Manual expression: how painful?

[lizlou29]

My Ophthalmologist (NHS) said he is willing to manually express my MG's with the forcep thingy. Didn't realise he did this which is why I went to see a private Moorfields specialist who said he might do it next visit but wanted me to use hydrocortisone cream intensively on my eyelids first. Didn't think it was worth the risk as he said to expect a big rebound effect from the cream but then we'd know if it was an autoimmune immune problem which I'm pretty sure it is anyway.

Anyway, my ophth said the expression will be painful and he'd have to do it every 4-6 weeks if it helps. I had Lipiflow and this really flared up my upper lids so I'm wary of this happening again. Is it normally only performed on the lower lids? He's done meibography and the glands look as they should for someone my age (30) but they are producing thick yellow oil and only under pressure. 6 months of Doxy and 3 years of fish oil don't seem to have helped. I do a warm compress daily but have to be careful because I don't think they are great for the ocular rosacea. Thoughts or experience welcome.

[peter56]

Hi Lizlou,
MGs should only be expressed, after warming the eyelids up with a facial Sauna!
Your ophthalm should know, that it is much too painful and almost useless expressing obstructed MGs without melting
down somewhat the meibum-sekret obstructions before.
That procedure has to be perfomed every week at home!
[DELETED BY MODERATOR. PETER: Do not recommend use of professional medical instruments at home by our users! This is inappropriate and unacceptable in the forum.

Yellow sticky meibum may indicate, that there is still a bacterial infection-blepharitis.
Did you ever tried Azyter-Azythromycin drops.
OK These drops do burn, but they are more efficient than doxy etc.


Peter

[lizlou29]

Hi Peter56

He is going to warm the glands up first. I wouldn't use a facial sauna as I have rosacea but I use the eye bag once a day, more than that and I have red sore lids as the heat makes the rosacea element worse.

Yes I've tried Azyter and Chloramphenicol (sp?) recently plus had swabs done so I don't think there is an infection.

I don't think I'd want to use the forceps at home and didn't think they were available for non - medical professionals to buy? I have one bandage lens in but not meant to put them in myself.

[DocwithDryEye]

Hi Lizlou,
MGs should only be expressed, after warming the eyelids up with a facial Sauna!
Your ophthalm should know, that it is much too painful and almost useless expressing obstructed MGs without melting
down somewhat the meibum-sekret obstructions before.
That procedure has to be perfomed every week at home!
It only takes a facial sauna, the collins forcep and protective plastic corneal shields or thick bandage lenses.

Yellow sticky meibum may indicate, that there is still a bacterial infection-blepharitis.
Did you ever tried Azyter-Azythromycin drops.
OK These drops do burn, but they are more efficient than doxy etc.


Peter

I agree with Peter that the glands need to warmed before expression is attempted. I had one of my doctor partners express my glands without a warm compress the first time, and I can honestly say I wanted to cry it hurt so bad. I was gritting my teeth with tears dripping down my face. We use the Bruder mask now on the patient for 10 minutes before attempting to express. Post LipiFlow appears to be much easier to express patients, but the warm compress before is a must. I've seen new meibum post op LipiFlow that can have a yellowish look to it. As Peter noted, it can indicate infection, but it may also may indicate better oils post op LipiFlow

Thanks for posting

DocwithDryEye

[lizlou29]

Just an update - I have been using Azyter for 3 weeks and can now see oil when I express my glands after a warm compress. It was yellow and thicker to start with, now my right eye is producing clearer oil without much pressure but my left eye is still producing yellow-ish oil though not as thick. I am seeing my Ophthalmologist in two days time so will see if he wants to do the manual expression. I am going to take my MGD eye bag with me to warm the glands first. I have quite severe aqueous deficiency so can't say I feel a whole lot better but Azyter has helped me more than Lipiflow. Thanks for your input guys.

[spmcc]

Post LipiFlow appears to be much easier to express patients, but the warm compress before is a must. I've seen new meibum post op LipiFlow that can have a yellowish look to it. As Peter noted, it can indicate infection, but it may also may indicate better oils post op LipiFlow.
DocwithDryEye

Thank you for all your input, DocwithDryEye. You're taking a lot of time helping us here and I appreciate it.

I've had LipiFlow twice (July 2011 and Nov 2011) and posted about both experiences in other threads. Anyway, at neither treatment were my glands expressed afterwards. Now more recently, I've been reading that the LipiFlow treatments include an expression post op. I find this so strange... the glands should be empty already after the heat and massage by LipiFlow. Why perform a manual expression after LipiFlow?

[DocwithDryEye]

Thank you for all your input, DocwithDryEye. You're taking a lot of time helping us here and I appreciate it.

I've had LipiFlow twice (July 2011 and Nov 2011) and posted about both experiences in other threads. Anyway, at neither treatment were my glands expressed afterwards. Now more recently, I've been reading that the LipiFlow treatments include an expression post op. I find this so strange... the glands should be empty already after the heat and massage by LipiFlow. Why perform a manual expression after LipiFlow?

Thanks for the reply spmcc.

Having dry eye myself prompts me to put a lot of time into responses and posts. I know how miserable things can be!

I should have clarified. We do the manual expression at the post op visits, 3 month and 6 months out if we see pasty thick secretions. I would agree that doing manual expression RIGHT after the procedure would have little clinical benefit.

DWDE

[spmcc]

Thanks for the reply spmcc.

Having dry eye myself prompts me to put a lot of time into responses and posts. I know how miserable things can be!

I should have clarified. We do the manual expression at the post op visits, 3 month and 6 months out if we see pasty thick secretions. I would agree that doing manual expression RIGHT after the procedure would have little clinical benefit.

DWDE

Well, I'm happy that you're here but I'm sorry that you're going thru what we're going thru...

Ah, so those manual expressions at 3- and 6-months post op make complete sense. But I'm pretty sure that others getting LipiFlow are reporting having manual expression RIGHT after their treatment. Hmmm, I think/hope/assume that I read the posts properly (damn eyes!). I'll try to find some posts as examples.

Changing the subject a little and switching to pre-LipiFlow (or pre-any-manual-expression)... many people are reporting (and Korb talks about it in his video and you mentioned it in Part II of your post) that lid debridement is important. Korb talks about using a golf club spud plus there's a new machine called Blephex that is like a dremel with a qtip attachment. And you mentioned doing it at home with a "good" cotton swab.

Anyway, I've talked about lid debridement with my cornea specialist who is very nice but a *complete* chicken (bok-bok-baaahk). He needs to see peer-reviewed literature (e.g., http://www.ncbi.nlm.nih.gov/pubmed/24145633) and THEN he needs to see or hear about it at a conference. Do you have any hints on how I can get my doctor on board with newer treatment options? Aren't golf club spuds something ophthalmologists have in their offices already?

Thanks again.

[DocwithDryEye]

Spmcc

If the doctor you see has the LipiFlow system, he should be receiving clinical updates from the company that sells the technology as to what is the most up to date method on treatment. Yes, the lid debridement has become "standard of care", in order to clean away any dead dry cells before the procedure. I have heard of a few doctors using the Blephex instrument, but I don't know if this is necessary if the doc is taking the time to use the spud. And yes, the doc should have at least two or three of these spuds in the office. He/she should be able to run this up and down the lid margin to remove any irritation.

I was thinking about your post regarding gland expression directly after LipiFlow. I saw a fellow doctor last night that saw one of my post lipiFlow patients earlier that day. The patient had had the procedure done 8 weeks ago, but still had a thick pasty secretion. I asked about his eye lids, and the doc said they are very red, and irritated. There are many patients that come in with red irritated inflammed glands, and there are patients that come in with calm quiet glands. I'm starting to think that maybe the gland expression DIRECTLY AFTER LipiFlow may be a good thing for these patients with horrible inflammation. It may be that the LipiFlow provides the perfect amount of heat to liquify the glands, but not enough pressure to get through they dry calloused lid margins. A good thing to look for in the future.

Thanks again for sharing and posting!

DWDE

[lizlou29]

Just to update I had my MG's manually expressed earlier today. I chose anaesthetic eye drops over injection. Was a bit painful but not too bad. The Azyter I've been using had already made a difference and the glands didn't take as much pressure to express with the Q tip and the consistency was better so I will use the Azyter again with breaks in between so I hopefully don't build up a resistance to it.

I fail to see how manual expression is that different to Lipiflow. Doc said I'd need them expressed again in about 6 to 8 weeks. I've heard very little about patients having the supposed 9+ months benefit from Lipiflow.

[bunnyrabbit123]

dear lizlou-
Congrats on finding someone who will do this for you. Over the past 4 years of struggling with this, I've never been able to get a doc to do this for me unless it was in connection with out of pocket procedure such as IPl. I've been to a number of doctors-they just won't do it here. Good luck to you-hope this and the azasite turns out to be your magic bullet!

[lizlou29]

Thanks bunnyrabbit! Went through a lot of Ophthalmologists before I found one who has an interest in dry eye though not his specialism. Still got the aqueous deficiency problem but my eyes feel very oily and wet this evening, strange feeling!

[browneyesblu]

I agree with Peter that the glands need to warmed before expression is attempted. I had one of my doctor partners express my glands without a warm compress the first time, and I can honestly say I wanted to cry it hurt so bad. I was gritting my teeth with tears dripping down my face. We use the Bruder mask now on the patient for 10 minutes before attempting to express. Post LipiFlow appears to be much easier to express patients, but the warm compress before is a must. I've seen new meibum post op LipiFlow that can have a yellowish look to it. As Peter noted, it can indicate infection, but it may also may indicate better oils post op LipiFlow

Thanks for posting

DocwithDryEye

First of all congratulations Liz on finally finding some relief--I hope it continues for you.

DWDE: Thanks for joining the forum and patiently answering all our questions. I have some about the Bruder eye mask. I've been advised to use moist heat for compresses and the reason was quite logical--water is a conductant and so transfers the heat more effectively. Does the Bruder mask deliver moist heat, as moist as a moistened wash cloth? Also elsewhere you mentioned it stays warm for 2-5 minutes. How do you use it for 10 minutes? Do you reheat it or do you use more than one? If the latter, how many do you need for a 10-minute treatment?

[DocwithDryEye]

First of all congratulations Liz on finally finding some relief--I hope it continues for you.

DWDE: Thanks for joining the forum and patiently answering all our questions. I have some about the Bruder eye mask. I've been advised to use moist heat for compresses and the reason was quite logical--water is a conductant and so transfers the heat more effectively. Does the Bruder mask deliver moist heat, as moist as a moistened wash cloth? Also elsewhere you mentioned it stays warm for 2-5 minutes. How do you use it for 10 minutes? Do you reheat it or do you use more than one? If the latter, how many do you need for a 10-minute treatment?

The Bruder mask can apply varying levels of heat, depending on how long you put it in the microwave. I've been using one myself for about six months, and I have found that if you microwave it too long, it is a more dry heat, and not as therapeutic. I find that 30 seconds is perfect. I starts relatively warm, and after three minutes or so, it starts to cool a bit, but when I take it off after 10 minutes, my eyes feel great. One microwave time of 30 seconds, no reheat.

DWDE

[DocwithDryEye]

LizLou

Glad to hear you are doing better with the Azyter. I don't think we have that available in the US, but AzaSite should be similar. I have not done much with it, but am considering doing more and I hear more and more about it on this forum. Most people seem to be getting some benefit. It's also great to hear gland expression was better after using it. That's good feedback. Once again, I'm considering doing more with the oral form, but just have to be on the lookout for patients with heart conditions. Many of my dry eye patients are over 60 years old, and most have heart issues, blood pressure, cholesterol, and diabetes, so I've been hesitant to use it. Once again, thanks for the feedback

DWDE