Pop, Gritty, and Probe

Not A Dry Eye Blog
Pop, Gritty, and Probe

If you’ve had your meibomian glands probed, you probably remember hearing loud “pops” as the probe pierced through a band of fibrotic tissue (periductal fibrosis) somewhere along the length of the gland. Or it could have felt as if the probe was passing through several bands of fibrotic tissue, producing a gritty sensation and a sound like a short machine gun round.

Of course there was no machine gun. Periductal Fibrosis MGD

The pop was just amplified in your head, the way a tuning fork can seem very  loud when it’s held up to your ear, or the way flossing your teeth can seem very loud, but only to you.

The doctor can also feel the fibrosis with the probe as it meets resistance. And he feels a “pop” or something “gritty” when the probe pierces through.

Pop, Gritty, and Periductal Fibrosis

Given how many of us who have been probed have heard and felt “pop” and “gritty,” it’s puzzling that a recent paper published in Bio Med Central Ophthalmology completely misses this essential aspect of meibomian gland physiology and dysfunction (MGD).

The paper claims that evaporative dry eye is thought to be caused by “ductal hyperkeratinization, plugging and obstruction” but doesn’t discuss the role of periductal fibrosis in MGD, something that hyperkeratinization may cause indirectly through obstruction and meibum stasis (stagnation) with inflammation.

(Keratinization is the production of keratin, a protein, by ductal epithelial cells. In meibomian glands, this happens in the cells lining the ducts and at the opening. Hyperkeratinization refers to an excessive production of keratin by these cells. Too much keratin blocks the normal flow of meibum, leading to obstruction, stagnant meibum, inflammation, and eventually periductal fibrosis).

We’re not disputing the fact that hyperkeratinization occurs in meibomian glands. It does. But missing is what it may cause, or what may develop concurrently, from any cause of inflammation – periductal fibrosis. Missing periductal fibrosis means missing an essential fact of MGD, a fact that can alter greatly diagnosis and, ultimately, treatment.

Because if you don’t accept that there’s fibrotic tissue inside the gland, which can be caused by numerous factors that involve inflammation, you’ll never comprehend why probing is an essential treatment. You’ll believe that all you need to do is clear the stagnant and hyperkeratinized cells with warm compresses and lid massage. And you’ll completely miss the fibrotic tissue that can neither be heated, nor massaged, away.

That fibrotic tissue requires a completely different treatment approach – a tiny probe the width of a hair to pierce it.

Send your comments to blogger@notadryeye.org

Pop, Gritty, and Probe” is very interesting. Does the probing take care of the problem forever or is it necessary to repeat it and how often? Can the block be prevented or at least its build-up slowed down? If so, is there a self-help approach that the doctor could recommend?
Walter, New York

Walter, we posed your question to Dr. Steven Maskin. He said:

Probing establishes that the meibomian gland duct is opened. Repeating the procedure is not always necessary, but this depends entirely on the patient and any other conditions or co-morbidities they may have which creates inflammation leading to periductal fibroses and re-obstruction. Our studies show that about 33% of lids are reprobed at an average of 18 months with 67% reprobed at average greater than 2 years. Any other conditions that may cause inflammation of the meibomian glands should also be treated at the same time, including aqueous tear deficiency, or allergies that may require topical treatments, infections, or infestation by demodex mites. Other considerations include oral medications such as Periostat (doxycycline) that can reduce inflammation, supplementation with Omega 3 fatty acids which may reduce inflammation and improve the quality of the meibum, and systemic treatments for autoimmune conditions that can cause systemic and periglandular inflammation. If it is well tolerated and there are no contraindications, warm compresses that can be done easily at home can help to liquefy the meibum, helping to prevent meibomian gland obstruction.


Meibomian gland dysfunction: hyperkeratinization or atrophy?
Jester JV, Parfitt GJ, Brown DJ
BioMed Central Ophthalmology
2015 Dec 17;15 Suppl 1:156. doi: 10.1186/s12886-015-0132-x.
View the full report

Intraductal Meibomian Gland Probing to Restore Gland Functionality for Meibomian Gland Dysfunction (MGD)
Maskin SL
May 2012

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