‘Plaque’ on your eyelids? Cleaning for your eyes not just your teeth

29 10 2012

The prevention of tooth decay and gingivitis has been a long established practice in Dentistry.  The first American to patent a toothbrush was H. N. Wadsworth and many American companies began to mass-produce toothbrushes after 1885.  The practice of minimizing and removing plaque has become common knowledge and both the at home maintenance as well as the in office components to teeth cleaning have become part of our culture.  The knowledge of gum disease by the individual is pervasive which helps to promote good oral health in the general North American public.

But what about our eyes?  Little common knowledge exists on lid disease and how lid hygiene is proving to be a critical point in the prevention of glandular dysfunction of the lids as well as chronic inflammation which leads to dry eye disease (DED).  What we do know is that symptoms in the majority of cases exist well past the onset of the disease itself.  Eye doctors are well equipped with tools to help identify and in fact manage the early manifestations, but don’t even realize this therapy exists.  In fact, only recently at the American Academy of Optometry during the Section on Cornea, Contact Lenses and Refractive Technologies Symposium delivered by Dr. Kelly Nichols and  Dr. Caroline Blackie OD PhD did the concept of lid staining and cleaning actually enter the realm of management options for meibomian gland dysfunction (MGD) and evaporative dry eye.

The Line of Marx (LOM), which is an anatomical junction between the wet conjunctiva of the inner eyelid and the dry lid surface, can only be visualized using vital dyes like fluorescein, Rose Bengal or Lissamine Green.  In healthy younger eyes, this line is uniform and thin running the span of the upper and lower eyelid.  It runs behind the meibomian gland orifice (MGO) or opening.  In the aging eye, and eyes that have a pro-inflammatory environment such as a dry eye with hyperosmolar tears or higher concentrations of biomarkers such as MMP-9, this region can thicken and run through or even past the MGO.    In fact, in hyperosmolar tears, LOM can provide a solute gradient that is a pathway for mediators of cell death and inflammatory proteins directly to the MGO thereby advancing MGD and decreasing the meibum quality before_afterLOMdebrideand likely contributing to obstruction of the gland (Bron, et al 2011, The Ocular Surface).

Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/ quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.

Dr. Caroline Blackie  OD PhD


The build up of epithelial debris or ‘plaque’ at the LOM can be easily viewed with vital dyes as seen in the image above.  Like the plaque on your teeth, the physiological insult of this ‘dead skin’ build up on this tissue results in further degradation of the LOM and therefore creating a stronger path to the MGO.  We see this natural thickening of LOM in the aging eye (Yamaguchi et al, 2006,  Am J Oph), however in patients with evaporative dry eye, this thickening is accelerated.

A simple in office procedure under optional topical anesthetic can be performed by an ophthalmologist or optometrist to promote a healthy lid surface and therefore maintain the health of the oil glands in the eye lids – this inevitably will help to decrease the risk of developing the most common type of dry eye – evaporative dry eye reported in some cases to be part of 87% of dry eye patients.

Lid cleanings should be added to the eye care recipe for good ocular health in a semi-annual fashion (every 6 months) in all patients particularly (but not limited to) contact lens wearers, patients with dry eye symptoms, psoriasis, 50+ patients and female patients.  Being a separate procedure altogether, patients should be aware of specialty fees associated with the service being provided, not unlike that observed in dentistry.  Please note that this is VERY new to eye care and may not routinely performed in general clinics so please seek out your nearest dry eye or ocular surface disease facility which may be better equipped to manage of the micro-anatomy of the eye lid and associated conditions.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.




8 responses

3 12 2012
Paul M Dobies OD FAAO

You advocate, as I do, a healthy LOM. To do this, you said to “see out your nearest dry eye or ocular surface disease facility which may be better equipped to manage of the micro-anatomy of the eye lid and associated conditions.” What specifically makes an “ocular surface disease facility…better equipped” to do this? What exact procedure(s) do you have in mind?

3 12 2012
Dr. Richard Maharaj OD FAAO

LOM debridement is, to date, not commonly performed in general clinics. In fact, LOM’s existence is often debated in medicine and optometry. This technique itself ( LOM debridement) is only offerred at 2 local centers due to the fact that it has only recently been described. That said, as eye care continues to evolve and practioners such as yourself provide leading evidence based services, lid expression/debridement will become common-place.

3 12 2012
Paul M Dobies OD FAAO

Where are the “2 local centers” so I can find out how they perform LOM debridement?

10 12 2012
Jay Johnson, OD

Are you treating blepharitis secondary to demodex infestation and if so, how?

11 12 2012
Dr. Richard Maharaj OD FAAO

Tea tree oil (diluted) applied weekly to the lid in office will irradicate. Cliradex is a new option available in the US.

11 12 2012
Paul M Dobies OD FAAO

What tea tree oil dilution percentage do you recommend and where do recommend obtaining it? Is an “ophthalmic grade” tea tree oil needed and available somewhere?

12 12 2012
Dr. Richard Maharaj OD FAAO

1:20 has been shown effective with minimal discomfort. Not aware of ophthalmic grade, however Cliradex is available US by Dr. Scheffer Tseng using T4O – which is the active component of TTO.

5 08 2013
Counterknowledge: Is Dry Eye a Disease or a Syndrome? | Eye on Eyes

[…] at eyeLABS is founded in ocular surface skin preservation and sustenance.  Lid Margin Debridement (click here for related article) and clinical gland expression provides a basis for the spectrum of treatment options and […]

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