Noh Filter (Fridays with Ada Noh, OD)
The Sixth Love Language (Planning Ahead)
Can we take a moment to appreciate the people in our lives who show up for us? I mean our family and friends, of course—but also the people we interact with professionally.
There’s something so refreshing about working with people who are thoughtful, reliable, and actually plan ahead. Maybe it’s just me, but I find myself getting more and more irritated by last-minute, haphazard attempts to schedule meetings, events, or commitments.
Is this maturity? Is it professionalism? Or am I just getting old? Because apparently, having a plan and respecting people’s time has become one of my love languages.
Anyone else feel this way?
From A to Z (Fridays with Andrew Zagelbaum, OD)
It’s Always Sunny (But the Data is Cloudy)
A few days ago, actor Glenn Howerton shared an instagram post about his experience with dry eye disease. He talked about dealing with chronic redness and irritation for decades, trying numerous treatments without getting the improvement he was looking for, and eventually traveling to Tampa to see Dr. Steven Maskin. After undergoing meibomian gland probing as part of his treatment, he says that he has finally experienced significant improvement.
First and foremost, I’m glad he’s doing better. Anyone who treats dry eye regularly knows how frustrating this disease can be, particularly for the patients who have been through treatment after treatment without finding meaningful relief. When someone finally finds something that helps after years of struggling, that’s a win.
Where the post gave me some pause was the call for eye doctors to adopt these protocols more broadly. I actually commented on the post because I think there’s an important distinction between saying, “This worked for me, and more people should know it exists,” and suggesting that a treatment should become part of the standard protocol for managing dry eye and MGD.
One patient’s success story can be incredibly compelling, especially when that patient has tried seemingly everything else. It still doesn’t establish efficacy, and it definitely doesn’t establish a standard of care.
Meibomian gland probing has been around for years, and there is published literature supporting its use. There are case series, retrospective studies, prospective studies, and randomized trials that have reported positive outcomes. At the same time, when you narrow the evidence down to what I consider one of the more important tests of a procedure like this, a double-masked, sham-controlled trial, we currently have only one.
That study looked at 42 patients with refractory obstructive MGD and compared probing with sham probing. Patients in the probing groups experienced improvement in certain symptom scores, which shouldn't be dismissed. If a patient feels better, that matters. What caught my attention, though, was what happened to the objective findings. At the four-week follow-up, there were no statistically significant improvements in the measured clinical signs in the probing groups. Tear breakup time, staining, Schirmer testing, and the number of glands yielding liquid secretion did not demonstrate significant improvement. Interestingly, the only significant improvement among the clinical signs was lid tenderness in the sham group.1
That doesn't prove probing doesn't work. It also doesn't mean Glenn Howerton didn't benefit from it, or that there aren't patients in whom probing may have a role. It means exactly what it means: we still have questions that better and larger controlled studies need to answer. A 2020 review of the probing literature reached a similarly cautious conclusion, noting that positive results from earlier uncontrolled studies weren't consistently reproduced when probing was evaluated against controls and calling for larger placebo-controlled trials.2
I think this is an important conversation in dry eye because our field is particularly susceptible to anecdotes. We treat a patient who has failed five things, we try number six, and they come back telling us they're finally better. Naturally, we get excited about number six. What we don't know from that experience alone is how much of the improvement came from the procedure, everything else we were doing at the same time, the natural fluctuation of the disease, placebo effect, or some combination of all of the above.
None of this is meant to take away from Glenn's experience. If anything, I'm glad someone with his platform is talking publicly about how debilitating dry eye can be. More awareness of this disease is good for our patients and for the doctors trying to take care of them.
I just think we have to be careful about the jump from “this finally worked for me” to “doctors should be doing this.”
Those are two very different statements, and the space between them is where good clinical research belongs.
1. Kheirkhah A, Kobashi H, Girgis J, et al. A randomized, sham-controlled trial of intraductal meibomian gland probing with or without topical antibiotic/steroid for obstructive meibomian gland dysfunction. Ocul Surf. 2020;18(4):852-856. doi:10.1016/j.jtos.2020.08.008.
2. Magno M, Moschowits E, Arita R, Vehof J, Utheim TP. Intraductal meibomian gland probing and its efficacy in the treatment of meibomian gland dysfunction. Surv Ophthalmol. 2021;66(4):612-622. doi:10.1016/j.survophthal.2020.11.005.
Have a great weekend.
Ada Noh, OD
Andrew Zagelbaum, OD