April 2010




Probe aims to relieve symptoms of MGD

by Vanessa Caceres EyeWorld Contributing Editor 


Tracking and treating MGD

– A new device, the Maskin Meibomian Gland Intraductal Probe, treats meibomian gland dysfunction by using a probe cannula that pops open obstructed ducts in the eyelids

– Patients are reporting relief of MGD symptoms with use of the probe. The exact duration of relief appears to vary anywhere from 1-18 months

– Patients should continue their normal therapy, such as warm compresses and scrubs, even after treatment with the probe

– The probe’s inventor, Steven L. Maskin, M.D., is exploring refinements for probe use, such as a more effective anesthetic during probing and possible delivery of pharmaceuticals directly to the ducts via small stainless steel tubes


Troublesome dry-eye cause targeted by probe

Gland Intraductal Probe The Maskin Meibomian Gland Intraductal Probe Source: Steven L. Maskin, M.D.

Meibomian gland dysfunction (MGD) is an often undertreated problem that can exacerbate dry eye. Now, a new device is treating patients who otherwise may not find relief. The Maskin Meibomian Gland Intraductal Probe (Rhein Medical, St. Petersburg, Fla.) treats inflamed and obstructed glands on the eyelids to relieve lid tenderness and other MGD symptoms.

“The turning point for me was when I had a patient who complained of lid tenderness. It was clear the patient had obstructive meibomian gland disease,” said Steven L. Maskin, M.D., Tampa, Fla., who specializes in dry-eye care. Although Dr. Maskin had seen his share of similar patients, there was something about this one that triggered an idea.

“I thought, ‘If only I could find a way to get inside the gland and find out why patients suffer,’” he said. Many times, patients with MGD must use warm compresses, baby shampoo, or oral medications such as tetracycline to alleviate MGD’s bothersome symptoms. Sometimes, even with regular treatment, MGD still occurs.

It was after seeing that particular patient that Dr. Maskin created the prototype for his probe cannula. “It was dramatic, and there was almost immediate improvement. I would put the probe in the gland, and there was some resistance in the duct but I was able to pop through.” It was then that Dr. Maskin partnered with Rhein; he said that 2010 is the second year that the device has been available. Physicians using the probe will apply anesthesia and treat obstructed ducts on the lids; some physicians even treat all ducts. The procedure can take anywhere from 5 minutes to a half hour, depending on the ducts and the patient. If the patient does not find relief with the initial 2-mm probe cannula, 4- or 6-mm probes are available.

Dr. Maskin gives this analogy: “It’s as if you have a highway with a 10-car pileup. In the past, you could remove the glass and debris, but you left the metal behind. Now you can be sure that there’s no metal left on the highway.”

Esen K. Akpek, M.D., associate professor of ophthalmology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore, who uses the probe, likens the probing to opening the pores of the skin during a facial treatment. The actual duration of relief from the probing is still under debate, but anywhere from one month to six months to even 18 months may be reasonable, said Dr. Maskin and other physicians who have used the probe. Dr. Maskin recommends that patients continue their usual therapy, such as using scrubs or warm compresses, after probing. This can help prevent further obstruction of the glands.

Patients pay for the probing treatment out of pocket, but Dr. Maskin’s office will submit a claim to the insurance company. “Patients may or may not get reimbursed. We had one patient who had to appeal the company’s decision, and she was successful,” he said.

Tracking clinical results

Dr. Maskin has treated more than 300 lids and close to 150 patients with the probe. At last year’s Association for Research in Vision and Ophthalmology (ARVO) meeting, he presented results from a number of patients in whom the probe had been used. At this year’s ASCRS•ASOA Symposium & Congress in Boston, Dr. Maskin will present follow-up results with 17 lids from seven patients in the ARVO report who had 18 months of follow up. Using the visual analog scale and another scoring device rating their symptoms between 1 and 100, these patients had a mean score of 66 out of 100 before probing. That score was reduced by 42% immediately after probing. At two to three months, their mean score had reduced by 91%. These patients seemed to continue to have symptom relief at the 18-month point. “Lid symptoms that improved included lid pressure, heaviness, puffiness, awareness, irritation, discomfort, sticky and gummy [feeling], photophobia, itching and scratching under the lid, sunburn under the lid, epiphora, and ptosis,” according to Dr. Maskin’s ASCRS abstract.

In another one of Dr. Maskin’s investigations, 44 lids of 20 patients who specifically had lid tenderness were analyzed. These patients had a mean pre-probing score of 60, which immediately reduced by 48 points after probing. At 2-3 months, their score had lowered by 80%. No complications occurred with these patients.

Dr. Maskin is trying a new anesthetic that seems to work well during probe use. This involves 8% lidocaine and 25% jojoba applied to the skin on the lid. “It permeates to reach the tarsal plate,” he said. Dr. Maskin is also exploring the use of small stainless steel tubes that can inject pharmaceuticals into the meibomian glands.

Testing it out

Physicians believe that the probe brings some much-needed attention to MGD.

“I applaud the fact that it gives more attention to MGD. The idea of popping the glands open to get them flowing is a good thought,” said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York. Dr. Latkany laments that many patients rely on various methods to get relief but often find these methods don’t help. He has not yet used the device.

“As I believe most dry-eye issues come from MGD, any effort to get these open is laudable,” said J.E. “Jay” McDonald II, M.D., Fayetteville, Ark., who has not used the probe.

Joseph Tauber, M.D., Kansas City, Mo., who has treated about 130 patients with the probe, said it is most helpful in patients who have obstructive MGD. When the probing starts, patients are a little nervous, and there can be minor transient discomfort. Dr. Tauber usually treats every duct in the lids. Relief of symptoms usually occurs within hours, he said. Dr. Tauber’s patients are finding relief with the 2-mm probe—he has not yet used the 6-mm probe. Some patients would like to see the effects from the treatment last longer. “I’ve had great success with [the probe]. If patients are not completely scarred, they do pretty well,” Dr. Akpek said. She has treated more than 10 cases with the probe in recent months; she finds it works most effectively with Xylocaine 2% (lidocaine, AstraZeneca, London) on the lid margins during treatment and six-week usage of AzaSite (azithromycin, Inspire Pharmaceuticals, Durham, N.C.). Although she has not yet targeted how long patients can attain relief without retreatment, she sees no reason why patients can’t go for six months, so long as they maintain their use of hot compresses and scrubs. Some physicians who applaud the idea of the probe are still not sure it is right for their particular patients. For example, Dr. Latkany has his own method to help MGD patients express their glands at home or in his office. He believes that the method he is using might be less invasive than the probe. “Whether you use the probe or another instrument, you need to get the glands flowing.” Dr. Latkany, whose patients often embark on their own dry-eye research, has had patients occasionally ask about the probe or even email him videos showing the probe being used.

“My concern in this approach [with the probe] is that as the genesis of the issue is from the inflammation inflicted to the lid wiper epithelium, it is important that the approach that opens these glands not induce inflammation,” Dr. McDonald said. “I would assume that technique is very important as any direct trauma might induce more inflammation.” Dr. McDonald is working with TearScience (Morrisville, N.C.) on a device that delivers thermal pulsation energies to the meibomian glands for treatment. Data for this device are currently submitted to the U.S. Food and Drug Administration for review.

Editors’ note: Dr. Maskin is the inventor of the Maskin Meibomian Gland Intraductal Probe (Rhein Medical, St. Petersburg, Fla.). Dr. McDonald is a consultant for Bausch & Lomb (Rochester, N.Y.) and is involved with the creation of another device for MGD treatment. Drs. Akpek, Latkany, and Tauber have no financial interests related to their comments.

Contact information

Akpek: 410-955-5494, esakpek@jhmi.edu
Latkany: 212-689-2020, relief@dryeyedoctor.com
Maskin: 813-875-0000, drmaskin@tampabay.rr.com
McDonald: 479-521-2555, mcdonaldje@mcdonaldeye.com
Tauber: 816-531-9100, jt@taubereye.com

Probe aims to relieve symptoms of MGD Probe aims to relieve symptoms of MGD
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