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48 EW CORNEA February 2012 Report puts meibomian gland dysfunction in the forefront by Vanessa Caceres EyeWorld Contributing Editor Researchers establish first steps to investigate MGD 2011 was a landmark year for meibo- mian gland dys- function (MGD). With the release of the special report "The International Workshop on Meibomian Gland Dysfunction," a series of nine arti- cles published in a special issue of Investigative Ophthalmology & Visual Science (IOVS) in March 2011, oph- thalmology finally gave attention to what researchers say might be the leading cause of dry eye around the world. The report, sponsored by the Tear Film and Ocular Surface Society, featured participation from 50 inter- national specialists and took 2 years to produce. The report articles focus on topics ranging from the defini- tion and classification of MGD, MGD's pathophysiology, diagnosis, treatment (which also features a treatment algorithm that divides the disease into four stages), and a re- view of MGD-related clinical trials. The report's executive summary provides a definition of MGD, some- thing that many say is crucial as in- vestigators struggle to find like terminology to define the disease. The definition provided in the re- port is as follows: "Meibomian gland dysfunction is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct ob- struction and/or qualitative/quanti- tative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye ir- ritation, clinically apparent inflam- mation, and ocular surface disease." Interest in the report has re- mained high since its release, said Kelly K. Nichols, O.D., M.P.H., Ph.D., Foundation for Education and Research in Vision professor, University of Houston, College of Optometry, one of the report's re- searchers. In September 2011, the various articles published in the spe- cial report appeared in the list of the top 15 most-read articles on the IOVS site. They have been on that list since the report's release. "Considering ocular surface re- search is a small part of the oph- thalmic community, this shows Moderate (stage 3) MGD Source: Kelly K. Nichols, O.D., M.P.H., Ph.D. interest [in MGD] and wide accept- ance of the report," Dr. Nichols said. Additionally, the report articles have been translated into 12 lan- guages, including Chinese, French, Spanish, Russian, and Turkish. Report researchers such as Dr. Nichols have been asked to speak around the world about MGD, and there are continued plans to help the report reach other areas globally, such as Africa, Dr. Nichols said. Other physicians who deal fre- quently with MGD and dry eye see value in the work done by the work- shop participants. "This is a landmark report that brings together information from wide sources to review all we know about MGD," said Steven L. Maskin, M.D., Dry Eye and Cornea Treatment Center, Tampa, Fla. Dr. Maskin, who invented the Maskin Meibomian Gland Intraductal Probe (Rhein Medical, St. Petersburg, Fla.). "I think the report was neces- sary to put MGD on everyone's radar and legitimize the disease," said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary. "This is a first attempt to make sense of meibo- mian gland dysfunction, which has received little attention until the last few years." "The report makes a strong statement about MGD as the cause of most dry eye disease," said J.E. "Jay" McDonald II, M.D., director, McDonald Eye Associates, Fayet- teville, Ark. Dr. McDonald said that much of what is discussed in the re- port supports his current approach to MGD treatment, which he changed almost 2 years ago. He said at that time, he switched to a more basic treatment with hot soaks, self- expression of glands, lid scrubs, and some use of AzaSite (azithromycin ophthalmic solution 1%, Inspire Pharmaceuticals, Raleigh, N.C.). He says his current approach "is not very sexy" but that it seems to help patients more. A future focus for MGD research Although clinicians say the report lays the foundation for MGD diag- nosis, epidemiology, and treatment, they still see room for improvement and future research. As the report explains the field's current but incomplete understand- ing of MGD, Dr. Latkany finds it a bit frustrating that it includes a treatment paradigm. "How can we base our treatment if we don't know half of what we need to know?" he asked. The difficulty of classifying MGD by stages with appropriate treatment is often exacerbated by co-existing disease and patient- and doctor-specific characteristics, he added. "Someone with mild MGD may be miserable but have no other ocular findings," said Dr. Latkany, who has noted a similar problem with dry eye diagnosis. "Treatment needs to be based on the doctor's judgment, comfort, and knowledge of what's available," he said. "We need to allow for some flexibility." Dr. Nichols said that future up- dates to the report and to MGD re- search in general will help tweak areas such as treatment recommen- dations that may seem rigid right now. She also would like to see fu- ture studies that compare traditional and emerging therapies for MGD, including studies that do an apples- to-apples comparison of the treat- ments in question. Research on the etiology of the disease—to hopefully be able to stop MGD before it begins—would be il- luminating, Dr. Nichols said. Dr. Latkany agreed. "We've only touched the surface of the disease process so far. From this report, better studies and research will emerge," he said. "It'll take a few years of research to get where we can find the patho- genesis," Dr. McDonald said. Dr. Maskin would like to see fu- ture MGD research, be it from the workshop participants or others, focus on the intraductal delivery of pharmaceuticals, an approach he is currently exploring. The articles from the Interna- tional Workshop report are available at no charge at www.iovs.org. For a full update on MGD as- sessment tools and treatments, watch for the secondary feature sto- ries in the March 2012 issue of Eye- World. EW Editors' note: Dr. Latkany has financial interests with Alcon (Fort Worth, Texas). Dr. Maskin holds a pending patent on procedures and instruments related to the treatment of MGD. Dr. McDonald has financial interests with Alcon, Bausch + Lomb (Rochester, N.Y.), Merck (Whitehouse Station, N.J.), and other ophthalmic companies. Dr. Nichols has financial interests with Alcon, Allergan (Irvine, Calif.), Merck, and other ophthalmic companies. Contact information Latkany: 212-689-2020, relief@dryeyedoctor.com Maskin: 813-875-0000, drmaskin@tampabay.rr.com McDonald: 479-521-2555, mcdonaldje@mcdonaldeye.com Nichols: 832-726-3902, knichols@optometry.osu.edu