Atrophied meibomian glands

[Rebecca Petris]

Is there anyone here who has been diagnosed as having all or most of their meibomian glands atrophied? If so could you contact me?

While I think it's common for meibomian gland dysfunction to go undiagnosed and untreated, irreversibly atrophied glands (actually I should probably say a high percentage of MG dropout) are another matter.

I was frankly dismayed today to hear from a patient who seems to be in this condition yet was only quite recently diagnosed with it. This patient had previously tried most dry eye treatments we're all familiar with, had even had AMT (with no benefit) and has now been deemed not a scleral candidate (due to degree of discomfort on initial trial). I only know of one other patient in a similar situation and I am interested in getting in touch with others who have had a similar diagnosis. Based purely on the vast anecdotal evidence here of people with high pain levels but not bad aqueous production and not obvious blepharitis etc, I have to believe there is more atrophic MGD going on than we're hearing about.

For those who have it and known it - as a minimum we can perhaps help people trade notes on the most effective palliative remedies but perhaps also we can get some dialogue going with some experts. For those who have it and don't know it, maybe we can raise awareness.

[Silverlady]

Possibly

Rebecca, I have not been diagnosed, but my meibomian don't produce any oil as far as I can tell. My eyes don't produce tears either. I have Sjogrens. It makes sense that the meibomian gland would be atrophied since my salivary glands show signs of being attrophied. I went undiagnosed for several years. Is there anything I can do about it?
Billye

[DrG]

Is there anyone here who has been diagnosed as having all or most of their meibomian glands atrophied? If so could you contact me?

While I think it's common for meibomian gland dysfunction to go undiagnosed and untreated, irreversibly atrophied glands (actually I should probably say a high percentage of MG dropout) are another matter.

I have such a patient. She has reasonably good aqueous production, but I am unable to extract any meibomian secretions from her lids. I am treating her with punctal occlusion and she is able to wear Acuvue Oasys contact lenses. I initially occluded all four puncta, but had to remove the uppers because of epiphora. The theory behind punctal occlusion was to make up in volume what the patient lacked in tear quality, and to help hydrate the contact lens. My theory is that if the contact lens remains hydrated, then it has a protective effect and a reservoir effect, because the TBUT is nearly zero.

[ericdinn]

I have been diagnosed with atrophied meibomian glands.

[sazy123]

Rebecca:

Hi could you explain atrophied meibomian gland to me, what basis would you asume that your meibomian glands are atrophied?

Its obviously not the case when you can see that your glands are clogged and you have to thin the oil with compresses. are the glands 'atrophied' when they are not producing oil or enough oil, with no clogging?

I have such a patient. She has reasonably good aqueous production, but I am unable to extract any meibomian secretions from her lids.

DRG: when you say you cant extract any secretions, do you mean from clogged glands.


I think my problem is MGD but i dont have clogging, just thought the glands werent producing enough oil. would this mean they are atropthied? i would have thought my glands weren't atrophied, coz they can work well during sinus pain, in which my eyes feel good for weeks.

[DrG]

DRG: when you say you cant extract any secretions, do you mean from clogged glands.

I mean that not only could I not express any secretions, but that there is enough scarring from past inflammation to have obliterated the orifices. The patient had already been on Restasis.

[Rebecca Petris]

Ericdinn,

By any chance have you had meibography performed (if you know)? If so do you know what percentage were deemed atrophied, or to put it differently what grade atrophic MGD you have?

DrG,

So you're basically saying chronic inflammatory MGD can progress to atrophy?

Has anybody around here ever had meibography?

Sorry Sazy, can't say much more till I understand this better myself. I have never really probed MGD and only recently became aware of a potential distinction between inflammatory and atrophic MGD.

[DrG]

DrG,

So you're basically saying chronic inflammatory MGD can progress to atrophy?

I'm saying that "a" chronic inflammatory process resulted in atrophy, as the neovascularization and scarring could be seen under the slitlamp. This is what Jeff Gailbard also says can be the end result of chronic dry eye. Whether it is preceded by the classic signs of meibomitis is another matter, and not a conclusion I can make. Obviously, some people suffer from many years of meibomitis, characterized by altered secretions, but can still express altered sebum with pressure, and respond to classic lid therapy along with tetracyclines. In the case of this patient, nothing could be expressed, and the ducts did not appear patent.

Sharapova just won the U.S. Open. Go Longhorns!

[Bennyboy]

I have been told I have scarring on my bottom lids. They produce little oil even though my upper lids now appearing to be producing normal oil now that I am on Doxy. Does anyone know if this means I automatically have atrophied glands or can I prevent this from happening? Is scarring reversible?

[nan]

i was wondering if Dr G's patient from May 2005 is doing better with the oasys lenses and plugs. any information is appreciated.

[DrG]

i was wondering if Dr G's patient from May 2005 is doing better with the oasys lenses and plugs. any information is appreciated.

I did see her a few weeks ago when she came in to order a supply of Oasys lenses. She seemed happy with her progress with the punctal plugs and the Oasys lenses.

Please note that I am not recommending this as a general therapy for dry eye, but simply responding to a request for information about a specific case.

[SusieD]

Is there anything that can be done to prevent atrophy of the glands?

DrG - regarding your patient, you mentioned that she had been on restasis - are you thinking this had anything to do with the atrophy, or just that she had been on it and it didnt help?

Many thanks.

[DrG]

Is there anything that can be done to prevent atrophy of the glands?

The inflammatory theory of anterior segment surface disease says that inflammation starts the fatal cascade of events that leads to irreversible dry eye. Therefore, it follows that the treatment should alleviate the inflammation. Long standing inflammation can indeed lead to irreversible changes because of permanent changes in the tissue.

DrG - regarding your patient, you mentioned that she had been on restasis - are you thinking this had anything to do with the atrophy, or just that she had been on it and it didnt help?

My take is that it didn't help. As I said, this patient did have borderline/normal aqueous volume, but the TBUT was nearly zero. I was unable to express much, if anything from her eyelids. There were no concretions in her meibomian glands, only the appearance of everything being scarred shut. I don't really know how this occurred. She has been contact lens intolerant for a long time, but has persisted in her attempts to wear them.

Jeff Gilbard's theory is that when the tear film becomes hypertonic, i.e. increased tear evaporation, the corneal epithelium becomes compromised. This is where the anti-inflammatory omega-3 EFA's come into play in the treatment of posterior blepharitis.

A link to his presentation may be found here.

[SusieD]

Thanks DrG and good to see you around again.

I just want to ask - when you look at these glands when examining a patient, can you see them with the naked eye or do you need to look at them under the slit lamp?

Where exactly are they located?

Thank you.

[DrG]

A link to Dr. Gilbard's presentation may be found here. There is a brief reference to long-standing blepharitis as causing permanent meibomian gland dropout.

"Eventually the chronic meibomian gland inflammation leads to meibomian gland dysfunction. When that happens, these patients develop a second peak in symptoms from dryness toward the end of the day. Finally, when the meibomian gland inflammation and secondary healing obliterate the meibomian glands, the morning symptoms resolve and patients are left with symptoms from dryness alone, with sandy-gritty irritation that gets worse as the day goes on."

The ducts of the meibomian glands open to the surface of the eyelid at the junction between the anterior and posterior aspect of the lid. I don't think that you can visualize them with the naked eye, unless perhaps they become stenosed with a concretion of hardened sebum. Sometimes the glands themselves can be seen with the slitlamp by pulling the eyelid down and looking at the conjunctival side. The glands can then sometimes be visualized as yellow streaks if they are filled with yellow sebum. Transilluination of the eyelid with a light source is also possible.