Finalists – Ashleigh Wood
Project – Contemporary management of meibomian gland dysfunction
Supervisor – Dr Katharine Evans and Dr Ashley Wood
This presentation used a real life case example of a patient (Dr Richard Earlam, a familiar face to readers who qualified from Cardiff University – figure 1) who had been diagnosed with meibomian gland dysfunction (MGD) back in 2011 and remained symptomatic.
Student Ashleigh Wood began with an accepted definition of MGD – ‘A chronic, diffuse abnormality of the meibomian glands characterised by terminal duct obstruction and quantitative and qualitative changes in the glandular secretion resulting in an altered tear film, clinical signs of inflammation, ocular irritation and eye diseases.’1
She added, there was also likely to be ‘hyperkeratinisation in meibomian gland central duct’ and that the condition was ‘normally triggered by age-related changes in the meibomian gland, affecting patients over 50 years old, could be secondary to other disease, hormonal changes and medication.’2
Figure 1: Dr Richard Earlam
Figure 2 shows the lids of the patient under discussion. Based on a number of observations, Wood explained: ‘Richard’s symptoms and clinical signs indicate that his MGD is stage 4 based on marked meibomian gland dropout and severely altered glandular secretion that is very difficult to express.’
Over the years, a number of management options had been explained to the patient. These were:
- Lid warming followed by massaging the lids. This is normally recommended to all patients with MGD from asymptomatic with clinical signs to severely symptomatic. Environmental factors that may be causing eye dryness such as medications, computer use and working environment humidity.
- Ocular lubricants such as artificial tears and liposome spray. They offer a short term relief from the symptoms, but do not manage the underlying cause.
- Dietary omega-3 fatty acids are discussed with symptomatic patients, either increasing intake through diet or by taking supplements.
- Oral tetracyclines are normally recommended last to patients who are unresponsive to other management advice.
Wood then went through each in some detail. Regarding the first, she said: ‘Patient compliance in this management is a crucial factor, as this relies on regular lid heating and massage. Richard, like many patients, reports struggling to find time to use the EyeBag, and is unsure about effective lid massaging.
Figure 2: Dr Earlam’s eyelids
The temperature reached by these devices is very important. Normal melting point of meibum is 32 degrees but in severe MGD it can rise to above 40 degrees so the temperature must be within the range of 40-45 degrees to be safe and effective.’ Wood also found through experimentation that different devices (the MGD Rx EyeBag and the EyeBag Instant) were variable in the temperature they achieved and maintained.
She went on: ‘In the past Richard had used artificial tears but found them a very ineffective form of management. I measured Richard’s tear break up time after using the liposome spray. It peaked between nine and 20 minutes and slowly decreased. He reported his eyes felt very comfortable throughout this time. I collected pilot data using healthy volunteers. Figure 3 shows the change in tear break up time from baseline of Richard and of a group of four patients without MGD.
‘Richard was advised omega-3 fatty acid supplements, and like many patients he did not comply with the treatment due to the expense of the products offered. However, Richard does maintain a diet that is rich in foods containing fatty acids such as tuna and salmon.
‘Oral tetracyclines are a contemporary method of managing MGD. They are not often advised as this is a systemic medication. They are normally used to treat rare infections such as chlamydia, Lyme disease as well as being used off-label for skin conditions such as acne. Richard has been taking tetracycline (408mg) for about three months now, and has found this the most effective treatment. He reported that he found this management option very convenient and easy. I asked Richard to complete the OSDI during a course of taking oral tetracyclines and his score improved from 29.1 to 14.1.’
Conclusion
Wood concluded that ‘traditional methods, as seen in Richard’s case are not always effective and can be difficult to comply with. Ocular lubricants treat symptoms but not the underlying cause, resulting in further progression of symptoms. The awareness of more contemporary management options is therefore important.’
References
1 Nelson, J.D., Shimazaki, J., Benitez-del-Castillo, J.M., Craig, J.P., McCulley, J.P., Den, S., Foulks, G.N., The International Workshop on Meibomian Gland Dysfunction: Report of the Definition and Classification Subcommittee. Investigative Ophthalmology and Visual Sciences 52(4) pp. 1930-7
2 Villani, E., Canton, V., Magnani, F., Viola, F., Nucci, P., Ratiglia, R. 2013. The Aging Meibomian Gland: An In Vivo Confocal Study. Cornea, 54(7) pp. 4735-40