MDG - Bacteria?

[Plat]

Hi I am from Canada, about a year ago I had sudden symptoms of dry eye and was told it was MDG/blepharitis. I squezzed my lower lids and a quite thick paste came out of the glands. I started with warm compresses, tried several antibiotics(or combination steriods) at different times,
- Gentamicin ointment(took for 4 days)
- Blephamide drops(took for maybe 3 days)
- Voltaren drops(took for 3-4 days)
- Todrax drops(took for 5-7 days)
- Fusidic Acid ointment( 5 days)
- signal vial prednisolone steriod(took 4 drops a day for 3 weeks when started cyclsporine)
- Oral Doxy(3 months)
- Oral Minocycline(2 months)
- Cyclosporine drops(compounded here in Canada)(6 months and still taking them)
Now, I don't think I gave a fair chance to any of the antibiotics and the longest period I tried one antiobitc drop or ointment is 5-7(tobradex).

Questions,
- When I squezze my lids now, sometimes the glands produce oil, sometimes they produce a thin or thick white secretion(although, not as thick as initially before treatment). What causes the oil to be oil sometimes and thin or thick at other times? Is it bacteria or hormonal?
- If one is taking antibiotic drops to treat the bacteria(if bacteria is present), how long should one be taking the antibiotic drops. And if the oil is thick because of bacteria, can it penerate the glands to treat the bacteria?
- If there is bacteria, different antibiotic drops and ointments treat different bacteria. Can the secretion from the gland be tested to see what bacteria is present so the appropriate antibiotic is used?

Thank you for your expertise.

[Plat]

Sorry I meant MGD and this is directed towards Dr. Bazan or any one else who can shed some light. Thank you

[skygoddess]

Well, just my 2 cents, but I had great success with Azasite, which is an antibacterial drop. Only problem is, I keep having to use it. Its new so no one is really sure how long I will have to keep it up. I saw my Dr. yesterday, and he said he had no idea how long, either. But, I can report, I have totally pain free lids today. Something I could never say before Azasite.

[Justin]

Thanks for asking some very impressive questions. Most eyecare providers don't ask these questions at lectures (let alone be able to answer them), so its very impressive to see these thoughts form in a patient.

I will try my best to provide some fair and reasonable answers in terms that forum members will understand. Keep in mind MGD is very complex and much of what is know is uncertain. What follows is my personal opinion mixed with current theories and research.

Questions,- When I squezze my lids now, sometimes the glands produce oil, sometimes they produce a thin or thick white secretion(although, not as thick as initially before treatment). What causes the oil to be oil sometimes and thin or thick at other times? Is it bacteria or hormonal?

I don't know if anyone knows with any certainty, I surely do not. In order to keep in alignment with the question, I will try to incorporate both hormones and bacteria into an MGD theory. It probably is multi-factorial and is influenced by both, and probably amongst others.

Hormonally regulated meibomian glands (MGs) begin to produce altered lipids which feed ocular bacteria that begin to reach abnormal levels. Those bacteria produce toxic waste products and can further alter the meibum composition (via lipase activity). This increased amount of toxic waste products and free fatty acids (altered meibum) are disruptive and harmful. These abnormal components mix with normal tears leading to the formation of toxic tears. These toxic tears cause a general ocular surface inflammation, including an inflammation the MGs. Inflamed meibomian glands can also contribute to meibum secretion inadequacies via both a physical obstruction of the orifice leading to decreased secretions and clogging, along with the possibility of directly altered meibum production.

Furthermore those altered lipids adversely effect the lipid layer leading to tear film destabilization and ocular surface dewetting which further promote inflammation and an increase in tear hyperosmolarity and ocular surface damage. I feel that the abnormal lipid layer may be thin, inadequately composed, and/or disturbed by large altered lipid components.

Alternatively one may hypothesize, ocular bacteria may be exclusively, non hormonally related, as an initial cause of MGD. Any event, ocular or systemic, that promotes an increase in the normal amount of ocular flora may contribute to this occurrence. This in turn leads to previously mentioned sequale associated with altered meibum and toxic waste products. Hormonal regulation may not play a role in every instance of MGD. For example, MGD is associated with certain contact lens wearers, without a clear hormonal (as well as bacterial) link. There might even be a mechanically induced inflammatory response altering MG function (directly or indirectly). We just don't know...yet.


- If one is taking antibiotic drops to treat the bacteria(if bacteria is present), how long should one be taking the antibiotic drops. And if the oil is thick because of bacteria, can it penerate the glands to treat the bacteria?

I am not really sure. It depends on the efficacy of the drop with regards to the bacteria. Lid margin disease does not seem to follow a clear pattern. Most antibiotic drops are dosed for at least 1 week, and in lid margin disease, many are dosed for a solid 2 weeks. I am not sure of tissue penetration but a pub med search might be helpful.

- If there is bacteria, different antibiotic drops and ointments treat different bacteria. Can the secretion from the gland be tested to see what bacteria is present so the appropriate antibiotic is used?

Culturing the secretion would lead to the typical ocular flora. I do not believe any valuable information will be gained from such a technique. If bacteria is involved, it is bacteria that is always present in your eye. Those bacteria are handled very well with current antibiotics. The role bacteria plays may be a changing as we uncover other possible causes of lid margin disease, such as demodex/Rosacea. If bacteria was one of the only major factors, rx'ing antibiotics would surely have better, more consistent results.

Hope the info was helpful. Time will give us some better answers and more insight into MGD. Stay tuned and keep up the great thoughts.

[Plat]

Thank you for your in depth answers.

The reason bacteria is the question is because one week before I got this, I was painting my ceiling and got paint in my eyes and was doing the landscaping in the same 2-3 days and got loam which consisted of manure in my eyes. Just makes me think.

Thanks again.

[stella]

Antibiotic ointment works for me

Thank you Dr Bazan for your very enlightening and comprehensive explanation of MGD
I have been using chloramphenicol eye ointment for nearly 5 months now , once nightly on lid margins and outer lids after steaming and squeezing my eye lids - with really good results .
I no longer need drops during the day, and at night my lids dont stick to my eyeballs anyway as bad as they used to
I am also on an HRT which contains a weak androgen. Although i have no proof that it has helped ,i continue on it anyway.
I would consider myself about 75% cured and can manage the last 25% quite easily without much disruption to my life
I DO HOPE i never get so used to the antibiotic that it ceases to be effective - I have never been quite sure if it is the emmolient effect of the ointment or the anibiotic effect / or maybe both - which is bennificial
Cheers

[Plat]

Hi Stella, what symptoms are alleviated by using chloramphenicol eye ointment(assuming that is what is helping). Thanks for your input.

[skygoddess]

Dr Bazan,
I read your response about MGD and bacteria, and thanks for all the helpful information.
I have been suffering with MGD and Blepharitis for 2years now, and I think that was the most informative explanation I have found.
Toxic tears describe my personal experience perfectly.

I was wondering what are the hormones regulating the meibomian glands?

I have rosacea, and am stating to go through menopause.
Does estrogen play a role?

I have had great improvement on my lid margins, since using Azasite,
but it does not last. The Azasite clears up the symptoms immediately,
but I assume it it does not address the root cause, because it keeps recurring.

[Plat]

Hi Skygoddess, can you please explain what symptoms are better when you use Azasite. Do your eyes feel normal while on Azasite and do you experience stinging, burning, dryness whithout Azasite. Not sure if you have seen this article yet.

http://otasia.advanstar.com/otasia/a...eID=1&sk=&date

Thanks

[stella]

Hi Plat - My symptoms were --
Firstly - blepharitis with prickly itchy eyelids -particularly the lid -margins ,and quite painful lids too when i had a bad flare-up
Secondly - evaporative dry eye symptoms due to the blepharitis - of burning, pain, and photophobea - so bad i had to wear sun glasses most of the time especially when doing the computer and watching TV ,also I especially hated supermarket lighting, and blow out heaters and having to stare at the preacher in church or if attending a lecture . I was always better in the fresh air even in wind
Every night i woke at least twice to "prise " my eyelids off of my eyeballs and that really hurt and i dreaded it and lost a lot of sleep
Thirdly - all this resulted in depression and loss of confidence
Now things are SOOO much better - no drops (not even my claramist eyelid spray)
I sleep all night now and the only symptom I have is that my eyes are blurred in the morning - only for a few moments and it helps if i yawn and blink and massage the lids a bit --- I can live with that
Then I go all day and can actually FORGET about my eyes until i do the eyelid stuff before bed
Hope that answers your question and gives some hope to other readers
Cheers

[Justin]

Dr Bazan,
I read your response about MGD and bacteria, and thanks for all the helpful information.
I have been suffering with MGD and Blepharitis for 2years now, and I think that was the most informative explanation I have found.

Great! I am really glad you found it informative. This is pretty confusing stuff and much of it is just speculation.

I was wondering what are the hormones regulating the meibomian glands?

MGs are thought to be sensitive to decreasing amounts of androgens. Androgens prevent the inflammatory effects of estrogen. Women inherently have low amounts of androgens and any decrease in them allows for inflammation of the MGs.

I have rosacea, and am stating to go through menopause.
Does estrogen play a role?

Many would say yes.

I have had great improvement on my lid margins, since using Azasite,
but it does not last. The Azasite clears up the symptoms immediately, but I assume it it does not address the root cause, because it keeps recurring.

I think your assumption is dead on. It can be thought that he azasite's anti-inflammatory properties take over in the short term but since the root cause is not addressed, the inflammation returns. Depending on the root cause, we may only be able to optimize the ocular surface by minimizing pro-inflammatory agents and maximizing anti-inflammatory agents.

[brd888]

Hormones

Justin,

you said "Hormonally regulated meibomian glands (MGs)" --

I assumed MGs just produced a constant stream of meibum. Isn't this true? What would be the purpose of the body regulating production via hormones? To stop production during sleep?

Also are you mainly talking about menopausal hormone changes - not affecting men or younger women ?

Thanks,
Bruce

[Justin]

Hi Bruce,

Thanks for asking some really good questions.

I assumed MGs just produced a constant stream of meibum. Isn't this true?

Hormones are regulators. In the MG, they are thought to not only influence the quality and the quantity of the meibum, but other functions as well. We are still learning about the specifics. Any variance from normal/appropriate hormonal levels can cause a dysfunction.

What would be the purpose of the body regulating production via hormones?

Hormones altering gene expression, which is how regulation takes place.

To stop production during sleep?

I am not exactly sure but we know many functions vary during sleep. Hormones are usually involved one way or another. We know that the larcimal unit exhibits decreased output in the evening/night for most people. I can not recall specifically about MG's.

Also are you mainly talking about menopausal hormone changes - not affecting men or younger women ?

Anyone. Menopausal women are believed to suffer higher levels of MGD possibly due to an androgen deficiency. Women in general are more prone to androgen deficiency because they have less quantities of androgens, therefore any loss is more substantial. One must keep in mind that menopause is only one influence on hormones.

For more info use the search terms "androgen deficiency, meibomian gland"

[odydnas]

I think your assumption is dead on. It can be thought that he azasite's anti-inflammatory properties take over in the short term but since the root cause is not addressed, the inflammation returns. Depending on the root cause, we may only be able to optimize the ocular surface by minimizing pro-inflammatory agents and maximizing anti-inflammatory agents.

Dr. Bazan, how does one determine the root cause of one's mgd? And if and when that happens, what are some ways, both naturally and medicininally minimize pro-inflammatory agents and maximize anti-inflammatory agents? Are simply talking about nutrition and exercise, coupled w/ azasite and corticosteriods when necessary, or is it something else? Thanks!!

[Natalie06]

Dr. Bazan

I am currently using Lupron Depot as a treatment for endometriosis and still battling MGD/Ocular Rosacea/Blepharitis. Knowing what I know now, the link between the low estrogen/androgen hormones seems pretty clear. Since Lupron works on the pituitary, it shuts off production of all sex hormones. I believe that's why men with prostate cancer use it as well.

Anyway:

My question: I have been on a variation of tetracycline for almost 2 years trying to control the blepharitis and I really want to get off the antibiotics. I am currently taking 50MG's of minocycline 1 x per day. Everytime I try and stop, the bleph returns full force.

Would changing over to the Azasite be a better option with fewer systemic
side effects? And could it possibly be more effective than oral antibiotics since it is applied directly to the source of the problem?

Thank you so much.

Natalie