upper, external lower, and internal lower lids) to 40°C or higher. The chemically activated EyeGiene, MGDRx EyeBag, and MediBeads compresses resulted in the lowest temperature increase at the inner palpebral surface.


CONCLUSIONS:

The Bundle method, although the most labor intensive, increased lid temperatures above therapeutic levels, as reported in the literature, for all measured sections during the WC application. As such, this method of WC application can be recommended for supplemental at-home therapy for meibomian gland dysfunction and any condition requiring that therapeutic heat of 40°C be administered to the meibomian glands.


1B.

 2011 Sep;37(5):298-301. doi: 10.1097/ICL.0b013e31821bc7c5.

Meibomian gland therapeutic expression: quantifying the applied pressure and the limitation of resulting pain.

Korb DR1, Blackie CA.

Abstract

OBJECTIVES:

The purposes of this study were to determine (1) the pressure required to express the first nonliquid material from nonfunctional lower lid meibomian glands, (2) the pressure required to evacuate all of the expressible material from the glands (simulating the authors’ methodology for therapeutic meibomian gland expression), and (3) the level of pain associated with these procedures.

METHODS:

All patients (n=28) were recruited from those presenting for ocular examinations at a single practice. Custom instrumentation exerting pressures from 1.0 to 150.0 psi was developed to quantify the pressure applied during expression. The instrument was applied to the inner surface of the lower lid. The lid was then compressed between the thumb and the contact surface of the instrument. The applied pressure was displayed on a digital meter. The first procedure evaluated the pressure required to obtain the first nonliquid material from nonfunctional glands. The second evaluated the pressure required for evacuating all expressible gland contents. The pain response was monitored throughout the procedure.

RESULTS:

The pressure to obtain the first nonliquid material ranged from 5 to 40 psi (mean=16.1±8.2 psi) and for the evacuation of expressible contents, from 10 to 40 psi (mean=25.6±11.4 psi). Only 7% of the patients could tolerate the pressure necessary to administer complete therapeutic expression along the entire lower eyelid.

CONCLUSIONS:

Forces of significant magnitude are required for therapeutic expression. Pain is the limiting factor for the conduct of this treatment.






2.
 2017 Jan 26. pii: S1542-0124(17)30019-8. doi: 10.1016/j.jtos.2017.01.006. [Epub ahead of print]

Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting.

Geerling G1, Baudouin C2, Aragona P3, Rolando M4, Boboridis KG5, Benítez-Del-Castillo JM6, Akova YA7, Merayo-Lloves J8, Labetoulle M9, Steinhoff M10, Messmer EM11.

Author information

  • 1Department of Ophthalmology, University Hospital Duesseldorf, Heinrich-Heine University, Duesseldorf, Germany. Electronic address: geerling@med.uni-duesseldorf.de.
  • 2Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts, University Paris-Saclay, Paris, France. Electronic address: chrbaudouin@aol.com.
  • 3Institute of Ophthalmology, Department of Biomedical Sciences, University of Messina, Messina, Italy.
  • 4Ocular Surface Centre, ISPRE Ophthalmics, Genoa, Italy.
  • 5Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
  • 6Hospital Clínico San Carlos, University Complutense, Madrid, Spain.
  • 7Department of Ophthalmology, Bayındır Hospital, Ankara, Turkey.
  • 8Instituto Universitario Fernández-Vega, University of Oviedo, Asturias, Spain.
  • 9Service d’Ophtalmologie, CHU Bicêtre, APHP, Université Paris-Sud, Le Kremlin-Bicêtre, Paris, France.
  • 10Department of Dermatology and UCD Charles Institute for Translational Dermatology, University College Dublin, Dublin, Ireland.
  • 11Department of Ophthalmology, Ludwig Maximilian University, Munich, Germany.


Abstract

Meibomian gland dysfunction (MGD) is a common and chronic disorder that has a significant adverse impact on patients’ quality of life. It is a leading cause of evaporative dry eye disease (DED), as meibomian glands play an important role in providing lipids to the tear film, which helps to retard the evaporation of tears from the ocular surface. MGD is also often present in conjunction with primary aqueous-deficient DED. Obstructive MGD, the most commonly observed type of MGD, is the main ocus of this article. MGD is probably caused by a combination of separate conditions: primary obstructive hyperkeratinization of the meibomian gland, abnormal meibomian gland secretion, eyelid inflammation, corneal inflammation and damage, microbiological changes, and DED. Furthermore, skin diseases such as rosacea may play a part in its pathology. Accurate diagnosis is challenging, as it is difficult to differentiate between ocular surface diseases, but is crucial when choosing treatment options. Ocular imaging has advanced in recent years, providing ophthalmologists with a better understanding of ocular diseases. This review presents a literature update on the 2011 MGD workshop and an optimized approach to accurate diagnosis of MGD using currently available methods and tests. It also outlines the emerging technologies of interferometry, non-contact meibography, keratography and in vivo confocal laser microscopy, which offer exciting possibilities for the future. Selected treatment options for MGD are also discussed.



3.
https://dryeyeandmgd.com/i-wake-up-brush-my-teeth-and-clean-my-eyelids/


1. I WAKE UP, BRUSH MY TEETH AND CLEAN MY EYELIDS…

September 19, 2016

After reading this title, you’re probably wondering why cleaning your eyelids should be a part of your daily hygiene. Well as funny and minimal as it seems, we’re here to explain why cleaning your eyelids may be one of the most important personal habits you can adopt on a regular basis – just like brushing your teeth.
In a perfect world, everyone would have 20/20 vision, see clearly and be able to get through the day without rubbing their eyes red. Unfortunately, as we all know, the world is far from perfect and so are most of our eyes. While we can’t do anything about visual issues that happen to many of us, like being nearsighted or farsighted, we can reduce some of those annoying dry eye symptoms and improve our overall eye health.  “Tell me more,” you say?  Ahhh, so we got your attention.
Yes, there are ways to maintain good eye health and even to potentially prevent those red, watery and itchy eyes.  It’s because for 86% of those who develop dry eye symptoms, the problem starts from the tiny glands in our eyelids, Meibomian Glands.  Just like anything else, eyelid debris build up occurs over the course of time and those glands can become clogged.  This leads to an unstable tear film, compromising the protective film on our eyes, and Meibomian Gland Dysfunction (MGD).

Can you hear your mother now?  
Clean-Lids-Brush-Lids
It is really that simple: clean your eyelids morning and night. Just like flossing and brushing your teeth.  According to Caroline Blackie, OD, PhD, one of the foremost experts in MGD, “MGD is like the gum disease of eye care.” You prevent gum disease and plaque from building up by brushing morning and night. Brushing and flossing your teeth takes just a couple of minutes. Cleaning your eyelids takes even less time, but it is an essential part of hygiene which most of us don’t do. Why? Because most of us are not aware of the impact that cleaning your eyelids has on our vision and eye health.  And what’s more? This simple task can reduce MGD and Dry Eye Syndrome that occurs to many of us as we age.
We like to keep our teeth in check for multiple reasons (reason number one is a little thing called eating), and we should also want to keep our eyelids in check for other reasons that are just as important. Hmmm what reason could that be… maybe our eye health so that we can see clearly and comfortably!  Or, maybe to slow down or possibly prevent us from losing glands that are essential to the healthy tear film necessary for protecting our eyes! A simple daily eyelid cleansing routine may be the difference between a lifetime of fighting MGD and Dry Eye, or a lifetime of healthy comfortable eyes.  We brush our teeth because we don’t want to lose them; therefore, clean your eyelids so you can protect your Meibomian Glands.  Yes, it can and does happen to millions every day.
  
How do I Clean My Eyelids?
Take a cotton swab, lightly coat it with petroleum jelly, mineral oil or coconut oil, and gently swipe it across the top and bottom of both eyelids (one at a time, please) back and forth a couple of times. Boom. You’re done and your eyelids are clean. What you are doing is removing debris that would otherwise build-up over time, because when it does, the glands can become blocked. This is when MGD begins. Learn more about MGD here. This is important for everyone, but ESPECIALLY for people who wear make-up every day.

Get In the Routine
While getting in the routine of cleaning your eyelids is first and foremost on the list of things to do for preventing the potential of a serious case of MGD, it isn’t the only thing we can do.
We can also do a few blinking exercises every day. Blinking is when the Meibomian Glands release protective oils that spread across the tear film protecting the watery layer in our eyes. Today’s digital society is blinking less and staring more, which means we are training our Meibomian Glands to stop doing their job.  So, as you get in the habit of cleaning your lids daily, you may just want to take a few minutes each day to remember to blink several times in a row, squeezing your eyes shut a few times in the process.  Together, these two tasks help to keep your Meibomian Glands clean and working properly.

Note To Moms and Dads:
It’s time to add a little something to those incessant calls for remembering to brush our teeth daily, “Did you remember to clean your eyelids?” If you don’t have kids or they have moved out of the house, this goes for all of us  – Wake up America, brush your teeth and clean your lids!






References:


1.The diurnal secretory characteristics of individual meibomian glands.Blackie CA, Korb DR.Cornea. 2010 Jan;29(1):34-8. doi: 10.1097/ICO.0b013e3181ac9fd0.PMID::

2. Recovery time of an optimally secreting meibomian gland.
Blackie CA, Korb DR.
Cornea. 2009 Apr;28(3):293-7. doi: 10.1097/ICO.0b013e31818913b4.

Horley DW, Korb DR, inventors; Contact lens instrument. US patent 3,411,364. Filed December 1965, Patented November 1968.
3. Comberg W, Stoewer E. Die Augendruck-steingende Wirkung vershiedener. Muskelaktionen und ihre Bedeutun. Z Augenheilk. 1923;58:617. [Context Link]

4. Miller D. Pressure of the lid on the eye. Arch Ophthalmol. 1967;78:328-330

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Dr. Brown writes many good things below which I agree with. I just have not found a reference to indicate that over-expression is possible. Lipiview/Lipiscan technology just came out in late 2016 so I am not sure how you could prove over-expression was dangerous back then unless you did a biopsy of the full lid to show the effects pathologically on the meibomian glands. 


The below posts were written in 2015

http://theralifeeye.blogspot.com/2015/06/expressing-meibomian-glands-how-much-is.html
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4. Expressing the meibomian glands (Sandra Brown, MD)
Introductory note from Rebecca:
I have observed a trend over the past couple of years where for various reasons more people seem to be overdoing eyelid care in hopes of improving chronic MGD. They are applying heat packs twice or more each day; scrubbing and massaging their lids frequently; and attempting to express the glands regularly. I’ve even observed some of the savviest patients purchasing medical instruments intended for professionals and using them at home to express their glands.
As a longtime proponent of lid hygiene and heat treatment for MGD I have viewed this trend with increasing concern because I fear that inappropriate use, and over-use, of such treatments might delay rather than assist recovery of the meibomian glands. As I so often have over the years, I went to the doctor who first helped me understand dry eye diseases to elucidate this topic for me. What follows is an article that she wrote for DEZ readers in the wake of our discussion about whether some of us may be actually beating our meibomian glands to death. Enjoy, and please let us know what you think via email DryEyeTalk, Facebook (The Dry Eye Zone) or Twitter (@dryeyezone)!

Expressing the Meibomian Glands
by Sandra M. Brown, MD – Cabarrus Eye Center, Concord NC
The meibomian glands live in the upper and lower eyelids.  There are approximately 15 – 20 glands per lid.  The gland openings lie on the edge of the eyelid just inside the eyelash line.  The body of the gland is inside the tarsal plate, which is a very thin piece of cartilage that gives the eyelid its defined shape.  When your doctor everts your lid (flips it inside out) he is flipping over the tarsal plate.


Although most diagrams of meibomian glands show a hollow tubular structure that looks like a permanently open space, a meibomian gland is more of a potential space.  If the gland is empty of meibomian oils, it collapses in on itself.  In fact even when the gland is “full” only a very thin film of oils may actually separate the cells lining the walls of the meibomian gland.


Meibomian oils are not squirted onto the surface of the eye.  They seep out slowly under the gentle pumping action of eyelid blinking, combined with continuous oil production which pushes oils out onto the eye lid margin when the gland’s potential space is fully expanded.


When the eyelid margin becomes inflamed, this inflammation can “cap off” the meibomian gland orifices.  There are numerous causes of eyelid margin inflammation that will not be discussed here.  If the glands continue to vigorously produce oils, the oils erupt through the sides of the glands and coalesce into a mass commonly referred to as a stye.  However in many patients, obstruction of normal oil seepage causes the meibomian gland to decrease production and the oils retained in the gland become thick and degraded.


In the past 2 – 4 years, eye care providers have become more widely aware of the connection between meibomian gland dysfunction and ocular surface symptoms.  One simple office test is to lightly press on the glands while the patient is seated at the slit lamp.  The examiner is looking for the quantity and quality of oils, how many glands express, how hard s/he has to push to make this happen, and how readily the oils disperse into the tear film.  Meibomian oils are quite easy to see at the slit lamp but essentially impossible to see with the naked eye except through elaborate magnification methods.
It is not necessary for 100% of the meibomian glands to function for adequate oils to be secreted into the tear film. Many asymptomatic patients have far fewer than 100% of the glands producing oils at any given time. Lower lid meibomian glands seem to “take a hit” sooner that upper lid glands, so it is important for your doctor to express both upper and lower lids to give your glands an overall function score. Patients with about 80% of their upper lid glands functioning well may have no symptoms even if the lower lid glands are producing almost nothing. 


Eye care providers sometimes prescribe meibomian gland self-expression or patients take it upon themselves to “clear out” their glands periodically. Generally the process is to apply heat to liquefy the oils, followed by eyelash cleaning (or sometimes the reverse order) and then gland expression.
A note on hot compresses. The temperature of eyelid skin is slightly below core “body temperature” and meibomian oils become more liquid just a little above core body temperature. So moderate, sustained heat can keep viscous oils thinner. Patients who use very hot compresses that they can tolerate for only 1-2 minutes are going about it the wrong way. Washclothes are ridiculous due to the very rapid cool-down. There is no difference between dry and wet heat from the perspective of the interior of the meibomian gland. A compress that stays “definitely warm” witout being uncomfortable for at least 4 minutes is probably the most effective approach. It is impossible to really “study” the differences between compress methods.
As regards meibomian gland self-expression, there are several problems with this activity.


First, not all meibomian gland problems are due to blockage of the orifices.  If the glands are simply under-producing oils (a common problem in peri-menopausal women) pushing on them won’t do anything.  If the lid margin inflammation is not under control and the orifices are tightly blocked, oils may not express even with hard pressure.  So the treatment is not helpful.  But secondly, self-expression can be harmful.


Remember that the gland is a potential space containing a small volume of oil.  If you express all the oil out of the gland, you have probably expressed several days’ worth of “production”.  You have depleted your supply.  When the gland is empty, it collapses in on itself and the cells lining the potential space come into contact with each other without an intervening “oil slick”.  This allows the cells to adhere to each other.  As the gland refills with oil the potential space expands and the cells separate.  Repeated expression can lead to the cells permanently adhering, causing obstructions deeper in the gland.  This process will be hastened by the microtrauma induced through the mechanical pressure, especially if applied vigorously and often.


I have seen patients who have basically murdered their meibomian glands through excessive self-expression.  How do I know?  Because the glands in the far nasal and temporal (ear side) areas are harder to reach.  It is also more difficult to apply direct firm pressure to the glands in the upper lids than to those in the lower lids.  So I see more non-functioning glands in the centers of both lids than the corners, and the lower lids have more non-functioning glands than the upper lids.


When is self-expression helpful?  Some patients have mildly occluded orifices or tend to produce oils that don’t seep well.  They get into a “stagnation” situation.  As part of their overall rehabilitation which MUST include efforts to improve oil quality and open the orifices, mild self-expression following a hot compress can be beneficial.


If you are a frequent (more than once per week) or aggressive self-expresser, ask yourself whether you are doing this “philosophically” because it seems like a smart thing to do or whether expressing truly improves your symptoms.  If you are expressing several times per day, it is extraordinarily unlikely that you are getting a “useful” amount of oils onto the ocular surface each time.  This habit will only increase the microtrauma to the meibomian gland structure.


Meibomian gland self-expression can be useful at certain stages of treatment.  It is recommended by eye care providers, including those who specialize in ocular surface disease.  It is important to understand that you can overdo it.  You should not use self-expression unless instructed to do so by your eye care provider.   If you have ocular surface pain and your provider has never expressed your glands, find a different doc.


What if you are a non-producer? Patients whose meibomian glands have ceased production are in a particularly difficult state. Peri- and post-menopausal women are most prone to this condition since meibomian gland function is regulated by androgen hormones. Some women become abruptly dry during pregnancy and don’t recover after pregnancy. Conversely some women have symptoms before pregnancy and actually feel better during pregnancy. We do not have a good understanding of the complex hormonal interplay that affects meibomian gland function. However, if your glands aren’t making oils because they aren’t receiving “go” signals from hormones or ocular surface nerves, many of the treatments described above will not be effective. Low production can combine with eyelid inflammation to further reduce the quality and quantity of oils reaching the tear film. Certainly related problems such as eyelid inflammation should be addressed. But for patients whose essential problem is markedly reduced production, it is particularly important to leave your meibomian glands alone!
Remember that the purpose of meibomian gland oils is to stabilize the tear film structure and slow evaporation. Barrier methods to slow evaporation (goggles, masks, etc.) are particularly helpful in this circumstance.
What helps meibomian glands and how:


heat – liquifies oils which tend to become more viscous just below body temperature (eyelid skin cooler than core body temp); see comments above about correct hot compress


doxycycline and minocycline, erythromycin – low dose for at least 60 days – acts as an anti-inflammatory which opens the orifices, thins out the oils in some fashion that we don’t understand, decreases the bacterial load on the eye lid margins which opens the orifices


TobraDex ointment – anti-inflammatory, decreased bacterial load; intraocular pressure must be followed if used for more than 1 month


Restasis – in my experience anti-inflammatory effects can improve meibomian gland inflammation as well


omega oils – antiinflammatory, antioxidant, ‘good ingredient’ for oil production


Azasite applied to eye lid margins (topical equivalent of erythromycin) – antibacterial, maybe something else as well?  seems to work for some people not others
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