MGD at AAO
I talked about how dead is dead when it comes to meibomian glands, and shared a lot of notes about IPL for MGD. I’m going to try to cram everything else of interest about MGD at AAO (American Academy of Ophthalmology, 2019 / San Francisco) into this post.
Probing
This year’s AAO was actually the first time I’ve ever heard so much about probing during MGD presentations at a conference. Whether I just never happened to be at the right sessions before, or there was an unusual coverage of it at this meeting, I don’t know. In any case, it was very interesting to finally start getting a stronger sense of how probing is viewed in the medical community and how it seems to be fitting into some of the dry eye specialty practices.
As with SO much else in the MGD world, it’s very important to note that probing is emerging medicine with very little track record in terms of published science. It’s very much driven by patients that are very, very uncomfortable and the doctors pioneering ways to help them. It will take time for things to settle down and patterns to emerge.
Random thoughts, observations and highlights to follow.
On the nature of “selection bias” and other matters
By the end of the conference, I found myself reflecting on the extraordinary experts teaching these classes. They are the doctors that many people come to only after they have already “been everywhere” and “done everything”. They are uniquely equipped to help and they have been exposed to so many people with challenging dry eye and MGD conditions. Several of them mentioned either how many things their patients had already tried, or how many doctors their typical patients had already been to.
Here’s a random thing I wondered about. If a doctor sees mostly exceptions rather than rules, what does that do to their perspective? I’ll just let that one sit awhile and circle back to it another day.
Then I found myself thinking about some of the implications of so often being the umpteenth doctor. For starters, have the patients really already done everything? As patients, when we feel we’ve done everything, we can be pretty impatient. We do not want to repeat things we’ve already done, and we aren’t necessarily too keen on variations on a theme. But… what does it mean when we say we’ve “done” something? Say, warm compresses? One person’s warm compress is a washcloth that they re-heat several times. Another’s is a Bruder bag. Another’s is a USB heat pack for 20 minutes. Applies, oranges and bananas. And so on down the line. You may say you’ve done lid scrubs but… what type, how often, and for how long? How do we really know we exhausted a potential therapy, if we haven’t been methodical about it? Food for thought.
On the nature of a boutique medical procedure, and probing
When it comes to specialty eye (and presumably other medical) procedures, there is a predictable pattern to how doctors relate. They can usually be readily identified as one of the following:
The pioneering guru. In probing, that’s Steve Maskin.
The coterie of enthusiastic true believers, who may or may not agree with the guru about the details but have definitely adopted the practice as a core therapeutic modality for their patient base. In probing, these are the ones for whom probing is the advanced treatment of choice for the vast majority of ‘stubborn’ MGD. Some of them may move ahead with ‘mechanical’ treatment with or without spending time on medication-based treatment.
The dispassionate “thanks, now I have yet another tool among others in my toolbox” adopters. These ones may use Lipiflow, IPL and/or others as well, and aim to suit the find the ‘niche’ for each.
The “thanks, but I’ll wait for more scientific evidence” conservative observers. These ones may have another in-office treatment, or may be relying more on conventional treatments, drugs, heat, manual expression, etc.
The naysaying disbelievers. Some are outspoken, most are silent. They may have concerns about disadvantages, whether risks or the inconvenience and discomfort to patients, or they may just not be convinced results are good enough. There is also a distinct school of thought that feels MGD in general does not warrant the attention it is getting and that focusing exclusively on MGD treatments is not often in a patient’s interest. (Every so often I raise my hand and confess to strong sympathies in that direction.)
The oblivious and/or indifferent masses. Because let’s face it, in the great big dry eye world, a tiny minority are using any kind of specialty dry eye treatment, let alone specialty MGD treatment.
Now about probing (finally):
You can google at least as well as I can, but there are studies about probing published in 2010, 2015, 2016 and 2019, and it is discussed in section 3.2.3.4 of TFOS DEWS II Management and Therapy report.
Gurus and true believers are always pretty readily identifiable but what I felt I got a better sense of at this conference was the “another tool for the toolbox” crowd. They are a bit more my speed, as I always tend to shy away from exclusive approaches or those that claim very high success rates. As we all know, this dry-eye-and-mgd critter is easier to address clinically than it is to remedy symptomatically - that is, it’s hard to predictably make people feel better, even if you can improve their test results.
Anyway, as I was saying, probing seems to be finding its place a more broadly in specialty MGD care, though each specialist has their own angle and their own feelings about WHEN best to employ it. All agree that you need to look for certain signs of gland obstruction - but some see those signs in most of their patients, and some seem them in only a few, reserving probing for only their worst cases. Dr Tauber insisted that obstruction is not always a perfectly straightforward determination, but felt that in general, probing is second only to lid hygiene in its potency to treat MGD. Some doctors are guided more by patients’ symptoms: if they’re still feeling bad after doing everything else, they’ll probe. One mentioned using lipiflow more for lipid quality issues, probing more for obstruction.
Then there’s the question of HOW. Dr Maskin describes meibography guided probing, while another doctor described probing all the glands he could see orifices for. Some debride before probing. Some do two sequential treatments within a couple of months (Dr Tauber, for example, believes “two does more than one”), some just one. Some repeat at a year, some sooner depending on the patient’s condition. There was a lot of discussion about the compounded (including at least one proprietary) solutions for anaesthetizing. Some combine it with other procedures - Dr Mina Massaro Giordano mentioned probing selectively after IPL for abnormal glands.
Why do I mention all this? Because on dry eye social media, there are so many people seeking after the “right” way to do it. People, there isn’t a right way. Every doctor has their experience and opinions and they’re entitled to hold their opinions based on their experiences. So at the end of the day, it’s more about deciding who you trust.
“Does it work”? The real bottom line - that always has a nuanced answer. For “mainstream” MGD - if I can call any of us that! - some doctors claim very high success rates with probing (as others do with other modalities). Me, of course, I’m skeptical of high success rate claims because I am a magnet for all of the “exceptions” - but also because I rarely see well documented, compelling, symptom-centric results analysis. Show me da numbers :)
What I find much more interesting and compelling is the information emerging about specific conditions. For example, Dr Perez talked about probing for cicatricial pemphigoid specifically. During Q&A, Dr Maskin talked about especially good results for recurrent chalazia patients - that they did not have recurrence after probing. I’m looking forward to more insights like these.
I also found a couple of the patterns Dr Maskin described suggestive - certain patients that experience immediate relief (he likened it to bowel obstruction) versus others that have less relief initially, but more over the course of three months following treatment. These types of things are very important for doctors to communicate - and for patients to listen to - before undergoing expensive and potentially uncomfortable procedures. Best to ask lots of questions about where to set your expectations.
Finally, one point I enjoyed was Dr Tauber describing how he will choose a specific symptom metric for a specific patient, on the basis that each of us is different. I think that’s really heading in the right direction, although based on our community survey data to date, I do not feel that a single symptom will ever be enough to measure. In our survey, participants reported an average of 14 different symptoms and at various rankings but relatively few had only one symptom that they ranked as primary. However, we have a long ways to go when it comes to developing useful language for symptoms.
Oh, and one last note. I scribbled something in my notes about Dr Hamrah saying 1 in 10 patients were able to get probing covered by insurance. Don’t quite me.
MGD and drugs, etc.
One of the MGD talks I enjoyed most was from the sole presented with no financial disclosures. It’s always refreshing to see that. Often there’s an entire slide full (sometimes small print), sometimes a tiny handful, less often none at all. Anyway, this particular presenter was Ahmad Kheirkhah.
He walked us systematically through the range of treatments from heat and hygiene (on which he didn’t go into detail as most of his patients have already done this without success) to lipid-containing tears to topical and systemic antibiotics. My take-home from that after he walked through studies was that topical is as good as or better than oral so why not stick with topical? He was the second presenter I heard from during the event that is not particularly in favor of oral doxycycline.
Then he discussed Restasis and Xiidra, and showed the inconsistent data on Restasis’ success. He said he uses it for MGD only if there is chronic mild inflammation. He did not feel there was enough data to support the use of Xiidra in MGD. He walked through steroid (very limited usefulness), topical tacrolimus ointment (compounded, he would use it more if it were available in the US), androgens (too little data) and diquafosol (again, not available here) then a variety of other things. He went into quite some detail on demodex, which he only treats if someone doesn’t respond to other treatments and also has cylindrical dandruff. There was more, but that’s about where my notes failed me.
MGD quotes
“This is a physical therapy disease"…”
V. Perez
"Don’t give up on a gland that appears to be atrophic. Maybe cells… that aren’t visible can restore functionality and secrete meibum.”
S. Maskin
Miscellaneous scraps of notes
In general, there seems to be agreement from the podium that specialty dry eye & MGD practices have to be cash pay. (Sigh.)
I enjoyed a discussion with a dr at my table who pioneered radiofrequency for MGD and intend to learn more about it.
There was a presentation in the MGD session about oral treatments and nutraceuticals. The bottom line with the nutraceuticals - no matter how much or little science we look at seems to be that doctors believe it is “likely beneficial” therefore they recommend it. Underscoring yet again why the whole fish oil thing is frustrating to me. I mean fine, it’s good for us, let’s take it, but let’s not pretend this is science.
I know there was more, but I think this is about all I’m going to squeeze out of my notes for now. I have one more post to go, from the pain session at AAO, and I hope to get that posted tomorrow morning.