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    Intraductal meibomian gland probing reduces inflammation

    Disposable, stainless stell cannulas open obstructed membranes

    Thousands of patients with meibomian gland dysfunction may find relief with a new method that probes the intraductal meibomian glands. The technique—in which 2-, 4-, and 6-mm disposable, stainless steel, sterile solid-wire probe cannulas (Rhein Medical) are used—appears to be highly effective in quickly relieving inflammatory symptoms of obstructive meibomian gland disease, said Steven L. Maskin, MD, at the annual meeting of the Association for Research in Vision and Ophthalmology. He and his colleagues currently are using an intraductal cannula to lavage the gland with pharmaceuticals.

    Figure 1
    "Meibomian gland dysfunction is arguably the most common cause of dry eye and has certainly been the most challenging to treat," said Dr Maskin, director of the Dry Eye and Cornea Treatment Centre, Tampa, Florida. "Traditional therapies have failed to consistently provide effective results, leading to ongoing suffering and frustration for patients and physicians alike."

    Retrospective study

    In light of this situation and the large numbers of patients with meibomian gland dysfunction, he conducted a retrospective study of the efficacy of this new invasive approach for treating symptomatic obstructive meibomian gland dysfunction. Twenty-five consecutive patients were included in the study.

    Dr Maskin said that 20 of the 25 patients with meibomian gland dysfunction complained of pre-treatment lid tenderness or soreness that was immediately relieved with probing. One month after the procedure, all 20 patients continued to have decreased tenderness or soreness. Additionally, eight of the 20 patients (40%) reported increased lubrication, five (25%) reported less friction or improved comfort on blinking comfort, three (15%) reported decreased need for artificial tears, two (10%) reported decreased light sensitivity, and two (10%) reported increased vision.

    The other five study patients had nonspecific complaints about lid margin congestion before treatment. After probing, two of the five patients (40%) reported increased lubrication, two (40%) reported decreased gumminess and filminess, and one (20%) each reported increased vision, decreased lid heaviness, and decreased light sensitivity. One patient with a localized mature hordeolum did not obtain relief after the procedure.

    No complications were associated with the technique, and the typical improvement lasted for at least 4 to 6 months.

    "The findings suggested that intraductal fibrotic and neovascular membranes were frequently identified," Dr Maskin said. "These membranes were opened up by probing, which allowed sequestered plugs of meibum to escape."

    The technique

    The lid margin and glands are examined with and without transillumination to evaluate the patency of the orifice and the status of the glands, with special attention to the gland proximal and distal atrophy, the length of the glands, and signs of ductal dilation that suggest proximal obstruction, he said. The glands are palpated individually for gland tenderness seen with inflammation and obstruction.

    Dr Maskin said he begins the procedure by passing the 2 mm probe through the orifice. A fine router movement may be needed to find the opening, especially in the setting of orifice metaplasia, he added.

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

    "Resistance may be encountered," Dr Maskin said. "Respecting the length of the gland will prevent extending the probing too deeply. Therefore, if resistance is obtained, the probe may be up against a fibrotic band. Check to ensure that the probe is co-linear to the gland, then provide additional force to pop through the intraductal scar."

    In some cases, a drop of heme can be seen at an orifice, which can occur as the probe passes through a fibrotic neovascular scar or simply a neovascular membrane.

    Pre-, postoperative changes

    He referred to preoperative and postoperative photos from a case. Following the procedure, the patient had less deep lid margin redness, less prominent superficial vessels, and reduced orifice pouting.

    "Together, these findings suggest reduced congestion correlating with the immediate and dramatic reduction in tenderness," Dr Maskin said.

    "Intraductal fibrotic and neovascular changes may explain the persistence of obstructive meibomian gland disease despite exhaustive therapies directed at the lid margin and orifice and the inconsistent effect of warm compresses and lid massage," he continued. "Intraductal meibomian gland probing appears highly effective in quickly relieving inflammatory symptoms of obstructive meibomian gland disease."

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