Why do expensive dry eye treatments fail? (And what is Maskin Probing?)

First - I am posting this on the first Monday of July - the official “Dry Eye Month!” Second, it happens to be the birthday of our nation - so Happy Birthday to the USA!

While I’ve blogged and posted extensively about common causes for such failures, one factor that I find to be a major, common theme, relates to the anatomic damage we find in the Meibomian Glands – those glands responsible for making the oils critical to good tears. Clinically we can image these glands with special photography, we can estimate the quantity and quality of the oils by assessing the “Tear Break Up Time” (TBUT) – or time it takes to see evaporation of tears off the eyes and most importantly, we can compress the glands and watch with a microscope to see how much and what kind of oil we can “squeeze out.” In healthy glands a little pressure will yield a “lot” of thin clear oil. Unfortunately, many times we find little to no oil – or we find chunks of waxy oils with high pressure.

In an extended discussion with Dr. Steve Maskin (USA inventor of the famous “Maskin Probes,” he is a cornea/dry eye specialist who has studied and written about dry eyes and obstructive MGD extensively and is based in Tampa, Florida) last year, he relates many dry eye treatment failures to multi-level degrees of scarring and strictures - or “periductal fibrosis” throughout the ducts of the MGs - which he finds is extremely common in MGD. This is akin to tiny “nooses” around the glands that can occur at different levels and block the deeper portions of the glands from participating in providing oils with a normal blink. (Remember that a single, strong, compression of the two lids together is considered a “good” or “normal blink.”) He feels this may be made worse with excessive attempts to purge the glands (hot or cold expression) – as cold or hot squeezing of those deeper portions of blocked glands - without clearing the scarring first - can cause more inflammation and damage (kind of like squeezing an acne pimple that doesn’t “pop”).

His fix is to do serially deeper probing of the glands, using tiny “piano-wire-like” probes that are placed by hand, with the help of a specialized microscope, into the mouths of each of the 25-30 Meibomian Gland ducts per eyelid, before instituting heated expression and/or IPL (generally a few weeks after the probing). To prevent further recurrence, he pursues lid hygiene and maintenance probing sessions (often yearly). My sense is that - caught early, simple heated expression can unclog MG obstructions and I tend to follow this “Korb/Blackie principal” in my practice. Once inflammation becomes more dominant, then adding IPL along with other anti-inflammatory/immune modulating treatments becomes helpful.

Once this periductal fibrosis begins to “prune off” the ducts, then probing appears increasingly beneficial. I’ve taken this to heart in my treatment algorithms. Dr. Maskin will inject steroids like Dexamethasone into the glands using proprietary, specialized cannulas and we discussed some of the more experimental therapies using stem cell products or anti-VEGF treatments, but I feel we still have a long way to go in fully understanding and then reversing this disease. When I do Maskin-style probing, I generally prefer starting with gentle IPL followed immediately by post IPL probing and then with off-label-aided Radio Frequency-heated expression right after probing. My rationale is to use the anti-inflammatory and pro-gland stimulation benefits of IPL but that RF can also make sense by melting residual waxy obstructions and helping to move that old, rancid, nasty oil out of these deeper pockets of the glands. I’m still waiting on the commercial availability of the micro-cannula (a tiny tube Dr. Maskin currently uses to deliver Dexamethasone or other anti-inflammatory products) though I typically prescribe a combination steroid and antibiotic drop taper of Tobradex to hopefully keep scars from recurring and germs from infiltrating/infecting in the immediate post-probing window.

That said, I think the obvious answer for now, is addressing this with general education, early detection and early treatments. The “ounce of prevention” has probably never been more needed as more of us spend the most productive hours of our lives with our digital devices - and diet, lifestyle and hygiene diverge increasingly further from the million years of evolution that produced the best environment that our eyes and bodies need - but no longer get. The “homework” of eating necessary nutrients, doing good blinking, getting good exercise, adequate rest and daily good lid hygiene become a baseline from which everything else flows in my practice.