Eyeworld

EW CORNEA 114 October 2017 by Liz Hillman EyeWorld Staff Writer to remove any residual JAO from eyelashes. EyeWorld: Are there different ap- proaches to anesthesia? Dr. Maskin: An alternative approach uses topical proparacaine on the ocular surface followed by a corneal protective shell and a cotton pledget soaked in 4% lidocaine placed into the fornix for 5 minutes. Then 1% li- docaine with epinephrine is injected using a transconjunctival approach into the fornix centrally, medially, and laterally with supplemental sub- cutaneous injection near the eyelid margin. 4 EyeWorld: How is the patient posi- tioned during the procedure? Dr. Maskin: While anesthetic is ap- plied in a reclined position for MGP, I position the patient at the slit lamp for virtually all my probing. An assistant is there to support the back of the head, if necessary. Other physicians may prefer reclining a patient on a surgical chair and using an operating microscope. EyeWorld: MGP can involve dif- ferent probe lengths; how is probe length selected? Dr. Maskin: I always begin with the 1-mm probe. The 1-mm probe is the shortest and stiffest and therefore most likely to penetrate through orifice or distal duct fibrosis or other unyielding fixed obstruction. Longer probes are used if there is persistent lid tenderness over a gland suggesting deeper obstruction with elevated intraductal pressure. Longer probes can also be used to reach into a developing hordeolum to promote drainage. When using longer probes, always use progres- sively longer increments. After the 1-mm, use 2-mm, and then 4-mm probes, if necessary. EyeWorld: How do you decide which glands are probed? Dr. Maskin: I probe all orifices. This is important as I have seen glands with minimal associated acini re- stored to functionality after probing and start expressing meibum. Fur- thermore, now that we know there can be post-probing growth of mei- bomian gland tissue from previously atrophic glands, it is important to stimulate growth associated with all orifices and/or glands. 5 healthy, and resilient meibomian gland lid population. 5 I use probing on patients with lid tenderness over the meibomian glands (indicating elevated intra- ductal pressure). Probing dramati- cally and immediately relieves lid tenderness from elevated intraductal pressures. I use probing to restore functionality to non-meibum ex- pressing glands, as well as to relieve symptoms of lipid tear deficiency. I also use probing to stimulate growth of gland tissue from glands with dropout or atrophy on meibography. EyeWorld: Can you describe the probes used for MGP? Dr. Maskin: The stainless steel probes are 76 µm in diameter with lengths of 1, 2, 4, and 6 mm. The probes are non-sharp to minimize alteration of tissue and allow the physician to better feel the tissue and resistance during the probing procedure rather than sharp blades that would slice their way through the tissue without yielding diagnos- tic information about the type and extent of resistance as well as likely cut through the duct wall, creating a false passage. Stainless steel is im- portant to give the probe a stiffness to allow safe and quick penetration through the orifice and into the duct. EyeWorld: How do you anesthetize a patient for this procedure? Dr. Maskin: I use my patented jojo- ba-based anesthetic ointment (JAO) containing 8% lidocaine available from O'Brien Pharmacy (Mission, Kansas). After placing one drop of topical anesthetic into the inferior fornix, I place a bandage contact lens on the eye and a generous amount of JAO on the lower lid margins. The eye is closed for 10–15 minutes during which time both upper and lower lid margins are anesthetized. The eye is opened and a second drop of topical anesthetic is placed in the inferior fornix. If the patient's lids are still sensitive after probing has begun, a second round of JOA applied to the lid margin is typically successful in making the procedure well tolerated. After probing is completed, the contact lens is removed and the ocular surface is copiously irrigated with sterile preservative-free saline. Then a cotton-tipped applicator is used including duct and orifice. Probing, by relief of intraductal obstruction, is therefore able to equilibrate intra- ductal pressures within the duct and promote removal of sequestered and other retained intraductal contents. At times, the introduction of intra- ductal lavage or microtube injection of pharmaceutical will act to remove material that was not released with probing and subsequent expres- sion alone. In summary, initial and maintenance probing: (1) relieves obstruction, (2) maintains patency of outflow channel, and (3) is asso- ciated with growth of meibomian gland tissue. EyeWorld: What are the indica- tions? Dr. Maskin: Probing has become a first-line treatment for MGD in my practice to eliminate intraductal resistance to meibum flow from all types of obstruction. This includes fixed, unyielding obstruction such as periductal fibroses as well as non- fixed obstruction such as thickened meibum and hyperkeratinization. I also use it for gland maintenance to help prevent initial or progressive atrophy similar to a dental analo- gy of periodic prophylactic tooth scaling and cleaning. Now that we have seen and published on growth of gland tissue after probing, we are also exploring the use of probing with adjunctive injection therapies to further stimulate gland growth and restoration of a full, functional, The scoop on the technique that aims to relieve obstructive meibomian glands S teven Maskin, MD, Dry Eye and Cornea Treatment Center, Tampa, Florida, first introduced the idea of inserting a wire probe into meibomian glands to relieve ob- structions that could be causing dis- comfort and dry eye in 2010. 1 Since then research has shown it to be, what he called, a "paradigm shift" in successful treatment of obstructive meibomian gland disease. 2–4 Dr. Maskin gave EyeWorld an in- depth look at his tips and tricks on meibomian gland probing (MGP). EyeWorld: What is MGP? Dr. Maskin: Meibomian gland probing is the introduction of a wire instrument to the gland orifice with insertion through the orifice and into the ductal outflow tract. EyeWorld: What's the purpose of probing? Dr. Maskin: Probing establishes and confirms with positive physi- cal proof a patent outflow channel Meibomian gland probing: The who, what, where, when, and why Meibomian gland intraductal probing of the upper lid to relieve fixed and non-fixed obstructions Source: Steven Maskin, MD Watch Dr. Maskin perform meibomian gland probing on several patients.

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