IPL at Univ of MI - Ann Arbor Kellogg Eye Center

[hopeful_hiker]

Milo007 you seem to misread my comment. Apart from the meibum being hard near the opening, you've repeated the same thing I said in more specific terms.

You seem not to carefully read the content you have published. It says bacteria is present in the the lid margin but is also cultivated in freshly expressed meibum in normal patients and patients with blepharitis.

What I said: "bacteria is not in the glands, it is on the lid margin (and somehow in the oil)". I suppose by extension that means that the bacteria is in the glands but I chose to word it the way the researchers did.

Well it's not the presence of bacteria that's the critical factor but their "overgrowth" and "over population" as a result of some "abnormal" conditions that help them to multiply in such large colonies and manifest their presence creating "abnormal" biochemical changes after sometime.

What I said: "Everyone has bacteria but MDG folks may have more hence the obstruction problem."

TFOS DEWS might be the single most comprehensive source of information but it doesn't include all independent research findings happening across the globe or even new findings that has taken place after the publication of TFOS DEWS II report. So I rely on more dynamic sources of information.

Yepp, good strategy, I think most people do that. One problem is that not being in the medical field, I find it harder to distinguish good study designs from bad designs when things get very technical.

So removing the epithelial covering by abrasion will only invite more epithelial formation and gland capping. I don't repeat the procedure too often as repeated injury to lid margin can result in scar tissue formation which is what I am afraid of most.

Good to know. My ophthalmologist used a callus analogy in the lid margin context.

Your assumption is totally wrong when you assume that meibum hardening takes place once it reaches the lid margin. Meibum hardening takes place inside the glands and that's why you need warm compresses to melt it internally. Watch the animation of the lipiflow procedure to get an idea of what I have said.

It is not completely wrong. In many cases once the hard oils are pushed out, good ones come out right away. I am one of those people. That means the oil stagnation/hardening, whatever you want to call it, happens not deep inside but near the lid margin opening (still inside but near the margin). I agree though, it can happen deep inside, too. I thought that in the bacterial case it happens once the oil is closer to the orifice (but still inside the gland obviously).
And yes, I've watched that animation before. I think most folks with MDG came across it as the video is one of the top results. Also, Korb talks about it a lot in his Spanish conference.

I was originally interested in reading the studies you had used to create your first comment since neither of us are professionals (correct me if I am wrong). Totally fine that you don't remember anymore where you got the info from. I was also hoping for a friendly open discussion. In my personal view, this is not the case so I will not go into this topic further. I do appreciate you sharing your learnings here though.

[Milo007]

Milo007 you seem to misread my comment. Apart from the meibum being hard near the opening, you've repeated the same thing I said in more specific terms.



What I said: "bacteria is not in the glands, it is on the lid margin (and somehow in the oil)". I suppose by extension that means that the bacteria is in the glands but I chose to word it the way the researchers did.



What I said: "Everyone has bacteria but MDG folks may have more hence the obstruction problem."



Yepp, good strategy, I think most people do that. One problem is that not being in the medical field, I find it harder to distinguish good study designs from bad designs when things get very technical.



Good to know. My ophthalmologist used a callus analogy in the lid margin context.



It is not completely wrong. In many cases once the hard oils are pushed out, good ones come out right away. I am one of those people. That means the oil stagnation/hardening, whatever you want to call it, happens not deep inside but near the lid margin opening (still inside but near the margin). I agree though, it can happen deep inside, too. I thought that in the bacterial case it happens once the oil is closer to the orifice (but still inside the gland obviously).
And yes, I've watched that animation before. I think most folks with MDG came across it as the video is one of the top results. Also, Korb talks about it a lot in his Spanish conference.

I was originally interested in reading the studies you had used to create your first comment since neither of us are professionals (correct me if I am wrong). Totally fine that you don't remember anymore where you got the info from. I was also hoping for a friendly open discussion. In my personal view, this is not the case so I will not go into this topic further. I do appreciate you sharing your learnings here though.

I agree with most of what you have said. If in your case the meibum is hardening near the lid margin then it's possibly one of the types of posterior blepharitis. I get the impression that your problem is not that advanced as some others I have come to know where the meibum hardens through the entire length of the glands. You are perhaps into the preliminary stage of MGD and that's a positive take. In my case I am struggling with epithelial cappings that pop when poked with a needle. But the tiny ones are very hard to focus and pop that way. It's risky too operating a needle right in front of the conjunctiva.

Yes I am not a medical professional. And I don't assert my knowledge to be infallible. I am very much open to discussion. I regret that I didn't keep track of whatever I have been reading for the past three months. If I come across the contents again I will provide the links obviously.

Why do think (personally) that I am not interested in an open friendly discussion?

If I sounded offensive or egoistic I apologize for that. I may lack the etiquettes of writing in open forums and the correct choice of words. I don't realize if I have hurt somebody unintentionally. But yes I am eager for more discussion to enhance my understanding regarding the condition.

[MGD1701]

Hi edmunder

Thanks for sharing. Great, you've found out the problem.

Firstly, is your secretion clear as baby oil?? Very curious to know since your MMP-9 is still positive.
If clear, gland orifices/composition should not be the issue, I guess.

Osmolarity, if they are within normal range, experts in USA will seek for other triggers, such as allergic conjunctivitis, CCH, lids exposure, floppy eyelids etc. Omsolarity test expert, Prof. Chris Starr mentioned if MMP-9 is positive, osmolarity are normal then likely allergic conjunctivitis, doctor needs to lift upper lids to examin. Seems possible in your case as only steroid works for you??

BlephEx helps remove years of biofilm (super glue/bacteria) on lid margin.
Most bacteria around eyes are staph - produce something very sticky so some doctors call it super glue

tea tree oil
I would add this given the high bacteria load - aften more demodex too - so good to explore it.

Allergy, IGE tests – may help to detect the exact triggers.

[edmunder]

Hi edmunder

Thanks for sharing. Great, you've found out the problem.

Firstly, is your secretion clear as baby oil?? Very curious to know since your MMP-9 is still positive.
If clear, gland orifices/composition should not be the issue, I guess.

Osmolarity, if they are within normal range, experts in USA will seek for other triggers, such as allergic conjunctivitis, CCH, lids exposure, floppy eyelids etc. Omsolarity test expert, Prof. Chris Starr mentioned if MMP-9 is positive, osmolarity are normal then likely allergic conjunctivitis, doctor needs to lift upper lids to examin. Seems possible in your case as only steroid works for you??

BlephEx helps remove years of biofilm (super glue/bacteria) on lid margin.
Most bacteria around eyes are staph - produce something very sticky so some doctors call it super glue

tea tree oil
I would add this given the high bacteria load - aften more demodex too - so good to explore it.

Allergy, IGE tests – may help to detect the exact triggers.

Oil secretion is toothpaste/motor oil normally. I have been using eye steroids/lotemax gel and then the oil is thin and mostly clear.

If I dont use steroids I wont have any oil secretions. Even after long warm compress (30 minutes) the oil is still thick and wouldnt express with my fingers. Needed a doctor to manually express.

I found a local doctor who offers blephex. Doctor said my lid margins look great. Doctor even suggested stopping such aggressive lid scrubs like i was doing.

Doctor flipped upper lids, looked for LWE lid wiper problem. No issue there. No allergies. No GPC.

Still no diagnosis. I have MGD. There is inflammation. Osmolarity is normal but high ( 295/296 is high - no eye issues its lower ie 290 or 280s).

[MGD1701]

As mentioned, one year ago, one doctor told me the same, my lids/lashes were so clean etc and I did not need BlephEx.
She even said no evidence shows that LipiFlow is effective - for this, I know she has limited knowledge.
Anyway, I did it recently by another doctor, a professor, as recommended.

Seems it is important to find a skillful doctor - it is more than just clean lashes but lid margin
(ie debridement - some experts even recommend apply dye in order to spot old/dead cells/bacteria better) too.

Maybe you could consult your new doctor, Dr. Jian. Hopefully he can give you an accurate diagnose. Good luck

[hopeful_hiker]

Milo007 No worries! Have you done lid margin debridement at a doctor’s office?

[Milo007]

Milo007 No worries! Have you done lid margin debridement at a doctor’s office?

Nope. I was adviced against a lid margin debridement the last time I visited my ophthalmologist. But I did it myself many times after that using a dry q-tip and it almost instantly helps me relieve my symptoms on most occasions. I gently rub below my Marx line with a dry q-tip to remove those extremely tiny cappings I can see in a mirror. I even notice oil flowing out after the cappings are punctured and my eyes feel almost normal for a day after the debridement. But unfortunately they form back again in a day and I have to repeat the procedure.

I am attaching a few pictures of what those cappings look like. In my case I get the bigger oil globules rarely but on most occasions the cappings are very tiny dome like structures blocking the gland orifices.The first picture is what my eye lid margins look like most times. The cappings are epithelial tissue blocking the gland orifices but not sure why they form. It is hypothesized that they are formed as a result of oxidation of epithelial tissue and meibum which is either facilitated by bacterial enzymes or by inflammatory mediators when tears are hyperosmolar due to evaporative stress. Another hypothesis assumes that the increased turn over of epithelial tissues as a result of dessication stress is responsible for such aggressive skin formations.

Have you ever noticed such cappings on your lid margins?

[MGD1701]

Hi Milo
How did you manage to take such clear, nice photos? what tools, brand names etc? Thanks!

pure HOCL should help to reduce bacterial overgrow - I can not get Avenova or others but have managed to find an alternative - NatraSan.
Heyedrate lid spray is also pure, from USA, which you might be able to get. just try your luck.

[Milo007]

Hi Milo
How did you manage to take such clear, nice photos? what tools, brand names etc? Thanks!

pure HOCL should help to reduce bacterial overgrow - I can not get Avenova or others but have managed to find an alternative - NatraSan.
Heyedrate lid spray is also pure, from USA, which you might be able to get. just try your luck.

Hi MGD1701

The photos are collected from the internet and not clicked by me. I have saved these pictures from various websites while searching for information on MGD and also via direct Google image search using keywords like "capped meibomian glands". I don't have a high quality camera or any arrangements to click actual photographs of my lid margin close up. So I will use these pictures rather to give an indication to my opthalmologist on what I mean to convey to her when I use the term "capping". She's very particular with terminologies and often asks me to explain the medical terms I use while speaking to her to check if I understand at all what I say!

I am not sure if the problem is due to bacterial overgrowth even though I read about the hypothesis in an article on MGD somewhere. This is because I used to get such cappings even while I was on 1% azithromycin ointment for a month. The other hypothesis assumes inflammatory mediators to be the culprit but I haven't tried long term steroids, restasis or xiidra to check for that either. I am really looking forward to my opthalmologist (scheduled visit next month) if she can shed some light on the formation of these cappings and the possible remedies to stop them from being formed.

I get the impression that you have something to offer regarding this issue. Do you know for certain if the cause of these cappings are bacteria?

Have you encountered such cappings yourself ever?

I am very excited if you have reference to some medical literature that explains the mechanism of formation of these cappings in detail.

Thanks in advance!

Edit Reason : Forgot to mention that your posts are very informative and I am subscribed to most of them!

[deep_dry_eye]

MGD1701 I found more data from a different local doctor. I thought you might have found it interesting.

I did osmolarity and inflamadry.

Osmolarity right eye 295, left eye 296.

Inflamadry weak positive. The pink line was barely noticeable.

Doctor said my eye was incredibly foamy so there is still a massive bacteria problem. Suggested i try avenova 3 times a day insteas of occusoft hypochrol. She found a way for me to get it so its not so expensive.

Doctor also gave me a prescription for lotemax gel and 4 refills.

Her idea is: my eyes look good. I have meibomian gland loss but its just shoterning of glands. No total losses.

Osmolarity is good. Very little inflammation. But lots of bacteria so i need to find a way to kill it. Use avenova 3-4 times per day. Try to kill the bacteria. Use lotemax to keep the glands open and working. Continue IPL.

EDIT ADD —- Doctor also wanted me to stop restasis and xiidra to see what happens. I will try that. Ive been on restasis for 4 months.


I will go see Jain as well.

Hi!

I am still very very hopeful for you!

I suggest you to continue IPL, get at least 6 treatments before drawing any conclusion on it. I am personally on monthly IPL as I firmly believe it to help. I went from being bedridden to being able to travel, and work on computer 10+ hrs a day.

Don't be discourages about Lotemax helping. The disease has very high variance, correlation does not imply correlation causation.

Your Lotemax experience suggest that it is indeed an inflammation problem, IPL, Restasis and Xiidra can all help that. I suggest continue the Restasis and Xiidra. These drugs can take some time to work. Additionally, even if you don't feel it right away, they might be helping reduce your internal inflammation of your glands. The fact that your osmolarity is pretty good suggests that indeed that the Restasis/IPL is helping you.

The fact that you don't have much gland loss is a very good sign. I suspect you to have a nerve issue as well, as your symptoms seem to not match your clinical signs. You might want to consider Prokera as well. Prokera helped me A LOT w/ my SLK.

[hopeful_hiker]

Milo007 I have been told I have capping but I was not really able to see them myself. I do sometimes get a tiny pimple on one of the glands that gets resolved within 24h but it does not look orange or fluid-filled. As for, debridement, did the doctor explain why? A metal scraping tool is fairly precise and clean/targeted. I’ve had that done 4 times in 10 months.

The doc said that inflammation and/or bacteria were responsible for formation of the “callus” on the lid margin. She did not explain it to me in detail, unfortunately.

[Milo007]

Milo007 I have been told I have capping but I was not really able to see them myself. I do sometimes get a tiny pimple on one of the glands that gets resolved within 24h but it does not look orange or fluid-filled. As for, debridement, did the doctor explain why? A metal scraping tool is fairly precise and clean/targeted. I’ve had that done 4 times in 10 months.

The doc said that inflammation and/or bacteria were responsible for formation of the “callus” on the lid margin. She did not explain it to me in detail, unfortunately.

Well I can see the cappings in my eyelid margins because I can see tiny objects close up with good clarity. It might be because I am myopic but I have had a good close vision since childhood.

Do those pimples you get on your eyelid margins look like clear fluid filled globules if not orange or yellow?

I think the last time when I visited my doctor I didn't have so many cappings on my gland orifices. I told her that I use a baby shampoo - water solution soaked q-tip to scrub my eyelid margins. She said that "won't be necessary" and adviced me to discontinue the practice. She didn't explain why. Also she didn't mention anything about cappings but advised me warm compress followed by lid massage. She never uttered a word about blephex or a manual debridement using a golf club spade tool.

It's interesting that your doctor mentions the problem clearly as "cappings". Did you notice a significant relief of symptoms immediately after the debridement was done? When I do lid margin wipe using a dry q-tip or a medical grade needle to scrap the lid margin along the marx line I sometimes could see lipids flowing out in good volume and coating my lid margin with a shiny layer followed by immediate relief of symptoms and my eyes feel normal for about 24 hours until the cappings start to form again.

In your case I am curious to know if the effect of debridement last longer. You can ask someone near you to take a close look at your eyelid margin to tell if you have cappings blocking your glands as in the pictures I posted. My problem is either the cappings alone or low production rate of meibum apparently.


A "callus" is entirely a different thing speaking medically. I don't know if your doctor meant those cappings as in the pictures by the term "callus". But yes indeed it could be either bacteria or inflammation or both. The essence of MGD is in fact bacterial overgrowth and inflammation which forms a cycle of events and disturbs the homeostasis of a normal tear film.

[hopeful_hiker]

Milo007 no, they are tiny and skin colored or white.

I think by callus she meant excess epithelium/thickening that grows in response to bacteria and inflammation, not cappings.


Capping. Yes, I hear that one a lot. Some are surprised that once you remove the cap or push on the glands, mineral oil quiality meibum comes out after the “plug”. However, the push is usually too strong compared to blinking push so I can’t just get those oils or safely push on my eyes like that. My biggest issue so far has been blinking pain and/or scrapey blinks so I think I don’t blink well as a habit plus due to prior discomfort.

[Milo007]

Milo007 no, they are tiny and skin colored or white.

I think by callus she meant excess epithelium/thickening that grows in response to bacteria and inflammation, not cappings.


Capping. Yes, I hear that one a lot. Some are surprised that once you remove the cap or push on the glands, mineral oil quiality meibum comes out after the “plug”. However, the push is usually too strong compared to blinking push so I can’t just get those oils or safely push on my eyes like that. My biggest issue so far has been blinking pain and/or scrapey blinks so I think I don’t blink well as a habit plus due to prior discomfort.

Well actually "cappings" are not exactly thickened epithelium but thin epithelial tissue coverage over the meibomian gland orifices that trap the lipids trying to come out of the orifices and hence form fluid filled globules that is hard to touch or doesn't go away even by a gentle brush. But it can be popped!

The next time you get one capping which is clearly visible in the mirror you may try popping it with a sterile single use needle available in medical shops and you will be surprised to see the "cappings" would deflate like a tiny balloon and lipids would come out of it. You should not try to mechanically remove those cappings as they are attached to the epithelial lining over the entire lid margin surface and is a part of it. Also please note that trying to push on your meibomian glands without removing or puncturing the cappings is a very bad idea since it will severely damage your glands as the amount of fluid pressure needed to "burst out" the cappings is far too greater than the threshold of intra-meibomian glandular pressure. If you try to remove the "cappings" by pushing the glands which is basically trying to burst the lipid filled globule by raising the lipid pressure and hence the pressure within the gland duct and acini, you may end up damaging the glands permanently. It's mandatory to remove any kind of blockage before you try to push out the contents of the meibomian glands manually. The same is true for those cappings. The most appropriate way to deal with those cappings is puncturing them using a needle or for very tiny cappings using a mechanical debridement tool to rupture them (need the help of an ophthalmologist for this).

On the other hand if you can actually remove the "plugs" you are talking about by gentle rubbing of the lid margins using a q-tip following a warm compress they are not epithelial formations as we are surmising. In that case they must be thickened meibum plugs protruding out of the gland openings (called as "pouting" of meibomian glands)

In any case please don't try to push on your glands before you clear the obstruction since trying to do so will only increase your intra glandular pressure and you may end up damaging your glands permanently.

I think the reason behind your painful blinks could be those "cappings" on your gland openings. Since lipids are filling up the glands and they don't have a way to come out they are increasing the pressure within the glands causing inflammation and also making the eyelids heavy due to increased weight of stagnant meibum. Provided you don't have a history of blepharitis the other reasons could be increased friction between the inner surfaces of your eyelids and the conjunctiva due to blocked glands and therefore increased dessication stress or it could be a demodex infestation causing inflammation of the eyelids.

Try to sort out as many possibilities as you can. For example make sure if it's a demodex infestation or not. If not then make sure if it's bacterial blepharitis or not. If not try to observe your lid margins closely (ask for help if you can't see them yourself) and see if they appear like clear lipid filled globlues as in the pictures I have posted or they appear like white tiny conical protrusions at the mouth of the gland orifices. This will distinguish if those are gland "cappings" or gland "pouting". The only way you can diagnose the actual cause of your problem is by careful troubleshooting and eradicating possibilities one by one until you stumble upon a single possibility.

I will post a picture of the gland "pouting" I am taking about.


The above pictures are illustrations of meibomian gland "pouting".

Please visit this link :

https://valleyeyeclinicdsm.com/dry-eye-diagnosis

[Rebecca Petris]

My main worry is that over time, without oil, my eyes are likely to become damaged. I cant wear the sclerals every waking hour.

...Im trying to think long term. Yeah it might be ok for a few weeks or maybe months. Im just terrified if I let the glands die and then I find out I needed them, would be a bad spot.

Personally I'm a believer in SHORT term thinking. Why? Stress is costly in every way. Too much focus on the long term, when you're in the midst of a challenging and extremely stressful situation, increases the anxiety exponentially, which increases pain, decreases coping skills and impairs judgment. Just my opinion.

I have seen people in the big fat scleral group who dont have any glands in one eye or the other. The ones I saw were looking for more comfortable lenses, or has complaints about the comfort in that eye.

People post when they have problems. You can't draw conclusions from it.

There certainly is part of me that wants to plug all 4, travel with the money i have saved and worry about any terrible future outcome later on, if or when.

I LOVE THAT.