Friday, June 12, 2015

Expressing Meibomian Glands- How much is too much?

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Expressing the Meibomian Glands


Meibomian Gland Dysfunction is believe to be a major problem in people with dry eyes.  Increasing number of people are getting their meibomian glands unclogged using various heat related treatments and manually expressing them on a regular basis.

Question is, can one over express and damage the meibomian glands? 

The meibomian glands are located 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 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 addressed 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.   It is now widely recognized that there is a connection between meibomian gland dysfunction and ocular surface symptoms.  One simple office test is to lightly press (express) on the glands with finger nails or q-tip.  Descriptions should be clear (normal), cloudy, tooth pate or nothing comes out.  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 doctors 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. Washclothes are inadequate 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" without being uncomfortable for at least 10 minutes is best.  Do it twice a day initially to restore normal function. 
  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.  

Can we over express meibomian glands?  The answer is yes. 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 frequent 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.  When is self-expression helpful?  

Some people 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.  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.

Above is an extract written by Sandra M. Brown, MD - Cabarrus Eye Center, Concord NC

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Sunday, June 7, 2015

New Devices for Measuring Dry Eyes

This article deals with how your eye doctors can now test you for dry eyes.  

Traditionally, Schirmer's Test and Tear Break Up Test - have been the standard.  More recently, new devices and instruments have been introduced to test for tear parameters that are indicative of dry eyes.  Knowing how dry your eyes are can help gauge your recovery, providing an objective measurement rather than subjective.  

Two devices that are commonly used to conduct objective dry eye testing in many eye doctor's offices:

1. Tear Lab Osmolarity System (TearLab, San Diego, CA) - measures the osmolarity of a 50-nL tear sample. 

2. InflammaDry, Rapid Pathogen Screening test (Rapid Pathogen Screening, Inc, Sarasota, FL). This is a new device which uses a disposable single-use assay that analyzes the matrix metalloproteinase 9 (MMP-9) qualitatively in tears. MMP-9 is considered to be a marker for inflammation, usually associated with dry eye. Enzyme-linked immunosorbent assay [ELISA] test was also used to determine and confirm the concentrations of MMP-9 in tears collected via Schirmer strips.

This research focuses on a study to evaluate the MMP-9 in tears and tear film osmolarity in a group of elderly patients (n=20; age = 72.0±6.1yrs) with previously un-diagnosed dry eye.  Dry eye symptoms (Ocular Surface Disease Index questionnaire) and signs (tear break-up time, Schirmer test, ocular surface staining) were also evaluated in these patients. 

Patients were classified into four groups: symptoms (classification A: OSDI ≥10), suspected mild dry eye (classification B), osmolarity difference > 8 mOsm/L between both eyes (classification C), and osmolarity cutoff at 308 mOsm/L (classification D: >308 mOsm/L). 

Eleven percent (11%) of the symptomatic group and 14% of the suspected mild dry eye were positive for MMP-9. ELISA tests confirmed that the InflammaDry MMP-9 tests were accurate. Sixty-seven percent (67%) of the symptomatic and 64% of the suspected mild dry eye were positive for tear osmolarity. 

Tear film osmolarity showed a trend toward correlation with symptoms, whereas the quantitative MMP-9 values showed a trend toward correlation with corneal staining. The research concludes that MMP-9 is possibly a late-stage sign that is hardly overexpressed in mild dry eye, whereas tear osmolarity tends to be a more frequent early indicator of ocular surface instability within mild dry eye patients. A limitation of this study is the small sample size. 

Abstract is from - 

1. Schargus M, Ivanova S, Kakkassery V, Dick HB, Joachim S. Correlation of Tear Film Osmolarity and 2 Different MMP-9 Tests with Common Dry Eye Tests in a Cohort of Non-Dry Eye Patients. Cornea. Apr 23 2015.


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Contact Lens Wearers Have More Bacteria on Eye Lids. Cause of Blepharitis and Conjunctivitis?


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Blepharitis - inflammation of the eyelids often are caused by bacterial, viral or mites infections in the eye lid and conjunctiva.   Another words, do contact lens wearers have higher incidence of Blepharitis and Conjunctivitis?

A team of researchers at New York University Langone has reported identification of a diverse set of microorganisms in the eyes of daily contact lens wearers that more closely resembles the group of microorganisms of their eyelid skin than the bacterial grouping typically found in the eyes of non-wearers. The researchers found that the conjunctiva has surprisingly higher bacterial diversity than the skin directly beneath the eye, and three times the usual proportion of Methylobacterium, Lactobacillus, Acinetobacter, and Pseudomonas bacteria in the eyes of their study's nine contact lens wearers than is typically found on the surface of the eyeballs of 11 other men and women in the study who did not wear contact lenses. When measured and plotted on a graph, statistical germ diversity scores showed that the eye microbiome of contact lens wearers had a composition more similar to that of the wearer's skin than the eye microbiome of non-lens wearers. 


This work was presented at the recent annual meeting of the American Society for Microbiology in New Orleans. More information can be found at http://www.sciencedaily.com/releases/2015/05/150531141014.htm.

  



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