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 willwash 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 Video

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.

Prescription Medications:

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

Antibiotic ointment at bedtime
Azasite (azithromycin ophthalmic solution) drops massaged into the base of your eyelashes at bedtime. Azasite is an antibiotic eye drop that also has anti-inflammatory properties. It has been shown to be an effective treatment for both meibomian gland dysfunction and dry eye, relieving the symptoms of both, 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
Other

Dr. Muller Recommends:

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

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.

This procedure treats meibomian gland dysfunction, blepharitis and ocular rosacea, enhances the health of your eyes, eyelids and meibomian glands, and helps with dry eye symptoms.

After the procedure, you are instructed as to how to maintain the benefits of the procedure. 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 treats meibomian gland dysfunction, blepharitis and ocular rosacea, enhances the health of your eyes, eyelids and meibomian glands, and helps with dry eye symptoms.

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 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 most.

This procedure treats meibomian gland dysfunction, blepharitis and ocular rosacea, enhances the health of your eyes, eyelids and meibomian glands, and helps with dry eye 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.

Meibomian Gland Probing:

Meibomian gland probing is a safe and effective technique for treating obstructive meibomian gland dysfunction. The procedure is performed comfortably in our office using a surgical grade topical anesthetic applied to the eyelids.

Probing relieves intraductal obstructions thus re-establishing patent outflow channels within the meibomian gland orifices and ducts.

Probing is performed through the natural gland openings, or orifices, physically unclogging the openings and the ducts of the meibomian glands. Meibomian gland probing mechanically clears the orifices and the ducts from blockage by thickened meibum, cellular debris, and fixed fibrotic obstructions thus allowing the oils to flow freely again. Having the oils flowing freely again improves the health of both the surface of your eyes, and your meibomian glands, decreasing irritation and inflammation, thus alleviating eye and eyelid discomfort.

We have found that our patients experience the best and longest lasting results when we combine intraductal meibomian gland probing followed immediately by a LipiFlow treatment. The principle is that once the meibomian gland orifices and ducts are mechanically opened via probing (which establishes patent outflow channels) a LipiFlow treatment can be performed to liquify or melt any remaining contents in the glands then express them.

It has been reported in the medical literature that most patients (24 of 25 cases, or 96%) experienced immediate relief of their symptoms, and that all patients experienced relief by 4 weeks after probing. Lasting relief of symptoms due to the reestablishment of orifice and central ducts, and removal of debris, by probing has also been reported.

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.

Following probing Dr. Muller typically combines the use of various topical antibiotic and anti-inflammatory medications to optimize your results.

Meibomian gland probing has also been reported to be associated with regeneration of missing, or atrophied, meibomian glands by promoting glandular regrowth/regeneration in part by mechanically re- establishing a patent orifice/duct system.

***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 Ocular Rosacea