When assessing the meibomian glands

Studies show that approximately 86% of our dry eye disease patients also have meibomian gland dysfunction (MGD).¹ Do you agree with this statistic? Asked another way, how many of your patients would you estimate have some level of MGD? An even deeper question, how are you assessing your patients for MGD? Specifically, are you grading both the structure and function of their meibomian glands?

Here, I explain why you may want to consider doing so, and how to do so.

Why

In a recent retrospective study performed by yours truly, Elizabeth Yeu, MD, and Hannah Calvelli, OD, we looked at the meibography of 391 patients age 50 or older seen for a preoperative cataract surgery workup.² Specifically, the amount of atrophy in the meibomian glands (MG) in the lower eyelid was graded via meibography and compared against slit lamp findings of meibomian gland function in the same patients.²

Meibography revealed that 95.1% of patients had MG atrophy of grade 1 or higher.² Additionally, of those patients with MG atrophy, there was a correlation with poor MG expressibility but not the grade of the meibum.² This finding implies that structural changes to the MGs sometimes precede functional changes in the meibum quality and expressibility. This gives credence to evaluating both in clinic to determine the most appropriate treatment, which would be at-home therapy with warm compresses, ocular nutritional supplements and lid hygiene, or adding in-office thermal treatment.

How

During slit lamp evaluation, optometrists grade MG function by assessing the quality of the meibum and the ease of the expression of meibum. This can be done using a cotton tip applicator, a meibomian gland expressor, or the thumb. When expressing the glands, optometrists want to take note of the consistency of the meibum: Is it like olive oil, cloudy, turbid, or even caseous? It is also important to grade how easily the oil is expressed and whether there are glands that don’t express. I track this in the patient’s chart, for example: “easily expressed,” “difficult expression,” or “no expression temporal lower lid.”

To grade structure, optometrists also have options, albeit some are easier than others. One is using a transilluminator applied to the outside of the lower eyelid and rolling the lid, so that we can view the glands and grade atrophy. Another option is meibography. This allows us to capture a photo and directly observe the architecture of the meibomian glands, evaluating for changes related to MGD.

Make the grade

If grading the structure and function of the meibomian glands is not something you routinely perform in your office, I encourage you to begin doing so for the reason outlined above. You can start simple: The next time you are behind the slit lamp, give those meibomian glands a little squeeze, see what comes out, or worse yet, what doesn’t come out. OM

References

1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. doi: 10.1097/ICO.0b013e318225415a.
2. Yeu E, Koetting C, Calvelli H. Prevalence of Meibomian Gland Atrophy in Patients Undergoing Cataract Surgery. Cornea. 2023 Jan 12. doi: 10.1097/ICO.0000000000003234.

DR. KOETTING practices in Denver, Colo. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active member of the AOA, and a speaker and consultant for multiple companies. Follow her on Instagram at Dr_Jazz_Hands, or email her at Dr.CeceliaKoetting@gmail.com.