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If you have been researching advanced treatments for evaporative dry eye, you would have likely come across in-office therapies such as Intense Pulsed Light (IPL) and Low-Level Light Therapy (LLLT). These technologies are effective at reducing inflammation and melting the hardened oils causing meibomian gland dysfunction (MGD).
However, within the eyecare community, there is an ongoing debate about what should happen immediately after the treatments: Meibomian Gland Expression (MGE).
Some ophthalmologists believe that manual expression is an absolute necessity to achieve therapeutic results, while others argue it is an uncomfortable and potentially unnecessary step.
So, what do we think about this topic? We think it is a crucial step and should be done after every treatment. But firstly, let’s explore this topic of MGE further.
The Meibomian Glands
There are dozens of tiny, tubular meibomian glands running vertically through your upper and lower eyelids. In a healthy eye, blinking acts as a natural pump, releasing a clear oil (meibum) that coats your tears and prevents them from evaporating.
In Meibomian Gland Dysfunction (MGD), this oil stagnates, turning from a healthy olive oil consistency into a thick, toothpaste-like paste.
This image shows gland expression using the Donald Korb Meibomian Gland Evaluator.
What is Meibomian Gland Expression (MGE)?
MGE involves gently squeezing or applying pressure to the oil glands to release or unblock the trapped oil. The process involves:
Anesthesia: A numbing drop is placed in the eye to ensure comfort and reduce blinking.
The Tools: The doctor will use specialized instruments. These can include a Mastrota paddle, expressor forceps or rollers, Korb expressor, cotton buds or simply digital pressure.
The Technique: One part of the tool is placed behind the eyelid and the other is placed on the outside of the skin. The doctor then applies gentle but firm pressure from the base of the gland up to the orifice to physically squeeze the meibum out.
The Pro-Expression Camp
The most vocal advocate for mandatory expression is Dr. Rolando Toyos, the ophthalmologist who pioneered the use of IPL and LLLT for dry eye disease.
The rationale for expression post treatment include:
Melting is Only Half the Battle: IPL and LLLT generate heat and energy that effectively melt the hardened, stagnant meibum. However, simply melting the oil does not remove it, especially if blockages are present.
Evacuating the Blockage: The blocked oil is often poor quality and contains inflammatory byproducts. If you do not physically squeeze this oil out of the gland while it is in a melted state, it will simply re-harden once the eyelid cools down.
Re-starting Synthesis: By emptying the gland, you signal the body's cellular machinery to begin synthesizing fresh, better quality oils.
The Treatment Only Camp
On the other side of the spectrum are experts who argue that routine manual expression is not strictly necessary, and in some cases, should be avoided. Their rationale includes:
Patient Comfort: Manual expression can be uncomfortable. The eyelids are incredibly sensitive, and applying the pressure required to express severely blocked glands can cause pain. Some practitioners worry this discomfort deters patients from returning for subsequent treatments or reviews.
Risk of Damage: Meibomian glands are delicate, microscopic structures. There is a clinical concern that aggressive, forceful squeezing with metal forceps can damage the acini, potentially causing long-term scarring or accelerating gland dropout.
Trusting the Biological Process: The theory is that once the inflammation is suppressed by IPL or LLLT treatment, the patient’s natural, daily blinking will be sufficient to gradually clear the glands without the need for manual expression.
Benefits and Risks: What You Should Know
If your practitioner recommends MGE as part of your treatment plan, here is what you should consider.
The Benefits:
Immediate Decompression: Severely blocked glands can feel heavy and sore. The blockage can also lead to internal hordeolums and styes. Expression provides immediate relief of that pressure.
Diagnostic Value: Expression is highly diagnostic. By assessing the meibum quality and volume, we can immediately grade the severity of your MGD and tailor treatments.
Jumpstarting Recovery: Many clinical studies show that patients who undergo targeted expression alongside light therapy report a faster improvement in their symptoms compared to light therapy alone.
The Risks and Side Effects:
Pain and Discomfort: Even with numbing drops, you will likely feel some pressure and potentially a sharp pinching sensation.
Transient Redness: Your eyelids and conjunctivita will likely be red and slightly swollen immediately following the procedure. This is normal and usually subsides within a few hours.
Minor Bruising: If you are on blood thinners or have very fragile skin, there is a small risk of minor bruising on the eyelids from the pressure of the forceps.
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Your Patient Action Plan
As a patient, you are an active participant in your dry eye management. Here is what we suggest:
Ask About Their Protocol: Before booking an IPL or LLLT package, ask the practice if manual expression is included as part of the treatment.
Communicate During the Procedure: If you opt for expression, establish a communication system with your doctor. It should feel like a deep, firm pressure. If the pain becomes sharp or intolerable, tell them to stop or reduce the pressure.
Commit to the Follow-Up: Expression and treatments are just one step of the treatment. After the oil blockages are cleared in the clinic, you must maintain the flow at home by continuing your daily warm compresses, blinking exercises and prescribed drops.