Are your eyelids red, soar, and puffy? You could be over-treating your meibomian oil glands (MGD).
A trend recently seems some people are overdoing eyelid care in hopes of improving chronic MGD. They are applying heat packs twice or more each day, scrubbing and massaging their lids frequently, and attempting to express the glands regularly. Some savviest people are purchasing medical instruments intended for professionals and using them at home to express their glands.
Lid hygiene and heat treatment for MGD is essential. This trend is causing concern due to inappropriate overuse resulting in the slow recovery of the meibomian glands. In other words, we might be treating our meibomian glands to death.
How do meibomian oil glands work?
The meibomian glands are located on the upper and lower eyelids. There are approximately 15 – 20 glands per lid. The gland openings lie on the edge of the eyelid just inside the eyelash line. The gland’s body is inside the tarsal plate, which is a very thin piece of cartilage that gives the eyelid its defined shape. When your doctor everts your lid (flips it inside out), he is flipping over the tarsal plate.
Although most diagrams of meibomian glands show a hollow tubular structure that looks like a permanently open space, a meibomian gland is more of potential space. If the gland is empty of meibomian oils, it collapses in on itself. In fact, even when the gland is “full,” only a very thin film of oils may actually separate the cells lining the walls of the meibomian gland.
Meibomian oils are not squirted onto the surface of the eye. The oil seeps out slowly under the gentle pumping action of eyelid blinking. When the oil is produced continuously, oils are pushed out onto the eyelid margin when the gland’s potential space is fully expanded.
When the eyelid margin becomes inflamed, this inflammation can “cap off” the meibomian gland orifices. Suppose the glands continue to vigorously produce oils. The oils erupt through the glands’ sides and coalesce into a mass commonly referred to as a stye. However, the obstruction of normal oil seepage causes the meibomian gland to decrease production. The oils retained in the gland become thick and degraded.
In the past 2 – 4 years, eye doctors have become more widely aware of the connection between meibomian gland dysfunction and dry eye symptoms. One simple office test is to lightly press on the glands while the patient is seated at the slit lamp. The examiner is looking for the quantity and quality of oils, how many glands express, how hard s/he has to push to make this happen, and how readily the oils disperse into the tear film. Meibomian oils are relatively easy to see at the slit lamp but essentially impossible to see with the naked eye except through elaborate magnification methods.
How much heat to unclog Meibomian Oil Glands
A note on hot compresses. The eyelid skin temperature is slightly below core “body temperature” and meibomian oils become more liquid just a little above core body temperature. So moderate, sustained heat can keep viscous oils thinner. Patients who use very hot compresses that they can tolerate for only 1-2 minutes are going about it the wrong way. Wash clothes are ridiculous due to the very rapid cool-down. There is no difference between dry and wet heat from the perspective of the meibomian gland’s interior. A compress that stays “definitely warm” without being uncomfortable for 10 minutes is the most effective approach.
Problem with a self-expressing oil glands.
As regards meibomian gland self-expression, there are several problems with this approach.
- Not all meibomian gland problems are due to blockage of the orifices.
- If the glands are simply under-producing oils (a common problem in peri-menopausal women), pushing on them won’t do anything.
- If the lid margin inflammation is not under control and the orifices are tightly blocked, oils may not express even with hard pressure. So the treatment is not helpful.
Why self-expression can be harmful
Remember that the gland is a potential space containing a small volume of oil. If you express all the oil out of the gland, you have probably expressed several days’ worth of “production”. You have depleted your supply. When the gland is empty, it collapses in on itself. The cells lining the potential space come into contact without an intervening “oil slick”. This allows the cells to adhere to each other. As the gland refills with oil, the potential space expands, and the cells separate. The repeated expression can lead to the cells permanently adhering, causing obstructions deeper in the gland. This process will be hastened by the microtrauma induced through the mechanical pressure, especially if applied vigorously and often.
Some people basically murdered their meibomian glands through excessive self-expression. Case in point, the glands in the far nasal and temporal (ear side) areas are harder to reach. It is more difficult to apply direct firm pressure to the glands in the upper lids than to those in the lower lids. So we see more non-functioning glands in the centers of both lids than the corners, and the lower lids have more non-functioning glands than the upper lids.
When is self-expression helpful?
Some people have mildly occluded orifices or tend to produce oils that don’t seep well. They get into a “stagnation” situation. As part of their overall rehabilitation, which MUST include efforts to improve oil quality and open the orifices, mild self-expression following a hot compress can be beneficial.
If you are a frequent (more than once per week) or aggressive self-expresser, ask yourself whether you are doing this “philosophically” or because it seems like a smart thing to do. Does expressing indeed improves your symptoms. If you express several times per day, it is doubtful that you are getting a “useful” amount of oils onto the ocular surface each time. This habit will only increase the microtrauma to the meibomian gland structure.
Meibomian gland self-expression can be helpful at certain stages of treatment. It is recommended by eye doctors, including those who specialize in chronic dry eyes. It is essential to understand that you can overdo it. You should not use self-expression unless instructed to do so by your eye doctors. If you have ocular surface pain and your provider has never expressed your glands, find a different doc.
What if you are a non-producer?
People whose meibomian glands have ceased production is in a challenging state. Peri- and post-menopausal women are most prone to this condition since meibomian gland function is regulated by androgen hormones. Some women become abruptly dry during pregnancy and don’t recover after pregnancy. Conversely, some women have symptoms before pregnancy and actually feel better during pregnancy. We do not have a good understanding of the complex hormonal interplay that affects meibomian gland function. However, if your glands aren’t making oils because of the lack of hormones or ocular surface nerves – meibomian oil gland expressions will not work. Low production can combine with eyelid inflammation to reduce the quality and quantity of oils reaching the tear film. Certainly, related problems such as eyelid inflammation should be addressed. But for people whose fundamental concern is markedly reduced production, it is imperative to leave your meibomian glands alone!
Remember that the purpose of meibomian gland oils is to stabilize the tear film structure and slow evaporation. Barrier methods to slow evaporation (goggles, masks, etc.) are beneficial in this circumstance.
What helps meibomian glands and how:
Heat – liquifies oils which tend to become more viscous just below body temperature (eyelid skin cooler than core body temp); see comments above about correct hot compress
Doxycycline and minocycline, erythromycin – low dose for at least 60 days – acts as an anti-inflammatory which opens the orifices, thins out the oils in some fashion that we don’t understand, decreases the bacterial load on the eyelid margins, which opens the orifices
TobraDex ointment – anti-inflammatory, decreased bacterial load; intraocular pressure must be followed if used for more than 1 month.
omega oils – anti-inflammatory, antioxidant, ‘good ingredient’ for oil production
Azasite applied to eyelid margins (the topical equivalent of erythromycin) – antibacterial, maybe something else as well? seems to work for some people, not others
How can Theralife help?
TheraLife protocol for recovery of MGD is to treat dry eyes, blepharitis, and MGD simultaneously. Formula targets to restore and revive tear production cells intra-celluarly from inside out.
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- .Goto E, Monden Y, Takano Y, et al. Treatment of non-inflamed obstructive meibomian gland dysfunction by an infrared warm compress device. Br J Ophthalmol2002;86:1403-1407. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009;7(2 Suppl):S1-S14. 3.Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-8. 4.Shimazaki J, Sakata M, Tsubota K. Ocular surface changes and discomfort in patients with meibomian gland dysfunction. Arch Ophthalmol. 1995;113(10):1266-1270.