My Doctor Search and IPL Question

[Guest]

I have been reading this forum for many months. Everyone sharing their experiences has been helpful to me. I am posting for the first time today so that my experience can maybe help others. Also, I have a question about IPL.

I live in Portland, Oregon. I had Lasik in 2018 and shortly thereafter was diagnosed with MGD. Through this website I found an excellent doctor in the Seattle area. He was very helpful and I learned a great deal from him. He told me that my posterior positioned MGs would likely not respond to Lipiflow. He was right, as I later learned. Anyway, I needed to find a local doctor, however, because Portland to Seattle round trip is a 6 plus hour drive and it is difficult to do routinely with a full time job.

I met with several doctors in Portland, two of whom were considered the “dry eye specialist” in their respective clinics. It was very clear in both situations that I knew more about MGD and treatments than the doctors. The treatment options at the clinics were generally limited to the basics (drops, restasis, plugs, lipiflow) and neither doctor would manually express MGs.

Though this forum I learned that the state-of-the-art treatment for MGD is IPL and the manufacturer (or one of the manufacturers) of the IPL machine is Lumenis. I searched the Lumenis website to find who in the Portland area had the machine. There was one clinic. I had my first appointment there a few weeks ago and they are, by far, the most knowledgeable in dry eye than anyone else in the area that I have met. I am grateful I found someone in the area who can help me.

My new doctor put me on Xiidra. Through the Xiidra website I am able to get the drug with a $10 per month copay. Another option on the horizon would be IPL. After reading this website I know that it has been successful for a lot of people and I would like to try it. I have pause, however. Eighteen years ago I had IPL done under my eyes for cosmetic purposes. It resulted in fat loss and a hollowing of my lower eyelids. I would appreciate insight from anyone who has had IPL done and if they noticed any fat atrophy after.

Thank you for reading.

[Guest]

I have had IPL on my face for rosacea by a dermatologist and for my mgd by an optometrist. In my experience the optometrist uses a lighter setting on the machine I barely noticed the zaps or after effects.

[Milo007]

He told me that my posterior positioned MGs would likely not respond to Lipiflow. He was right, as I later learned.

Can you explain what your doctor meant by posteriorly placed meibomian glands?

If I guess it correctly your meibomian gland orifices have migrated towards the posterior side of the mucocutaneous junction (marx line) and they open up in the mucosa of the palpebral conjunctiva. I have a similar problem. Most of the meibomian gland orifices in my lower eyelids have migrated posteriorly to intersect the mucocutaneous junction and some are just anterior to the mucocutaneous junction. This normally advances with age (60-70 years or more) but with advanced MGD they happen in young patients. It's cicatricial MGD and unfortunately the morphological changes are permanent and irreversible.

[Guest]

He did not describe the positioning in technical terms as you have above.

When Dr. Korb was developing Lipiflow he found he was not successful with all patients. He sent the "unsuccessful" patients to my Seattle doctor and he discovered a common thread. The positioning of the MGs.

[Milo007]

He did not describe the positioning in technical terms as you have above.

When Dr. Korb was developing Lipiflow he found he was not successful with all patients. He sent the "unsuccessful" patients to my Seattle doctor and he discovered a common thread. The positioning of the MGs.

Yes cicatricial MGD wouldn't respond to lipiflow or any other treatments other than highly advanced surgery.

[deep_dry_eye]

Can you explain what your doctor meant by posteriorly placed meibomian glands?

If I guess it correctly your meibomian gland orifices have migrated towards the posterior side of the mucocutaneous junction (marx line) and they open up in the mucosa of the palpebral conjunctiva. I have a similar problem. Most of the meibomian gland orifices in my lower eyelids have migrated posteriorly to intersect the mucocutaneous junction and some are just anterior to the mucocutaneous junction. This normally advances with age (60-70 years or more) but with advanced MGD they happen in young patients. It's cicatricial MGD and unfortunately the morphological changes are permanent and irreversible.

Question, do we know for a fact that the glands migrated ? or perhaps its possible that the glands were like this when you were born. i.e., is it a scientifically proven fact that straight normal glands can become crooked and migrate? or is this speculation and perhaps a subset of the population was born with crooked glands.

[Milo007]

Question, do we know for a fact that the glands migrated ? or perhaps its possible that the glands were like this when you were born. i.e., is it a scientifically proven fact that straight normal glands can become crooked and migrate? or is this speculation and perhaps a subset of the population was born with crooked glands.

I think you are mistaking posterior migration of the meibomian gland "orifices" with meibomian gland tortuosity.



This is what happens when the central duct of the meibomian glands shift within the tissues beneath the palpebral conjunctiva due to tensile stresses generated within the tissues as a result of chronic eyelid inflammation.

So the meibomian gland orifices normally present on the anterior side of the mucocutaneous junction shifts to either intersect or move posterior to the mucocutaneous junction opening up into the mucosa to release the meibum inside the tear film which is functionally useless.

What happens is shown as an example in the next two pictures :




Do you notice the meibomian gland orifices opening up in the mucosa of the palpebral conjunctiva rather than the eyelid margin?

Also note the narrowing of the meibomian gland orifices and the protrusion of the central ducts.

I don't think meibomian gland orifices could be congenitally located posterior to the mucocutaneous junction in new borns as it would completely make the meibomian glands non functional anatomically and anyone born with this will have severely dry eyes from the moment they open up their eyes.