Near Uniform Success: Probing procedure eases MGD
April 1, 2011
by Lynda Charters
Reviewed by Steven L. Maskin, MD, FACS, and Joseph Tauber, MD
“Up to 70% of patients with obstructed meibomian glands have favorable response.”
Kansas City, MO – A procedure that uses meibomian gland intraductal probing (Maskin Meibomian Gland Intraductal Probe, Rhein Medical) seems to be helpful in patients with severely obstructed meibomian glands.
Joseph Tauber, MD, said that in his hands, 70% of patients treated with this technique reported relief from meibomian gland dysfunction (MGD). The disorder commonly is encountered in ophthalmic practices and even more so in anterior segment/ocular surface practices. The standard therapy that patients should adhere to daily is lid hygiene, which consists of warm compresses and cleansing with mild soap plus oral tetracycline with the goal of changing the nature of the oil in the glands. However, MGD can be refractory to standard therapy; all symptoms do not resolve, said Dr. Tauber, clinical professor of ophthalmology, Kansas University School of Medicine, and in private practice in Kansas City, MO.
The initial probing procedure, which involves application of anesthetic followed by probing of the glands on the lid with a 1- and 2-mm probe in patients who complain of lid tenderness as well as symptoms excluding lid tenderness such as burning and stinging, was developed by Steven L. Maskin, MD, FACS, in private practice in Tampa, FL. Four- and 6-mm probes also are available as well as microtubes to inject a pharmaceutical. Dr. Maskin reported in 2009 that he was experiencing near uniform success using the probe in a substantial number of his patients. Based on those results, Dr. Tauber became interested in this technique in order to provide more effective care for his patients with MGD. He has refined some aspects of the treatment to suit his patient population better. “Patient selection is an important factor, ” Dr. Tauber said. “Certain procedures work for certain patients.” He performs the probing technique for patients with obstructive MGD, that is, those patients for whom lid compression produces little or no secretion. This differs from Dr. Maskin, who treats these patients but also treats patients with lid tenderness, which Dr. Tauber believes is a rare complaint in the patients he sees.
Another difference between the two surgeons is the extent to which they use the probe, with Dr. Maskin focusing on eliminating lid tenderness by ensuring treatment of tender glands in lid tenderness cases and treating all glands in cases with symptoms excluding lid tenderness, and Dr.Tauber treating all glands. The biggest drawback to the procedure, Dr. Tauber pointed out, is the patient discomfort resulting from the probing. In light of this, Dr. Tauber refined what he considered to be woefully inadequate anesthesia for use in his practice. He now applies a custom-formulated topical gel preparation of tetracaine and lidocaine prepared by a compounding pharmacy.
Dr. Maskin now uses a topical anesthetic ointment applied to the lid margin of lidocaine 8% and jojoba oil 25%.
The procedure, which Dr. Tauber describes as “well-tolerated by most patients, ” usually requires about 20 minutes of office time to complete with most patients. The patients experience transient discomfort in varying degrees related to the probing. About 10% to 15% of patients take 5 mg of diazepam before the procedure.
No postoperative medications are required, and there is a low likelihood of postoperative side effects associated with the probing. The only side effects that do occur are related to the anesthesia and eye rubbing, according to Dr. Tauber.
After having treated about 200 patients with MGD using the probing technique, Dr. Tauber analyzed his results. However, difficulties associated with analyzing the patient results arise because there currently is no standardized grading system for MGD and the grading of symptoms also is unclear.
In addition, there is a great deal of symptom overlap between MGD and dry eye disease and 50% of patients with MGD also have dry eye disease. Insight of this , Dr. Tauber has anticipated the outcome from the international Workshop on Meibomian Gland Dysfunction that will standardize the grading of the condition.
He found that both at 30 days and at longest follow-up, 70% of the patients had a response to the therapy, that is, they reported that the probing was beneficial. “The patients quantitated this by saying that probing, regardless of their symptoms, provided a mean degree of relief of about 60%, ” Dr. Tauber said. Patients reported symptom relief within hours using the 2-mm probe. Few patients have been satisfied with undergoing only one treatment, according to Dr. Tauber. After the first treatment, most patients request repeat treatments in hope of achieving even more relief. The first retreatment usually is 30 days after the initial treatment, but the choice of undergoing additional treatments is totally voluntary.
Most patients with advanced disease want treatments at intervals of 3 or 4 months. Others may undergo treatments 1 or 2 months apart and then wait 6 months or 1 year for the next treatment. During the post-treatment period, lid hygiene must continue; noncompliance with lid hygiene promotes obstruction of the glands, Dr. Tauber said. This procedure is covered by most insurance plans. While there is high patient satisfaction associated with the results, most patients wish that the results would last longer. Unfortunately, this treatment is not a cure. However, in conjunction with this, Dr. Tauber pointed out that this is the perfect procedure for use with adjunctive eye drop pharmaceutical therapy.
In commenting on this procedure, he believes that the probing procedure “should be put in its proper place. ” “MGD is a disorder that cannot be cured for the majority of patients, ” Dr. Tauber said.
“The ideal treatment would normalize the meibomian gland secretions. MGD is wide open for a pharmaceutical strategy to change the nature of the oil in the glands and [try to] prevent obstruction, ” he added. “Right now we rely heavily on warm compresses and expression of secretions to reduce stagnation of secretions with subsequent inflammation caused by retained oils. ”
One product that seems to elevate the efficacy of heat application is an eye mask (Fire & Ice Mask, Rhein Medical) made of gel beads as opposed to a cavity containing a liquid.
“Patients love this product,” Dr. Tauber said. “It is better at holding heat than a warm wash cloth. It provides 10 minutes of good uniform heat.” The mask is heated in a microwave for 8 to 15 seconds depending on the unit. The mask design is a perfect size for the eye lids without touching the forehead and cheeks. It is superior to using a face cloth to apply heat to the lids, according to Dr. Tauber, because there is no wetness or dripping. While it is slightly more expensive than most mass-produced gel masks, he said he believes that it is worth the cost.
Steven L. Maskin, MD, FACS
Dr. Maskin developed the initial probing procedure.
Joseph Tauber, MD
Dr. Tauber has no financial interest in any technology mentioned in this report.