Meibography

[dryirisheyes]

Hi all,

After suffering with dry eye for many years I only recently got a diasgnosis of MGD. I am going for a meibography this week and I am pretty nervous about it. I am worried as my MGD went unidentified for a good few years that my glands have died off or are in a very poor state. I guess either way after the meibography I will know where I stand. I am just wondering what other people experiences of meibographies are and if there are any specific questions I should ask?

Thanks all.

[mbperso]

Hi,
I have been in the same case, I've been diagnosed a few years too late.
I had the meibography with Lipiview device.
Lipiview will provide you : photo of your glands + LLT(lipid layer thickness) + blinking.

-Make sure that the meibography will be done for lower and upper eyelid. (some do only lower)
-Ask the % of lost glands if it is.
-Ask the lipiview report with photos + LLT + blinking. They can send it by email.
-Ask the doctor to watch the quality of the oil and if some glands are clogged
-If possible ask a test for AD : Schirmer or PRT(phenol red thread)

[pythonidler]

Hi all,

After suffering with dry eye for many years I only recently got a diasgnosis of MGD. I am going for a meibography this week and I am pretty nervous about it. I am worried as my MGD went unidentified for a good few years that my glands have died off or are in a very poor state. I guess either way after the meibography I will know where I stand. I am just wondering what other people experiences of meibographies are and if there are any specific questions I should ask?

Thanks all.

I was in a similar boat when I got my MGD diagnosis - more than a year after my initial symptoms. I wish I had known more about MGD and dry eye before I went to the doctor.

One important thing that meibography can reveal is scar tissue. Scar tissue is a long-term result of MGD that hasn't been treated well enough. Scar tissue can block the meibomian glands and make treatments like Lipiflow ineffective.

I would ask your doctor if you have scar tissue. If he doesn't know what you're talking about, or says he can't determine it from meibography, it may be time to get a new doctor. Scar tissue will appear in images as dark areas near the lid margin. See figure 2 from this report: http://bjo.bmj.com/content/early/201...ol-2016-310097

If you do have scar tissue, you'll need to have probing done to break up the scar tissue, in order for Lipiflow or IPL (another tool to treat MGD) to be effective.

[mbperso]

Hi Pythonidler,
I'm not sure dark areas near the lid margin are scar tissue, because we cannot see any dark area for proximal MG (deeper in the lid and the gland).
And proximal MG leads to atrophy and shortening glands.
It could only be light effect.
So the question still remains for me : how to see clogged gland on the lid margin AND deeper in the gland on image ? specially with Lipiview ?

Another point : why MG regrowth with probing and not with Lipiflow/heat, though both unclog MG ?

[dryirisheyes]

mbpersopythonidler thank you both for coming back to me with your advice and some good questions!

So I went for the meibography today - it was an infrared meibography I am not sure about the difference between this and Lipiview. But basically it came out as a black and white image that shows the shape of the glands on both upper and lower lids. Good news is that my glands for the most part are still there - there was some drop out particularly in my left eye but they were in ok shape.

However it seems that my oil glands are pretty much blocked up she said that there was hardly any oil in my tears and when she pushed on my glands to try to release some oil pretty much nothing was coming out. So I am going to try probing next to unblock the glands and perhaps IPL after that.

It it was pretty scary to hear that I pretty much have a non exsistant oil layer in my tears but I guess at least I am armed with more information now. I am hopeful that probing might help. Have either of you had probing or IPL and what are your experiences of these? As for scar tissue on my glands I am not sure - I am going to send the images of the meibography to my usual opthamologist for review as today i went to a different clinic.

[pythonidler]

Hi Pythonidler,
I'm not sure dark areas near the lid margin are scar tissue, because we cannot see any dark area for proximal MG (deeper in the lid and the gland).
And proximal MG leads to atrophy and shortening glands.
It could only be light effect.
So the question still remains for me : how to see clogged gland on the lid margin AND deeper in the gland on image ? specially with Lipiview ?

Another point : why MG regrowth with probing and not with Lipiflow/heat, though both unclog MG ?

You could be right about those images. When I asked my doctor about this, who does probing, he said scar tissue is identified as dark areas on IR-based meibography. So whether those dark spots on the figure I linked to were the scar tissue - who knows - but the point is that an ophthalmologist that has the right equipment and is trained to look for it should be able to see it.

As for growth - the article I posted earlier showing regrowth after probing was from a study from Dr. ******. However, I imagine that as long as someone is managing their MGD well enough (perhaps using Lipiflow or IPL on a regular basis), that glands might be able to "grow" back (or lengthen, as my doctor called it). By the way, the regrowing doesn't seem to happen for all patients - just a fraction of them.

[pythonidler]

mbpersopythonidler thank you both for coming back to me with your advice and some good questions!

So I went for the meibography today - it was an infrared meibography I am not sure about the difference between this and Lipiview. But basically it came out as a black and white image that shows the shape of the glands on both upper and lower lids. Good news is that my glands for the most part are still there - there was some drop out particularly in my left eye but they were in ok shape.

However it seems that my oil glands are pretty much blocked up she said that there was hardly any oil in my tears and when she pushed on my glands to try to release some oil pretty much nothing was coming out. So I am going to try probing next to unblock the glands and perhaps IPL after that.

It it was pretty scary to hear that I pretty much have a non exsistant oil layer in my tears but I guess at least I am armed with more information now. I am hopeful that probing might help. Have either of you had probing or IPL and what are your experiences of these? As for scar tissue on my glands I am not sure - I am going to send the images of the meibography to my usual opthamologist for review as today i went to a different clinic.

I've had Lipiflow, IPL, and probing, all at different points of the progression of my MGD.

The most important thing is finding out whether your have scar tissue. If you have the scar tissue and get Lipiflow or IPL, neither of those treatments will do you any good. I can speak from experience, since I had both of them done before I ever knew about scar tissue.

So if you have scar tissue, you'll definitely need probing to break it up. Probing is very expensive, however - in the range of a couple thousand to several thousand dollars. You can call the manufacturer of the probes, Rhein Medical, and ask them about doctors who buy their probes. I know of at least four doctors that do them, but the most well known (Dr. ******) is probably the most expensive. Whether he does a better (more thorough) job of it, I'm not sure, but what I do know is that he charges the most for it.

After your scar tissue is cleared up, theoretically (at least according to my doctor) you won't need it again as long as you get regular IPL or Lipiflow treatments. When I asked my doctor to rank the procedures from most effective to least effective, he said:

1. Heated manual expression (a kind of heated probing - only Dr. Korb in Boston has done this, and I kind of doubt he will do it in the future since he's heavily invested in TearScience, the manufacturer of Lipiflow)
2. IPL (Intense Pulsed Light)
3. Lipiflow

About Lipiflow:
I had Lipiflow done a couple times. The first time was just in my right eye, and the second time it was in both eyes. At the time, the doctor charged $750 per eye for it (though I've heard the price has come down to around $500 per eye since then). Unfortunately due to the scar tissue, neither of the Lipiflow treatments I had were very effective.

About IPL:
Intense Pulsed Light was originally a cosmetic procedure designed to rejuvenate the skin. Dr. Toyos, however, noticed that some of his patients reported that it improved their dry eye symptoms. So Dr. Toyos investigated and developed an IPL procedure to use with dry eye patients. You're supposed to get a treatment once a month for the first four months, then every [x] number of months thereafter, where [x] depends on the individual. Some need IPL more often, others less often.

I've had IPL several times. The first three times I had it done was before I knew about scar tissue. My doctor charged $500 out of pocket for each session, then advised against a fourth session since it wasn't helping me. Somehow, however, charges for the IPL were submitted to the insurance, even though I was told insurance wouldn't cover the procedure. And my insurance (Aetna) ended up covering it. With my deductible met, I paid a 10% coinsurance on the contracted rate of $400, so only $40 each session.

After I had probing in December 2016, I started getting IPL treatments again this year. I had four treatments from February through May and noticed improvement after the second treatment. As before, I submitted my IPL charges to insurance and they were accepted. I now pay 20% coinsurance on the contracted rate of $350, so $70 each session.


For me, IPL is the clear winner over Lipiflow. Lipiflow costs are completely out of pocket, whereas IPL charges can be submitted to insurance (although I wouldn't guarantee every insurance company would cover them). And on top of it my doctor thinks IPL is more effective than Lipiflow anyway.

[pythonidler]

Other things I wanted to mention about IPL:

• You should only be going to an eye doctor to get IPL done. I don't trust dermatologists or other cosmetic doctors to do it properly for dry eye, since the procedure calls for the doctor to manually express the glands after treatment.
• Before you make an appointment for IPL, make sure the doctor has some kind of eye protection for you. They should be using either disposable eye patches that go on top of your lids, or corneal shields that go underneath the eyelids. Corneal shields are probably the safest bet, IMO.
• My doctor says IPL should be done every 3 months - though I've heard some people say they get it done more often and others say less often. I'm personally still trying to figure out the right interval for me.

[mbperso]

The most important thing is finding out whether your have scar tissue. If you have the scar tissue and get Lipiflow or IPL, neither of those treatments will do you any good. I can speak from experience, since I had both of them done before I ever knew about scar tissue.

I've had IPL several times. The first three times I had it done was before I knew about scar tissue..

- Thanks for sharing this important info.
I cannot understand that doctors who are specialist in IPL/Lipiflow didn't check scar tissue !!!
I'm chocked they adviced you to do IPL/Lipiflow without checking scared tissue!

- A doctor who is a professor told me that Lipiflow is better than IPL.
So I don't know what to think about what is better: Lipiflow or IPL.

- Another doctor who did me Lipiflow didn't tell me anything about scare tissue.
Now I wonder if I did well without asking them to check scar tissue. I'll ask my doctors next week.

[PhoenixEyes]

It it was pretty scary to hear that I pretty much have a non exsistant oil layer in my tears but I guess at least I am armed with more information now. I am hopeful that probing might help. Have either of you had probing or IPL and what are your experiences of these? As for scar tissue on my glands I am not sure - I am going to send the images of the meibography to my usual opthamologist for review as today i went to a different clinic.

Are you in the UK? Just wondering where you're planning to get probing done. So far doctors I've asked in the UK feel probing may cause more scarring for me so they're reluctant.

[Guest]

Hi everyone. I just had a question on scar tissue if anyone could answer? I have really severe MGD (off work and sit at home with my eyes closed a lot of the time) though my glands are open and produce milky meibum. I'm guessing not enough oil is coming out as my TBUT is 0-1 and when I use the hot compress there is no blurring of oil after whereas when it wasn't so bad there used to be (my schirmer test is now about 8 with aesthetic so not too bad on aqueous)
If the glands are open does that mean there is no scar tissue? I can't understand why my TBUT is so low, so thought they might be scarred inside and this might be causing low oil production?? Thanks!

[MGD1701]

Hi Lena

Inflammation & scar tissue

I think it is important to know if inflammation presents? It relates to scar tissue anyway.
Did you do InflammaDry Test? Some inflammation is low/hiddden and only confocal microscopy can detect it, according to Dr Korb.
If not, did your dr say you have such issue and what are his/her recommendations?

Scar Tissue: My dr examined with slit lamp some months ago and confirmed I do NOT have such issues - the dr did NOT take any images.

[pythonidler]

Hi everyone. I just had a question on scar tissue if anyone could answer? I have really severe MGD (off work and sit at home with my eyes closed a lot of the time) though my glands are open and produce milky meibum. I'm guessing not enough oil is coming out as my TBUT is 0-1 and when I use the hot compress there is no blurring of oil after whereas when it wasn't so bad there used to be (my schirmer test is now about 8 with aesthetic so not too bad on aqueous)
If the glands are open does that mean there is no scar tissue? I can't understand why my TBUT is so low, so thought they might be scarred inside and this might be causing low oil production?? Thanks!

If you've had a doctor look at your glands, and say they are "open", that is probably a sign that you don't have scar tissue. Only meibography will tell you for sure, though.

It sounds like right now your problem is the quality of the oil. Oil should be clear and fluid, not opaque or extremely viscous. Since there's a chance you don't have scarring yet, I would look into either Intense Pusled Light (IPL) or Lipiflow as treatment. My vote is for IPL, for two reasons:

1. My doctor thinks IPL is more effective than Lipiflow
2. IPL, even if insurance doesn't cover the cost, is cheaper than Lipiflow. I have submitted IPL charges to insurance, and every time insurance has covered the procedure and I've paid between 10-20% of the cost out of pocket.

Chances are, at this point, that you're going to have to get regular treatments of either IPL or Lipiflow. How often those treatments are depends on the severity of your MGD. I have heard people spacing treatments for IPL anywhere between 6 weeks and a full year.

[pythonidler]

See this chart for ideal oil color and consistency (lower numbers are better):
http://www.djo.eg.net/viewimage.asp?..._208534_t1.jpg

[dryirisheyes]

pythonidler Thank you so much for all of the information above! I have emailed my opthamolgist the images so hopefully he can confirm if there is scar tissue or not. I understand that hardly any oil is coming out of my glands and some of them appear closed so I suspect scar tissue is an issue at least on some of my glands. I was told yesterday that I pretty much don’t have any oil in my tear film which doesn’t stack up as the images of my glands show that they are in decent shape. I figure probing might help things.
PhoenixEyes I am based in Ireland I will PM you the details of who I am seeing!