Why do some people produce “pasty meibum?” PART 4

Part 4:

This brings us to the issue of lid hygiene. Germs feast on our oils and Demodex likes to feast on the germs fat on our oils, as well as feasting on those oils, themselves. Rosacea-related - and many other cases of dry eye disease-related - inflammation is commonly stirred up by those germs and particularly by the Demodex mites involved with those germs. Based on what I've read about Demodex and rosacea - and given the near pandemic of rosacea I find in the northeast, I think there is good reason to prescribe anti-Demodex therapy for those who have rosacea and/or MGD. (I've heard statistics that suggest that we may all get infested with Demodex if we live long enough – approximately 30% have it by age 30, 50% by age 50 and 90% by age 90.)

I also find it rare to see rosacea patients who don't have some degree of evaporative dry eye disease. (the form of dry eye that comes from too little, or the wrong kind of oils in our tears). Though many have thin, clear oil (if scant), I find frequent soap-suds-like bubbles in their tear film - presumably from bacteria. Demodex can add inflammatory elements to those “clear oils” - making the oil more like “kerosene,” than like the “extra virgin olive oil” you’d prefer in your “salad dressing.” Because of the good luck I've had with Cliradex, I have been reluctant to abandon its use in select cases - but I also find that the Avenova iLid cleanser can work well, coupled with ZocuWipes – and is less irritating to the sensitive skin of most of these rosacea patients. I routinely package these in my dry eye “kits” that can be additionally custom tailored to meet the needs of each patient I see. Topical Ivermectin has shown good activity against Demodex and there is a pipeline drug, likely coming to market within the year. IPL, along with improving the flow of oils (with the many tools available for this) both help control Demodex, along with lid hygiene. Combined with pure Hypochlorous Acid sprays, this is for most) an effective way to control bacteria and mites from adding to dry eye (and eyelid) misery.

To combat this problem, I think we need to better educate patients. Just as we teach kids to eat a less sugary diet, brush and floss their teeth and go to the dentist regularly to save their teeth, we need to do something similar for encouraging better blinks, diets rich in the essential Omegas, physical activity/exercise and lid hygiene to save their eyes. Procedures that melt and express these waxy oils are necessary in the more advanced stages, but if caught early, I believe we can largely prevent MGD - or at least better control it. I’ve used Dr. Korb's technique of debridement of the lid margin as an adjunctive tool to his Lipiflow technology, though as I’ve noted, I’ve published on modifications of this with some off-label use of radiofrequency for a more customizable expression and often combine it with a BlephEx lid hygiene treatment and Intense Pulsed Light Therapy (see my earlier posts on this). It is ironic that the nation leading in health and technology is poised (in some part due to our computer-dependent workforce and lifestyles) to be a nation of irritated, dry eyes - as we fail to properly care for our eyes even as we over-use them and - thanks to every other aspect of modern medicine - begin to outlive our MGs and their basic but critical tear functions. The “homework” I prescribe (and have endlessly posted on) remains the mainstay of what has - for the majority of my patients - been an effective way to support and promote the Meibomian glands and to prevent the “pasty Meibum” that is so common a cause of obstructive MGD and resulting evaporative dry eye disease.