Appendix
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Ophthalmology

Meibomian Gland Disease

Meibomian gland dysfunction encompasses various disorders affecting the meibomian glands, causing ocular discomfort, dry eyes, and visual disturbances. Factors like aging, digital device use, and hormonal changes contribute to its onset. Blocked meibomian ducts lead to reduced lipid secretion, tear film instability, and ocular surface inflammation. Diagnosis relies on outpatient tests and questionnaires to determine disease severity, guiding treatment decisions. Clinicians participating in this

v1 · Reviewed Nov 8, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Severe dry eyes can result in blurred vision, an inability to wear contact lenses, headaches, corneal keratinization, scarring, or corneal ulcers.
  • If left untreated, permanent damage to the eye and vision loss may occur.
  • Early identification and treatment prolong the asymptomatic phase and prevent meibomian gland dropout and irreversible ocular damage, including vision loss.
  • Diagnosis relies on outpatient tests and questionnaires to determine disease severity, guiding treatment decisions.
  • Clinicians diagnose MGD through a clinical examination.
  • To aid in detecting asymptomatic MGD, all patients presenting for an eye examination should ideally undergo a rating of the expressibility and texture of the meibum by applying moderate pressure over the lower lid.
  • A symptom questionnaire is helpful for symptomatic patients in quantitatively measuring symptoms resulting from MGD.
  • Additional symptom assessment questionnaires include the Ocular Surface Disease Index (OSDI) and the Dry Eye Questionnaire (DEQ).
  • Following questionnaire administration, symptomatic patients should undergo a slit-lamp examination, including the following based on availability:
  • Evaluation of lid morphology: Meibography using either a transillumination technique, in which the clinician everts the eyelid over a light source or an infrared video camera, to look for lid margin irregularities, pouting or plugging of the orifices, vascular engorgement, and changes in the mucocutaneous junction.
  • Meibography methods have evolved to include infrared meibography, visible light transillumination, laser confocal meibography, and optical coherence tomographic meibography.
  • Expressibility from the meibomian gland openings: Meiobiam gland openings should be patent with the expression of clear fluid.
  • Note the number of functional glands, obstructive capping or plugging, and the color and consistency of the meibum.
  • Transillumination through everted eyelids or infrared photography detects meibomian gland dropout.
  • Tear film break-up time: Fluorescein stain in the eye measures tear film stability.
  • The patient's tear film is abnormal if blue gaps develop in less than 10 seconds.
  • Schirmer test: This test quantifies the number of tears produced by each eye using Whatman number 41 strips, measuring 5 mm wide and 35 m long.
  • Conjunctival and corneal staining: Fluorescein staining is utilized to assess the continuity in the corneal surface.
  • Lissamine green or Rose Bengal staining highlights the dead and devitalized epithelium in the cornea.
  • Diagnostic methods used for MGD include slit lamp examination, meibography to visualize gland morphology and dropout, tear film breakup time (TFBUT), tear osmolarity measurement, and conjunctival and corneal staining.
  • Patients should optimize their work and home environment and avoid excessive screen time and direct exposure to wind, as these factors can increase the tear film evaporation rate.
  • Regular eyelid compresses with warm water for a minimum of 4 minutes, once or twice daily, followed by a firm massage to express inspissated secretions, is a beneficial treatment.
  • Additionally, increasing dietary omega-3 fatty acid consumption is recommended.
  • Artificial lubricants, topical antibiotics like azithromycin, and emollient or liposomal spray may be considered case-to-case.
  • Oil emulsion tear substitutes improve the lipid layer thickness and overall tear film stability.
  • Patient education is essential at each stage, emphasizing the influence of diet, home, or work environment on tear evaporation.
  • Encouraging frequent blinking, particularly during activities like reading or computer use, is recommended.
  • Warm compresses directly heat the lid margins, melting altered meibomian secretions and providing symptomatic relief with regular treatment adherence.
  • After warm compresses, digital massage of the lids facilitates the expression of thicker meibum from the glands.
  • Encourage patients to maintain regular lid hygiene through warm water lid scrubs, with or without local shampoo application.
  • Emphasize cleaning the base of the eyelashes behind the lid margin to reduce bacterial load and clear meibum, thereby minimizing inflammation.
  • Lubricant eye ointment at bedtime provides symptomatic relief.
  • The key components are applying warm compresses for 10 minutes daily, cleansing the eyes with baby shampoo or lid scrubs, and using preservative-free eye lubricants and sprays.
  • Oral tetracyclines have also demonstrated clinical improvement due to their anti-inflammatory effects.
  • Topical anti-inflammatory eye drops like 0.05% cyclosporine A, topical N -acetylcysteine, lifitegrast 5%, and topical steroids like loteprednol etabonate have shown to be beneficial in reducing inflammation in stage 4 MGD.
  • A selective nicotinic acetylcholine receptor agonist, varenicline, stimulates the trigeminal parasympathetic pathway in the nasal mucosa, leading to goblet cell degranulation and stimulation of meibomian gland and lacrimal gland secretions.
  • In some patients with severe MGD, when conservative management is ineffective, mechanical opening of the terminal ducts and meibum expression may be necessary.
  • Probing or electronic heating devices facilitate the mechanical opening of blocked ducts or assist in meibum expression by applying heat.
  • Intraductal probing is a slit lamp procedure involving the mechanical opening and dilatation of the blocked meibomian gland orifices and ducts.
  • Initially, 1 to 2 mm Maskin probes penetrate the gland orifices, followed by 4 to 6 mm probes to achieve ductal patency.
  • Several electronic heating devices are now available on the market, with LipiFlow (Johnson and Johnson) being widely used and effective.
  • The Systane iLux and Systane iLux MGD Thermal Pulsation Systems (Alcon) are handheld devices that enable the operator to visualize the expression of the meibum while applying heat and pressure to the meibomian glands.
  • The MiBo Thermoflow (MIBO), another electronic heating device model, utilizes an external paddle heated to 42.2 °C and is applied with a gel buffer to the eyelids.
  • Intense pulse laser therapy uses a light source that generates wavelengths from 500 to 1200 nm.
  • Intranasal Tear Neurostimulation
  • Patients undergo treatment 3 minutes daily for 3 weeks for optimal benefit.
  • Pulsed dose of steroids with ocular surface disease
  • Steroids for phlyctenular keratitis
  • Epilation or cryotherapy for lash trichiasis
  • Intralesional steroids or incision and curettage for patients with a chalazion
  • Lid hygiene, warm compresses, topical antibiotic for anterior blepharitis
  • Tea tree oil scrubs for Demodex mite infestation
  • MGD is a chronically recurring disease.
  • Though patients tend to have temporary relief, symptoms usually reappear after some time without ongoing treatment.
  • Thus, patient education is essential to ensure maintenance and regular follow-up.
  • Following any intervention, such as probing, thermal laser treatment, or intense pulse laser therapy, the patient needs topical medications, frequent lid hygiene, and warm compresses to prevent further blocking of the meibomian ducts and promote easy meibum expression.
  • MGD can lead to severe evaporative dry eye disease symptoms when not treated correctly in the early stages.
  • In addition, patients may experience inflammation of the eyelids, further predisposing them to bacterial infection, increased redness of eyelid margins, and unsatisfactory tear film quality.
  • Demodex infestation is another complication in untreated MGD cases.
  • While treatment of MGD shows that gland regeneration is somewhat possible, the consensus is that meibomian gland loss is only partially reversible, and lack of treatment results in meibomian gland dropout and permanent loss in most cases.
  • In advanced cases, corneal keratinization begins, which can be progressive and challenging to reverse with topical medications.
  • Dilatation of acini leads to atrophy of meibomian gland ducts and the glands themselves over time.
  • Restoring normal function to the glands is difficult.
  • Particular caution is necessary for patients with MGD planning on cataract surgery or any other intraocular procedure.
  • Studies show that patients with MGD who undergo cataract surgery are at an increased risk of persistent dry eyes and meibomian gland dropout.
  • These patients are also at risk of penetration of infection from the periocular surfaces when undergoing an intraocular procedure.
  • For this reason, a detailed examination of the eyelids or associated dry eyes is of the utmost importance when examining a patient with a cataract to avoid severe complications like endophthalmitis.
  • Topical antibiotic ointment with lid hygiene may be sufficient to prevent grave complications like endophthalmitis in patients with MGD.
  • Prolonged topical corticosteroid use may cause elevated intraocular pressures or cataracts.
  • Patients should use alternative regimens and undergo close monitoring to prevent further complications.
  • Patients not improving with conservative forms of treatment should be referred to an ocular surface specialist for detailed evaluation.
  • review
    Meibomian Gland Disease. StatPearls [Internet] — Kirandeep Kaur, Thomas J. Stokkermans — StatPearls Publishing, 2024

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov