Reviewed by Juan F. Batlle, MD
Santo Domingo, Dominican Republic—Lid therapy using a specialized instrument (Batlle Forceps) for mechanical compression of the meibomian glands is effective for improving the signs and symptoms of dry eye disease in patients with obstructive meibomian gland dysfunction (MGD), said Juan F. Batlle, MD.
Dr. Batlle, medical director Centro Laser, Santo Domingo, Dominican Republic, evaluated the technique in a pilot study that enrolled 11 patients who had between 10 and 30 obstructed meibomian glands.
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Individuals with atrophic MGD or having an inflammatory component to their lid margin disease were excluded as were patients with rosacea or chronic blepharitis due to seborrhea.
Lid therapy protocol
The lid therapy protocol involved application of warm compresses over the eyes for 30 minutes, deoperculation of the meibomian gland orifices, and massage of the lid margins using the forceps designed by Dr. Batlle. Each patient underwent three in-office treatments performed at an interval of 2 weeks between sessions.
Overall, outcomes evaluations showed reduction in the number and percentage of obstructed glands and improvements in meibum quality and measures of tear film quality and stability after just a single treatment.
These endpoints continued to improve with each successive treatment, and patients also benefited with improvement in a range of dry eye-related symptoms.
Final assessments performed after three treatments showed all patients had fewer than ten obstructed glands, and the mean percentage of obstructed gland per patient had decreased from about 70% to about 25%.
Expressed meibum was clear and oily in all patients, mean tear meniscus height doubled from 0.4 mm at baseline to 0.8 mm, and mean tear film break-up time increased from 5 to 12 seconds.
“Evaporative dry eye caused by MGD is the most frequent type of dry eye disease and a cause of numerous complaints in affected patients,” Dr. Batlle said. “Early treatment to relieve meibomian gland obstruction is important to avoid future atrophy of the gland.”
Compared with other methods for lid therapy, use of this simple tool to encourage mechanical drainage of obstructed meibomian glands is simple and relatively inexpensive, he noted.
“Experience using it in this pilot study and in a larger follow-up investigation shows it is an effective method for improving meibum flow and restoring normal tear film stability,” Dr. Batlle said. “Longer term follow-up is now needed to evaluate the duration of the treatment effect.”
How therapy works
Application of the warm compresses is performed with the patients lying down. Each eye is covered with a small warm towel or gel packs, and the compresses are exchanged every 5 minutes in order to maintain a temperature of about 40º C.
Prior to forceps massage, the lids are lubricated with lidocaine gel and the operculum removed using a “hockey stick” tool.
The forceps designed by Dr. Batlle has a chalazion-like platform on the arm facing the cornea, a scleral depression, T-shaped tip on the opposing arm, and a safety stop mechanism that prevents excessive pressure to the tarsus and glands.
The tool is used to massage the upper and lower tarsi in a vertical direction by initiating compression of the tarsus in the fornix and moving with gentle pressure to the meibomian gland, sliding the forceps in the direction of the gland orifices.
The massage is repeated three times on each upper and lower lid, beginning by moving from nasal to temporal and then reversing direction two times.
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“During the first pass, the expressed meibum will have a white toothpaste-like appearance, but it will become more oily and clear with each pass,” Dr. Batlle said.
Patients may experience some discomfort during the massage, particularly if there is any inflammation of the lid margin.
“However, in our experience, a very small minority of patients complain, and almost patients we have treated say they would undergo the procedure again if necessary,” he said.
After the massage, patients wash the eyes to remove the lidocaine gel and continue using their topical treatments for MGD.
“In a larger series of 50 patients treated with the massage protocol, the only adverse events encountered were single cases of lidocaine allergy and corneal abrasion requiring patching for 24 hours,” Dr. Batlle said.
The abrasions are avoided by having the patient look away from the lid being massaged. Patients are instructed to look down for the upper lid massage and look up when the lower lid is being treated.
Dr. Batlle noted that although MGD is the most common cause of dry eye disease, it is frequently overlooked by busy clinicians.
“When evaluating a patient with complaints associated with dry eye disease, it is critical to assess the meibomian gland orifices to determine if they are open, whether there is evidence of inflammation, and to characterize the quality of the gland secretions,” he said.
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In addition to undergoing the meibomian gland compression protocol, all patients with obstructive MGD are started on a regimen that includes, oral supplements of omega-3, topical cyclosporine A, artificial tears during the day, and a methycellulose gel-based lubricant at bedtime.
Juan F. Batlle, MD
This article was adapted from Dr. Batlle’s presentation at the 2015 meeting of the American Society of Cataract and Refractive Surgery. The Batlle Forceps was developed in coordination with Dr. Batlle.