1. Results of Intraductal Meibomian Gland Probing (MGP) for Symptoms of Inflammatory Meibomian Gland Dysfunction (MGD) Excluding Lid Tenderness
Steven L. Maskin, MD FACS
Dry Eye and Cornea Treatment Center
Tampa Florida
.com
DISCLOSURE: Patent Pending Class One Device Made of Stainless Steel.
COMMERCIAL RELATIONSHIP: Rhein Medical, Inc.

2. BACKGROUND:
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.

3. PURPOSE:
We presented in ARVO 2009 the technique of intraductal meibomian gland probing to successfully relieve lid tenderness in MGD. Follow up on these initial patients now extend to 1-2 years showing procedure to be safe and well tolerated. This prospective study was to evaluate and quantify results of intraductal MGP for symptoms of MGD excluding lid tenderness.
METHODS:
Intraductal MGP as previously described in ARVO abstract 2009 was performed on patients with a variety of symptoms of MGD excluding lid tenderness. Symptoms were evaluated on 21 lids of 8 patients. Three patients used a questionnaire on a 0 to 100 scale and 5 patients used a standardized VAS test. Lids were evaluated pre probing, immediately after, between 1 week and 1 month, 1 and 2 months and 3 and 9 months. Inclusion criteria required pre probing symptoms greater than 25 on the questionnaire and 25mm on the VAS. .

4. RESULTS:
Patients ages ranged from 17 to 85 with average age of 56 (SD=23.1). In 21 lids of 8 patients there was a mean pre probing score of with an immediate post probing score of and a reduction of Symptoms yielded a mean reduction of (36.6%) between one week and one month, (54.2%) between 1 and 3 months and (63.0%) between 3 and 9 months. Eleven lids of 4 patients have reached this last follow up point. The average last measurement of all patients was , an average reduction of 61% at an average last follow up of months. Lid symptoms which improved included lid pressure, heaviness, puffiness, awareness, irritation, discomfort, sticky and gummy, photophobia, itchy and scratchy under the lid, sunburn under lid, epiphora and ptosis.

5. MEIBOMIAN GLAND PROBING EXCLUDING LID TENDERNESS
PATIENTS WITH SUBJECTIVE & VAS TESTING ≥ 25 OUT OF 100
VAS PATIENTS: 5 SUBJECTIVE PATIENTS: 3
Range of Patient Age: (SD ± 23.1)
Average Patient Age: 56
Average of Difference (mm) (Preprobing - Post Probing)
Total # of Patients
Total # of Lids
IMMEDIATE
22.4 (SD ± 17.1) 6 14
˃ 1 WEEK ≤ 1 MONTH
27.9 (SD ± 35.2) 4 8
˃1 MONTH ≤ 3 MONTHS
41.3 (SD ± 36.5) 5 11
˃ 3 MONTH ≤ 9 MONTHS
48.0 (SD ± 19.9)
Mean Score (mm)
Total # of Patients
Total # of Lids
PREPROBING
76.2 (SD ± 14.7) 8 21
IMMEDIATE POSTPROBING
50.7 (SD ± 19.9) 6 14
LAST MEASUREMENT
29.9 (SD ± 24.0)
AVERAGE LAST FOLLOW UP DATE
3.6 (SD ± 3.2)

6. Results of Meibomian Gland Probing On VAS For Symptoms of MGD Excluding Lid Tenderness
41.3 ± 36.5
(54 %)
48.0 ± 19.9
(63 %)
27.9 ± 35.2
(36 %)
IMMEDIATE
n = 6
I =14
22.4 ± 17.1
(29 %)
(As Of 2/3/10)
PREPROBING
˃ 1 WEEK
≤ 1 MONTH
n = 4
l = 46
˃ 1 MONTH
≤ 3 MONTHS
n = 5
l = 11
˃ 3 MONTHS
≤ 9 MONTHS
n = 4
l = 11

7. Results of Meibomian Gland Probing On Excluding Lid Tenderness
VAS For Symptoms of MGD
Excluding Lid Tenderness
n = number of patients
l = number of lids
Preprobing
n = 8
l = 21
Immediate Post Probing
n = 6
l=14
Last Measurement
@ 3.6 ± 3.2 Months
n = 8
l=21
(As Of 2/3/10)

8. 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.

9. 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.

10. A PLUG OF SEQUESTERED MEIBUM.
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.

11. Before Intraductal Probing
80 Year Old Man With Obstructive Meibomian Gland Dysfunction.
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 symptoms measured by VAS from pre probing score of 45 out of 100 to his latest score of 4, 2 months post probing.

12. Dry Eye and Cornea Treatment Center
CONCLUSIONS:
Intraductal Meibomian Gland probing appears highly effective in rapidly reducing standardized VAS patient scores of a variety of symptoms 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 Center
Tampa Florida
.com