IVCM and AS-OCT of MGs furnish objective parameters regarding the amount of orifices and their diameter, as well as the number of MG, their length, and their width. The AS-OCT is also able to give an overview of MG distribution in the upper and lower eyelid [5]. These imaging technologies have potential to guide physicians in the management of MGD therapy . The choice between topical and systemic therapy is guided by live imaging of the glands themselves. Visualization of intraductal inflammatory cells and fibrosis are fundamental pieces of information that can be obtained from IVCM and AS-OCT. It should be noted that near-infrared imaging of the meibomian glands with devices such as LipiView™ or Keratograph 5M™ can now provide very nice images and information about the morphology of the glands (higher quality than AS-OCT images); however, they cannot provide cellular level detail about inflammatory cells which can only be provided by IVCM. In this case, the findings are an indicator for the success of intraductal meibomian gland probing as a measure to improve symptoms attributable to glandular obstruction [6].

Intraductal MG probing was performed with 1 mm and 2 mm probes for all glands, after a 2% lidocaine local injection (into the upper lid) and proparacaine eyedrops were applied. Additionally, the lids were expressed with a meibomian gland expresser. The patient tolerated the procedure well. Further treatment included systemic treatment of doxycycline 100 mg two times per day, azithromycin ophthalmic solution 1% one application at night to eyelids, prednisolone 0.12% drops twice per day, and hot compresses along with lid massage. Flaxseed oil supplement was also prescribed.

Treatment of MGD can include a surgical approach, medical therapy, or a combination of both. Invasive orifice penetration and intraductal probing is a relatively new and successful application to consider when you have to manage recurrent and severe MGD caused by intraductal fibrosis. This approach yields results immediately and is effective in relieving symptoms that accompany dry eye disease. AS-OCT and IVCM can guide this approach to therapy. These instruments are able to visualize the number of atrophic glands that are not candidates for probing. Moreover, these instruments furnish information that can reveal the length of MG ducts. This data can then be used to select the appropriate length probes before the procedure. Medical treatments include systemic tetracyclines (doxycycline, minocycline) and topical macrolides (1% azithromycin) [7–11]. These drugs have anti-inflammatory properties, such as inhibiting microbial lipase production, reducing the activity of tissue matrix metalloproteinases (MMP), and lowering the release of pro-inflammatory-free fatty acids and diglycerides onto the lid margin [12–16].

Her latest IVCM scans showed MG ducts were more prevalent than before treatment and did not show inflammation in the meibomian ducts (Fig. 3.2a ). IVCM results indicated that some areas of fibrosis persisted, but obstruction was significantly reduced (Fig. 3.2b ). AS-OCT of upper and lower lids revealed a change from abnormal gland morphology (Fig. 3.1e, f ) to a more normal state (Fig. 3.2c, d).