That is the question

Meibomian gland manipulation should be performed to assess expression rate and quality of meibum in patients suspected of having dry eye disease. Meibography then facilitates us in our ability to identify and quantify meibomian gland dysfunction (MGD).¹

Also, gland manipulation enables early diagnosis of MGD, allowing for the preservation of the existing glands. Further, we know that those who have gland dropout or atrophy should treat their MGD aggressively to prevent further damage.²

Here, I discuss the forms of meibomian gland manipulation and their respective value.

MANUAL MANIPULATION

Several manual meibomian gland expressors are available. Manufacturers include: MEDI Instruments, Precision-Vision, Prettyia and Titan Medical.

Additionally, intraductal pro-bing is a manual approach in which a blunt tip is inserted into each gland duct to break up the meibum and obstructions. The patient’s eye is well anesthetized beforehand. The manual approach has been shown to help improve quality of the meibum and expressability.² Manufacturers of such probes include Katena (mgdi.com/get-probing-now ).

MICROEXFOLIATION

Microexfoliation of the lid margins helps to remove lid debris and microbial biofilm from the lid margins. It is particularly effective in the treatment of Demodex brevis, which can colonize the meibomian glands, leading to posterior blepharitis and MGD.^3,4 Two such devices are available: BlephEx (blephex.com ), performed by the doctor, and NuLids (nusightmedical.com ), which can be performed by the patient.

HEATED LID MASSAGE

Application of heat followed by lid massage is thought to help melt the thickened meibum within the meibomian glands, allowing for better secretion. To review, the meibum in MGD patients is thought to have reduced lipids and free sterols, causing it to have a higher melting point at 35°C than non MGD patients at 32°C.⁵ Lid hygiene product companies include Akorn, Alcon, BioTek, Bruder, Cliradex, EyeEco, NovaBay, Novartis, OcuSoft, Paragon, TheraTears, TherMEDx and We Love Eyes.

THERMAL PULSATION

This technology delivers controlled intermittent gentle pressure to the lids, to liquify obstructed meibum. One study shows both the LipiFlow (Johnson & Johnson Vision) and iLUX (Alcon) “produced significant improvements in meibomian gland function and symptoms.”⁶ Another study shows TearCare (SightSciences) is an effective treatment option for DED patients, with the effects on the signs and symptoms of DED persisting for at least 6 months.⁷ MiBo Thermoflo (MiBo Medical) is another such device.

INTENSE PULSED LIGHT

It is thought that closing the abnormal blood vessels near the lid with intense pulsed light (IPL) helps to improve MGD by decreasing the release of inflammatory mediators. The treatment is typically well accepted by patients, as it is non-invasive and rarely produces adverse events.⁸ Also, its results can be maintained over time via periodic sessions.⁸ Examples of IPL devices: OptiLight (Lumenis), the M22 (Lumenis) and Quadra Q4 Platinum Series IPL (Dermamed).

PROVEN VALUE

Regardless of your chosen tool, you can see that gland manipulation offers patient benefits. OM

References are available in the online version of this column.

DR. KOETTING practices at Virginia Eye Consultants, and she is adjunct faculty for Pacific University, MCPHS, Salus University, Southern College of Optometry and the University of the Incarnate Word. She has received consulting fees or honorariums from Oyster Point, Glaukos, Quidel, Horizon, Ocular Therapeutix and Eyevance.