Intraductal Meibomian Gland Probing for Meibomian Gland Dysfunction Using VAS Testing

(updated 2.8.10)

DISCLOSURE: Patent Pending Class One Device Made of Stainless Steel.

COMMERCIAL RELATIONSHIP:

Rhein Medical, Inc.

Steven L. Maskin, MD FACSDry Eye and Cornea Treatment Center

Tampa Floridawww.drmaskin .com

Meibomian Gland Disease is arguably the most common cause

of Dry Eye and has certainly been the most challenging to treat.

Traditional therapies have failed to consistently provide effective

results leading to ongoing suffering and frustration for patients

and physicians alike.

BACKGROUND:

PURPOSE:

To evaluate results of Intraductal Meibomian Gland probing for lid tenderness using a standardized VAS test.

METHODS:

Intraductal Meibomian Gland probing as previously described in ARVO abstract 2009 was performed on

patients with pre probing lid tenderness in the setting of Meibomian Gland Dysfunction. Data was collected

prospectively. Pre probing lid tenderness was evaluated using a standardized VAS with post probing

VAS responses at various post probing time points including immediately, weekly for the first month, then monthly. Inclusion criteria required pre probing VAS to

be greater than 25mm.

RESULTS:

Average patient age was 64 + 18.4 with a range from 17-85. Fifty nine (59) lids of 24 patients were probed with a pre probing VAS mean score of 58.5 + 18.9 mm. There was an immediate reduction of mean VAS score of 44.1

+ 21.2 mm (75.3%) to 14.5 mm. Lid tenderness continued to improve to a reduction of mean VAS score

of 47.5 + 24.3 mm (81.1%) between one week and one month, 44.8 + 23.5mm (76.6%) reduction between 1 and 3 months and 49.8 + 21.7mm (85.1%) reduction between 3 and 6 months. Twenty one (21) lids of 8 patients have reached the 3 to 6 month follow up visit. The average

last measurement was 11.8mm, an average reduction of 80% at an average follow up of 2.4 + 1.8 months.

 Average of Difference (mm) (Preprobing - Post Probing)

Total # of Patients Total # of Lids

IMMEDIATE 44.1 (SD ± 21.2) 24 57

≤ 1 WEEK 44.7 (SD ± 14.9) 8 20

˃ 1 WEEK ≤ 1 MONTH 47.5 (SD ± 24.3) 15 51

˃ 1 MONTH ≤ 3 MONTHS 44.8 (SD ± 23.5) 15 53

˃ 3 MONTHS ≤ 6 MONTHS

49.8 (SD ± 21.7) 8 21

  Mean Score (mm) Total # of Patients Total # of Lids

PREPROBING 58.5 (SD ± 18.9) 24 59

IMMEDIATE POSTPROBING

14.5 (SD ± 18.1) 24 57

LAST MEASUREMENT 11.8 (SD ± 19.9) 24 59

AVERAGE LAST FOLLOW UP DATE

2.4 (SD ± 1.81) 24 59

MEIBOMIAN GLAND PROBING WITH LID TENDERNESSPATIENTS WITH VAS TESTING ≥ 25

Range of Patient Age: 17-85 (SD ± 18.4)Average Patient Age: 64

Results of Meibomian Gland Probing on VAS For Symptoms of MGD With

Lid Tenderness

44.8 ± 23.5(77%)

47.5 ± 24.3(81%)

49.8 ± 21.7(85%)

˃1 WEEK≤ 1 MONTH

n =15l = 51

˃ 1 MONTH≤ 3 MONTHS

n = 15l = 53

˃ 3 MONTHS ≤ 6 MONTHS

n = 8 l = 21

IMMEDIATEn = 24l = 57

n = number of patientsl = number of lids

44.1 ± 21.2(75%)

PREPROBING

Results of Meibomian Gland Probing On VAS For Symptoms of MGD

With Lid Tenderness

FINDINGS:Probing often identified four findings.  Three findings were of variable resistance which may be present in each gland. 

These included: (1) orifice resistance, (2) a mostly proximal gritty sensation like piercing through a “rice krispy”, and (3) moderate resistance which released with a “pop” and is usually deeper in the duct and suggestive of fibrovascular

tissue.  The fourth finding was frequent orifice hemorrhages which were self limited.  There were no probe fractures in this study. There were no adverse sequelae.

TECHNIQUE:

We Use 1, 2, 4, and 6 mm stainless steel sterile solid wire probe cannulas with

attached ergonomic handle.

With Transillumination Without Transillumination

The lid margin and glands were examined with and without transillumination

to evaluate patency of orifice and status of the glands, specifically looking at

gland proximal and distal atrophy,

length of glands and signs of ductal dilation suggestive of proximal

obstruction. Glands were palpated individually for gland tenderness seen

with inflammation and obstruction.

PENETRATION WITH A 2MM PROBE.

NOTE HEMORRHAGE AT ORIFICE OF ADJACENT GLAND.

A PLUG OF SEQUESTERED MEIBUM.

Topical tetracaine or lidocaine gel anesthetic was applied to the lid margin. In some cases discomfort with probing required additional direct application of 4% lidocaine solution. The 1 or 2 mm probes were passed through the orifice. At times a fine router movement was needed to find

the opening, especially in setting of orifice metaplasia.

After penetrating the orifice with the 1 or 2 mm, the 4 or 6 mm probe was then used depending on the length of the gland to achieve complete patency of the ductal highway.

At times resistance was encountered. Respecting the length of the gland prevented extending the probing too far. Therefore, if resistance was obtained, the probe was felt to be against a fibrotic band. After checking to ensure the probe was co-linear to the gland, additional mild force was

used to pop through the intraductal fibrotic tissue. A dot hemorrhage was frequently noticed at the orifice.

Before Intraductal Probing After Intraductal Probing

 Pre probing photo on left shows appearance of left upper lid with lid margin vascular engorgement and gland plugging.  The photo on the right is two months later after

gland probing showing vessel regression with marked reduction in vascular caliber and gland plugging.  There was an associated marked reduction in lid tenderness VAS from pre probing score of 45 out of 100 to his latest score of 4, 2 months post probing.

80 Year Old Man With Obstructive Meibomian Gland Dysfunction.

CONCLUSIONS:

1) Intraductal Meibomian Gland probing appears highly effective in rapidly reducing standardized VAS patient scores of lid tenderness associated with Meibomian Gland Dysfunction.

2) VAS scores remain markedly improved for at least 3-9 months.

3) Three levels of probing resistance and orifice hemorrhage frequency may enable a grading scale of meibomian gland dysfunction for clinical use.

4) Additional topical anesthetic is required by some patients to tolerate meibomian gland probing.

Steven L. Maskin, MD FACS

Dry Eye and Cornea Treatment CenterTampa Florida

www.drmaskin .com