Q: What are the appropriate treatments for meibomian gland disease (MGD)? Also, are any new treatments available?
A: First, you must differentiate whether the MGD is primarily non-obstructive or obstructive gland disease, says Katherine Mastrota, O.D., M.S., center director of Omni Eye Surgery, in
Non-obstructive MGD. This is characterized by an overproduction of turbid abnormal meibum, which occurs with ocular rosacea. In addition to lid hygiene, an effective treatment is the new Cleeravue-M Convenience Kit (StoneBridge Pharma), which includes 50mg minocycline tablets and SteriLid eyelid cleaner. In addition to its antimicrobial properties, the SteriLid cleaner contains linalool and tea tree oil, which are known to have acaricidal (mite-killing) properties. That is advantageous because sebaceous cell mite infestation (both Demodex folliculorum and Demodex brevis) has been associated with MGD and rosacea, Dr. Mastrota says.
Obstructive MGD. The mainstay of treatment for obstructive MGD remains warm compresses followed by lid massage. Also, expressing the glands in the clinic is useful diagnostically and may prove therapeutically beneficial when performed routinely, Dr. Mastrota says. She designed the Mastrota Meibomian Gland Paddle to facilitate in-office gland expression and to be less traumatic to the palpebral conjunctival surface than cotton swabs.
Two new lid hygiene solutions are now available: LidHygenix (LidHygenix, Inc.) and OCuSOFT Lid Scrub Plus Extra (Cynacon). These products effectively remove debris associated with anterior blepharitis (staphylococcal or seborrheic), as well as the seborrheic discharge of posterior MGD. These products also reduce the bacterial load on the eyelid surface, quelling the bacterial lipase breakdown of meibum into free fatty acids that irritate the ocular surface. Lid hygiene involving rubbing or massage has the added benefit of expulsing the congested oil from the meibomian glands in order to keep them patent, Dr. Mastrota says.
A new development: Researchers at the Ocular Surface Center, in Miami, found that using products that contain tea tree oil effectively reduces the inflammatory effects of dermatologic and ocular rosacea due to the acaricidal properties of tea tree oil.1 These same researchers are also developing an ointment aimed at unplugging the meibomian gland orifices and keeping them patent; chronically plugged meibomian glands ultimately can lead to gland atrophy, Dr. Mastrota says.
Q: When should you consider comanaging these patients?
A: When you have determined the clear basis for MGD and have exhausted all the basic therapies, yet the patient remains symptomatic, then consider using oral medications, Dr. Mastrota says. For patients with ocular rosacea, doxycycline is the standard oral therapy; however, some clinicians favor minocycline (used in the Cleeravue-M kit) as it is better tolerated. But, minocycline may have more adverse side effectsincluding autoimmune syndromes, scleral pigmentation and tooth discolorationthan the other tetracyclines.2-5
Clinicians who cannot or choose not to prescribe oral medications might prefer to comanage the patient with a dermatologist who has experience treating rosacea, she says. A dermatologist can also offer patients therapies for rosaceas cutaneous effects.
1. Gao YY, DiPasquale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007 Feb; 26(2): 136-43.
2. Elkaayam O, Yaron M, Caspi D. Minocycline-induced autoimmune syndromes: an overview. Semin Arthritis Rheum 1999; 28:392-7.
3. Morrow, GL, Abbott RL. Minocycline-induced scleral, dental and dermal pigmentation. Am J Opthalmol 1998;125:396-7.
4. Fraunfelder FT, Randall JA. Minocycline-induce scleral pigmentation. Ophthalmology 1997;104:936-8.
5. Bradfield YS, Robertson DM, Salamao DR, et al. Minocycline-induced ocular pigmentation. Arch Ophthalmol 2005;121:144-5.