Update from opthamologist appointment - MGD

[dijon84]

Hi

I've been dealing with seborrheic blepharitis and MGD for almost two years now. I had a useful ophthamologist appointment on Thursday and would be grateful for some comments.

Symptoms: My main complaint is the gritty eye sensation in both eyes, to some degree, at all times. Most of the time it is not too bad, but it does get pretty uncomfortable sometimes.
My eyelids and area surrounding the eyes also look and feel quite greasy (not related to the E45 cream I use - if I don't put E45 on, they still get greasy). I think this is overproduction of sebum.
I also quite often get an aching sensation in the forehead and between the eyes. I've been told this is something to do with eye irritation affecting the muscles around it in the rest of the face.

Supplements currently used:
Multivitamin with probiotic
Probiotic
Vitamin C sustained release
N-Acetyl Cysteine (150mg twice a day)
Fish oil
Flaxseed oil

Current routine:
In the shower in the morning, wash the eyelids with Dr Organics Manuka Honey Shower Gel (from Holland Barrett). Keep eyes tightly closed then rinse out. After the shower, clean the eyelids with a tissue then apply E45 cream on the eyelids and around the eyes.
Before bed, clean the eyelids with a tissue then put in several drops of Blink Intensive Plus and lie down with eyes shut for 3 minutes. Clean up residues of the eye drops with a tissue then apply E45 cream on eyelids and around the eyes.

Outcome of appointment on Thursday:
I described how it started in February 2011 with using a contaminated towel then waking up the following morning with lots of gunk around my right eye. The doctor (she) said it was likely viral conjunctivitis. With an episode of viral conjunctivitis, problems can be ongoing for 12-18 months or longer. She said some of her colleagues in Moorfields experienced this.
She couldn't see any blepharitis, and said there is no reason to change my current treatment routine (except possibly use the E45 cream on the eyelids less often - she could see some of the cream in my tear film I think). She made these observations:
- I have 'small' meibomian glands.
- The meibomian glands could have been affected by the mild acne I have had since I was a teenager (10+ years)
- I have 'controlled meibomian gland inflammation'
- Inside my eyelids have the appearance of papillary conjunctivitis (not sure if she said I actually had it or not - just described the appearance)
- I haven't got meibomian seborrhea (overproduction of meibomian oils)
- I have normal tear break up time (an optometrist said the same thing a month ago), normal tear production and normal pressure. I asked how this could be, considering I get gritty eyes all the time - she said the gritty eye sensation is caused by the eye rubbing against the enlarged eyelid and concretions.
- She asked me if I had any allergies - not that I am aware of. I have wondered if I do have allergies but haven't been able to identify anything yet.

She prescribed me with steroid eye drops (Maxidex 0.1 w/v Dexamethasone) to use with care. 1 drop in each eye, 3 times a day for 7 days. 2 times a day for the next 7 days. Once a day for the next 7 days. 2-3 times in total over the next 7 days. So that's 4 weeks of treatment. She said stop using it if things get worse over the first week. I am going back in for a follow-up appointment in mid-Jan so that my eye pressure can be checked.

I haven't yet started using the steroid eye drops and just wanted to get a few comments from here. I will start using them at some point but just wanted to check first.
- Any idea what the steroid drops will actually do in terms of treatment?
- Any problems that people have encountered with using them?

I think I finally have a good doctor to help me here, judging by what she was saying and the fact she used to work at Moorfields.

Has anyone got any comments about anything in my post? I'm wondering if cold compresses could help with the meibomian gland inflammation?

Thanks
Dave

[HYPERHEAD]

Hi dave,

Who did you see ..was it spire? Your current regime looks good , but be careful with the e45 on the lids. I would be very reluctant to use steroids drops personally ..due to raised ocular pressure and risks of glaucoma ..I'm sure it wouldn't hurt to use it on a short term basis

You don't have severe inflammation and redness so I wondered why they gave you steroids..grittiness could be caused by swollen glands rubbing on the eyeballs , ocular infection, corneal abrasions, sub epithelial damage.

Mario..

Hi

I've been dealing with seborrheic blepharitis and MGD for almost two years now. I had a useful ophthamologist appointment on Thursday and would be grateful for some comments.

Symptoms: My main complaint is the gritty eye sensation in both eyes, to some degree, at all times. Most of the time it is not too bad, but it does get pretty uncomfortable sometimes.
My eyelids and area surrounding the eyes also look and feel quite greasy (not related to the E45 cream I use - if I don't put E45 on, they still get greasy). I think this is overproduction of sebum.
I also quite often get an aching sensation in the forehead and between the eyes. I've been told this is something to do with eye irritation affecting the muscles around it in the rest of the face.

Supplements currently used:
Multivitamin with probiotic
Probiotic
Vitamin C sustained release
N-Acetyl Cysteine (150mg twice a day)
Fish oil
Flaxseed oil

Current routine:
In the shower in the morning, wash the eyelids with Dr Organics Manuka Honey Shower Gel (from Holland Barrett). Keep eyes tightly closed then rinse out. After the shower, clean the eyelids with a tissue then apply E45 cream on the eyelids and around the eyes.
Before bed, clean the eyelids with a tissue then put in several drops of Blink Intensive Plus and lie down with eyes shut for 3 minutes. Clean up residues of the eye drops with a tissue then apply E45 cream on eyelids and around the eyes.

Outcome of appointment on Thursday:
I described how it started in February 2011 with using a contaminated towel then waking up the following morning with lots of gunk around my right eye. The doctor (she) said it was likely viral conjunctivitis. With an episode of viral conjunctivitis, problems can be ongoing for 12-18 months or longer. She said some of her colleagues in Moorfields experienced this.
She couldn't see any blepharitis, and said there is no reason to change my current treatment routine (except possibly use the E45 cream on the eyelids less often - she could see some of the cream in my tear film I think). She made these observations:
- I have 'small' meibomian glands.
- The meibomian glands could have been affected by the mild acne I have had since I was a teenager (10+ years)
- I have 'controlled meibomian gland inflammation'
- Inside my eyelids have the appearance of papillary conjunctivitis (not sure if she said I actually had it or not - just described the appearance)
- I haven't got meibomian seborrhea (overproduction of meibomian oils)
- I have normal tear break up time (an optometrist said the same thing a month ago), normal tear production and normal pressure. I asked how this could be, considering I get gritty eyes all the time - she said the gritty eye sensation is caused by the eye rubbing against the enlarged eyelid and concretions.
- She asked me if I had any allergies - not that I am aware of. I have wondered if I do have allergies but haven't been able to identify anything yet.

She prescribed me with steroid eye drops (Maxidex 0.1 w/v Dexamethasone) to use with care. 1 drop in each eye, 3 times a day for 7 days. 2 times a day for the next 7 days. Once a day for the next 7 days. 2-3 times in total over the next 7 days. So that's 4 weeks of treatment. She said stop using it if things get worse over the first week. I am going back in for a follow-up appointment in mid-Jan so that my eye pressure can be checked.

I haven't yet started using the steroid eye drops and just wanted to get a few comments from here. I will start using them at some point but just wanted to check first.
- Any idea what the steroid drops will actually do in terms of treatment?
- Any problems that people have encountered with using them?

I think I finally have a good doctor to help me here, judging by what she was saying and the fact she used to work at Moorfields.

Has anyone got any comments about anything in my post? I'm wondering if cold compresses could help with the meibomian gland inflammation?

Thanks
Dave

[littlemermaid]

http://one.aao.org/CE/PracticeGuidel...9-15d014f613b9 American Academy of Ophthalmology Preferred Practice Guidelines for Blepharitis, Dry Eye, Conjunctivitis. Always worth a look. Current practice is to reduce and control inflammation to enable the functions of the eye to work again. This is why they use short courses of anti-inflammatories. What a skill.

Article on Anterior and Posterior Blepharitis, Katherine Mastrota Hi Dijon and Hyperhead, I thought this short article was useful for obstructed seborrheoic blepharitis. We are using dexamethosone 0.1% but have managed to reduce to 1/week. We are also maintaining to control any demodex with tea tree oil products and any Malassezia with Head & Shoulders. With obstructed reinfecting MGD, we have done well clearing the glands with short courses of Azyter (azithromycin). I'm glad you like honey because for us I don't think it does any harm and might do some good. We also use TTO shampoo and face wash and moisturiser sometimes, even the docs like that these days.

So we've had to use the steroids, as in the article, to control the inflammation while we're improving the glands and consistency of meibom. And we haven't had any problems like raised intraocular pressure although this does need checking within a couple of weeks of starting (see Unicorn's unusual experience, raised pressure within 10 days on dex) and regularly thereafter. I've been talking to Irisheyes about cataracts - she's a long-term strong steroid user including high doses for iritis - and she has some signs in her 50s. Obviously, everyone's different and I've talked to very experienced ophthalmologists about this. We've considered using the cyclosporine 0.06% from Moorfields but it needs instilling twice a day, involving yet more chemicals, whereas we are managing very well on an amazingly minimum weekly dose of steroid. So in the past we've done a similar inflammation control regime. It works if you address all the other factors - warm compress, improving the meibom, cleaning. We all know blepharitis can come back but we are looking for improvement and maintenance.

Maxidex has preservatives, doesn't it? You could ask for unpreserved Minims vials dexamethosone 0.1%, easily available. I would just email or ring up asking about this if you've got questions - it's good to communicate. A pharmacist can chat about what's available, esp hospital pharmacy, whether NHS or independent.

Close the tear drains with a finger by gently pressing the inner eye corner beside the nose after putting steroid in to avoid systemic absorption into the sinus. Also we wipe around the eyes to avoid tissue thinning in chronic use. Mostly it says all this in the drug instructions now but not always.

Have you ever tried lower punctal plugs? And I'm wondering how the E45 helps - do you have dry skin? Have you tried eyelid cleaners like Blephasol in your regime or do they make you sore?

What a relief to find a doc you like to work with, Dave. Do you think you might PM Villfan about getting a cornea doc?

[robster]

Was it Carol Lane you saw, just from reading what you've wrote and the mentioning of small meibomain glands that's exactly what she said to me when I saw her. She does seem to have a very good knowledge of dry eye.

[dijon84]

Thanks all for your comments - yes it was Dr Lane I saw in Heath Hospital. Think I've finally got a complete diagnosis, after almost 2 years! I am reducing the use of the E45 cream but I think it has helped me so far - the eyelid skin is feeling smooth, albeit a bit greasy sometimes (as I said, it gets greasy even when I don't use E45).

Maxidex has BAK in it, which I'm not that keen about (at all). I'll go into Boots tomorrow to ask about the non-preservative version (although it was the hospital pharmacy that prescribed it for me). Thanks for pointing out the post by Unicorn, I've read that now. Once I start using the drops, still not sure what symptoms I should be looking out for as an indication to stop using the drops immediately - hopefully I will just know at the time! Thanks for the advice about closing the tear drains also. Someone else has said they got sinus troubles after using steroid drops, but it recovered after stopping the drops.

Not tried punctal plugs. I don't have especially dry skin, although my eyelid skin has got a bit dry at times. I think I've got normal to greasy skin - mild acne has been with me for 10+ years now - still trying to deal with it.

I've tried Blephasol and Blephagel to treat the eyelids. I didn't have any side effects from using them, but I found they just weren't cleaning the eye areas as well as the showergel in the shower routine is at the moment.

Yes, I can PM Villfan about the good doc.

Thanks
Dave

[dijon84]

I had a follow up appointment with the eye doctor last Tuesday. My eyes weren't feeling better but she said the MGs were looking better. Continue the steroids at a low dose (3 times per week in each eye) for 3 months, then come back in. I've got some preservative free vials of the steroids too. Will have to see how that goes.

[dijon84]

I had a 3 month follow up on Tuesday with the same doctor. I had been told to continue on the low dose of steroid drops (3 times a week for 3 months) then come back in. I stopped using the steroid drops after 1 month as I felt that they weren't doing much good, plus I was a bit concerned about the long term effects of using them (I had been on them for 7-8 weeks by the point where I stopped). The doc told me that everything was looking much better and didn't need to see me again. I am still getting gritty eyes most of the time but to a lesser degree than in the past. Also, I used to get problems at night but don't really any more. The doc also said that categorically (100%) I don't have demodex mites, which is obviously good! The main things I have changed in the past few weeks / month are:
- adding 5000 IU of vitamin D (D3) to my supplement intake (plus vitamin K2 - see amazon reviews for vit D3 and some will recommend to take vit K2 in addition). Someone I know who had blepharitis adding vit D3 to their diet and experienced improvements. Guess this was due to a previous vitamin D deficiency (which is not unlikely considering the weather we've had in the UK so far in 2013!).
- lighter touch on the eyelid cleaning. About once or twice a week I do eyelid cleaning with aveeno colloidal oatmeal soap and the edge of a flannel. In morning and night, I'll splash cold water on the eyelids about 5 times and dry it off with a tissue for 15 secs (the excess sebum should hopefully come off too).
- in the past week or so, I've been putting coconut oil on and around the lids, twice a day (just after I finish with the cold water and drying the lids with a tissue). I've been using it due to the properties of caprylic acid in it, which should hopefully help with any yeast problem. I'm careful not to use too much otherwise it can go in the eye. I think an advantage that coconut oil has over some other oils is that it is a solid at room temperature. Rubbing it in your fingers turns it into the oil that can be spread onto the skin. Because of this, I think it is less runny and less prone to creep into the eye (than oils which are liquid at room temperature).
- I've started adding various helpful herbs and spices to my meals - turmeric, ginger, coriander, oregano, cayenne pepper etc.

Hard to say which of these things is helping me most at the moment, perhaps they are all helping. Bit of a random post but thought it might help someone.

There are still many things that I want to try to improve things yet further and get rid of the gritty eyes / papillary inflammation inside the lids. I suspect I have some sort of gut / yeast / candida problem, as I do get some bowel symptoms (and apparently bowel issues can be the first thing to cause skin problems). Something to look into further. I still get a few white specs on the eyelashes when I wake up so still some sort of seborrheic issue there.