For many years, warm compresses have been a mainstay of first-line therapy for patients who have meibomian gland dysfunction (MGD). The well-known obstacles that we face with regard to the effectiveness of this treatment include poor patient adherence and compliance, inability to reach therapeutic temperatures, and rapid heat dissipation. Fortunately, we have been able to tackle these challenges with a combination of careful patient education and technological advances in treatments. Unfortunately, these strategies are not entirely foolproof, as is highlighted by a case involving a 62-year-old Middle Eastern female who had severe symptoms of grittiness and burning and who had failed various pharmaceutical and over-the-counter topical interventions over several years.

Initial Findings and Treatment

At her initial visit, significant slit lamp findings included scalloped inferior lid margins, minimal expression from only 20% of her meibomian glands, and a reduced tear breakup time (TBUT). Surprisingly, there was no lissamine green or sodium fluorescein staining of the ocular surface. These findings, along with the failure of her past therapies (which were targeted at treating aqueous deficiency), led us to direct our attention toward her lipid layer.

Meibography clearly showed that she was suffering from MGD and early gland loss. After thorough patient education on the potential for increased dropout without intervention, we prescribed an emollient artificial tear three times daily and scheduled her for a thermal pulsation treatment.

On treatment day, the patient was educated that she may experience exacerbated symptoms before improvement and that she could prolong the therapeutic effect of the in-office treatment by committing to home warm compresses and lid massage. She was given both verbal and written instructions on the procedure and was shown a video demonstration of manual lid massage.

Unexpected Results

One month later, the patient reported fluctuating burning and an overall “abnormal feeling” in and around her eyes, with an added concern of poor-quality vision. Upon gross observation, there was pronounced wrinkling and mild redness of her lid and periorbital skin. Admittedly, the increase in symptoms despite our careful education and in-office therapy was disheartening.

The patient explained that her husband helps with her treatment by standing behind her and digitally massaging the beads of the heated mask against her closed eyes for the entirety of the 10-minute compresses. She described discomfort during these sessions, but it was clear that the couple was committed to following our instructions, reminding themselves that she may feel worse before she feels better. Biomicroscopy revealed vertically oriented patches of coalesced staining across the inferior-central corneas of both eyes that very closely mirrored her meibography images (Figure 1).

Relief at Last

We educated the patient that her increased discomfort and visual disturbance resulted from the forceful digital pressure being applied during the warm compresses, evidenced by the marked corneal changes observed. She discontinued home heat therapy for two weeks to allow for complete healing before performing gentle lid massage after removal of the heat mask. At her next visit, all symptoms were significantly improved, and all corneal staining was resolved. CLS