Of forests, trees, dry eye, and meibomian glands: Have you lost the plot?
Have you lost the plot?
I want to challenge your perspective on the role of meibomian glands in dry eye.
Somehow, in the vast, diverse forest of dry eye disease, patients are finding themselves increasingly corralled into a relatively small corner dominated by a single genus of tree: meibomian gland dysfunction.
Genus MGD is so interesting, encompasses so many species, and covers such extensive acreage that the lack of biodiversity goes unnoticed by patients and physicians alike.
The meibomian gland obsession
Don’t worry… I will cut to the chase before the metaphors get stretched beyond recognition. I’m talking about the fact that dry eye patients are getting more and more obsessed with MGD. Their entire dry eye world is shrinking to the perceived state, significance and potential manipulation of a row of sebaceous glands in each eyelid.
This trend is fundamentally unsound and is fresh evidence of how, despite every outward sign of progress in the dry eye world in terms of clinical research, many of our most skillful, as well as a not insignificant number of our most well-meaning, clinicians are failing to serve their patients well in real terms.
The journey: How did we get here?
Oh, just the usual predictable path: It started in a great place scientifically. Then industry and medical practices dragged it rapidly down a steep slippery slope into a profit center. Even in that place, it has, arguably, served many patients better than where we were before, except perhaps monetarily.
Fifteen years ago, when I first started taking a serious interest in dry eye, the profession at large and what little there existed of a dry eye industry were mostly meibomian gland illiterate. Patients were diagnosed with dry eye, not MGD, and treated uniformly with Ye Olde Plug & Drop, which from 2003 on morphed rapidly into Plug & Drop Plus Restasis.
When I was first taught about meibomian glands (and Dr Brown, if you’re reading this, I hope that you never forget that it ALL started with YOU and a simple email you sent me one day), and learned that the majority of people diagnosed with dry eye did not have impaired tear secretion but rather some form of lid margin disease, I got really excited and jumped on the education bandwagon. I was constantly sending patients back to their doctors armed with questions like “How are my oil glands looking? Any signs of inflammation or blockage?” I enthusiastically cheered on and to this day highly esteem the doctors like Rob Latkany (author of The Dry Eye Remedy) who were part of this path towards eyelid literacy long before it was popular or profitable. My (now defunct, waiting for a re-write) original pages on MGD on the original DryEyeZone website were amongst its most heavily trafficked ever.
Then came TFOS DEWS, published in 2007. The Dry Eye Workshop, the product of a three year project by an international collection of researchers, was a huge breakthrough in terms of creating a dry eye bible that told us what was what - including explaining the role of MGD. Not long after, there was the TFOS International Workshop on Meibomian Gland Dysfunction, published in 2010.
Then industry went to work.
The first real craze I remember was Azasite. It was THE wonderdrug du jour. If memory serves, that trend started before the MGD workshop, and it cooled down relatively quickly, but the way it rode the MGD wave was a big deal at the time.
Then there was the “cult” of IPL, which gradually morphed into more of a mainstream MGD treatment.
Then came Lipiflow. Game over.
Yet Lipiflow is, in my opinion, beautiful technology. Social media for many years was quite brutal to Lipiflow, fueled by a combination of patients who were oversold by their doctors, and patients who formed unrealistic expectations all by themselves. (At $1600 or so a pop - at least, that was common pricing ‘back in the day’ - and no insurance coverage, it’s understandable that patients who did not have improved symptoms would be unhappy.). Yet… like I said, it really is beautiful technology. To be clear, when I say Lipiflow, I’m speaking really of the “suite” of products- Lipiflow, Lipiview and Lipiscan.
Lipiflow defined itself as a potential profit center, and it took firm hold. I’ve never studied the actual numbers in depth, but I’ve always suspected that the 2008 financial crisis, the subsequent drop in disposable income and the resulting drop in LASIK surgery all played a significant role in this. Ophthalmology needed new revenue sources even if less lucrative than LASIK. Dry eye patients can often be so uncomfortable that they are highly motivated and more than willing to spend out of pocket. So, at some point after Lipiflow’s FDA approval in 2010, I saw a growing trend where eye doctors started hanging a new shingle from their practice: Dry Eye Clinic, or Dry Eye Center. Lipiflow, even for so-called Dry Eye Clinics that did not offer it, is what made that market positioning possible in the first place.
Ever since then, the entire industry has been “educating” doctors (at medical meetings) and patients (on fancy screens in waiting rooms) about meibomian glands, MGD and the treatment thereof. We have heard about The Three Layers Of The Tear Film ad nauseum. Every new over the counter drop claims to treat all three layers. There has been a constant stream of new artificial tears containing a lipid of some kind.
Meantime, on the device side, there has been a steady stream of new medical treatments for MGD. We have IPL available more broadly. We have probing. We have blephex. We have cheap knockoffs of Lipiflow. We have a gajillion warm compresses and of course we have a gajillion and one nutritional supplements all aimed at “the oil layer” of the tear film.
All of this has served to undergird the view that dry eye isn’t about tear secretion; it’s about oil secretion. Period.
Because of the superfluity of treatments (and please don’t kid yourself, because when treatment looked like baby shampoo and a hot washcloth, MGD was not exactly a sexy diagnosis!) MGD is now the official Low Hanging Fruit of the dry eye diagnostic and treatment tree. So even if your patient has multiple co-morbidities, the disease that will get the attention and treatment is the MGD, simply because there are now so many handy hammers to hit it with.
Meantime, we’ve turned patients on to the role of MGD and there seems to be no going back. And that is why I think the usefulness of the MGD diagnostic craze is peaking.
What this has looked like from where I sit
You may or may not have any idea what I do. In addition to running the DryEyeZone and DryEyeShop websites, I have done a ton of what I would loosely call “patient consulting”. That is, whether by design or accident, I have frequent lengthy conversations with dry eye patients who have hit a wall and are looking for new light.
I listen carefully to their stories. I ask many questions - history of diagnoses, treatments, symptoms, any potentially related health conditions or treatment. I probe for any and every detail that might play a role. I use all this to try to get a sense of the big picture, and come up with some recommendations for where next to go, based on mentally matching them with a long history of other patients like them and how they fared by going down a variety of paths. What questions could they ask their doctor? What kind of doctor might they need next, if it’s time to move on? What additional diagnostics might be useful? What additional treatment options might they ask about? But most importantly, the BIG picture: what is really going on with them: what PROBLEM do they want to solve, and what ideas can I come up with for how they might solve that problem? Is this a pain problem? Is it a visual function problem? Something else? And, since pain patients so often struggle with the inevitable mental health impact, where are they at in that regard: is that aspect interfering with their treatment compliance or their ability to advocate for themselves? Are they getting all of the support they need?
It’s incredibly fascinating work. I get to talk to patients all over the world, with a vast array of corneal diseases. Few cornea specialists anywhere in the world can possibly have had more total “talk time” and symptom-data-gathering opportunities than I have had with patients suffering from obscure corneal conditions or, most often, what I think of as complex comorbidity clusters.
I am not a medical professional and would never try to diagnose someone or tell them what treatment they need. Of course, as an unavoidable consequence of the kind of work I do and all of the time I pour into studying medical literature, I have accumulated a great deal of specialty knowledge in the medical side of ocular surface diseases. But what I see myself as engaged with is simply the business of identifying the REAL problem, from the patient’s perspective, and suggesting paths towards solutions from all directions - medical, pharmaceutical, practical, etc. (If you want a better understanding of what I mean by the REAL problem, try a terrific book called “Are your lights on?” by Gerry Weinberg.)
And it is here that I am seeing a new thing happening.
Historically, patients’ language and concerns have always revolved almost exclusively around their symptoms - especially burning and pain - and the desire to pursue anything that could potentially make them feel better, that is, to control the symptoms.
Now, I am seeing a gradual trend amongst my ‘consultees’ in recent years where many of the more educated amongst them are adhering tenaciously to questions about their meibomian glands and what more they can do to or about said glands, even when MGD is clearly only one of many things they have going on, and when they frankly have no way of knowing whether the MGD is the one that’s causing their symptoms. (Because, let’s be honest, there are a ton of people out there with meibomian gland function impaired in some degree, who have no symptoms whatsoever and are blissfully ignorant of the very existence of meibomian glands.) Now, a growing number are manifesting constant anxiety about how to keep their glands flowing or at least how to prevent them, at all costs, from atrophying, even when they have absolutely no experience or data indicating any correlation whatsoever between how their glands are doing and how they feel.
Those are signs of MGD obsession, and it’s happening right in the face of everything we know about the classic sign v symptom mismatch of dry eye. And it’s not helping patients get “better”, in any real sense: it’s not helping them get their quality of life back under control, and to the extent it sometimes just contributes to both over-treatment and an anxiety loop, may just be making things worse.
Why is this happening?
Dry eye patients were and are and always will be naturally symptom driven… BUT:
MGD is an obvious part of the dry eye equation.
Meibomian gland patient education is more readily available than any other type.
Lucrative MGD treatments have proliferated, and are the treatments most likely to be emphasized in advanced dry eye practices.
Social media groups (including mine, sad to say) foster constant conversation on this topic.
Doctors are focused on MGD treatments because they are readily available.
What could clinicians be doing differently?
In my opinion, clinicians should be focusing on:
Careful diagnosis of co-morbidities, some of which require painstaking history-taking.
Methodical collection of symptom data, which requires use of scientifically validated instruments.
Conversation with patients to better understand symptom patterns and to establish priorities and goals in functional terms.
Because… let’s face it. YOU, the clinician, probably don’t know a damned bit more than I do, and, all things considered, quite likely a whole lot less, about whether your patient’s most bothersome SYMPTOMS are attributable more to their MGD, their lagophthalmos, their CCH, their mild blepharitis, their mild ocular rosacea, or one, two or three of the above, or none of the above. You see signs of disease and you want to treat it and that’s fine - but you also need to listen to the patient and find out what is actually affecting their life, figure out how to measure changes to that thing, and assess the efficacy of your treatments accordingly. Are they vision driven? Pain driven? Is this all about what happens at 3am? Is it all about light sensitivity, or all about eye redness? What is the actual PROBLEM?
Incidentally, I consider myself very skilled in eliciting key symptom data patterns from ocular surface disease patients. Yet, now and then, I discover something completely unexpected, and very telling, only after 15-30 minutes of continuous conversation! My first thought is: “Bet their doctor doesn’t know that, and what their doctor doesn’t know is hurting them.”
What could we patients be doing differently?
Finding language to articulate our symptoms more effectively.
Collecting symptom data at regular intervals - like using the OSDI app on our smartphones.
Thinking more about what really MATTERS to US: Forget Schirmer, TBUT, tear film osmolarity, meibography and anything else you have learned about the doctor’s dry eye language. Return to fundamentals. What is bothering you? What is the problem? What do you want less of or more of? What do you want to be able to do less of or more of? And then communicate that to your doctor.
Meibomian glands are only part of the picture.
Suppose you could return your meibography, TBUT or staining to normal.
If you didn’t feel better… if you still experienced burning every time you looked at a computer, would you care? If you still woke up twice every night with eye pain, would your test scores give you any consolation?
Addressing dry eye successfully involves pragmatism and thinking in purely practical terms about your daily vision function and comfort.
Patients, don’t allow yourselves to be indoctrinated with medical terminology to the point of speaking the doctor’s language and losing sight of your very real, very personal needs. YOU ARE MORE THAN THE SUM OF YOUR MEIBOMIAN GLANDS AND THEIR CURRENT STATE OF OIL PRODUCTION!
Doctors, never forget that resolving the clinical signs of dry eye does not constitute a success if you are not also resolving symptoms.
Look beyond meibomian gland health.
See the forest, not the trees.