Meibomian gland dysfunction (MGD) affects approximately 35.8% of the world’s population, and is growing. Traditionally, the highest MGD rate has been seen among men 60 years of age or older, but that demographic is swiftly shifting, with more younger adults and even pediatric patients now showing signs of glandular obstruction and damage .1,2
Risk factors for MGD can include allergies, hormonal imbalances, certain medications, and increasing age. If left untreated, MGD can lead to dry eye disease, ocular surface diseases, and corneal damage.1
Today, a number of novel pharmaceuticals are changing MGD and dry eye care, including Miebo™ (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) and Xdemvy® (lotilaner ophthalmic solution, 0.25%, Tarsus). But, while medications, manual expression, intranasal stimulation, and punctal plugs are viable options, ophthalmologists have another tool in their armamentarium to offer patients: in-office meibomian gland procedures. Among the most common procedures are meibomian gland probing (MGP), intense pulsed light (IPL) treatments, and topical radiofrequency (RF) therapy.1
An understanding of the application of these techniques and appropriate patient selection issues surrounding their use can give ophthalmologists a robust option portfolio for patients living with advanced meibomian gland dysfunction.
Meibomian Gland Probing
Conventional meibomian gland probing (MGP) has emerged as a pivotal intervention in managing obstructive MGD. Introduced in 2010, MGP is a minimally invasive procedure that uses a wired probe to remove obstructions through natural orifices, restoring duct integrity, normalizing intraductal pressure, and enhancing gland functionality and meibum production.3,4
Recent studies have demonstrated the role of meibomian gland precursor cells in maintaining gland homeostasis, suggesting that MGP’s efficacy may lie in activating these cells and releasing obstructions. “MGD has been found to be the major etiology in close to 90% of dry eye cases,” said Steven Maskin, MD, a dry eye and cornea treatment specialist at Dry Eye and Cornea Treatment Center in Tampa, and the chief developer of the technique, which is sometimes called Maskin Meibomian Gland probing. “The most common presentation of MGD in dry eye cases is an obstructive gland.”
In vivo confocal microscopy (IVCM) studies show post-MGP changes in duct microanatomy, emphasizing accelerated epithelial response and basement membrane formation. Immediate post-MGP imaging showed more superficially organized orifice-associated rete ridge epithelial/basement membrane structures (OARREBS), along with increased duct wall epithelial cell layers (DWECL) and duct wall thickness (DWT).3
“What happens is, we look at the percent increase of duct wall thickness, and we have an immediate — within less than a month — increase in the thickness of the duct wall,” Dr Maskin said. “It peaks in about 1 to 3 months, and then, over the course of a year, it gradually induces still, by the end of the year, by 10% greater than the beginning.”
Clinical trials consistently report significant improvements in symptoms and signs post-MGP, even in cases resistant to standard therapies. Studies demonstrate MGP’s effectiveness in addressing ocular surface disease and severe MGD cases.5,6 Additionally, a combination of MGP and IPL yielded maximal therapeutic benefits, particularly for patients with severe meibomian gland obstruction and inflammation.6
Improvements in symptoms have been observed, too. One study shows a group of patients who underwent MGP and treatment with Blephamide (sulfacetamide/prednisolone, AbbVie) experienced significant Ocular Surface Disease Index (OSDI) changes (P =.02), and Symptom Assessment in Dry Eye (SANDE) scores (P =.002) compared with baseline. A subset of patients who underwent MGP with artificial tears also improved, but that improvement was only significant in the SANDE score (P =.01).7
Another study shows 76% of patients had symptom relief 1 day after probing before the administration of any additional medical treatment, and that patients who received treatment with fluorometholone alone had no significant improvement. Patients in that study who received MGP and fluorometholone did improve.8
“The probing technique exfoliates dead cells, the old senescence cells of the duct, allowing and stimulating and allowing proliferation of the unhealthy cells in terms of better quality of oil, better functionality of glands, and patient benefit,” Dr Maskin explained. “There are no other techniques that have been shown to activate the stem cells and show the same level that we show to demonstrate that we could exfoliate the old senescence cells and stimulate and activate the gland stem cells. So probing is uniquely able to restore comfort to patients by addressing the root cause of the disease.”
In Dr Maskin’s experience, most meibomian glands appear to have scar tissue somewhere along the length of the gland. “So by entering the natural orifice of this gland, and passing this probe, we are able to release the scar tissue and no other technique can do that,” he said.
Collectively, these findings appear to underscore the therapeutic potential of MGP in refractory MGD cases, advocating for its inclusion as a primary or adjunctive therapy option. The substantial improvements observed across various studies highlight MGP’s role in alleviating symptoms, stabilizing tear film, and enhancing patient quality of life, thus positioning it as a cornerstone in managing MGD.3
Meibomian Gland Management With Intense Pulsed Light
Intense pulsed light (IPL) is another technique for managing MGD and evaporative dry eye. IPL therapy involves the application of polychromatic pulses of noncoherent light, utilizing the principle of selective photothermolysis to target chromophores in the skin, including hemoglobin, melanin, and water. By generating heat, IPL destroys tissue and ablates blood vessels, thereby addressing the underlying pathology of MGD. IPL has been extensively utilized in dermatology since its commercial approval in 1994, with observations of improved dry eye symptoms in patients with acne-rosacea since 2002. Patients with rosacea-related ocular surface disease, particularly those with Fitzpatrick skin types I-V, have been identified as ideal candidates for IPL treatments.9
Several studies have demonstrated the safety and efficacy of IPL as a standalone treatment for MGD. For example, prospective trials have reported significant improvements in lipid layer grade, tear break-up time, and symptom scores following IPL therapy.10-12
In a 2015 study, a prospective trial of 28 participants evaluated the effect of IPL on MGD and found improvements in tear film quality, with 82% of treated eyes showing improvement in lipid layer grade and significant increases in tear break-up time. Additionally, symptom scores improved in 86% of participants, highlighting the therapeutic potential of IPL in alleviating discomfort associated with MGD.10
Furthermore, combining IPL with other modalities has shown promising results in enhancing therapeutic outcomes. A recent study evaluated the combination of IPL with radiofrequency (RF) treatment, demonstrating improvements in subjective symptoms and objective findings of MGD. This novel approach resulted in reductions in OSDI scores and improvements in meibography, indicating revitalization of meibomian glands and alleviating dry eye symptoms.12 These findings underscore the potential of combined IPL and RF treatment as a comprehensive approach for managing MGD, offering patients a safe and effective treatment option to improve their ocular surface health and quality of life.
Topical Radiofrequency Therapy
Topical radiofrequency (RF) therapy is a noninvasive in-office meibomian gland procedure that uses electromagnetic waves. The radiofrequencies transfer oscillatory electric fields to target tissues, inducing vibrations in tissue particles and subsequent heat generation. This controlled heat application holds therapeutic potential for various medical applications, including surgery, tumor ablation, skin tightening, and pain control, by promoting tissue regeneration and modulating inflammatory processes. In dermatology, RF has been established as a standard skin rejuvenation and tightening treatment.14
In recent years, RF therapy has been explored as a treatment modality for MGD. The hypothesis is that its heat application could help liquefy obstructive secretions within the meibomian glands, promote neocollagenesis, and mitigate inflammatory responses. While initial studies have shown promise in improving symptoms and objective clinical measures associated with MGD, further investigation is needed to elucidate its efficacy and fully understand optimal treatment protocols.14
Pilot studies evaluating RF-assisted meibomian gland expression have reported significant improvements in patient-reported symptoms, including Standard Patient Evaluation of Eye Dryness (SPEED) scores and OSDI scores, along with objective clinical measures such as tear breakup time (TBUT) and corneal fluorescence score (CFS). Additionally, improvements in meibomian gland function, as assessed by the Meibomian Gland Score (MGS), have been observed following RF therapy.15,16
Combining RF therapy with other modalities, such as IPL therapy, has shown synergistic effects in enhancing treatment outcomes for MGD. Studies have reported a doubling of meibomian gland expression and improved meibum quality in both upper and lower eyelids when RF is combined with IPL. However, further randomized controlled trials are necessary to determine the relative contribution of RF in improving MGD outcomes when used alone or in combination with other therapies. Overall, topical RF therapy presents a promising avenue for addressing the underlying mechanisms of MGD and may offer effective long-term management for patients suffering from dry eye syndrome associated with this condition.14
Other Therapies
While probing and other techniques have been in use for more than 20 years, new developments in in-office meibomian gland procedures are consistently emerging. Results from a study presented at the 2024 Association for Research in Vision and Ophthalmology (ARVO) annual meeting revealed that a novel device called MGrX (OcuSci Inc.) can significantly reduce OSDI score. The score decreased from 26.89 before treatment to 13.29 after treatment (P <.01).17
Additionally, gaining a better understanding of the pathogenesis of MGD can lead to new therapeutic developments. Another ARVO 2024 presentation suggested that changes in the melting state from fluid to solid, as well as changes in the radius of the terminal excretory duct and the force exerted by the eyelid, can result in decreased meibum flow, indicating alternative mechanisms for meibomian gland obstruction.18
Alice Epitropoulos, MD, FACS, who specializes in refractive and cataract surgery and dry eye at The Eye Center of Columbus in Columbus, OH, employs the LipiFlow (TearScience/Johnson & Johnson Vision) thermal pulsation therapy. LipiFlow, FDA approved in 2011, uses a combination of heat and vectored pulsation to the anterior and posterior surface of the lens to unclog obstructed meibomian glands, Dr Epitropoulos explained. “One treatment can potentially last for 2 to 3 years, and in clinical trials, about 80% of patients notice an improvement after 1 treatment of the LipiFlow thermal pulsation treatment.” After using LipiFlow, Dr Epitropoulos follows up with meibomian gland expression.
A device that became available in 2019, the iLux® (Alcon) is a handheld version of a thermal or warming device that allows direct visualization of the glands through a magnifier.19 With the iLux, “You can see the lid as you are heating and expressing the glands through a light source, and you can customize treatment and go back and target certain glands that appear more inflamed or more obstructed,” said Dr Epitropoulos.
Advanced Treatments For Advanced Disease
Not every patient needs these sometimes invasive (albeit, minimally invasive) procedures to alleviate the dryness caused by meibomian gland dysfunction. A nuanced understanding of the individual patient’s MGD journey is elemental to targeting treatment. For instance, Dr Epitropoulos explained, “If I see patients with MGD and I’m not getting a lot of meibum through the glands when I’m expressing them, that would be a good reason to do thermal pulsation treatment or iLux.” She added that, if patients have a lot of redness around the lid and abnormal blood vessels around it, they might be good candidates for the IPL procedure.
Meibomian gland dysfunction presents a significant challenge in ocular health, affecting a substantial portion of the global population. However, advancements in treatment modalities offer hope for effectively managing MGD and improving patients’ quality of life. MGP, IPL therapy, RF therapy, and others have emerged as promising interventions, each offering unique mechanisms to address the disease’s underlying pathology.
Clinical trial evidence supports the efficacy of these treatments in alleviating symptoms, enhancing tear film quality, and restoring meibomian gland function. Moreover, combining these modalities has synergistic effects, further enhancing treatment outcomes. While more research is needed to elucidate these interventions’ optimal protocols and long-term efficacy fully, they represent valuable tools in managing MGD.
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