Unclogging the Meibomian glands and reducing the obstruction that occurs with Meibomian Gland Dysfunction is very important to your long term care if you have dry eye syndrome caused by meibomian gland dysfunction. Unclogging the glands in my clinical experience helps with the signs AND the symptoms of dry eye disease.
There are a number of procedures available to unclog your glands, and the one offered to you will vary depending on the one your Optometrist or Ophthalmologist carries in their office. In today’s blog I’m comparing the common procedures and their pros and cons as well as giving you some insight as to what to expect if you’re having thermal expression.
This is the eye school, with me Dr. D, where I teach you about products and treatments related to dry eye syndrome and eye beauty. Eye care providers have known for some time about the association between meibomian gland dysfunction and dry eye syndrome. Throughout the 90’s the belief was that dry eye was the result of not producing enough tears, or an “aqueous” issue. If you had dry eye back then, you know that our most common recommendation was to try artificial tears.
Evolving treatments for meibomian gland dysfunction and dry eye syndrome
However, that thinking really started to shift in the 2000’s and the DEWS MGD report came out in 2010. This was about when I started practicing, and I remember thinking that MGD was truly the biggest cause of Dry Eye Disease. Now, we understand that MGD is implicated in 86% of dry eye syndrome. We also know that the obstruction doesn’t clear itself and daily hot compresses at home are not enough.
Thankfully, there have been a number of innovations that have come to market to address the issue of blocked meibomian glands. We now have light therapies like IPL and LLLT, radiofrequency, and thermal expression. Thermal expression is the idea of heating the glands in a clinic setting, then “expressing” or milking those glands to get as much backed up oil out of them as possible.
For a primer on the meibomian glands and their importance, check out my MGD video!
There are a number of heat+ expression devices your doctor may offer you, and I would tell you that ultimately, SOME thermal expression is better than none. Your doctor likely chose their particular device based on a mix of qualities; ease of use, integration into a busy clinic, cost to himself and you, etc.
With at home compresses just softening the meibum and not really cleaning it out, at home compresses have become adjunctive therapy. Primary meibomian gland therapy should occur in-office where the glands can adequately be heated and expressed. If you’re visiting a dry eye doctor that is recommending one of these thermal expression therapies, you are undoubtedly seeing a doctor on top of his/her game offering the latest and greatest in dry eye care.
Groundbreaking meibomian gland dysfunction devices
LIPIFLOW
Lipiflow was developed first, and has the longest time on the market as a thermal pulsation device. LipiFlow Thermal Pulsation System is FDA approved and consists of an activator and console. The activator is disposable so would only be used for your procedure. The activator is designed to vault the cornea, and aside from an initial drop of topical anesthetic, no other medications are needed.
The entire procedure lasts for two cycles, 12 minutes total. The first cycle is composed of 4 minutes of regulated heat at 42.5°C, and maintains this heat throughout the entire 12 minute procedure. Once at therapeutic temperature, the pressure sensors activate to apply 5.2psi pressure to the meibomian glands. This cycle repeats once more for a total of 12 minutes.
One single Lipiflow procedure is equally efficacious as warm compresses applied twice a day for three months in improving symptoms and meibomian gland function and these results are sustained for 12 months after just one treatment.7 Additionally, the procedure increases soft contact lens tolerance by an additional four hours in patients with concurrent MGD and DED8.
PROS | CONS |
Heats + expresses at once | No doctor control of expression, cannot adjust pressure |
Heats backside of eyelids | Not great for small eye openings |
Automated | |
Heat and pressure are calibrated | |
TEARCARE
TearCare is a blink-assisted warming device that delivers heat to the meibomian glands. The sterile, disposable wearable elements are attached to a small, portable heating hub that delivers 45°C of heat to the eyelids for 15 minutes. The heat temperature is adjustable, and patients can keep their eyes open throughout the entire time.
Within three minutes after the heating session, meibum clearance is performed manually with a clearance tool, allowing the clinician to spend as much time as is necessary to evacuate the meibomian glands. Each of the four eyelids are compressed individually, one section at a time.
When compared with at-home warm compresses twice a day for four weeks, TearCare was superior in improving tear break up time one month after the procedure. A second procedure at six months was found to be beneficial in improving signs and symptoms of MGD and DED9. Initial results of the OLYMPIA trial, which compared TearCare to LipiFlow, showed that 76% of females noted improvement in symptoms after one month, compared to 56% of females who received Lipiflow.10
PROS | CONS |
Temperature adjustable | Must quickly express glands after finishing warming treatment |
Treatments customizable | Takes longer than other treatments (20 mins+) |
Open eye experience | Outer surface heat only |
Portable | Doctor must be good at gland expression |
Good for any eyelid size | |
Tearcare is the thermal expression treatment I offer in my practice, and so I have some of my expression videos to share with you. I did choose this procedure because of the customizability, and I have noticed that the amount of pressure I need to apply varies wildly, not only by patient but by treatment day.
All about meibomian gland dysfunction thermal expression
MIBOFLO
The Mibo Thermoflo device consists of a small, portable console and handheld tip. The device delivers heat to the outer surface of the eyelids at 42.5°C, penetrating to the meibomian glands to soften meibum. The temperature is adjustable for patient comfort.
Ultrasound gel is applied to the heating tip to allow it to move easily across the eyelids for a gentle massage to the meibomian glands. Two tips are available for ease of use, the more recent tip allowing a larger surface area of coverage and less movement. The heat treatment is completed in 12 minutes.
Both eyes can be performed at the same time with an updated version of the device. Manual gland evacuation must then be performed. Patients reported immediate symptomatic relief after the procedure and expressibility of the meibomian glands also improved.12 Re-treatment is often necessary; manufacturer recommendations are three treatments, two weeks apart.
PROS | CONS |
No disposables (lesser price) | Tx is generalized |
Adjustable temperature | Increased patient visits |
Doctor directed expression makes it customizable | Depends on doctors expression capabilities |
Systane ILux
The iLux MGD Treatment System is an FDA-approved, handheld warming and evacuation device for the treatment of MGD. It works by simultaneously applying LED-based heat and pressure to a localized area of each eyelid. A sterile, disposable tip makes direct contact with the inner and outer surfaces of the eyelid, and the device maintains a temperature of 38-42°C. The treatment takes 8-12 minutes total.
Meibomian glands that are difficult to express can be re-treated and the device allows direct visualization of glands being expressed for target areas. Tear break up time and expressibility of the meibomian glands has been shown to improve in 4 weeks, and treatment with iLux has been shown to be non-inferior to the Lipiflow System.
PROS | CONS |
Can Adjust temp | Can be difficult to maneuver around lids |
Can be done anywhere, portable | Outer surface heat only |
Not limited by eye aperture size | |
Somewhat customized | |
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