EyeWorld India December 2013 Issue

51 EWAP PHARMA FOCUS December 2013 antibiotics in Demodex cases, Dr. Tseng finds that there can be difficulties with this. “The problem here is that oral medication as well as topical medication will be very hard to get into the intestine of the mites,” he said. However, since the mites are a carrier of the bacteria, killing the Demodex with Cliradex, he believes, is indirectly an effective way to control the bacterial invasion. In addition to Demodex mites, Dr. Maskin observed that Staph bacteria are a common cause of anterior blepharitis. With such bacteria he uses antibiotic treatment. However, drops are not recommended. “The proper way to treat anterior blepharitis is not with drops,” he said. “It’s with ointment because of the residence time of therapy at the site of infection. You put a drop in the eye and it’s gone in five minutes or so, but you put the ointment on the lid margin and it stays for longer.” Unchecked blepharitis can damage the meibomian glands, which are just millimeters away from the lashes, Dr. Maskin said. This, he finds, can cause meibomian gland inflammation and periglandular fibrosis, which can lead to ductal obstruction to meibum flow with elevated intraductal pressure and subsequent loss of glandular tissue. Dr. Maskin said that he recently pioneered a technique making it possible to get inside the gland, ensuring that it is open. “The ability to physically get inside of a gland and remove the obstruction is a game changer and has produced dramatic and immediate results in my patients,” he said. Along with this new technique has come the idea of being able to deliver therapies inside the gland. “Not only do we have probes that Meibomian gland obstruction with released sequestered meibum through orifice after probing Source: Steven L. Maskin, MD open up the gland, we have tubes that I insert inside the gland,” Dr. Maskin said. He has already injected different types of steroids here in more advanced cases. A wax ester compound called jojoba, which together with lidocaine forms the basis of the anesthetic used for probing the gland, plays a key role here and can be ordered from Leiter’s Pharmacy. “The main secretion of the meibomian gland are wax esters,” Dr. Maskin said. “The jojoba seems to escort the anesthetic into the tarsal plate in the gland, allowing for well-tolerated probing.” The probing technique involves beginning with a very stiff 1-mm probe, getting into the gland, and breaking through fibrotic tissue to establish and confirm a patent outflow duct, Dr. Maskin explained. If this does not stretch far enough to reach deeper obstructions, a longer probe can then be used. Overall, Dr. Maskin views this as an exciting era for treating lid margin disease. “I’ve been practicing for almost 25 years, and this is the most exciting time to be treating lid margin disease, meibomian gland disease, and dry eye,” he said. “Why? Because we can now for the first time treat meibomian gland disease with an approach that enables us to get inside of the gland and release occult resistance to meibum flow throughout the entire ductal system, to open it up, and restore gland functionality.” Dr. Tseng is extremely gratified that blepharitis in particular is now gaining its share of attention. “I think it’s a good thing for the research community and pharmaceutical community together to focus and take an active interest in this because it is an important, common, and annoying eye condition afflicting a large population,” he said. However, he cautioned that more research is needed into what he sees as a multifactorial issue. “On the one hand mites are parasitic and then on the other there may be some bacteria,” he said. “I think effective treatment should be merged, and we believe that we made the first step toward that goal.” EWAP Editors’ note: Dr. Maskin has a patent on the use of jojoba to treat meibomian gland disease and pending patents on the intraductal meibomian gland apparatus and methods, as well as a license agreement with Rhein Medical (St. Petersburg, Fla., USA). Dr. Tseng has financial interests with Bio-Tissue. Contact information Maskin: +1-813-875-0000, drmaskin@tampabay.rr.com Tseng: +1-305-274-1299, stseng@ocularsurface.com