About AAO (Ophthalmology) 2019…

I attended the American Academy of Ophthalmology meeting in San Francisco a couple of weeks ago. I didn’t have time to blog about it while I was there (and it wasn’t my main purpose in attending), but, as always, many things came up that I know will be of interest, so I’m going to do my best to summarize them!

I’m starting with MGD. Funnily enough, I have a bit of an aversion (understatement?) to MGD these days but I know it’s a top interest in the groups, so for what it’s worth, this post and the next care all dedicated to MGD scoop.

SO:

When is a meibomian gland irretrievably dead?

This is an interesting topic and it is something that came up repeatedly at AAO, mostly in the context of IPL and probing presentations.

And it matters, for many reasons, including the fact that….

MGD anxiety is on the rise

I hear a lot of talk in the groups about their meibomian glands being dead, or atrophied, and the dry eye patient community seems to be experiencing more and more “MGD anxiety” - that is, a tendency to extrapolate the idea of any decree of gland loss into inevitable, irretrievable loss of quality of life.

That’s a long leap. Even more so if “gland loss” is not something doctors agree about how to define.

So my ears prick up anytime I hear about doctors treating “atrophied” glands.

A bit of context

At ARVO last May, Dr Reneker (U of Missouri) presented exciting data about meibomian gland regrowth and regeneration that seemed very hopeful. The crucial question seemed to be whether the ductile structures remained intact. (Likewise, a J&J sponsored study was presented at ASCRS that a majority of “atrophied” glands showed improvement after Lipiflow.)

A meibomian gland, it seems, may appear to have dropped out (the orifice at the lid margin disappears) but that does not mean it’s really and truly irrecoverable.

The point of confusion for us patients, of course - and no small one at that - is whether they can rely on their doctor’s assessment, since this is clearly a matter of emerging medicine.

The boogeyman of meibomian gland atrophy

It’s (relatively) easy for a clinician to talk glibly about gland atrophy. They don’t live with chronic eye pain, and don’t necessarily understand that hearing your glands are atrophied tends to be interpreted as hearing you have no hope of recovery. That is why it is becoming increasingly important to get some sense of what we do, and even more importantly, do not know about meibomian gland atrophy.

Opinions about atrophy

Fastforward to AAO in October. Drs Rolando Toyos (who pioneered the use of IPL in MGD) and Steve Maskin (who pioneered meibomian gland probing) each discussed the use of their respective preferred treatments on glands that appeared to be non-functioning. Here is a note I jotted down during Dr Maskin’s presentation:

“Don’t give up on a gland that appears to be atrophic. Maybe cells that aren’t visible, can restore functionality and secrete meibum”

Some days earlier, Dr Toyos, during a Lumenis-sponsored dinner during which many a tasty sirloin was washed down with many a glass of cab (and yes, I feely confess that free food was a key attraction for my very tight travel budget) discussed this same issue while answering questions about his presentation. He mentioned a patient whose glands began to show new signs of life after 13 sessions. Must have been an impressively determined patient. But in the course of Q&A afterwards, someone asked “If the glands are gone, how could IPL bring them back?” to which he replied that they aren’t “dead”, they’re “dormant” and the IPL “wakes up” the mitochondrion cells.

All that to say, there are opinions and claims and scraps of data here and there as we slowly progress towards knowledge. But I think there’s enough out there to increasingly show how much we DON’T know about meibomian gland atrophy.

The bottom line: We have every reason for hope.

It does not make sense to give up hope of recovery when we clearly know so very, very little still.

Even the very best experts in the field have limited knowledge about what an atrophied meibomian gland is, and when and exactly how you can know if a gland is past hope or not.

Dry eye and meibomian gland disease are emerging areas of medicine. There’s a lot way to go, and a lot of hope to be had.