On this episode of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, is joined by Cecelia Koetting, OD, FAAO, Dipl. ABO, to discuss the role of meibography in ocular surface examinations and pearls for using it effectively in clinical practice.
Dr. Koetting is an optometrist and assistant professor of ophthalmology at the University of Colorado School of Medicine in Aurora, CO.
Meibomian gland dysfunction fast facts
- Meibomian gland dysfunction (MGD) remains the leading cause of evaporative dry eye disease (DED)—accounting for 51 to 86% of cases—and commonly presents with an increased degree of meibomian gland (MG) dropout, particularly in the lower lid.1-4
- The following morphological changes in MGs are key indicators of MGD:4
- Gland shortening
- Tortuosity
- Atrophic tissue loss
- Bifurcation
- Gland dropout
- Many patients show extensive MG loss on meibography despite minimal or absent symptoms.5
Example of meibography in severe MGD
Dr. Koetting shared meibography of a 70-year-old Caucasian male patient who presented with 95% meibomian gland atrophy and dropout (Figure 1). At baseline, this patient had no functioning MGs, such that when she pushed on his glands nothing came out, putting him at high risk of progressing to complete MG dropout.
Consequently, Dr. Koetting proceeded with an aggressive treatment of MG probing, intense pulsed light (IPL) therapy, and thermal expression. This approach revived dormant MGs, leaving the patient with four functioning glands on each eyelid, which was enough to stabilize his symptoms.
Figure 1: Lipid layer interferometry and lower lid meibography of the patient demonstrating significant MG atrophy.
Figure 1: Courtesy of Cecelia Koetting, OD, FAAO.
Understanding differences in meibomian gland structure and function
While meibography highlights meibomian gland structure, function (i.e., meibum expressability and quality) must be evaluated separately, because the two don’t always correlate.6 For example, a patient may have truncated or atrophied MGs on meibography, but better function than expected when the glands are expressed, and vice versa.
Moreover, Drs. Dierker and Koetting agreed that in managing meibomian gland dysfunction, the level of treatment aggressiveness is guided more by function than structure; however, the timing of interventions, such as IPL or thermal expression, may shift based on the degree of atrophy observed on meibography.
To illustrate this, Dr. Koetting outlined three examples of MGD patients of different severity and their corresponding treatment recommendations:
- Severe (95%) MG dropout: Warrants immediate, aggressive in-office treatment (IPL, expression, probing) alongside an at-home regimen (ex: warm compresses, nutraceuticals, lid cleaning, etc.)
- Moderate (40 to 70%) MG atrophy: If the patient has similar MG function to the morphology, she initiates IPL/expression and emphasizes the importance of at-home care. If the MG function is good IPL is still discussed but may not be done immediately.
- Mild atrophy and/or clogged MGs: Patients are instructed to start an at-home regimen for the next 6 weeks to build good habits, and at the follow-up she reassesses if they should proceed with IPL and thermal expression.
Using meibography for patient education
Dr. Koetting emphasized that she doesn’t sugarcoat the diagnosis and information for patients like the one above, who are at a high risk of losing complete MG function. She conveys a controlled sense of urgency due to the high risk of progression, which meibography can support because it provides a visual for the information.
Example scripts for discussing MGD and meibography with patients
She starts patient education on meibomian gland function during the slit lamp exam and while pushing on the glands she says:
“Do you feel what I’m doing? We have oil glands that line the upper and lower eyelids that are really important for eye health. They provide nutrients to the front surface of your eye and help keep tears from evaporating too quickly. The oils should look like olive oil and come out easily when you blink, but yours are [insert severity] and have a consistency closer to toothpaste.”
Later, she shows the patient the imaging to discuss MG structure and says:
“We can image the oil glands that I mentioned earlier, and this is what they’re looking like. They should look like [show an image of healthy MGs], think a ‘white picket fence’ across the lid. Here we can see that yours are missing and short, and we’re at a critical point of addressing this issue before it progresses to a point where you may lose the rest of those glands, and I can't do anything to get them back. So, I need to make sure that I do everything I can to get them under control so that they function better, which will decrease the risk of progression.”
Monitoring patients with meibography
As a clinician practicing in a tertiary cornea and ocular surface disease center, all patients receive baseline meibography, with subsequent imaging performed every 6 to 12 months for patients with minimal MGD in most cases.
Conversely, for individuals at high risk of losing MG function, she follows up every 3 months to monitor for signs of progression. However, for a general practice, meibography is likely most helpful in patients at risk of MG loss, those showing earlier signs of MGD (ex: thickened, opaque expressed secretions), and pre-surgical patients.
Dr. Koetting noted that repeat meibography following IPL and thermal expression may be useful for documenting stabilization of MG architecture and the absence of progressive gland dropout. Of note, she emphasized that, in her experience, visible changes in meibography after treatment occur in only ~10% of patients.
She recommends that patients on Accutane (isotretinoin) come in once a month when they’re actively on the medication due to its association with changes in MG morphology and function during usage.7 She even recounted observing MGs beginning to atrophy within 4 weeks of starting Accutane.
Comparing structure and function in MGD
Dr. Koetting mentioned a 2023 study she collaborated on with Dr. Elizabeth Yeu that evaluated the prevalence of MG atrophy in patients presenting for cataract surgery.8 The study determined that in a cohort of 391 patients, over 95% had MG atrophy ≥ grade 1, with 50% having grade 1, 26% having grade 2, and 19% having grade 3.8
Dr. Koetting noted that while some degree of MG atrophy occurs naturally with aging, it can usually be distinguished from MGD by its nasal-predominant distribution, which is thought to reflect incomplete blink mechanics.
For optometrists who don’t have access to a meibographer, Dr. Koetting recommended using a transilluminator to assess MG morphology. While it is more difficult to show the patient the results, it still allows the clinician to get an idea of their MG structure.
Figure 2: Meibomian gland transillumination in a patient with MGD.
Figure 2: Courtesy of Cory Lappin, OD, MS, FAAO.
Key takeaways
- Meibography reveals MG structure, but function (ex: meibum expressibility and quality) must be evaluated separately because the two don't always correlate.
- Treatment aggressiveness is driven more by function than structure, but the timing of interventions may shift based on the degree of atrophy observed on meibography.
- Patients with severe dropout (95%) warrant immediate, aggressive treatment, while those with 40 to 70% atrophy may start with home care before escalating.
- Meibography can be helpful as a visual tool for discussing MG health with patients, especially if it is necessary to convey a sense of urgency due to a high risk of progression.
- If a meibographer is not readily available, a transilluminator can be used to evaluate MG structure.
Conclusion
Dr. Dierker noted that abnormal MG expression warrants further investigation into the underlying cause, requiring assessment of both gland structure and function through meibography and gland expression, respectively. Together, these tools provide a more complete picture of MG health and inform a more targeted treatment strategy.
