Your Dry Eye Mystery Solved Reversing Meibomian Gland

Dysfunction, Restoring Hope

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 Your
Dry Eye
Mystery
Solved
Reversing
Meibomian Gland Dysfunction,
Restoring Hope

STEVEN L. MASKIN, MD
with NATALIA A. WARREN, MBA, MHA

YALE UNIVERSITY PRESS/NEW HAVEN & LONDON

Published with assistance from the foundation established in memory of Calvin
Chapin of the Class of 1788, Yale College.
The information and suggestions contained in this book are not intended to
replace the services of your physician or caregiver. Because each person and
each medical situation is unique, you should consult your own physician to get
answers to your personal questions, to evaluate any symptoms you may have,
and/or to receive suggestions on appropriate treatment.
The authors have attempted to make this book as accurate and up to date
as possible, but it may nevertheless contain errors, omissions, or material that is
out of date at the time you read it. Neither the authors nor the publisher have
any legal responsibility or liability for errors, omissions, out-of-date material,
or the reader’s application of the medical information or advice contained in
this book.
Conflict-of-interest statements: Steven L. Maskin, MD, is the founder and
owner of MGDinnovations, Inc., which holds patents on instrumentation and
methods for intraductal diagnosis and treatment of Meibomian gland disease as
well as jojoba-based topical anesthetics and therapies used in treating MGD.
Natalia A. Warren, MBA, MHA, is the chair and cofounder of Not A Dry Eye
Foundation.
Copyright © 2022 by Steven L. Maskin, MD.
All rights reserved.
This book may not be reproduced, in whole or in part, including illustrations,
in any form (beyond that copying permitted by Sections 107 and 108 of the U.S.
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Library of Congress Control Number: 2021948485
ISBN 978-0-300-25033-6 (paperback : alk. paper)
A catalogue record for this book is available from the British Library.
This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of
Paper).
10 9 8 7 6 5 4 3 2 1
Dedicated to patients everywhere suffering with
Meibomian gland dysfunction and Dry Eye
This page intentionally left blank
 C O N T E N T S

Preface  ix

Acknowledgments  xiii
1 Meibomian Gland Dysfunction:
The Most Common Factor in Dry Eye  1
2 The Eye  21

3 The Meibomian Gland  37

4 Meibomian Gland Dysfunction Explored  51

5 Comorbidities and Cofactors  73

6 Symptoms: Living with Pain  121

7 The Last Day of My Life  144

8 Seven Principles of Meibomian Glands and Meibomian

Gland Dysfunction  162
9 The Diagnosis  170

10 Treating Meibomian Gland Dysfunction

and Comorbidities  217
11 Intraductal Meibomian Gland Probing: The Maskin® Probe
and Protocol  265
12 Guidelines for Managing Your Life with Meibomian
Gland Dysfunction  322

Glossary  339

Bibliography  361

Index  391
This page intentionally left blank
 P R E F A C E

I n late 2018, I was speaking with Jean Thomson Black, my pub-

lisher at Yale University Press, about my first book, Reversing Dry
Eye Syndrome. Sales hadn’t slowed; Dry Eye patients were still looking
for information on their condition. Having since made significant
discoveries about obstructive Meibomian gland dysfunction (MGD),
the most common factor in Dry Eye, and its underlying cause, per-
iductal fibrosis, I suggested updating the book. Instead, Jean asked if
I might write another book. Although the medical community has
known about Meibomian glands for hundreds of years, this would
be the first book for lay readers emphasizing the role of these glands
in the management of MGD and Dry Eye.
I first encountered periductal fibrosis in the mid-2000s while
diagnosing a desperate Dry Eye patient with “mysterious,” intracta-
ble eye pain. Suspecting the cause was inside his Meibomian glands,
I inserted a probe into them. That moment charted the course of
my career for the next fifteen years, leading to an expanded practice
that includes research on Meibomian glands and MGD, publications
in peer-reviewed journals, and a chapter in a textbook for eye doc-
tors treating MGD. I patented the Maskin® Probe and methods for
the intraductal diagnosis and treatment of obstructive MGD and
started giving presentations on probing and the protocols I follow
for successfully managing both straightforward cases and cases of
severe and incapacitating MGD. Later I founded MGDinnovations,
Inc. (MGDi.com), a biotech translational research company focused
on the diagnosis and treatment of MGD.
For this book, I would need a writer and collaborator with in-
depth knowledge of Meibomian glands and MGD, preferably some-
one who could also offer the patient’s perspective. I proposed the
x P reface

project to Natalia Warren, one of my patients who had suffered with

severe Dry Eye and MGD. She had a journalism background and a
master’s degree in health administration. She had cofounded Not
A Dry Eye Foundation, a nonprofit dedicated to raising awareness of
Dry Eye syndrome, and was responsible for content on the organi-
zation’s website. In November 2018, she agreed to tackle the years-
long marathon of writing this book.
Together we conceptualized the book for patients seeking basic
information about MGD as well as those interested in learning more.
We then curated the salient points from my research and practice
and Natalia’s experience as a patient and patient advocate. Although
our book is not a medical textbook, we delve into important details
not typically found in patient-focused Dry Eye literature. We review
the science of Meibomian glands and MGD and, based on my re-
search findings, challenge the commonly held view of the proxi-
mate cause of this disease. We describe patient symptoms and their
impact on daily life and discuss the comorbidities and cofactors that
contribute to disease, explaining how successful management of
chronic Dry Eye is a process, unlike a quick ten-day course of peni-
cillin for strep throat.
As we were finishing early drafts of two key chapters, 10 and 11,
the COVID-19 pandemic surfaced. Once we established safety for
our families and I reorganized my practice, patients, and staff, Na-
talia and I concentrated on the book. Then one day, a new patient
from out of state arrived at my practice with eye pain so severe she
was suicidal. She had seen over two dozen doctors, some at leading
medical institutions in the country. What eluded her doctors, like a
“medical mystery,” to me was clear. Her other doctors had simply
missed occult MGD and other significant comorbid ocular surface
diseases. Because they based their diagnoses on incomplete concepts
of MGD, their tests and diagnostic techniques didn’t discover these
diseases. Consequently, they had prescribed insufficient treatments.
The patient initially doubted my advice. Despite having traveled
hundreds of miles for treatment, she expected failure and couldn’t
imagine how her symptoms might improve. Thus, I would have to
restore not only the health of her eyes, but also her faith in a future
without pain and her trust in at least one doctor.
I started by explaining how the tests and techniques I use to
 P reface xi

elicit symptoms definitively indicate diseases others can miss. Re-

maining skeptical, she resisted my diagnosis and treatment plan and
consented to treatment only because she believed I was her last
hope. Wasting no time, I initiated treatment that day, and her symp-
toms eased instantly. By the time she left the office, her pain had
dropped from a level 10 to a level 3 (with 10 being the worst pain
ever, so severe it can lead to suicidal thoughts, and 0 being no pain).
Within twenty-four hours, the pain dropped to 1.5. Once we ad-
dressed other comorbidities, it dropped below 1.
Unfortunately, this was not an isolated case. Later that week,
another new patient came to my office with a similar history. He had
seen many doctors and tried many treatments but still suffered with
intractable eye pain due to MGD. For these patients, inadequate di-
agnoses and ineffective treatments were like the random cacophony
of an orchestra performing without sheet music. Plus, by not offer-
ing Meibomian gland probing, their doctors had acted like orches-
tra conductors who had sent home entire violin sections.
Although a book is not a substitute for a personal eye doctor,
Natalia and I wrote this book for patients just like these two. The
views expressed, based on my current thinking and personal re-
search, will equip patients with valuable information about Meibo-
mian glands, MGD, and common ocular surface comorbidities. Our
collaboration represents the intersection of a doctor’s quest to un-
cover the mystery surrounding a common but enigmatic eye disease,
and his patient’s harrowing journey with a painful, incapacitating
disease. We hope our joint effort will shift conventional thought
about MGD, its diagnosis, and treatment toward a new paradigm
based on clinical evidence that reveals the true nature of this dis-
ease, and we offer this book as a beacon of hope for patients need-
lessly suffering with inadequately diagnosed and treated MGD.
This page intentionally left blank
 A C K N O W L E D G M E N T S

A book doesn’t materialize out of thin air. First, we acknowledge

the important work that preceded ours, from the first descrip-
tions and illustrations of Meibomian glands by Heinrich Meibom,
MD, in 1666, to the first mention of periductal fibrosis by Ivan Cher,
MD, and the many other researchers in the late 1990s and early
2000s who contributed to our understanding of Meibomian glands
and MGD. Their notable contributions created a solid foundation
for my research and this book.
Along the way, many other people provided their support and
expertise, for which we are grateful.

Steven L. Maskin, MD, offers the following acknowledgments:

First, I am thankful to Natalia A. Warren for her steadfast dedi-
cation to this book and many thoughtful contributions. She gener-
ously offered her writing talent and a passion for educating those
who suffer with a disease that had threatened her own life, and
willingly shared this traumatic but ultimately triumphant experi-
ence with the world so you, as a patient, may benefit. I fervently
pray this book and her story will provide hope and guidance to the
countless patients all over the world who are in pain, desperate for
help, and suffering with MGD and Dry Eye.
I am thankful for the work of Sreevardhan Alluri, MPH, a grad-
uate student from India who has assisted my research, and Whitney
Testa, MBMS, DPT, who made important contributions to my early
research.
I thank Katey Mulfinger, operations and marketing specialist at
MGDinnovations, for her creativity on illustrations for the text, and
Reza Zarif for technical support.
xiv A c k nowledgments

My practice staff continues to care for patients, and I am thank-

ful to them, in particular Maria C. Jaimes, who has worked with me
for many years, and Nancy Marte, MHA, who recently joined my
practice and has already made a positive impact on patient care.
I thank Shellace James and Ruthie Dibble, PhD, two of my pa-
tients who generously shared their stories of being misdiagnosed,
losing hope, and finally finding help. Others, understandably, asked
that I not use their names, and I appreciate their support and gen-
erosity as well.
I am ever grateful for the support of my agent, Linda Konner;
my publisher at Yale University Press, Jean E. Thomson Black; as well
as Margaret Otzel, senior editor; Kate Davis, copy editor; Maureen
Noonan, production manager; Sonia Shannon, book designer; and
editorial assistants Elizabeth Sylvia and Amanda Gerstenfeld.
I am grateful to Scheffer C. G. Tseng, MD, PhD, and the expe­
rience I gained from 1988 to 1991 as a research fellow in his lab.
There, while observing under a microscope, I learned firsthand that
Meibomian gland ducts can be held and manipulated without dis-
integrating. This singular insight led directly to my breakthrough
discovery and treatment for an occult, ubiquitous, and sometimes
life-altering disease.
Finally, I would like to thank my parents, Sol and Dorothy
Maskin, who always provide loving support and who, along with
my beautiful children, Benjamin, Jacob, Sarah, and David, have been
understanding and patient during the writing of this book.

Natalia A. Warren, MBA, MHA, offers these acknowledgments:

Besides those Dr. Maskin mentioned who contributed generously
to this book, I am grateful to my family and friends. You shared your
expertise, drove me to appointments, fed me, and gave me support
at every step. It takes a village. You were all in mine: Zina D. Haj-
duczok, MD; Andrew Dmytrijuk, MD; Ceil Warren; John Warren;
George Hajduczok, PhD, JD; Lynn Veitch (who clocked the most
miles), and Jess Henson, Usha and Mojundar Sridhar, Dede (my BFF)
and Curt Rector, Linda Sparn (who clocked the most trips), Nancy
Albright, Eithne Clarke, Kim K. Johnson, and so many others who
went above and beyond countless times.