Evaporative dry eye disease due to meibomian gland dysfunction: Preferred practice pattern guidelines for diagnosis and treatment

Evaporative dry eye (EDE) due to meibomian gland dysfunction (MGD) is one of the common clinical problems encountered in ophthalmology. It is a major cause of dry eye disease (DED) and of ocular morbidity. In EDE, inadequate quantity or quality of lipids produced by the meibomian glands leads to faster evaporation of the preocular tear film and symptoms and signs of DED. Although the diagnosis is made using a combination of clinical features and special diagnostic test results, the management of the disease might be challenging as it is often difficult to distinguish EDE from other subtypes of DED. This is critical because the approach to the treatment of DED is guided by identifying the underlying subtype and cause. The traditional treatment of MGD consists of warm compresses, lid massage, and improving lid hygiene, all measures aimed at relieving glandular obstruction and facilitating meibum outflow. In recent years, newer diagnostic imaging modalities and therapies for EDE like vectored thermal pulsation and intense pulsed light therapy have emerged. However, the multitude of management options may confuse the treating ophthalmologist, and a customized rather than a generalized approach is necessary for these patients. This review aims to provide a simplified approach to diagnose EDE due to MGD and to individualize treatment for each patient. The review also emphasizes the role of lifestyle modifications and appropriate counseling so that patients can have realistic expectations and enjoy a better quality of life.

Dry eye disease in head and neck cancer patients undergoing radiotherapy

Purpose: To study the incidence of dry eye disease (DED) in head and neck cancer (HNC) patients undergoing external beam radiotherapy (EBRT), to find a correlation between tumor location and total radiation dose with DED, and to report various radiotherapy (RT) induced acute toxic effects on ocular and adnexal structures. Methods: A prospective cohort study was conducted at a tertiary eye?care center on 90 patients of HNC undergoing EBRT from March 2021 to May 2022. All underwent a thorough clinical history and complete ophthalmological examination including an ocular surface disease index (OSDI) questionnaire, visual acuity, anterior segment, angle and posterior segment examination, dry eye workup including the Schirmer test, tear meniscus height, tear break?up time, corneal fluorescein staining and grading, and meibography by auto?refractometer and its scoring at each visit. Patients were evaluated before the start of RT and then at 1 week, 4 weeks, and 12 weeks post?RT. Radiation records of all patients were noted. Data were analyzed using percentage and Microsoft Excel. Results: Of the 90 patients, 66 were male and 24 female (M: F ratio of 2.75) with a median age of 52.5 years (range 24 to 80 years). The most common HNC was the carcinoma oral cavity and lip. Most patients received a total radiation dose between 46 to 55 Gy. DED developed in 48 (53.3%) patients. The incidence of DED increased with the increase in total radiation dose (r = 0.987). DED was also found to be correlated with tumor location (r = 0.983). Conclusion: The incidence of DED positively correlated with the total radiation dose and tumor location.

Automatic segmentation and quantified analysis of meibomian glands from infrared images

Purpose: An algorithm for automated segmentation of meibomian glands from infrared images obtained using a novel prototype infrared hand?held imager has been proposed in this study. Meibomian gland dysfunction (MGD) is quantified in terms of five clinically relevant metrics. A comparison of these metrics in patients with MGD has been presented against a sample of the normative healthy population. Methods: This is a prospective cross?sectional observational study. Patients presenting to the clinics were enrolled after written informed consent. The everted eyelids of 200 eyes of patients (of which 100 were healthy and 100 were diagnosed with MGD) were imaged using a prototype hand?held camera. The proposed algorithm was used to process the images using enhancement techniques and the glands were automatically segmented. A comparison of glands of normal eyes versus MGD?affected eyes is performed using five metrics presented in this study: (i) drop?out, (ii) length, (iii) width, (iv) the number of glands, and (v) the number of tortuous glands. Results: The 95% confidence interval for the metrics did not show any overlap between the two groups. In MGD patients, the drop?out ratio was higher than normal. The length and number of glands were significantly lesser than normal. A number of tortuous glands were more in the MGD group. The metrics for MGD versus healthy and cut?off ranges were computed in the results. Conclusion: The prototype infrared hand?held meibographer and the proposed automatic algorithm for gland segmentation and quantification are effective aids in MGD diagnosis. We present a set of five metrics, which are clinically relevant for guiding clinicians in the diagnosis of MGD

A simple technique of meibography for morphological and functional evaluation of meibomian glands in dry eye conditions

Purpose: Dry eye disease (DED) is because of a decrease in the tear film’s volume or a change in the composition of tears. Evaporative dry eye is the most common type, which is due to meibomian gland dysfunction (MGD). In this study, the morphology of meibomian glands was evaluated in all kinds of dry eyes to look for any loss of meibomian glands, assess the function of remaining glands, and investigate the relationship between anatomy, function, and severity of DED. Methods: A total of 300 patients were included in the study, with 150 eyes in the study group and 150 in the control group. Meibomian gland morphology was assessed by examining the tarsal plate after everting the eyelids. Tear film function was evaluated using tear film break?up time (TBUT) and Schirmer’s test (SCH I and II). Meibomian gland morphology was examined with a slit?lamp under magnification, a transilluminator using a small light emitting diode (LED) bulb, and non?contact meibography using an auto refracto?keratometer (ARK). Results: Females had a higher prevalence of dry eyes in our study. In all, 103 eyes (68.6%) in the study group had evaporative dry eye, making it the most prevalent type. Among the 150 controls, 104 controls with 69.3% had no dry eye symptoms, and in those with symptoms, the evaporative type was the most common, with a 28% prevalence. Conclusion: TBUT should be performed in all patients with detectable MG abnormality. Meibography has high specificity and sensitivity to diagnose MGD and in turn dry eyes and should be considered a routine screening modality.

Evaluation of meibomian gland morphology and anterior segment parameters by Sirius topography systems in polycystic ovary syndrome

Purpose: To compare findings in specular microscopy, corneal topography, and noncontact meibography in polycystic ovary syndrome (PCOS) patients with healthy controls. Methods: A total of 40 women with PCOS and 32 healthy controls were enrolled in the study. Schirmer’s test, Ocular Surface Disease Index (OSDI), noninvasive tear break-up time (NITBUT), the mean keratometry (Km), maximum keratometry (Kmax), central (CCT), thinnest (TCT) and apical (ACT) corneal thicknesses, meibomian gland (MG) loss, meiboscores, morphology of MGs, endothelial cell density (ECD), coefficient of variation (CV), and percentage of hexagonal cells (PHEX) were analyzed. Correlations between anti-Mullerian hormone (AMH) and sex hormones and the findings of PCOS patients were evaluated. Results: Mean OSDI score, intraocular pressure, Km and Kmax values, the mean MG loss of upper and lower eyelids, lower eyelid meiboscore, and degree of morphological abnormalities of MGs were higher in cases with PCOS than healthy controls. There were no significant differences between groups in Schirmer results, first and average NITBUT, mean values of TCT, ACT, CCT, ECD, CV, and PHEX (P > 0.05, for all). There were correlations between plasma AMH level and Kmax, back Km and PHEX, and between estradiol (E2) and PHEX; there were negative correlations between E2 and total MG loss and CV and between total testosterone and ACT. Conclusion: Loss and morphological deterioration of the MGs are observed in PCOS patients, even if the tear parameters are not impaired yet. In eyes with PCOS, keratometry values become steeper in proportion to AMH levels. The PCOS patients should be followed carefully for the development of corneal ectasia.

Comparative analysis of meibomian gland dysfunction in eyes with and without eyelid margin tattoos

@#OBJECTIVE: To compare the presence and severity of meibomian gland (MG) dysfunction among eyes of female subjects with and without eyelid margin tattoos using infrared meibography and colored photographs. METHODS: This is a cross-sectional, descriptive study that involved 38 Filipino females with and without eyelid margin tattoos. Infrared meibography was performed on the upper and lower eyelids of each eye to assess total or partial MG dropout. Colored photographs were taken to evaluate vascularity, irregularity, thickening of the lid margins, and plugging of MG orifices. Severity of MG dysfunction (MGD) was assessed using Arita’s MGD proposed grading scale. Independent t-test was used to compare MG dropout and other lid margin parameters between the two groups. Prevalence ratio and prevalence odds ratio were calculated to measure the likelihood of MGD among eyes with eyelid tattoos. RESULTS: Seventy-four (74) eyes were included in the study (36 in the tattoo group and 38 in the control group). Scores for abnormal vascularity, irregularity, and thickening of the lid margins were significantly higher in the tattoo group compared to the control group (p<0.0000001). However, plugging of gland orifices scores between the two groups were found to be similar (upper eyelid: p=0.65; lower eyelid: p=0.91). Total MG dropout was significantly greater in the tattoo group (upper eyelid: -1.11 ± 0.82; lower eyelid: 1.37 ± 0.75) compared to the control group (upper eyelid: 0.53 ± 0.83; lower eyelid: 0.45 ± 0.76) (upper eyelid: p=0.003; lower eyelid: p=0.000001) for the upper and lower eyelid, respectively). Analysis of total MG dropout between the two groups showed a prevalence ratio of 2.13. CONCLUSION: Eyelid margin tattoos are associated with several eyelid margin abnormalities and increase the risk of meibomian gland droupout.

Morphologlc changes of the meibomian gland and its correlation with dry eye in blepharitis patient / 中华实验眼科杂志

Background Blepharitis is a common ocular surface disease.It is associated with the disorder of lipid secretion of meibomian gland.The change of tear film stability can cause dry eye symptoms,so blepharitis is thought to be one of the factors causing dry eye,but the relation between them is in study. Objective This study was to observe the morphology of meibomian gland in blepharitis patients and to investigate the correlation of morphology of meibomian gland with dry eye. Methods A series of case-observational study was designed in this study.A total of 83 eyes of consecutive 83 blepharitis patients were enrolled in Henan Eye Institute from October 2010 to April 2011.Blepharitis was diagnosed based on American Preferred Practice Pattern Guidelines.Some relevant ocular examinations were performed under the informed consent of the subjects,including the anterior segment manifestation by the slit lamp,such as meibography,lid margin abnormality,and the dry eye-relevant examinations,such as tear film break-up time (BUT),Schirmer test Ⅰ and corneal fluorescein staining also been carried out.Tear film shape was examined by film interference images and scored.Absent degree of meibomian gland was graded under a Noncontact Infrared Meibography.The correlations of absent degree of meibomian gland with ocular syndrome score,dry eye examination results were evaluated using Spearman rank correlation coefficients.Informed consent was obtained prior to this trail. Results No significant difference in the frequencies of blepharitis was found between male and female among different ages (x2 =2.69,P =0.75 ).Absent grading of the meibomian glands was positively correlated with age of blepharitis patients ( r =0.58,P =0.00 ),lid margin abnormality scores ( r =0.64,P =0.00 ),conjuntival hyperemia score ( r=0.50,P =0.00),tear film interference imaging grade ( r =0.23,P =0.04 ),corneal fluorescein staining score( r =0.50,P =0.00 ) but was negatively correlated with BUT ( r =-0.32,P =0.00 ).No significant correlation was found between meibography grading and gender( r =-0.09 ; P =0.99 ) or Schirmer test Ⅰ ( r =-0.05;P =0.69 ).No significant difference was found in meibography grading between male and female in different age groups(Z=-0.09,P=0.93). Conclusions Blepharitis can irriter dry eye symptom because of overevaporation of tear fluid and abnormality of secreting function of meibomian glands.The missing of the meibomain glands increases with age in the patients with blepharitis.Noncontact Meibography System is an assistant tool to the diagnosis of blepharitis.

Assessment of Meibomian Gland Dysfunction and Comparison of The Results of BUT and Schirmer Test According to Meibomian Gland State

We analyzed 75 patients (150 eyes)who visited our hospital from April to August 1999, and divided into 4 groups by using meibography and meibomian expression;meibomian gland orifice obstruction group (group 1), meibomian gland destruction group (group 2), meibomian gland destruction and meibomian gland orifice obstruction group (group 3), normal control group (group 4). We performed BUT and Schirmer test, and asked symptoms of dry eye in each group. The mean BUT was 8.20 +/-2.16 sec, 7.70 +/- 2.12 sec, 6.22 +/-2.07 sec, and 14.56 +/-2.55 sec in group 1, 2, 3, and 4 respectively and the mean number of symptoms of dry eye was 2.10 +/-1.06, 2.33 +/- 0.97, 2.92 +/-0.77, and 0.72 +/-0.71. These differences were statistically significant (p0.05). These results suggest that meibomian gland dysfunction decreases the BUT results and discomforts patients with dry eye symptom. Thus, we expect that meibography and meibomian expression technique which are easily used at out-patient department are relatively objective and helpful methods to evaluate meibomian gland dysfunction, and it would be helpful to perform these examinations in patient with dry eye to detect the causative factor and perform the proper treatment of this disease.