Eyeworld

EW CORNEA November 2010 23 A new treatment for ob- structive meibomian gland dysfunction (O- MGD) might get better marks than lid massages and warm compresses. Steven L. Maskin, M.D., the Dry Eye and Cornea Treatment Cen- ter, Tampa, Fla., refers to the tech- nique as meibomian gland orifice penetration and intraductal probing and has found it provides com- pelling levels of relief for patients. "It is impressive that symptoms are relieved so immediately and dra- matically in over 95% of cases," Dr. Maskin reported online in July 2010 in Cornea. "Relief of symptoms with probing suggests that the cause of symptoms may be reversible." The technique at a glance Dr. Maskin performed the technique on 25 patients with O-MGD plus lid tenderness (LT) or complaints of lid margin congestion (LMC), or what is now referred to as symptoms exclud- ing lid tenderness (XLT). "The strategy was to clear the duct of the obstruction and let the meibum flow, reducing intraductal pressure (IDP), inflammation, and lid congestion with improvement of symptoms," Dr. Maskin reported. "The eyelid chosen and area of eye- lid initially selected to be probed was that with the greatest severity of symptoms." Patients were given topical vis- cous gel anesthesia, with additional application of 4% lidocaine as needed. Because of discomfort among some patients, in certain cases, probing was performed on only six to 10 glands on the lid ex- hibiting the worst symptoms. To ob- tain a more comfortable probing experience, jojoba anesthetic oint- ment with jojoba 25%, lidocaine 8% in petrolatum is now being used routinely, allowing for probing of all glands within a lid. "Before probing, the patency of gland orifices and status of glands including proximal and distal atro- phy, length of glands, and signs of ductal dilation were evaluated with transillumination," Dr. Maskin re- ported. "This information was to help develop a strategy for probing." A sterile probe handle and beveled solid stainless steel probes (Rhein Medical, St. Petersburg, Fla.) were used. Two-millimeter probes were initially used at the slit lamp. "Now, I start with 1 mm probes as these are the shortest and stiffest and allow for entry into even fi- brotic orifices, in some cases per- forming orifice reconstruction." "In case of persistent tenderness after the 1 and 2-mm probing, the 4- mm probe was subsequently used," Dr. Maskin reported. "This subse- quent and deeper probing was easier for the patient, with less discomfort in all cases." The need for deeper probing after the shorter probes sug- gested residual obstruction deeper in the gland. The appearance of blood was not a bad sign. "This varied from a dot to a fine trickle of blood onto the lid margin, but in all cases, hem- orrhage was immediately self-con- tained without the need for external pressure," Dr. Maskin reported. "The appearance of orifice blood was not always accompanied by resistance to probing. However, relief of intraduc- tal resistance was nearly always asso- ciated with a perceptible 'pop' and trickle of blood at the orifice." Results were quite good. "Twenty-four of 25 patients (96%) had immediate postprobing relief, whereas all 25 (100%) patients had relief of symptoms by 4 weeks after the procedure," Dr. Maskin reported. "All 20 patients (100%) with LT and 4 of 5 patients (80%) with LMC had immediate postprobing relief." Both treated and retreated pa- tients experienced improvement in symptoms. "For the patients need- ing 1 treatment only, all 20 (100%) had immediate relief of symptoms," Dr. Maskin reported. "For the re- treated patients, 4 of 5 (80%) had immediate relief of symptoms, with the fifth patient reporting relief of symptoms at the 1-month follow- up." by Matt Young EyeWorld Contributing Editor Treatment option could offer more relief for O-MGD patients Current continued from page 22 swab with a little anesthetic removes probably 75-90% of viral antigen, which accelerates healing," he said. However, in doing this he cautions against pushing too deeply with the swab since this could push the viral antigen deeper into the stroma. "My current strategy would be to use ganciclovir gel five times a day," Dr. de Luise said. "I would see the patient 3 or 4 days later to assess the situation." He also suggested using a drop a day of an antibiotic to protect the eye that has the ulcer from getting any kind of secondary bacterial infection. When the pa- tient returns he uses a variety of vital dye stains to ascertain the extent of healing of the ulceration. The patient almost always im- proves. By the end of the seventh day he cuts down the ganciclovir gel to three times a day for the second week. John A. Hovanesian, M.D., Jules Stein Eye Institute, David Geffen School of Medicine, Univer- sity of California, Los Angeles, like- wise favors the use of ganciclovir gel alone. "For isolated epithelial kerati- tis where there's not significant in- volvement or for a mild case, I think topical treatment alone is more than sufficient," he said. "But with topical treatment we should use the gentlest option that we have, and that's Zirgan." The fact that toxicity is less of a factor makes the decision to use topical therapy alone easier. "In some cases with the old drug when we would worry about toxicity to the cornea, we would extend treat- ment with systemic therapy," Dr. Hovanesian said. "Here we can more comfortably use topical therapy alone." Dr. Hovanesian finds that be- cause ganciclovir is not toxic to the epithelium, successful healing of HSV keratitis is evident to both the patient and the physician at an ear- lier stage. "Although the new agent is more expensive, because we use it for a shorter time, we end up saving some money," he said. Overall, Dr. Hovanesian pointed out that the new ganciclovir gel, while a real step up for HSV keratitis, is not likely to be a moneymaker for the pharmaceutical company like an antibiotic would be. EW Editors' note: Dr. de Luise has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), and Bausch & Lomb. Dr. Hovanesian has financial interests with Allergan, Bausch & Lomb, and ISTA Pharmaceu- ticals (Irvine, Calif.). Contact information de Luise: eyemusic73@gmail.com Hovanesian: drhovanesian@harvardeye.com Treatment of O-MGD takes 3 steps 1. Use probe to establish or confirm the orifice and duct outflow system as patent 2. Focus on keeping the outflow system patent 3. Optimize meibum quality through lid hygiene, pharmacotherapy, and treatment of co-morbid disease (Steve Maskin, M.D., the Dry Eye and Cornea Treatment Center, Tampa, Fla.) continued on page 24

• Cover