Referral to an Ophthalmologist Skilled in Meibomian Gland Dysfunction

[Physician]

I'm not an eye doctor. For the past two months I've had increased tears, never enough to run over my cheeks. I've been to three optometrists and three Ophthalmologists from San Francisco to San Jose, California. Not one of the eye doctors agreed on a treatment, but they all said via slit lamp my Meibomian glands are not functioning properly and appear dry.

I've tried eight different ocular lubricants, singularly and in combinations, and the best one has been the new Systane Balance. Used a week of Azasite 1% eye drops twice a day. Pataday drops (an anti-histamine eye drop) did not help.

The two annoying symptoms are:

• 1. Feeling the excess tears at the lid margins, and
• 2. Visual blurring only related to and caused by the tear pool.

There are no other symptoms... no buring, itching, foreign body sensations, pain, etc. Four of those professionals said my NLDs were obstructed, but they are wrong. Fluorescein dye flows well into my nose. The naso-lacrimal ducts are not obstructed.

Have have prescriptions for oral Azithromycin and Vibramycin but haven't started either. have read many websites on this subject and it seems that this condition is poorly understood and treatments are variable and not definitive.

Does anyone here have the name of an unusually skilled optometrist or Ophthalmologist, well-trained in MGD, from San Francisco to San Jose, California ?

[Rebecca Petris]

I really like Michael Gagnon MD in Pleasanton. I know many of his patients. He knows MGs. I think the practice name is Valley Eyecare.

Were you given any other MGD-specific treatments besides Azasite?

That's a very odd symptom pattern for MGD alone.

[Physician]

More Rxs recommended; new approach

Were you given any other MGD-specific treatments besides Azasite?

That's a very odd symptom pattern for MGD alone.

Thank you for your reply.

MGD specific ? I didn't anything was specific treatment for this ailment.

I do have an M.D. degree but constructed my start post so that non-M.D.'s will understand. With MBD, one loses the oil component of tears with resultant symptoms.

Many other RXs have been recommended:

Baby Shampoo eyelid scrubs
Ocusoft foam eyelid scrubs
Tobramycin + Dexamethosone eyedrops
Systane, Systane Ultra, and I found the Balance by chance.
Tears Natural
Blink
Refresh, Refresh Plus
Warm to hot eye compresses
Zithromax
Months of doxycycline
Genteal eyedrops

I have absolutely no systemic disease. This is a localized problem.

After getting a headache from reading all the websites and papers, two days ago I started two things on my own.

1. In the shower every morning allowed the showerhead to gently pulsate warm water on my lids, and

2. Several times a day rub Systane saturated Q-tips over the margins of my lower lids, back and forth about six times. (Too difficult to do it to the top lids)

Initial results are promising.

[indrep]

Excess tears can be diagnosed as the early stages of ocular surface disease. They are a reflex to something that is creating a trigger mechanism to the brain. Usually, according to the DEWS report (published in April 2007), something has created an elevated osmolarity of the tear film at the ocular surface.

The tears that are currently on your ocular surface are not the steady state tears, they are the reflex tears. These tears are high in salt content (hypertonic) and with this environment cell apoptosis will create an unstable tear film further exacerbating the issue. I have seen this clear up many times with 90 day punctal occlusion and Oasis TEARS Plus. The goal is to reverse the osmolarity of the tear film by holding more water on the ocular surface.

[Physician]

The tears that are currently on your ocular surface are not the steady state tears, they are the reflex tears. These tears are high in salt content (hypertonic) and with this environment cell apoptosis will create an unstable tear film further exacerbating the issue. I have seen this clear up many times with 90 day punctal occlusion and Oasis TEARS Plus. The goal is to reverse the osmolarity of the tear film by holding more water on the ocular surface.

Yes, but aren't you actually stating that the Meibomian contribution is lacking ? Please explain more about This "punctal occlusion" therapy, and what is so unique about Oasis Tears Plus compared to all the other ocular lubricants listed. Are the orifices occluded physically or by the Tears Plus ?

Strange to have "reflex tears" when I feel no irritation or symptoms.

[indrep]

Dear Physician,
Ocular surface disease in most cases is multifactorial. This can be attested to by the six different opinions received so far. If indeed the meibomian glands are not functioning then the "cause" of the hypertonic tears could be rapid evaporation of your steady state tears. Once the brain is signaled that a hypertonic tear film is in contact with the ocular surface the inflammatory response is activated. So now there are three issues contributing to ocular surface disease: the original rapid evaporation, cell apoptosis from hypertonic tear and inflammation reducing the secretions of steady state tears and possibly the lipid secretions from the meibomian glands.

The idea behind punctal occlusion is to keep as many steady state tears on the ocular surface for as long as possible. What is occluded is the lacrimal duct that drains tears from the ocular surface. This duct is physically occluded with a variety of types of plug. It would be physician dependent.

Oasis TEARS is able to hold more water and lipids per molecule than other formulations. So the combination of the two treatments could reverse the osmolarity issue and give your cornea the microenvironment it needs to heal.

[Physician]

More about occlusion. More about Oasis.

Dear Physician,
Ocular surface disease in most cases is multifactorial. This can be attested to by the six different opinions received so far. If indeed the meibomian glands are not functioning then the "cause" of the hypertonic tears could be rapid evaporation of your steady state tears. Once the brain is signaled that a hypertonic tear film is in contact with the ocular surface the inflammatory response is activated. So now there are three issues contributing to ocular surface disease: the original rapid evaporation, cell apoptosis from hypertonic tear and inflammation reducing the secretions of steady state tears and possibly the lipid secretions from the meibomian glands.

The idea behind punctal occlusion is to keep as many steady state tears on the ocular surface for as long as possible. What is occluded is the lacrimal duct that drains tears from the ocular surface. This duct is physically occluded with a variety of types of plug. It would be physician dependent.

Oasis TEARS is able to hold more water and lipids per molecule than other formulations. So the combination of the two treatments could reverse the osmolarity issue and give your cornea the microenvironment it needs to heal.

Okay, however:

1. Why is Oasis different from other drops with 0.2% Glycerin ?
2. Are you in any way related to, or have a conflict of interest in the company producing these drops ? Unusual to hear such an enthusiastic recommendation for a product.
3. Is the occlusion by these drops or is a actual device accomplishing the occlusion ?
4. A few websites indicate that Oasis is ONLY available at a doctor's office and on-line (http://www.dryeyeyellowpages.com/pro...asistears.html) and not in local pharmacies. If so, why ? If not true, where's the fastest place to get some locally ?
5. Is Oasis actually superior to Systane Balance ® ?
6. Difficult to understand this "occlusion" therapy since the bulk of the opinions have been my problem is secondary only to the consistency and paucity of the Meibomian secretions. This is why instead of oral therapy I'm mechanically abrading by lids and heating/massing by lids.

http://www.oasismedical.com/Products...iew.asp?id=944

http://www.dryeyeshop.com/catalog/ne...tears-plus.htm

[indrep]

1. The excipient with the glycerin are unique to any other drop available.
2. I am not an employee of OASIS.
3. The drops are not the punctal opening occluder. Occlusion is performed with Punctal plugs. There are various versions of these: 3-5 day dissolvable, 90 day dissolvable, long term silicone and long term intracanalicular.
4. You can order them right from this website and they can be delivered tomorrow I think.
5. Superior can be described many ways. The patient can perceive comfort and clinically the ocular surface is not healing. The eye care provider can see clinical signs of improvement and the patient may not perceive any improvement due to nerve issues. So superior product would have to be a collaborative issue between patient and doctor.
6. In order to better understand the origin of the issue I would recommend reading the DEWS report published in April 2007. There are two issues which start the cascade of debilitating events that compound the disease. These two issues are lack of aqueous (water) and rapid evaporation of aqueous. The lipid deficiency you are experiencing leads to the rapid evaporation. It is ultimately irrelevant which is the original cause, the goal is the same, bring the osmolarity of the tear film back to normal and give the cornea an environment in which it can heal.
6b. The oral therapy mentioned is designed to reduce the inflammation of the meibomian glands and allow for lipid secretion.

I hope this helps. Ocular surface disease is a complicated disease which can require a multitude of different therapies to bring relief to each individual's unique set of circumstances.

[Physician]

Q-tip scrubbing associated with near complete relief

Impressive post which leaves one speechless and typeless. Difficult to understand why when my M glands have clogged secretions why plugging them physically would help. Debridement makes more sense.

I'm now about 90% better by simply Q-tipping my lid margins QID (four times a day) with Systane on the cotton tip !! So far, no drops required for 30 hours.

Best I've been since this has started.

[Rebecca Petris]

There is a great deal about dry eye which does not make superficial sense. Signs, symptoms and solutions (that is, solutions to symptoms and/or signs) often do not match up in predictable, as about 99% of our membership can attest to... along with any drug company working on an NDA.

The technicalities of it all I prefer to leave to the experts, but at a practical level, I know a great many people helped by plugs or not helped by plugs under circumstances where the rationale for why/why not does not seem to stack up. But since it works well for so many people, and has a strong rationale supporting it in many cases, I've always considered it a reasonable thing for someone to try when they have tried a lot of other solutions unsuccessfully.

I'm glad the systane on the lid margins is helping you.

[Physician]

I'm glad the systane on the lid margins is helping you.

I don't know if it's the Systane (highly unlikely as it didn't bring this result before), or the physical abrading, or wishful thinking, or the new damp weather. Time will tell.

If one fiddles with the NLD and scarring occurs, that might require reconstructive surgery. Is there no such scarring as a consequence of placing foreign objects in the MG ducts ?

Has anyone else found Systane Balance to be superior to the many other Systanes ?

Can I place these plugs myself ? (j/k). Who is skilled at installing these plugs ?

[indrep]

Physician,
It is not the meibomian glands that are plugged. It is the opening to the lacrimal canalicular canals, the puncta, that are plugged.

When thinking of the lacrimal functional unit the lacrimal gland ducts that secrete tears and the meibomian gland ducts that secrete lipids should be as open as possible. The puncta, one upper and one lower located nasally along each lid margin can be closed to maintain more tears on the ocular surface.

[Physician]

I don't want more tears

Physician,
It is not the meibomian glands that are plugged. It is the opening to the lacrimal canalicular canals, the puncta, that are plugged.

When thinking of the lacrimal functional unit the lacrimal gland ducts that secrete tears and the meibomian gland ducts that secrete lipids should be as open as possible. The puncta, one upper and one lower located nasally along each lid margin can be closed to maintain more tears on the ocular surface.

Then these eye docs are poor communicators. My naso-lacrimal ducts are open. I have abundant liquid in my eye (conj. sac) and no one so far has wanted to plug anything.

If I had MORE tears they they would be dripping down my cheeks. Please explain further.

BTW, I found further improvement by NOT using nearly the original quantity of eye drops. Now I simply put a small drop on a finger tip and touch it to he medial aspect. Works much better.

[indrep]

Post #4 and #6 explain the situation.

[Physician]

Still do not fully understand

Post #4 and #6 explain the situation.

Still do not fully understand. If the drainage of tears is impeded, I'll have even more tears. My eyes feel absolutely no irritation or any other symptoms.

I'm about 90% better on my self-prescribed regimen, includung cutting back on the amount of lube instilled (only a small drop of Systane Balance® on fingertip ---> then touching medial portion of each eye corner), Q-tip sanding of lower lid margin twice a day with Systane or Refresh). Possibly the most bothersome symptom is that 25% of the time there's a slight double image in either eye (not diplopia, as each eye separately can have a double image) promptly but variably relieved by blinking.

Several times a day I feel mild excess tear pooling, and occasionally my vision feels "brighter" throughout. Difficult to explain.

Because you recommended Glycerin, today I locally obtained "Refresh Optive Sensitive Preservative-free". It has Glycerin 0.9% and Carboxymethylcellulose 0.5% and no preservatives, packaged in unidose vials. Haven't tried it yet. The other line-up of ocular lubes in my cabinet do not have any glycerin.