Education:

Dr. Muller and her staff place a huge emphasis on education. They spend a lot of time explaining your diagnosis, treatment options, and what you can do to have the healthiest, most comfortable eyes and eyelids, and maintain your best vision, always.

Eyelid Hygiene:

Twice each day, in the morning and in the evening, you should apply warmth to your closed eyes for 20 minutes. Warmth is best applied using the Wizard Research Electric Heated Dry Eye Mask. Gel packs, heat masks (Optase, Bruder, other) which are heated in a microwave, and washcloths, are not as effective or convenient. This application of heat against your closed eyelids serves to loosen, or soften, the contents of your meibomian glands.
This application of warmth should be followed immediately by washing your eyelids, either at the sink or in the shower. Washing your eyelids immediately following the application of heat will wash away the contents of your meibomian glands which you have loosened or softened, wash away bacteria that tends to gather at the base of your eyelashes and eyelids, and mechanically milk, or massage your glands to keep their contents flowing. This is best accomplished by closing your eyes and using gentle soap and water to “shampoo” your eyelashes/eyelids for a full minute (which is a very long time with your eyes closed). You can simply use your face soap or bar soap. If you strongly prefer to use a towelette, Optase is Dr. Muller's favorite.
In person, Dr. Muller and her staff will teach you how to perform "eyelid hygiene" optimally, including massaging the oil secreting glands in your eyelids (meibomian glands). Eyelid Hygiene

EYELID CLEANSING IS ANALOGOUS TO BRUSHING YOUR TEETH

Most of us know that brushing our teeth prevents the accumulation of plaque, and the development of cavities and gum disease. Another part of your daily hygiene should be taking the time to clean your eyelids and eyelashes. Cleaning your eyelids removes debris that can build up over time causing obstruction and loss of your meibomian glands, known as meibomian gland dysfunction (MGD). Prevention of MGD using early detection and intervention is essential to the long-term health and comfort of your eyes.

Preservative Free Artificial Tears:

One drop instilled proactively into each eye 4-8 times each day.

Some artificial tear options include preservative free: OCuSOFT Retaine MGD, NanoTears MXP Forte, NanoTears TF, Systane Ultra, TheraTears, Refresh Optive Advanced, Soothe, GenTeal Lubricant Eye Drops for Mild to Moderate Dry Eye.

Omega-3 fatty acid supplements, in addition to a diet rich in Omega-3s:

Omega-3 supplements should be purified and from re-esterified triglyceride EPA and DHA. Please note that 3000 mg/day are recommended.

https://prnomegahealth.com/products/dry-eye-omega-benefits/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975557//

Manuka Honey – Optimel brand:

Manuka honey has both natural antibiotic and anti-inflammatory properties. Dr. Muller is always looking for natural ways to treat ocular inflammation (i.e., dry eye, meibomian gland dysfunction, blepharitis, ocular rosacea). Since these conditions are chronic Dr. Muller would rather lean on natural treatments rather than medications.

Dr. Muller recommends Manuka honey in two forms: drops and gel.

Manuka honey eye drops consist of 16.5% honey and contain a food preservative (Benzoic acid). We recommend our patients use these drops four times each day.

Manuka honey gel consists of 98% honey and are preservative free. We recommend our patients apply the gel to their eyelids one to two times each day.

Manuka honey products can sting or burn. The stinging/burning can last for seconds or minutes. This usually dissipates over time.

N-acetylcysteine (NAC):

N-acetylcysteine is an acetylated derivative of the natural amino acid, l-cysteine. It has both antioxidant and mucolytic properties. N-acetylcysteine reduces inflammation by modulating the inflammatory process.

Topical 5% N-acetylcysteine eye drops have been shown to be effective in treating Meibomian gland dysfunction and dry eye resulting in significant improvement in patients’ symptoms.

Prescription Medications:

Depending upon the severity of your meibomian gland dysfunction the following medications may be prescribed by Dr. Muller:

Antibiotic ointment at bedtime
Antibiotic eye drops massaged into the base of your eyelashes at bedtime. These antibiotic eye drops also have anti-inflammatory properties and have proven to be an effective treatment for blepharitis, ocular rosacea, meibomian gland dysfunction, styes, chalazia and dry eye by relieving symptoms, while enhancing the overall health of the eyes and eyelids.
Antibiotics by mouth (doxycycline, tetracycline, minocycline, etc.)
Restasis, Cequa, and/or Xiidra
Mild steroid drops such as Alrex, Inveltys, Flarex, FML, or Lotemax
Miebo (perfluorohexyloctane ophthalmic solution) prescription eye drops four times daily. These drops mimic the meibomian gland secretions reducing the rate of evaporation of your tears from the surface of your eyes. This is especially important while engaged in visually intense tasks such as watching television, driving, reading hard copy, the screens on your devices, and/or your computer.
Other

Dr. Muller Recommends Using a Nanodropper:

The use of a Nanodropper Adaptor on your eyedrops to reduce the eyedrop volume released each time you use your eyedrops. This reduces cost, waste, and the mess of excess drops running down your face. https://nanodropper.com/

Mechanical Treatments

Blepharoexfoliation: Golf Club Spud Exfoliation

Blepharoexfoliation, or exfoliation of the eyelids, unclogs or uncaps your meibomian glands at their openings called orifices. This has proved to be an effective treatment for blepharitis, ocular rosacea, meibomian gland dysfunction, styes, chalazia, and dry eye by facilitating the ongoing flow of the oils from the meibomian glands.

This enhances the health of your eyes, eyelids and meibomian glands and makes you much more comfortable.

A numbing drop is placed in each eye prior to treatment. Using a handheld instrument known as a golf club spud Dr. Muller painlessly cleans and exfoliates your eyelids removing keratin, debris and the biofilm* plugging, or blocking, the openings of your meibomian glands.

After the procedure, you are instructed as to how to maintain the benefits. The procedure is typically repeated at intervals which vary based upon each person’s individual needs.

MicroBlepharoexfoliation (MBE) using BlephEx:

BlephEx™ is a comfortable in-office procedure performed by Dr. Muller using a revolutionary new patented medical device which employs a high speed rotating micro-sponge to deep clean and exfoliate your eyelids and eyelashes, removing dandruff, scurf, debris and the biofilm* plugging, or blocking, the openings of your Meibomian glands.

This procedure an effective treatment for blepharitis, ocular rosacea, meibomian gland dysfunction, styes, chalazia, and dry eye. It enhances the health of your eyes, eyelids and meibomian glands.

A numbing drop is placed in each eye prior to treatment. The procedure lasts about 6 -8 minutes, is comfortable and soothing. Most patients simply report a tickling sensation.

After the procedure, you are instructed as to how to maintain the benefits. The procedure is typically repeated at intervals which vary based upon each person’s individual needs.

iLux:

iLux is a handheld medical device which gently and comfortably heats your eyelids to a safe, therapeutic temperature which softens the contents of your meibomian glands. Once the contents are softened, manual pressure is applied to your eyelids to unblock, clean out, and evacuate the contents of your glands. iLux treatments can be customized to optimize your results by applying more compressions combined with a longer heating time in the areas where you need it the most.

iLux is an effective treatment for blepharitis, ocular rosacea, meibomian gland dysfunction, styes, chalazia, and dry eye. It enhances the health of your eyes, eyelids and meibomian glands. It makes you much more comfortable by reducing your symptoms.

Not all LipiFlow Treatments are Created Equal: Dr. Muller’s Unique Approach

The results achieved by Dr. Muller’s patients from LipiFlow treatments performed in her office have proven significantly more effective and longer lasting when compared with the results from LipiFlow procedures performed elsewhere.

This is due to Dr. Muller’s thoughtful and intensive methodology which consists of a unique pre-LipiFlow treatment process including blepharoexfoliation to uncap or unclog your meibomian gland orifices (the glands' openings in your eyelids). Immediately after your LipiFlow treatment Dr. Muller manually expresses any remaining contents from your glands, all of which is followed by her exclusive, proprietary post-LipiFlow treatment protocol.

Dr. Muller participates in each LipiFlow procedure performed in her office (the procedure is not simply performed by a technician).

It is these distinct differences, combined with the extensive education that each patient is provided, that ensure that Dr. Muller’s patients receive the most effective and longest lasting results from their LipiFlow treatment.

LipiFlow:

LipiFlow is the “gold standard” for treating meibomian gland dysfunction, blepharitis, ocular rosacea and dry eye. This is because LipiFlow is the most effective way to unclog and evacuate your meibomian glands. LipiFlow is an FDA-cleared electronic medical device that removes meibomian gland blockages and restores gland function. Through advances in the application of Vectored Thermal Pulsation (VTP) technology, the LipiFlow treatment utilizes a patented algorithm of heat applied comfortably to your eyelids, followed by massage, to remove the obstructions and evacuate the contents of your glands. This deep cleaning allows the meibomian glands to resume proper oil production and flow, once again contributing the oil layer to your tear film. The entire treatment takes approximately 12 minutes, is comfortable and is extremely effective.

A frequently asked question about iLux and LipiFlow treatments is "How often will I benefit from/need one of these in office deep heat treatments?" The answer is twofold: Dr. Muller explains that most all medical conditions exist on a spectrum. You can have mild, moderate, or severe diabetes, hypertension, meibomian gland dysfunction, blepharitis, or ocular rosacea. You have limited control over this. The part of the equation over which you do have control is your compliance with the home care/maintenance Dr. Muller recommends. People who follow Dr. Muller's instructions go for much longer intervals, or periods of time, between heat treatments because the home care is designed to keep your meibomian glands flowing (and keep them from clogging). After a deep cleanse is performed in our office each patient is given a proprietary regimen which Dr. Muller has developed over decades and continues to hone. Part of this regimen includes, but is not limited to, using the Wizard electric heat mask twice daily for 20 minutes at a time followed immediately by proper eyelid cleansing (which we teach in our office). By using the Wizard mask to apply the highest heat you can tolerate (without hurting yourself) to your closed eyelids you loosen, or soften, the contents of your meibomian glands. This should be followed immediately by proper lid hygiene which washes away the contents of the meibomian glands you just loosened or softened, washes away the bacteria which tend to gather at the base of your lids and lashes, and mechanically massages, or milks, your meibomian glands keeping their contents flowing.

Meibomian Gland Probing (MGP):

A safe, effective, restorative treatment.

Meibomian Gland Probing (MGP) is a safe and effective procedure for treating Obstructive Meibomian Gland Dysfunction (OMGD).

What is Obstructive Meibomian Gland Dysfunction (OMGD) and how does it differ from “traditional” Meibomian Gland Dysfunction (MGD)?

In “traditional” Meibomian Gland Dysfunction (MGD), the meibomian glands are clogged; in Obstructive Meibomian Gland Dysfunction (OMGD), the meibomian glands are mechanically obstructed or blocked.

There’s a distinct and very important difference between the clogged meibomian glands seen in “traditional” Meibomian Gland Dysfunction (MGD) and the mechanically obstructed meibomian glands seen in Obstructive Meibomian Gland Dysfunction (OMGD).

In “traditional” Meibomian Gland Dysfunction (MGD) the oils inside the meibomian glands become thickened or viscous, clogging the glands and resulting in back pressure which stresses the glands, causing the glands to shorten, atrophy, and ultimately be lost. These cases can typically be successfully treated with natural remedies, medications, and the application of heat at home, coupled with proper lid hygiene. These treatment modalities are often followed by an in-office deep heat treatment known as a LipiFlow, iLux, or TearCare which involves the (comfortable) application of heat and pressure to liquify and express the contents of the meibomian glands, thus cleaning the meibomian glands out. LipiFlow, iLux, and TearCare treatments are extremely effective at melting and expressing the contents of the glands, thereby allowing the meibomian gland oils to flow freely into the tear film again. Unless there are mechanical intraductal or periductal obstructions or blockages.

Obstructive Meibomian Gland Dysfunction (OMGD) is Meibomian Gland Dysfunction with either fixed, focal intraductal mechanical obstructions (thickened meibum, cellular debris, and/or fibrous tissue) or periductal fibrosis, resulting in blockage of the meibomian gland ducts. These blockages obstruct the flow of oils, creating increased pressure behind the blockages. This pressure can result in lid tenderness and inflammation, gland shortening, atrophy and loss, recurrent eyelid infections, and the classic symptoms of ocular irritation associated with dry eye, meibomian gland dysfunction, blepharitis, and ocular rosacea.

Obstructions can occur at various points in the glands, allowing glands to be partially functional and secreting some oil, or entirely blocked. This is why some glands may produce a little oil, but still not be healthy.

The above referenced medical treatment and in-office heat procedures used to clear clogged glands when treating patients with traditional Meibomian Gland Dysfunction (MGD) will not provide sufficient relief for meibomian glands with fixed obstructions found in patients with Obstructive Meibomian Gland Dysfunction (OMGD). The obstructions must first be removed or released so the patient can obtain relief from his/her symptoms, and to halt the progression of the damage to, and loss of, his/her meibomian glands. That’s when meibomian gland probing becomes invaluable.

If the meibomian gland obstructions are not mechanically cleared the condition will progress. While symptoms can be episodic, the ongoing irritation, inflammation, and back pressure from the process can result in cumulative, irreversible damage to the meibomian glands, the eyelids, and the surface of the eyes.

How is Obstructive Meibomian Gland Dysfunction Diagnosed?

An obstructive component must be suspected when the standard, traditional, first line medical treatment modalities for meibomian gland dysfunction have been employed, however, have failed to provide sufficient relief and improvement. The clinical diagnosis of Obstructive Meibomian Gland Dysfunction (OMGD) should be considered in a patient who is not getting the expected response having exhausted standard meibomian gland treatment, continues to have progression of the condition, continues to have symptoms and/or signs of the condition, or continues to have recurrent infections of the eyelids (styes, hordeola, chalazia, cellulitis, etc.).

In this situation, Dr. Muller may suggest a Diagnostic Meibomian Gland Probing to obtain additional information. During Diagnostic Meibomian Gland Probing, Dr. Muller probes an area of your meibomian glands to determine if mechanical obstructions are present. Such probing can establish the diagnosis of Obstructive Meibomian Gland Dysfunction (OMGD).

How Does Meibomian Gland Probing Work/Help?

Meibomian Gland Probing (MGP) effectively treats Obstructive Meibomian Gland Dysfunction (OMGD) by mechanically clearing the obstruction or blockage of each gland’s lumen, or releasing the periductal cinching of the gland, thus restoring the integrity and patency of the glands’ central ducts. This improves gland form and function, improves the flow of oil secretions, equilibrates intraductal pressure, relieves symptoms, and can stimulate regeneration of damaged and missing glands.

Meibomian Gland Probing followed by a deep heat treatment which clears the glands, allowing oil secretions to flow freely into the tear film (outermost sealant layer of the tear film) relieving symptoms of ocular irritation and dryness.

How is Meibomian Gland Probing (MGP) Performed?

Meibomian Gland Probing (MGP) is a comfortable in-office procedure. The procedure is performed using a combination of topical anesthetic drops and surgical grade anesthetic ointment applied directly to the eyelids.

Once the eyelids are anesthetized, Dr. Muller gently exfoliates all four eyelids to uncap, or unclog, the meibomian gland openings (orifices) located along the eyelid margins.

Next, ultra-fine specially designed intraductal meibomian gland probes of varying lengths are delicately passed through the natural openings of the glands and into the meibomian gland ducts to physically unclog them. Resistance from obstructions is typically encountered. With a bit of additional advancement of the probe a (painless) “pop” can be felt and heard by both the patient and Dr. Muller. The successful popping through and release of the obstruction confirms the presence of Obstructive Meibomian gland dysfunction (OMGD) and restores the patency of the gland duct.

There are approximately 30 oil glands (meibomian glands) per eyelid; each should be probed to obtain maximum relief of symptoms and protect against ongoing progression of damage.

Once Meibomian Gland Probing (MGP) has mechanically relieved the intraductal and periductal obstructions and re-established the patent outflow channels of the meibomian glands, a LipiFlow treatment is performed to completely clean out, or evacuate, the meibomian gland contents. Patients are then placed on a medical regimen which combines the use of various topical antibiotic and anti-inflammatory medications to optimize the results. Additionally, patients are instructed regarding an at home treatment regimen designed to maintain the benefits of their Meibomian Gland Probing (MGP) and avoid the development of future obstructions.

Meibomian Gland Probing (MGP) of all four eyelids takes about 30 minutes and is followed by a 12-minute LipiFlow procedure. Patients typically return to work immediately with no downtime.

Outcomes:

Patients experience maximum symptomatic relief, with the longest lasting results, along with protection against ongoing progression of damage when they have undergone intraductal Meibomian Gland Probing (MGP) of all four eyelids, plus a LipiFlow treatment, followed by the aforementioned medical regimen and home maintenance program.

It has been reported in the medical literature that 92% of patients experienced immediate relief of their symptoms, and that all patients experienced relief by four weeks after probing.

The reported lasting relief of symptoms is thought to be due in part to the re-establishment of meibomian gland orifice and central ducts after the removal of debris and obstructions. This allows the meibomian gland oils to flow freely again. There are also reports in the medical literature of Meibomian Gland Probing being associated with regrowth of damaged meibomian glands upon mechanical re-establishment of patent orifices and duct systems, and the regeneration of missing or atrophied meibomian glands secondary to the promotion of glandular regeneration via stem cell stimulation, activation, and cellular proliferation.

How Frequently Do Meibomian Glands Need to be Probed?

Inflammation is known to contribute to the formation and reformation of meibomian gland obstructions. As a result, all sources of irritation and inflammation of the eyes and eyelids should be identified and properly treated to minimize the possibility of the meibomian glands becoming obstructed again.

The specific answer to the question regarding the frequency with which any given patient would benefit from repeat meibomian gland probing is multifactorial and unique to that individual, and based on a variety of factors which include:

Does that patient have coexisting ocular surface issues such as dry eye, environmental allergies, ocular rosacea, blepharitis, Demodex, etc. contributing to the irritation and inflammation of his/her eyes and eyelids?

If the patient has any of the above coexisting conditions, are the conditions mild, moderate, or severe?

Are these coexisting conditions being treated?

How compliant is the patient with the medical regimen/treatment Dr. Muller has placed him or her on?

Does the patient remain completely comfortable and asymptomatic, or has he/she started to have symptoms again?

On objective diagnostic testing in the office, is there evidence of progression of meibomian gland dysfunction, or have we been successful at halting the progression of the condition? Is there evidence of recurrent Obstructive Meibomian Gland Dysfunction (OMGD)?

Both initial and maintenance probing are intended to mechanically open meibomian gland orifices and ducts, remove obstructions, maintain patency of orifices and ducts, and restore functionality of glands, thus relieving symptoms of meibomian gland dysfunction, blepharitis, ocular rosacea, and dry eye. In addition, the goal is to halt the progression of meibomian gland dysfunction by specifically stopping the progressive shortening or loss of glands, promoting the recovery of existing damaged glands that are thin and struggling, thereby getting them to plump up again and be robust and healthy, increasing oil production, and potentially stimulating regeneration of missing or damaged meibomian glands.

How Long has MGP Been Around and is it Safe?

MGP has been around for over 15 years. Studies analyzing Meibomian Gland Probing (MGP) focusing on the procedure’s safety and efficacy have been conducted in the United States, Mexico, China, Russia, Cuba, Turkey, India, and Japan; dozens of peer reviewed articles have been published. These studies have shown MGP is a safe and effective treatment for OMGD in patients refractory to standard care as a first-line treatment for meibomian gland dysfunction. In the studies reviewed, 92% of patients treated with MGP benefited from relief of their symptoms when compared with patients in the control groups.

No negative side effects or complications were reported.

***A biofilm is a slimy, sticky film of bacteria that coats the surface of the eyelids. A biofilm is composed of a well-hydrated matrix of bacteria and their glycocalyx, a sugary coating that allows cells to adhere to and communicate with each other. The eyelid margin with its moisture, nutrients and warmth, is the perfect environment to cultivate a thriving bacterial biofilm. Some people experience an increased frequency of accumulation of a tenacious biofilm along their eyelid margins. These individuals benefit from periodic exfoliation of their eyelids to keep their meibomian gland orifices (openings) uncapped of unclogged. This helps to ensure the health of the meibomian glands, and decrease irritation and inflammation, thus keeping the eyes and eyelids healthier and more comfortable.

Diagnosing MGD