【Key words】Abnormal lid gland function; lid gland massage; health education; nursing care
MGD is a common disorder of the lid gland that can cause blepharitis, conjunctivitis and other ocular surface diseases such as evaporative dry eye. It causes chronic, recurrent discomfort in the eye, has a high rate of misdiagnosis, severely affects the quality of life, and predominates in middle-aged and elderly people [1,2,3]. With the development of the aging trend of the population, the incidence is increasing. Some studies have found that MGD has an increasing trend in young and middle-aged patients, causing disturbances in daily life. It is important to give proper treatment and nursing guidance to patients. In our hospital, we modified the method of blepharoplasty and applied it to patients with abnormal blepharoplasty function, and developed a health care plan and health education content for the patients’ morbidity, and achieved effective results.
1 Data and Methods
1.1 Clinical data
From January 2010 to June 2011, 108 patients with abnormal lid function and ocular surface discomfort were seen in the ophthalmology clinic of the Second Affiliated Hospital of Fujian Medical University, of whom 68 patients (48 males and 20 females, mean age 53.6±10.3 years) were treated with modified lid massage. 40 patients (27 males and 13 females, mean age 51.36±12.7 years) were treated with traditional lid massage. The mean age was 51.36±12.7 years. The difference in gender and age between the two groups was not statistically significant. All patients were diagnosed with chronic conjunctivitis due to ocular redness, foreign body sensation, photophobia and other ocular discomforts and had used various antibiotics and hormonal eye drops (Renso, Helene, Norgard, Haloperidol, Telbivudol, Bactrim, Dimethoate, etc.) with symptoms varying from mild to severe and lasting for 3 months to 6 years.
1.2 Modified lid gland massage method
The modified lid gland massage method is performed under the slit lamp or can be performed with the patient seated in a reclining chair without conjunctival sac surface anesthesia. METHODS: The index finger of one hand is positioned in the middle of the upper lid under the eyebrow and at the lid margin position, and the thumb is positioned below the lower lid margin. Both fingers are pressed together from the lid skin surface and squeezed together from the lid plate against the fornix toward the lid margin to squeeze out the lid gland secretions and unblock the lid gland opening (Figure 1) once every 2 weeks, with a 2-month treatment follow-up. The treatment was followed up by 5 days of ocular spotting with artificial tears, combined with daily eyelid cleansing and hot compresses.
1.3 Treatment procedure and results
The duration of conventional blepharoplasty was 15±3.5 minutes (n=40) from the time of topical drops of dicaine surface anesthesia to the end of the massage, and the duration of modified blepharoplasty was shortened to 2.2±2.5 minutes (n=68), with a significant difference (P<0.01).
All patients felt discomfort in the eye despite the use of surface anesthesia with geocaine in the eye during conventional blepharoplasty, and 15 patients experienced significant eye irritation during massage in the modified blepharoplasty patients, which was tolerated by the patients, 40 patients experienced mild eye irritation, and 13 patients did not complain of discomfort during massage. Within 5 minutes after the end of the massage, all patients’ eye discomfort disappeared. Among them, 58 patients felt the heaviness of the eyelids reduced after massage. After the treatment, all patients’ eye redness, foreign body sensation, photophobia and other eye discomfort symptoms were significantly relieved. The disturbance caused to daily life disappeared. No patient had the side effects reported in the literature such as subconjunctival hemorrhage and acute conjunctivitis after massage.
2 Health education and care
2.1 Pre-massage health education
Patients with abnormal blepharoplasty have long-lasting, recurrent ocular discomfort, often diagnosed as chronic conjunctivitis, and have used a variety of eye drops with poor results, so patients lack confidence in the treatment of the disease, which requires us to do a good job of psychological intervention with a cordial attitude to relieve patients of various negative emotions. The nurse should greet the patient warmly and explain to the patient that the cause of the disease is increased epithelial keratinization of the lacrimal ducts, narrowing of the duct lumen and poor discharge of the lacrimal gland secretions, or unhealthy lacrimal secretions that irritate the eye. Explain the need for blepharoplasty to the patient. Because blepharoplasty can be painful and irritating, it is important to explain this to the patient beforehand. To assist the physician with the ocular surface disease questionnaire, explain the various symptoms and the assessment of the severity of the disease, and keep records.
2.2 Care during massage
When performing massage, the movements should be gentle, rigid and soft, try to press out the secretions in the lid gland, and record the nature of the lid secretions and the blockage of the opening of the lid gland, communicate with the patient, ask and pay attention to the patient’s feelings until the end of the massage. If eye irritation is more obvious, add a tissue pad to the jaw during massage to avoid wetting the slit lamp pad after tear drops, and massage can be interrupted for a few moments before proceeding when patient discomfort is obvious.
2.3 Health education and care after the massage
Because maintaining ocular surface health in patients with abnormal lid function requires long-term persistence, and sometimes symptoms cannot be completely relieved, patients are instructed to learn the methods of lid massage after the massage and to try to perform self-massage on a regular basis, as well as to teach patients the daily methods of eyelid cleaning and eye hot compresses. Because patients with abnormal lid function often have a combination of lipid-deficient dry eyes that require topical eye drops such as artificial tears, the patient should also be shown the correct method of self-treatment with eye drops.
2.3.1 Eyelid cleansing method
This can be done at the same time as washing the face or bathing. After wetting the face and eyelids, place a small amount (about 0.2 ml) of face wash or body wash, or perhaps baby shampoo, on the middle fingers of both hands, close the eyes tightly and massage the eyelids and the roots of the eyelashes from the inside to the outside for about 1-2 minutes to remove the lid margin grease and scales, then wash the eyelids with plenty of water and wipe dry.
2.3.2 Method of applying heat to the eye
Usually done after the eyelids have been cleaned, a cotton dressing cloth is placed in hot water, wrung out to a temperature that does not burn the hands, folded to a size that completely covers both eyes, and placed on the eye with the patient lying flat with the eyes closed and the cloth cooled to a temperature below body temperature and then changed once or twice.
2.3.3 Self-drop eye drops
First wash both hands, separate the upper and lower eyelids with the thumb and index finger of the left hand, gaze upward with the eyes, hold the eye drop bottle with the index finger and thumb of the right hand, lean the middle finger lightly against the ring finger of the left hand so that the eye drop bottle is at about 10 mm from the lid margin, place the eye drop in the lower part of the exposed area (Figure 2), and then compress the inner corner of the eye for 2-3 minutes to prevent the drug from being discharged too quickly via the tear duct. Only 1 drop of eye drops should be used each time. If more than two types of eye drops are used, they should be crossed at an interval of 5 minutes before another type of eye drop is applied. The mouth of the eye drop bottle should not touch the eyeball or eyelashes to avoid infection. If the mouth of the eye drop bottle is suspected to be contaminated, it should be discarded. Eye drops should be kept in a cool and light-proof place, and in summer they should be kept in the refrigerator to avoid contamination or expiration that may affect the effect.
2.3.4. Health education
The lid gland is the largest sebaceous gland in the body and its secretion is influenced by many factors. A low-fat, easily digestible, vitamin-rich diet is recommended, and patients are advised to abstain from smoking, alcohol, and spicy stimulating foods.
3 Discussion
The most effective treatment for abnormal lid gland function is lid gland massage. Because lid gland massage requires auxiliary instruments (e.g., cotton swabs, glass rods, lid rests, etc.) to be placed on the conjunctival surface of the lid and has significant ocular irritation, the lid gland massage methods reported at home and abroad have been performed under surface anesthesia [4,5,6]. In this study, the modified lid gland massage method was applied clinically, and although there was still some ocular irritation, it was within the patient’s tolerance range and no ocular complications occurred. Combined with meticulous peri-treatment care and health education, it provided a good therapeutic and demonstrative effect. The eyelid cleaning and self-dropping methods mentioned in this article are also simple and practical experiences that the authors have developed in their long-term clinical practice. In this article, 25 patients were taught and demonstrated to learn self-massage, which is difficult to do with traditional lid massage methods and allows for long-term, effective patient self-care that has not been reported in the literature.
The modified lid gland massage method, which greatly shortens the treatment time, is simple to learn and effective, is a method worth promoting and applying, and strengthening patient health education transforms patients from passive acceptance of treatment care to active cooperation and participation, achieving good results. The limitations of this massage method are that it is not suitable for patients undergoing double blepharoplasty, as double blepharoplasty causes tight localized scar adhesions between the lid and eyelid skin, which affects the mobility of the lid skin, making the operation unsuccessful and requiring traditional lid gland massage.