Pathophysiology, Diagnosis and Treatment of Blepharitis and

Meibomian Gland Dysfunction

Eric Donnenfeld, MD Clinical Professor of Ophthalmology NYU

Trustee Dartmouth Medical School

Disclosure

I am a consultant for:

Acufocus

Allergan

Alcon

AMO

Aquesys

Bausch & Lomb

Better Vision Network

CRST

Elenza

Glaukos

Katena

Lacripen

Lensx

Merck

Novabay

Odyssey

Pfizer

PRN

QLT

Sarcode

Tearlab

TLC Laser Centers

TrueVision

Wavetec

Meibomian Gland Disease

Posterior Blepharitis/Meibomian Gland Dysfunction or Disease (MGD) –

Pathophysiology1,2

Posterior blepharitis is a chronic ocular condition that involves the posterior lid margin and the meibomian gland orifices1, 2

MGD commonly presents with acne rosacea and other dermatologic conditions and is most commonly caused by the obstruction and inflammation of the meibomian glands

Altered functionality of the meibomian glands can result in atrophy of the glands and a higher incidence of chalazia

1. Jackson. Can J Ophthalmol. 2008;43(2):170-179. 2. AAO. Blepharitis, Preferred Practice Pattern. 2008.

Posterior Blepharitis/MGD – Pathophysiology1-9

Ocular surface inflammation/damage

Altered Composition

of Meibomian Gland

Secretions

Irritation/Inflammation of lid margin

and ocular surface

Bacterial

lipase

Altered

lipids Hormone

imbalance

Age Inflammation

Evaporative dry eye

Destabilization of tear film Pro-inflammatory and irritative effects

of altered meibum

Pathophysiology of Meibomian Gland Disease

Normal meibomian gland secretions convert from unsaturated lipids that melt at body temperature to saturated fats that inspissate the meibomian glands.

Lid bacteria secrete lipases that break down lipids from soaps to fatty acids.

Posterior Blepharitis/MGD – Clinical Presentation1,2

The signs and symptoms of posterior blepharitis may include:

Altered meibomian gland orifices

Altered meibomian gland secretions

Chalazia

A thickened or scalloped lid margin

Hyperemia of the lids

Burning

Foreign body sensation

Rapid tear break up time

Visual Fluctuation

1. Jackson. Can J Ophthalmol. 2008;43(2):170-179. 2. AAO. Blepharitis, Preferred Practice Pattern. 2008.

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Ocular Surface Staining

Lissamine Green Alone Rose Bengal added to

Lissamine Green Photos Courtesy of MA Lemp

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Tear Film Breakup Evaluation

0 seconds 1 second 2 seconds 3 seconds

6 seconds 4 seconds 5 seconds 16 seconds

Tear film breakup is indicated by the dark areas that appear on the cornea.

Photos courtesy of Alcon Research, Ltd, Ft. Worth, TX

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Tear Break up Time

Inadequate Tear Film Lipids Cause Evaporative Dry Eye

Bacterial Lipases Break Down Lipids to Soaps

Prevalence of Meibomian Gland Dysfunction, A Leading Cause of Dry Eye Disease

MGD is present in ~37% of entire ophthalmic practice

patients and ~47% of optometric practice patients1

“Meibomian gland dysfunction (MGD) may well be the leading cause of dry eye disease throughout the world.”2

—The International Workshop on Meibomian Gland Dysfunction: Executive Summary

1. 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.

2. Nichols KK, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.

Lipid Secretion: Meibomian Glands

The lipid layer restricts evaporation to 5-10% of tear flow

Also helps lubricate

Obstruction of meibomian gland ducts reduces lipid secretion

Causes increased evaporation of the aqueous component

Meibomian gland dysfunction Transillumination of

meibomian glands

Medical Treatment

Hot compresses

Antibiotic (azithromycin) and corticosteroid ointments (loteprednol)

Low dose oral doxycyline for chronic or severe disease, especially with facial involvement

Nutritional supplements

DEWS Management and

Therapy

Omega-3

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Mechanical Treatment

Lid massage

Meibomian gland probes

Pulsed light therapy

Lipiflow

Lid Massage

LipiFlow Thermal Pulsation System

LipiFlow safely and effectively treats Meibomian gland

obstruction in both upper and lower eyelids simultaneously

• In-office procedure

• 12 minutes per eye

Heat applied to the palpebral

surfaces of the upper and

lower eyelids directly over

the Meibomian glands

Heat >40°C and Pressure to Liquefy and

Evacuate Obstructed Glands

Lid warmer

Composed of a heater, eye

insulation, and vaulted shape

Activator

Composed of an inflatable

air bladder and a

rigid activator

Graded pulsatile

pressure delivered

to the outer eyelid

Ocular Surface Staining

Lissamine Green Alone Rose Bengal added to

Lissamine Green Photos Courtesy of MA Lemp

Thank You

Photo courtesy of Justin Kwan, MD, Alcon Laboratories. 2010.