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Assessment of Meibomian Gland Function in Dry Eye Using Meibometry

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Assessment of Meibomian Gland Function in Dry Eye Using Meibometry CLINICAL SCIENCES Assessment of Meibomian Gland Function in Dry Eye Using Meibometry Norihiko Yokoi, MD, PhD; Federico Mossa, MD; John M. Tiffany, PhD; Anthony J. Bron, FRCOphth Objective: To study meibomian gland function in dry eye, and 268.5 ± 6.3 for controls, showing lower val- eyes using meibometry. ues in the MGD group relative to all others (P,.001). Results of IM gave similar results (P,.001, P = .01, Methods: Forty-two patients with clinically diagnosed and P,.001, respectively). Lipid layers appeared lower dry eye that was reclassified as meibomian gland dys- for the MGD group than others. function (MGD [n = 12]), aqueous-tear deficiency (AD [n = 10]), MGD combined with AD (n = 2), “incom- Conclusions: Compared with controls, lid lipid levels plete” dry eye (n = 12), and non–dry eye (6 eyes) were are reduced in patients with MGD, and increased in compared with 41 healthy control subjects. The follow- women with AD. Lipid layer thickness is increased in ing 2 techniques of meibometry were applied: direct mei- women with AD compared with patients with MGD. Both bometry (DM) measuring lipid imprints using the Mei- meibometric techniques may be useful for evaluating bometer, and integrated meibometry (IM) using image- MGD. Although DM requires special equipment (the Mei- scanning and computer densitometry. Tear film lipid layer bometer), it provides a record of immediate diagnostic thickness was assessed using interference microscopy. value. Although IM is less effective than DM, it offers vi- sual documentation of the lipid imprint, which may it- Results: Imprints were homogeneous for all subjects self be of diagnostic value, and uses equipment avail- except those with MGD. Mean ± SE readings on able in many laboratories. results of DM were 127.24 ± 24.4 for MGD, 306.4 ± 9.2 for AD, 248.6 ± 13.2 for incomplete dry Arch Ophthalmol. 1999;117:723-729 EIBOMIAN gland dis- tear evaporation and ocular surface dam- ease is a common con- age due to increased osmolality.8,10,11 dition that is often It is important to be able to classify symptomatic.1,2 Meibo- and quantify MGD for diagnostic reasons mian gland dysfunc- and to observe the effects of treatment. The tion (MGD) is a term adopted by Jester et diagnosis of MGD is difficult, but various M3 al chiefly to describe obstructive meibo- methods are now available to assess mei- mian gland disease. The primary disease bomian gland status. Simple clinical tests is common, but there is a strong associa- include grading the clinical features of mei- tion between MGD and certain forms of bomian gland disease1 and grading the ex- skin disease such as atopic and sebor- pressibility and quality of the meibomian rheic dermatitis and acne rosacea.4 It also oil.1,12 More specialized methods are the may be caused by systemic retinoid detection of “gland dropout” using mei- therapy5 or less commonly by polychlor- bography1,2,10-13 and the measurement of From the Department of inated biphenyl.6 Obstructive MGD may casual oil levels at the lid margin and lipid Ophthalmology, Kyoto be focal, with patchy involvement of delivery rate using meibometry.14-16 In ad- Prefectural University of glands, or diffuse, when oil expression is dition, thickness of the preocular oil layer Medicine, Kyoto, Japan impaired in all glands.7 Cicatricial and non- can be gauged using interferometry,17-19 (Dr Yokoi), and Nuffield cicatricial forms of MGD exist.7 and evaporative water loss can be mea- Laboratory of Ophthalmology, Obstructive MGD may give rise to sured using evaporimetry.10,20,21 University of Oxford, Oxford, symptoms directly, because of local lid Meibometry is a simple test for quan- England (Drs Mossa, Tiffany, margin changes, or indirectly, by induc- tifying the amount of lipid at the lid mar- and Bron). The authors do not 8 have any commercial or ing an evaporative dry eye. It is consid- gin and has been used successfully in 15 proprietary interest in any ered to be the major cause of evaporative healthy subjects. It involves the blot- product or company discussed dry eye.9 In this condition, a decreased de- ting of lipid onto a loop of translucent plas- herein. livery of meibomian oil causes increased tic tape from the central region of the lower ARCH OPHTHALMOL / VOL 117, JUNE 1999 723 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 PARTICIPANTS AND METHODS INTEGRATED MEIBOMETRY Integrated meibometry (IM) is performed on the imprint ob- STANDARD MEIBOMETRY tained by DM. Immediately after the meibometry reading, the tape loop is opened and attached to a strip of exposed Standard meibometry uses the clinical Meibometer (MB 35-mm negative film to provide a black backing. The blot 550; Courage & Khazaka Electronic GmbH, Cologne, Ger- appears as a dark line on the uniform gray tape (Figure 2). many). Lipid is blotted from the central third of the lower The oil imprint is scanned using a handheld scanner (Scan- lid with a force of 15 g onto a handheld loop of plastic tape Man; Logitech Inc, Fremont, Calif) into a computer (Mac- 8 mm wide, supplied by the manufacturers. Contact is intosh PowerBook 5300cs; Apple Computers Inc, Cuper- maintained for 10 seconds. The oil creates a translucent tino, Calif) for densitometric analysis using the Scananalysis band across the tape. The tape is then scanned across the densitometric program (Biosoft, Cambridge, England). An reading window of the photosensor of the Meibometer, automated background subtraction method is applied. The and the maximum reading is taken from the densest part program provides an integrated analysis of densities over the of the blot as it passes the line of the window.14-16 In whole area of the imprint. To prevent spread of oil over the healthy subjects with an even distribution of meibomian tape in warm weather, tapes were scanned as soon as pos- oil, the readings have been used to calculate average rest- sible after the DM reading. ing values for meibomian lipid at the lid margin (the For this study, DM and IM readouts are given in arbi- casual level).15 trary instrument units, and all measurements were performed 5 times and averaged. All data are given as mean ± SE. DIRECT MEIBOMETRY PARTICIPANTS The standard technique of meibometry was modified as follows (ie, direct meibometry [DM]). A preformed loop After explanation of all procedures and with fully of meibometry tape is placed in the reading head of the informed consent, 42 patients (8 men and 34 women; Meibometer to establish the zero reading. The loop is mean age, 63.4 ± 2.2 years) who had received a clinical formed by heat-sealing the tape at a predetermined point diagnosis of dry eye were recruited from the external to give a loop length of 20 mm. The handle is clipped to disease clinic. An additional 41 healthy control subjects the prism housing of a Goldman applanation tonometer (16 men and 25 women; mean age, 56.4 ± 2.1 years) (Keeler, Windsor, England) mounted on the slitlamp were enrolled into the study. Exclusion criteria for con- biomicroscope. This permits controlled placement of trols were biomicroscopic abnormality of the cornea, the probe on the lid margin under direct vision. The conjunctiva, or meibomian glands; lacrimal drainage tonometer is set at zero for each impression. With the problems; signs of dry eye; and a history of contact lens subject looking upward without blinking, the lower lid wear or use of eye drops for any reason during the pre- is gently everted (avoiding stretching, which might ceding 3 months. This research conformed to the tenets express oil), and the loop is pressed onto the central of the Declaration of Helsinki and was approved by Cen- third of the lid margin with sufficient pressure to obtain tral Oxford Research Ethics Committee, Oxford Univer- an imprint across the width of the tape, without bending sity, Oxford, England. the handle of the loop. A line of contact is seen across the full width of the tape (Figure 1), and contact is ASSESSMENT OF THE LID MARGIN maintained for 3 seconds. After blotting, the tape is kept AND OCULAR SURFACE in air for 3 minutes to allow evaporation of any tears picked up from the lid. The loop is placed in the reading The following assessments were made successively on the head of the Meibometer, and a reading is taken in the left eye of all subjects. The order of the test was chosen to standard way. minimize the effect of one test on succeeding tests. First, lid. An index of the resting amount of lipid on the lid the sampled area, which could result in erratically low margin (the casual level) is obtained by a spot photo- meibometry values in patients with MGD. metric reading taken from the center of the lipid im- We therefore devised 2 modifications to the stan- print.14,15 The technique has been used to establish nor- dard meibometry technique, which allowed us to assess mal casual levels for male and female subjects across the the full range of oil deposition on a segment of the lid age span.15 The use of meibometry for the diagnosis of margin. We herein describe the methods and their ap- MGD is of interest, but the standard technique has cer- plication to the study of a mixed population of patients tain disadvantages. The tape used is 8 mm wide and with dry eye. samples the pool of oil along the central third of the lower lid margin (and also the corresponding region of the up- RESULTS per lid, since lipid is exchanged during eye closure).
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