Meibomian Gland Disorder and the Three-Step Treatment

Jun 24, 2022
5 min read
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In June of 2021, I had the pleasure of meeting patient Linda for a dry eye consultation. At her initial visit, she was diagnosed with obstructive meibomian gland dysfunction (MGD) in both eyes.

Linda had been experiencing constant and bothersome dry, irritated eyes as well as eye fatigue for approximately 6 months and was finding that her symptoms were worsening in the afternoon, which prompted her visit. She found minimal to no relief with previous at-home therapies, including hot towel compresses, use of over-the-counter lubricating eye drops (5x/day) and over-the-counter lubricating ointment (nightly use).

For background, Linda does not consume alcohol and is a non-smoker with no history of previous refractive surgery or ocular trauma or injury. For over 2 years, she had taken Losartan 100mg (1x/day) to control her hypertension. In general, her best corrected visual acuity was 20/20 in each eye.

Diagnosing meibomian gland dysfunction

Image 1 illustrates lower eyelid with long-standing tattoo eyeliner and missing lashes (madarosis).

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Image 1

Upon examination, I discovered that Linda had long-standing tattooed eyeliner, madarosis, toothpaste-like Meibomian gland expression, and mild lid wiper epitheliopathy (LWE). Her corneas were clear of any vital dye staining; however, she had a reduced tear breakup time (TBUT) of 5 seconds in each eye and had an abnormal score of 18/28 on the Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED). Her Tear Osmolarity (TearLab) revealed normal values of 293 mOsms/L and 290 mOsms/L, in the right and left eye, respectively.

Image 2 illustrates lower eyelid manual expression post-LipiFlow (1st visit)

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Image 2

Using the Keratograph 5M (Oculus), her tear meniscus height (aqueous) was reduced in the right eye and normal in the left eye. Linda’s non-invasive tear breakup time (NIKBUT) was moderately reduced in both eyes while her conjunctival injection was mild in both eyes.

Additionally, infrared imaging with meibography showed significant gland changes in both lower eyelids with her right lower eyelid graded as 1.5 out of 3 and her left lower eyelid with a grade of 2.2 out of 3. (Grading scale for MG structures: 0 = normal, 1 = mild changes, 2 = moderate changes, and 3 = severe change).

Image 3 shows meibography of the right lower eyelid.