Dr. (Col) Rajendra Prasad Gupta, G03008, Dr. Vinod Kumar Baranwal
ABSTRACT:
Introduction-Meibomian gland dysfunction (MGD)is a chronic diffuseabnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes inthe glandular secretion. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation & ocular surface disease. MGD is classified as obstructive & non-obstructive meibomian gland disease.Basic pathologic mechanism in non- obstructive MGD is destruction of glands itself due to increased bacterial overload.Obstructive MGD is caused due to hyperkeratinisation of ductal epithelium as seen in seborrhoeic conditions or due to altered lipid contents of meibomian secretion due toinflammatory process.
Seborrheapatientsmainly complain of burningsensation due to increased free fatty acid in their meibomian secretion, while those with plugged glands have crusting , foreign body sensation, tearing or recurrent chalazia.Whatever may be the pathology , ultimate effect of reduced meibomian secretion is unstable tear film due to increased evaporation of tears, leading to increased tearosmolarity and ocular surface inflammation.
Aim& Objectives-
- To study theetiologicalfactors &pathophysiology of MGD in rural patients attending ophthalmicOPD of a tertiary care hospital.
2.Takeappropriate medical measures to prevent chronicity and recurrences, thereby preventing dry eye disease.
3.To provide patient education on preventive measures for dry eye.
Materials and methods
Patients attending ophthalmic OPD at atertiary care hospital were screened for MGD from 01stOctober 2016 to 31st March 17.100 MGD patients were screenedout of a total of 2341 patients. All the100 patients were given a questionnaire:
- Age
- Sex
- Occupation (exposure to heat, dust, sunlight)
- Laboratory work
- Prolonged computer work
- Environmental factors – Humidity
-Pollen
-Dirt
- Contact lens use
- Medications-topical
1 Antihistaminics
2 Anti depressants
-systemic 3 Retinoids
4 Omega 3 fatly acids
5 Medicine for BHP (benign prostatic hypertrophy)
- Pet care
- Domesticanimals
- Menopause
- Hormones;post menopausalhormonetherapy
- H/O –Diabetes Mellitus
-Hypertension
-Joint Pains (recurrent)
-Allergic disorders
-Bronchialasthma
- Demodexfolliculorum
1 Acne
2 Psoriasis
-Dermatological disorders 3 Rosacea
4 Atopy
Complaints of
Irritation
Burning
Itching
Watering
Discharge
-Crust formation
Foreign body sensation
On Examination
Visual Acuity was checked by Snellen’s drum. BCVA was checked with glasses .Refractiveyerror was recorded. Detailed lid examination was done; lid margins were examined for any thickening, redness,vascularisation,discharge and its characters, scales,crust formation, eye lashmaceration at the canthus.
Status of meibomian glands orifices was noted as r normal, any blockage or occlusion. On expression over the lids whether it was exuberant discharge or not & its character.Depending upon character it was graded as.
grade 0: No disease.
grade 1: Serous secretion on compressing lid margins,
grade 2 : Toothpaste like thick white secretion on compression,
grade 3 : Blocked openings with no secretion on compression. Palpebral surface examined for follicles ,papillae, concretions or scarring.Subtarsalsulcus was examined for any foreign body.Surrounding ocular surface & bulbar conjunctivawas examined for xerosis, cyst or tumor or coloured patch.
Corneal examination for any infiltration ,thining , vascularisation&opacity was seen .Details of anterior segment &fundus examination wererecorded.
Based on questionnaire information& examination datawas compiled &analysed.
Results
Out of 100 patients,maximum number of patients with MGD were found inage groupof 40 to 60 and 60 to 80.Prevalence of MGD increases with age.Thiswas seen in our study too.
Table 1.AGE(in years)
| less than 20 | 20-40
|
40-60
|
60-80
|
Above 80
|
| 03 | 18 | 39 | 36 | 04 |
Table 2.SEX
| Male | Female |
| 52 | 48 |
Male, female ratio was 52..48 .
Table 3.Occupation–
38patients were farmers ,22 were involved in care of domestic animals.19 were homemakers,17 patients were involved in some form of activities dealing with dust like labourers, factory workers, vendors, carpenters,shop owners etc.
| Farmer | Animal handler | Housewife | Student | Others (carpenter,Labourer, factory worker,vendor ,shop owner etc ) |
| 38 | 22 | 19 | 4 | 17 |
Table 4. CO-MORBIDITY
| Diabetes Mellitus | Hypertension | Allergy | Others (Arthritis) | Recurrent boils |
| 4 | 17 | 9 | 05 | 03 |
Table 5.Type of Discharge –
| No discharge | Mucoid | Mucopurulent | Purulent | Watery |
| 7 | 12 | 33 | 17 | 31 |
Table 6.Severity of Meibomian Gland Disease (MGD)
|
Grading |
Farmer | Animal handler | Homemaker | Other |
| Grade 1 | 31 | – | 17 | 12 |
| Grade 2 | 7 | 13 | 1 | 3 |
| Grade 3 | – | 9 | 1 | 3 |
Corneal vascularisation was noticed in 17 patients .Only one patient had corneal vascularisation in superior half of cornea .Tepatient was also positive for rheumatoid factor. Rest others had corneal vascularisationinferiorly .
Thickening of lid margin was noticed in 51 patients. Maceration of lateral canthus was seen in 24 patients while 05patients had maceration at both the inner and outer canthus.
19 patients had punctate staining of cornea mostmarked inferiorly. Filamentary keratitis was noticed in one patient, while diffuse punctate keratitis was also seen in one patientonly.
Table 7.SYMPTOMS
| Burning | Itching | F B sensation | Crusting |
| 41 | 58 | 40 | 28 |
.Gritty or F B sensation and crusting of lid margins, both findings are suggestive of plugging of glands.
Discussion-prevalence of MGD increases with increasing age, has been noticed in Japanese study1.
Our findings also confirms this and it is believed to be due to age related glandular atrophy . In our study 39 patients were in the range of 41 to 60 years of age and 36 were found in 61 to 80 years. Only 4 patients were above 80 years of age. This could be due to less number of population in this group due to poor life expectancyin this area.
In a study published in British Journal of Ophthalmologyby Christophe Baudouin2, the number of MGD patients <=30 years was 33%as compared to 72% >60years. In our study it was 10 %and 49% respectively.
Out of a total of 10 individualsin <=30 age group, 4 patients were involved with near work for more than 6 hours, 2 of them were working for 8 to 10 hours per day on computers and one was dealing with handling of construction material.
2 students above 15years were suffering from acne and were on retinoid treatment for the same.One had history of drugallergy and other had attack of angio-neurotic oedema after consuming prawn.One 17 years old girl student was found to have blocked meibomian gland openings in both eyes and even had a persistent epithelial defect (PED) in one eye.
Youngest patient in our study was 08 years old student with good hygiene and good nutritional status but suffering from dust allergy and dry skin. He had punctate staining of both cornea inferiorly and clogged meibomian glands with TBUT less than 10 seconds in both eyes.
In this age group we also had one 30 years old patient who was involved with care of domestic animals and was positive for punctate staining of corneain inferior portion.
Thereforeoverall all patients who developed MGD in young age i.e. below 30 years had some predisposing factorssuch as exposure to dust, animal handling, allergy ,acne, prolonged near work&computer work.
Occupation–
Association of occupation has not been studied in earlier MGD studies. Although in the dry eye study by Khurana et al3, it was found that 32% of patientswere farmers,28% labourers, 5%homemakers,4%office workers,and 12%students. In our study 38% were farmers,22% patients were involved with handling of domestic animals ,19%were homemakers and 6%were involved with near work for more than 6 hours. The remaining werewere group of patients who had exposure to dust more than general population such as labourers,construction workers,sweeper,vendors,carpenter,painter &lab assistant.So on analysis all the patients who had MGD either had some predisposing factorssuch as dry skin, poor hygiene, scalp dandruff ,history of retinoid treatment ,painting ,exposure to dust and UV radiation due to outdoor nature of work or other factors..
Severity of MGD-
63%,24% and 13% patients were classified in grade 1,2 and 3 respectively as per meibomian gland classification based on expressibility of meibomian secretions.Out of a total of 13 patients with severe grade 3 MGD in our study; 9 were animal handlers ,one house wife/ homemaker(she too had a pet cat). 1 lab technician, 1construction worker&1 ordnance factory worker.
Co-morbidity–
increased incidence of MGD has been reported in diabetics. 56% prevalence of MGD has been found in diabetics in one study4.In contrast, in our study we found 17% were hypertensives and were on treatment
As compared to only 4% diabetics. Iranian study5 has also found significant co- relation between hypertension,D M and MGD .Whether hypertension itself s the factor or it’s the effect of antihypertensive treatment, is not known.NSAIDs and anti-hypertensives are known to causedry eye .
(THIS PARAGRAPH IS NOT COHERENT)
Nine patients had some form of allergy, while 5% had arthritis mainly of knee joints and were on medication, on as-and-when required basis. Only one patient had history of positive rheumatoid factor .3 patients had history of doing painting work of buildings for more than 5 years .
19% patients with MGD in our study had scalp dandruff . 9 patients had some lid lesion in the form of ectropion,entropion ,marginalchalazion or some cystic lesion in either lids .
Total of 58patients had itching in the eyes.Out of these 13 patientscomplained of itching in the morning and 04 in the evening .16 patients had itching throughout the day while rest had itching at any time of the day.
Patientswith seborrhoea mainly complained of burning due to increasedfree fatty acid in their meibomian secretion .41%patients complained of burning in their eyes in our studyas compared to 46.9%in another study4.37% patients had foamy discharge over the lid margin suggestingmeibomitisIt may indicate infective etiology.
Patients with poor hygiene were found to have MGD more frequently and improved symptomatically as well as objectively with lid hygienic measures. Alghamdiet al6 also found subjective improvement in their study population with lid hygiene compliance.
Conclusion-We conclude that hyposecretory MGD in rural population is primarily due to inflammation of meibomian glands due to colonization of lid by bacteria .Evidence in favour of our hypothesis is that prevalence of MGD was found more in animal handlers. In our study,patients with poor hygiene had more severe MGD and they all responded very well to lid hygiene measures.The patient who did not comply with lid hygiene measures either did not improve significantly or had recurrence on withdrawal of hygienic measures.Greater severity of MGD was also found in patients exposed to more dust due to predisposing occupation.
Seborrhea is responsible for obstructive variety of MGD and prevalence of seborrheic patients was also found to be very high in rural population.
Maximum number of patients(39) were seen in 40 to 60 yrs of age group compared to (36) in 60 to 80 years, suggesting role of inflammation rather than age related7 MGD in rural area.
Pet care and farming is the major contributing factor for meibomitis in rural patients.
References
1.Amano S, i Inoue K. Estimation of prevalence of meibomian gland dysfunction in Japan.Cornea. 36(6):684–688, June2017
2.Baudouin C, MessmerEM et al Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016 Mar; 100(3): 300–306.
3.Khurana A K, Choudhary R, Ahluwalia B K, Gupta S. Hospital epidemiology of dry eye.Indian J Ophthalmol 1991;39:55-8
4.Pathan R. Prevalence of meibomian gland disease in Type II diabetic patients & its clinical presentations. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 4, January 26, 2015; Page: 346-353.
5.Hashemi H1, Rastad H2, Emamian MH3, Fotouhi A4.Meibomian gland dysfunction and its determinants in Iranian adults: a population-based study. ContLensAnterior Eye. 2017 Aug;40(4):213-216.
6.Alghamdi YA1, Camp A, Feuer W, Karp CL, Wellik S, Galor.Acompliance and subjective patient responses to eyelid hygiene.Eye Contact Lens. 2017 Jul;43(4):213-217.
7.ChyongJyNien, MD; Salina Massei, BS; Gloria Lin, BS et al.Effects of age and dysfunction on human meibomian glands FArchOphthalmol. 2011;129(4):462-469.
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