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Guide to Using LipiFlow® To Treat Meibomian Gland Dysfunction

Nov 11, 2019
42 min read

What Is Meibomian Gland Dysfunction and What Role Does It Play In Dry Eye?

The term “meibomian gland dysfunction” (MGD) was first introduced by Drs. James McCulley and George Sciallis in 1977, and again by Drs. Donald Korb and Antonio Henriquez in 1980, but gained national attention in the last decade thanks to TearScience’s line of medical equipment that allows eye care professionals to actively and systematically assess gland function, image glands, and treat MGD using LipiScan®, LipiView® II, Meibomian Gland Evaluator (MGE), and LipiFlow®.

The International Workshop on Meibomian Gland Dysfunction (MGD) defines MGD as “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.”2 It’s also important to note that MGD is both chronic and progressive in nature.

Meibomian glands are a sebaceous gland that contains a grape-like cluster of individual acini that secrete the oil product meibum, which includes lipids and proteins. Understanding the lipid pattern and composition is conceivably the next phase of research needed to discern meibomian gland dysfunction and a critical piece in testing for non-obvious meibomian gland dysfunction and early treatment. Meibomian glands are holocrine glands, meaning the cell is destroyed and excretions include dead cell fragments. Because the acini cells are constantly having to regenerate, discovering what inhibits this regeneration is vital to understanding meibomian gland dysfunction. While the upper lid (25-40) has more meibomian glands than the lower lid (20-30); their relative functional contribution has yet to be determined.3

Risk Factors:

  • Demographics: geriatrics, women, Asian
  • Systemic conditions: Lupus, RA, Sjögren’s syndrome, etc
  • Medications
  • Environmental
  • Ophthalmic Surgery

MGD is a multifactorial condition with many causes contributing to atrophy and changes secondary to gland obstruction. Not all the causes are fully understood and more are being hypothesized and researched. We do know that older patients, women, and patients of East Asian descent may be at greater risk for meibomian gland dysfunction.3

Hormonal changes also affect the meibomian gland production as the nerves are affected by androgens, estrogens, and growth factors. Inflammatory systemic conditions like Rosacea, Rheumatoid Arthritis (RA), Lupus, and Sjögren’s syndrome have been linked with MGD. Some medications, such as Accutane and topical glaucoma medications, have been associated with gland changes and atrophy.3 Environmental factors are linked to meibomian gland dysfunction, especially the misuse of eyeliner and make-up. Other environmental factors include long duration of screen use or high cognitive demand tasks and consequently decreased or incomplete blinking. There are some studies that show extended or daily wear, non-daily-disposable, contact lenses are linked to meibomian gland atrophy.12 More research is needed to assess to what extent if contact lens wearers are at increased risk for meibomian gland dysfunction. Iatrogenic dry eye after ophthalmic surgeries have been linked to meibomian gland dysfunction as well. The following figure nicely sums up the multifactorial causes and processes of meibomian gland dysfunction.

Signs & Symptoms of Meibomian Gland Dysfunction:

While the symptoms of meibomian gland dysfunction are similar amongst many dry eye patients; redness, dryness, burning, grittiness, intermittent blurry vision, and foreign body sensation, the signs are where we can differentiate and diagnose MGD from other causes of dry eye syndrome. In one study, research from Lemp et al9 showed that as many as 86% of patients with dry eyes have MGD, while another study by Korb and Blackie showed that as many as 39% of asymptomatic patients had MGD!4

What Is TearScience?

TearScience was founded in 2005 by Dr. Donald Korb and Tim Willis as a medical device manufacturer committed to providing solutions for eye care professionals (ECPs) to treat meibomian gland dysfunction and evaluate meibomian gland health. In 2009, the LipiView® system was launched and in 2011 the LipiFlow® system was launched.

LipiView® functions to capture lipid layer thickness and blink analysis, and LipiFlow® provides treatment for evaporative dry eye by liquefying and evacuating meibomian gland obstructions. LipiView® II was introduced by TearScience in 2014, which provided high definition structural meibomian gland images by utilizing reflected and transilluminated light sources. In 2016, TearScience released a high-definition gland imager called LipiScan®, which allows ECPs to assess meibomian gland structure in a practice setting.

In 2017, TearScience was acquired by Johnson & Johnson Surgical Vision, Inc., joining their growing portfolio of consumer eye health products and services to help them fulfill their commitment to improving and restoring sight for patients worldwide.

How to Evaluate Meibomian Gland Dysfunction By Assessing Structure and Function

The Johnson & Johnson Vision portfolio of products, including LipiScan® and LipiView® II, provides the tools needed to assess structure via meibography. The physician, with the aid of a slit lamp, can grossly check using a transilluminator, but it is helpful for patient education to be able to photographically show patients their glands in high definition. Gland atrophy can be present in the absence of symptoms. LipiScan® and LipiView® II use Dynamic Meibomian Imaging™ (DMI) to provide fast, high-definition images of the meibomian glands with both transillumination and surface illumination images of the meibomian glands.

You can get an image of both lower lids in about 60s with a trained technician using LipiScan®. I only tell my technicians to evaluate the upper glands with lid eversion if there is significant atrophy of the lower lid meibomian glands. By teaching your technicians lid eversion with a cotton tip applicator, they can easily capture both upper and lower lids when needed. With patients in the chair, I start by showing them the meibomian gland atrophy progression chart (Image 1), point to the top, and say “We are looking to assess meibomian gland structural compromise.” I then show them where they fall on the scale from normal to severe. For recording, I will count the number of complete gland atrophy in each eye, as well as estimate the amount of truncation in four categories (0-25%, 25-50%, 50-75%, >75% truncation). I will also note any significant tortuosity or fracturing (gland atrophy in the middle of the gland, which, overall, is less common). It is also important to note any atrophy, which could have been a result from a hordeolum or surgery.


Image 1: Transilluminated View of Meibomian Gland Structural Changes

Assessing Meibomian Gland function:

The two objective clinical tests I always do are Tear Break-Up Time (TBUT) to assess tear film homeostasis and the Meibomian Gland Evaluator™ (MGE) to assess gland function. I usually have the patients back one month after a comprehensive exam to perform these two tests. During the comprehensive exam, I am using more pressure to assess the quality of the meibum on a scale of clear and flowing (0) to opaque and obstructed (4): does it most closely resemble fresh olive oil, thickened/cloudy inspissated oil, honey, or toothpaste? There may also be no secretion at all. During the follow-up visit we will then perform MGE and count how many glands are functioning with normal blink pressure.


Image 2: Clear oil upon expression