Meibomian gland disorder knowledge Ophthalmology ppt

Mgd

1. MEIBOMIAN GLAND DYSFUNCTION AND BLEPHERITIS Dr. Ashna Mohanan Department of Ophthalmology, GMC Surat

2. Glands of the Eyelid

3. Gland of Zeis 1. Sebum exhibits self-sterilizing properties, which affects the viability of some kinds of bacteria. 2. Secreted lipid contains vitamin E, it prevents the aging process and helps maintain a healthy skin barrier. 3. Glycerol produced in the pilosebaceous follicle plays a role in skin hydration. 4. Dysfunction causes insufficient hair cell function.

4. Gland of Moll The moll gland has positive immunohistochemical reactions by producing secretory components, such as immunoglobulin A, mucin 1, and lysozymes in the glandular cells. This suggests that the moll gland is a vital component for immune defense against pathogenic microorganisms in the eyelid and ocular surface.

5. Meibomian Gland Tarsal gland Lipid component of lacrimal fluid Sebaceous gland with holocrine secretion 25 in upper eyelid and 20 in lower eyelid

6. WHAT IS MEIBUM? Mixture of lipids of various classes, including wax esters, cholesteryl esters, (o-acyl)-v-hydroxy fatty acids and their esters, acylglycerols, diacylated diols, free fatty acids, cholesterol, and, in smaller amounts, other polar and nonpolar lipids

7. LIPID LAYER CONSTITUTES POLAR AND NON POLAR LIPIDS 30% OF POLAR LIPIDS ARE SPHINGOLIPIDS WHICH INCREASE IN MGD THEREBY INCREASING METABOLITES OF SPHINGOLIPIDS.

8. MEIBOMIAN GLAND DYSFUNCTION International workshop on meibomian gland dysfunction defines MGD as a chronic, diffuse abnormality of meibomian glands that is commonly characterized by terminal duct obstruction or qualitative or quantitative changes in glandular secretion It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.

9. SYMPTOMS OF MGD

10. SIGNS OF MGD

11. RISK FACTORS AND ASSOCIATIONS 1. Dry Eye Decrease in lysozyme and immunoglobulins causes more bacterial growth MGD causes more evaporation and many patients have coexisting aqueous deficient dry eye

12. 2. Dermatological conditions 95% of patients with seborrheic blepharitis also had seborrheic dermatitis. In patients with a subset of MGD called primary (diffuse) meibomitis, 74% had a seborrheic dermatitis and 51% had rosacea

13. 3. Rosacea Middle aged women Facial flushing and telangiectasia 4. Isotretinoin- Staph aureus 5. Giant papillary conjunctivitis- MGD

14. DIAGNOSIS

15. EXAMINATION Malar skin Eyelids- hyperemia , telegenctesia , scales, ulceration, keratinizaton , chalazion TEAR FILM ANALYSIS - DRY EYE TESTS Cornea with staining Palpebral and bulbar conjunctiva

16. MEIBOGRAPHY Early meibography systems visualized the structure of meibomian glands through illumination of the tarsal plate from the skin side and were thereby able to detect abnormalities in gland morphology. Drawback of contact meibography - small area,sharp and hot edge probe. A normal meibomian gland is approximately linear and 3-4 mm in length, traversing the posterior eyelid perpendicularly from the lid margin to the opposite edge of the tarsus.

17. APPLICATIONS OF NON INVASIVE MEIBOGRAPHY Aging Contact lens wear- morphology as well as function is affected (after 2 years of age) does not deteriorate does not reverse with CL discontinuation for 6 months Allergic conjunctivitis – distortion

18. OCULAR SURFACE ANALYZER Studies the surface reflection pattern and dynamics of the lipid layer of the tear film, thus allowing the measurement of the tear film stability and the thickness of the lipid layer. The device enlights the lipid layer and the pattern defined can be compared with the reference grading scale. Ocular symptom score, lid margin abnormality score, meiboscore , and tear film BUT in decreasing order of importance were valuable for distinguishing MGD from the normal condition, with the combination of these three; symptoms, lid margin abnormalities and meiboscore parameters showing a sensitivity of 84.9% and a specificity of 96.7% for the diagnosis of MGD

19. MEDICAL MANAGEMENT 1. ΑΝΤΙΒΙΟ TICS a) Tetracyclines- Bacteriostatic, anti-inflammatory(main role) Acts on lipases, free fatty acids (proinflammatory), inhibition of MMP, action on neutrophils and lymphocytes b) Azithromycin Topical 1% eye ointment Oral azithromycin 1 gm single dose (14 days)

20. 2. ANTIINFLAMMATORY a) Cyclosporine A 0.05% (Restasis - FDA approved for DED) Calcineurin inhibitor Improvements in lid margin redness, meibomian gland inclusions, telangiectasia, and corneal staining, as well as in the quality of meibomian gland secretions. S/E- Stinging sensation

21. b) Lifitegrast - Lymphocyte function-associated antigen (LFA)-1 antagonist that blocks T-cell binding to intercellular adhesion molecule (ICAM) Available as Xidra 5% - FDA approved for DED

22. 3. CORTICOSTEROIDS - limited studies in MGD Short term use in acute conditions, DED 4. ESSENTIAL FATTY ACIDS - anti-inflammatory Oral supplementation with omega 3 fatty acids

23. DRY HOT FOMENTATION

24. Mechanical intraductal probing Electronic heating devices INTENSE PULSED LIGHT

25. LIPIFLOW- THERMAL PULSATION SYSTEM

26. BLEPHARITIS Blepharitis is a chronic ocular inflammation that involves the eyelid margin primarily and is a common cause of chronic ocular irritation It is among the most common ocular conditions, affecting up to 47% of patients seen in the clinical setting

27. CLASSIFICATION Anterior blepharitis affects the eyelid skin, base of the eyelashes and the eyelash follicles, and posterior blepharitis affects the meibomian glands. Staphylococcal, seborrheic, meibomian gland dysfunction (MGD), or a combination thereof. Staphylococcal and seborrheic blepharitis involve mainly the anterior eyelid and can each be referred to as anterior blepharitis

28. STAPHYLOCOCCAL BLEPHARITIS Scaling, Crusting, Erythema of lid margins and Colarette formation Acute on Chronic - Ulcerative blepharitis Cornea- Punctate erosions, marginal keratitis, peripheral epithelial defects and corneal neo vascularization

29. SEBORRHEIC BLEPHARITIS Greasy scaling of the anterior eyelid often associated with generalized sebborhea that may involve scalp and nasolabial folds Seborrheic blepharitis is often associated with meibomian gland dysfunction in addition to anterior blepharitis

30. ETIOLOGY

31. SYMPTOMS Overlapping Symptoms of DED and ocular surface inflammation,usually worse in mornings. Irritation, redness, discomfort, foreign body sensation Exacerbation of coexisting conditions such as allergic eye disease & aqueous deficient dry eye

32. ROSACEA BLEPHARITIS Hypertrophic sebaceous glands in areas of facial flushing Progresses to plaques and phymatous change at the face Rhinophima is the most advanced stage 30-40 year old

33. MARGINAL KERATITIS 2, 5, 8 and 10 o clock Topical steroids and treat underlying cause

34. DIAGNOSTIC TESTS No specific clinical diagnostic tests for blepharitis. Cultures of the eyelid margins may be indicated for patients who have recurrent anterior blepharitis with severe inflammation as well as for patients who are not responding to therapy. Microscopic evaluation of epilated eyelashes may reveal demodex mites, which have been implicated in some cases of chronic blepharoconjunctivitis Confocal miroscopy

35. EYELID HYGIENE use warm, moist compresses on closed eyelids to clear superficial debris and soften secretions; do this for 5-10 minutes, at least once daily Then clean the eyelid margins carefully and thoroughly; do this using a cotton bud soaked in dilute baby shampoo or sodium bicarbonate, or use a commercial eyelid hygiene kit Incorporate eyelid hygiene into your daily routine, and continue long term to avoid relapse

36. TREATMENT Warm compresses and ocular hygiene Eyelid cleansing, including eyelid massage in cases of MGD to express the meibomian glands Lid scrubs Antibiotics (topical and/or systemic) Topical anti-inflammatory agents ( e.G. , Corticosteroids, cyclosporine)

37. TREATMENT 1. MACROLIDES - anti inflammatory + anti bacterialBroad spectrum, good penetration and prolonged duration of action Oral tetracyclines - dual mechanism of action Oral azithromycin S teroid use for blepharitis should be limited to short-term use for acute exacerbations and should be low potency when possible.

38. ANGULAR BLEPHARITIS Angular blepharitis involves the lateral parts of the lids and is associated with fissuring of the skin at the lateral and median canthus. Similar changes may be seen in patients with severe allergic conjunctivitis. 1. Pathogenesis. The infection is usually caused by Moraxella lacunata or S. aureus although other bacteria and rarely herpes simplex, have also been implicated. 2. Signs Often unilateral red, scaly, macerated skin at the canthus. Associated papillary and follicular conjunctivitis may occur. 3. Treatment involves topical chloramphenicol, bacitracin or erythromycin cream.

39. DEMODE X Most common ectoparasite found on human skin Demodex folliculorum, found primarily in lash follicles, and demodex brevis, found mainly in the sebaceous and meibomian glands of the lids.

40. D. Folliculorum directly damages cells at the base of the hair follicle, causing reactive hyperkeratinization and resulting in the formation of cylindrical dandruff. D. Brevis physically blocks the meibomian glands, resulting in agranulomatous reaction from tissue irritation and thus predisposing to MGD and chalazia

41. Tea tree oil-A one-month treatment of weekly 50% TTO lid scrubs in the clinic and 10% lid scrubs daily at home has been shown to eradicate ocular demodex. Home therapy with daily lid massage and 5% TTO ointment has also been found to significantly decrease mite counts by four weeks and provide significant relief from itching.

42. Phthiriasis palpebrarum An infested person may transfer the lice to another hairy area such as the chest. axillae or eyelids. Phthiriasis palpebrarum is an infestation of lashes which typically affects children living in poor hygienic conditions. Diagnosis 1. Symptoms consist of chronic irritation and itching of the lids. 2. Signs The lice are anchored to the lashes by their claws. The ova and their empty shells appear as oval. brownish, opalescent pearls adherent to the base of the cilia. Conjunctivitis is uncommon.

43. Treatment 1. Mechanical removal of the lice and associated lashes with fine forceps. 2. Topical yellow mercuric oxide 1% or petroleum jelly applied to the lashes and lids twice a day for 10 days. 3. Delousing of the patient, family members, clothing and bedding is important to prevent recurrences.

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