Rethinking Meibomian Gland Dysfunction: How to Spot It, Stage It and Treat It

Clinical Update

CORNEA Rethinking Meibomian Gland Dysfunction: How to Spot It, Stage It and Treat It

by linda roach, contributing writer interviewing penny a. asbell, md, marguerite b. mcdonald, md, kelly k. nichols, mph, phd, od, gustavo e. tamayo, md, and joseph tauber, md

eibomian gland dys- Meibomian Gland Dysfunction function (MGD) is thought to be the leading cause of dry eye disease. Despite the importance Mof MGD to eye health, many questions have persisted about its classification and treatment. Now, answers abound in a comprehensive, 168-page, evidence-based report recently issued by an international panel of experts Examining the eyelid margins for possible meibomian gland dysfunction is an im- convened by the Tear Film & Ocular portant step in avoiding complications in cataract and refractive surgery. Recogni- Surface Society (TFOS) and supported tion and treatment of MGD can also improve patients’ quality of life. by unrestricted grants from 13 indus- try sponsors. Of particular interest to late 2008 to launch the two-year proj- can compromise surgical results. “The clinicians, the report includes a new ect. Their report, published in March, final visual result of refractive surgery algorithm for recognizing, classifying reviews the limited research on MGD, is largely dependent on the status of and treating MGD. incorporates emerging concepts about the tear film,” said Gustavo E. Tamayo, According to Marguerite B. Mc- the condition and identifies future re- MD, director of the Bogotá Laser Re- Donald, MD, a refractive surgeon search needs.1 fractive Institute in Bogotá, Colombia. at Ophthalmic Consultants of Long “The correct diagnosis and treatment Island and clinical professor of oph- Report’s Significance for Clinical Care of any possible cause of dry eye, such thalmology at New York University, MGD is “the most underrecognized, as MGD, is mandatory for any type of “There has been surprisingly little re- underappreciated and undertreated surgical procedure.” search on how to classify and manage disease in ophthalmic care. It is so Penny A. Asbell, MD, professor of MGD. You can sum up all the research common as to be taken as ‘normal’ ophthalmology at Mount Sinai Medi- that has been done very briefly.” After in many clinical practices,” accord- cal Center in New York City, agreed: reviewing the report, she commented, ing to Joseph Tauber, MD, an anterior “To get good vision you need a good “This group put an enormous amount segment subspecialist and refractive ocular surface. But the role of the mei- of effort—hundreds and hundreds of surgeon in Kansas City, Mo., who was bomian glands in providing that good hours—into culling the past research, a member of the workshop’s Manage- ocular surface has been underappreci- weighing the evidence and developing ment and Treatment Subcommittee. ated.” Dr. Asbell chaired the work- a treatment algorithm based on what Yet taking MGD for granted can have a shop’s Design and Conduct of Clinical is known about MGD. They admit that serious effect on the success of anterior Trials Subcommittee. the result might not be perfect, but it’s segment surgery. Minimizing postsurgical complica- an important first step.” Ocular surface is key to surgi- tions. Dr. Asbell noted that tear film At the behest of TFOS, the 50-plus cal outcomes. The new staging and irregularities change corneal reflectiv- researcher and clinician members of treatment algorithm has particular ity and can lead to inaccurate preop- the International Workshop on Meibo- importance for cataract and refractive erative K readings and mistaken IOL

eyenet 27 Cornea refractive results, especially if the pa- Why meibum matters. The work- Do a slit-lamp exam. At every pre- tient paid extra for presbyopia-correct- shop analysis divided MGD into two surgical exam, examine the lids thor- ing IOLs. In addition, untreated MGD major types: 1) low delivery states, the oughly at the slit lamp by pulling down can put cataract patients at higher risk most common form, characterized by on the lower lid and up on the upper for infection and inflammation. “We a reduction in meibum, resulting from lid to expose the lid margin. Be sure to want to avoid lid inflammation that either hyposecretion or obstruction; look closely at the orifices, where the could be a source of contaminants and 2) high delivery states, character- meibomian secretions come out. during surgery as well as a risk factor ized by hypersecretion. In this new Examine the meibum. Use pressure for greater postoperative inflamma- classification system, the relationship to express some meibum and evalu- tion,” she said. between MGD and ocular surface ate its appearance, which indicates diseases such as dry eye is based on the MGD stage (see table for meibum Untangling the Terminology of MGD changes in meibum secretion, which grading). Since the term meibomian gland dys- alter the makeup of the tear film and “I bet that nine out of 10 ophthal- function first appeared in the literature lead to subsequent surface irritation mologists don’t look closely at the lid in 1980, it has been used interchange- and inflammation. when doing an eye exam before sur- ably with a confusing array of other gery,” Dr. Asbell said. “Both of these names for meibomian gland and eyelid Highlights for Busy Clinicians steps should be routine in every preop- conditions, the workshop’s Defini- Acknowledging that busy comprehen- erative patient.” tion and Classification Subcommittee sive ophthalmologists might not have From detection to action. Dr. notes. These have included posterior time to read the full report, the work- Tauber advises clinicians to be alert blepharitis, meibomian gland disease, shop produced a two-page overview of for signs of MGD when a patient com- meibomitis, meibomianitis and mei- the highlights for clinical use. plains of nonspecific eye irritation bomian keratoconjunctivitis. Staging and treatment algorithm. or visual blur. Symptoms of MGD Consequently, an important ele- The most important part of the over- are very similar to those of aqueous- ment in the MGD report is its attempt view is a table proposing a staging and deficiency dry eye, but complaints of to standardize the definitions of MGD treatment algorithm for MGD. (See burning suggest lid margin disease, he and related terms based on their “Staging and Treatment of Meibomian noted. pathophysiology: Gland Dysfunction.”) “Optimizing the ocular surface • Blepharitis, the most general of the This algorithm fills a void that health preoperatively is highly advis- terms, describes inflammation of the has hampered MGD treatment and able, as it is far easier to prevent de- eyelid as a whole. Marginal blepharitis research in the past, and it will set the compensation than to rehabilitate the is inflammation of the lid margin and stage for future improvements, accord- surface later,” Dr. Tauber said. “Stag- comprises both anterior and posterior ing to the workshop’s leaders. “Once ing MGD is important, because in blepharitis. our algorithm is out there and is seen some cases, the addition of lid hygiene • Anterior blepharitis refers to in- by clinicians, studies can be designed measures alone will be sufficient prior flammation of the lid margin anterior around it to test it. You have to start to surgery, while in other cases, sur- to the gray line, concentrated around somewhere, and I felt that we would gery should be deferred for weeks or the lashes. It may be accompanied by be doing a disservice if we didn’t try to even months, until high-grade MGD is squamous debris or collarettes around define something that people could try brought under control.” the lashes, and inflammation may spill to shoot holes in,” said the chairwom- MGD and quality of life. Dr. Mc- onto the posterior lid margin. an of the workshop’s Steering Com- Donald reminds her colleagues that • Posterior blepharitis is an inflam- mittee, Kelly K. Nichols, MPH, PhD, blepharitis and MGD also deserve at- matory condition of the posterior OD, associate professor of optometry tention because they pose substantial lid margin. It has a variety of causes, at the Ohio State University and an ex- quality-of-life issues for patients. “Even including MGD, conjunctival inflam- pert in ocular surface diseases. without any surgical considerations, mation (allergic or infectious) or other Dr. Tauber agreed: “Learning to untreated blepharitis or MGD causes conditions, such as acne rosacea. use a standardized grading system in very significant problems for them,” • MGD is “a chronic, diffuse ab- MGD will allow for an organized ap- she said. “They can’t wear their con- normality of the meibomian glands, proach to therapy, rather than the ran- tact lenses. Their eyes are so red and commonly characterized by terminal dom, grab-bag approach prescribed by puffy that it puts their professional and duct obstruction and/or qualitative/ many practitioners currently.” personal lives in jeopardy—because quantitative changes in the glandular they show up looking like they have a secretion. This may result in alteration How to Detect Lid Problems drinking or drug problem.” of the tear film, symptoms of eye ir- For ophthalmologists who want to do ritation, clinically apparent inflamma- a better job of identifying MGD, Dr. MORE ONLINE. For background information tion, and ocular surface disease.”1 Asbell had these tips: on the International Workshop on Meibomian

28 july/august 2011 Cornea

Gland Dysfunction and links to the overview Dr. Asbell has received speaking or consul- Alcon, Allergan, Inspire Pharmaceuticals, and report, go to www.tearfilm.org. Or go di- tant fees from Inspire, Aton, Pfizer, Bausch + Pfizer and TearLab. Dr. Tamayo has received rectly to www.iovs.org/content/52/4.toc for the Lomb, Johnson & Johnson, Vindico, Merck, research funding from Eyegenics, is a member complete report. Santen and Otsuka. Dr. McDonald is a con- of the speakers’ bureau for Presbia and has sultant for Allergan, Alcon, AMO, Bausch + received speaking fees, research grants and 1 The International Workshop on Meibo- Lomb, Santen, Inspire, Ocularis Pharma, travel funding from Abbott Medical Optics. mian Gland Dysfunction. Invest Ophthalmol Focus Labs and NexisVision. Dr. Nichols Dr. Tauber is a consultant for Alcon, Allergan Vis Sci 2011;52(4):1917–2085. has received speaking or consultant fees from and Inspire. Staging and Treatment of Meibomian Gland Dysfunction

STAGE CLINICAL DESCRIPTION TREATMENT 1 No symptoms of ocular discomfort, itching or photophobia Inform patient about MGD, the potential impact of diet Clinical signs of MGD based on gland expression and the effect of work/home environments on tear evapo- Minimally altered secretions: Grade >2 to <4 ration, and the possible drying effect of certain systemic Expressibility: 1 medications No ocular surface staining Consider eyelid hygiene including warming/expression as described below (±)

2 Minimal to mild symptoms of ocular discomfort, itching or Advise patient on improving ambient humidity; optimizing photophobia workstations and increasing dietary omega-3 fatty acid Minimal to mild MGD clinical signs intake (±) Scattered lid margin features Institute eyelid hygiene with eyelid warming (a minimum Mildly altered secretions: Grade >4 to <8 of four minutes, once or twice daily) followed by moderate Expressibility: 1 to firm massage and expression of MG secretions (+) None to limited ocular surface staining (DEWS grade 0–7; All the above, plus (±) Oxford grade 0–3) Artificial lubricants (for frequent use, nonpreserved preferred) Topical emollient lubricant or liposomal spray Topical azithromycin Consider oral tetracycline derivatives

3 Moderate symptoms of ocular discomfort, itching or All the above, plus photophobia with limitations of activities Oral tetracycline derivatives (+) Moderate MGD clinical signs Lubricant ointment at bedtime (±) h lid margin features: plugging, vascularity Anti-inflammatory therapy for dry eye as indicated (±) Moderately altered secretions: Grade >8 to <13 Expressibility: 2 Mild to moderate conjunctival and peripheral corneal staining, often inferior (DEWS grade 8–23; Oxford grade 4–10)

4 Marked symptoms of ocular discomfort, itching or photo- All the above, plus phobia with definite limitations of activities Anti-inflammatory therapy for dry eye (+) Severe MGD clinical signs KEY h lid margin features: dropout, displacement (+) = supported by evidence; (±) = limited or emerging evidence. Severely altered secretions: Grade >13 Meibum quality is assessed in each of 8 glands of the central Expressibility: 3 third of the lower lid on a 0–3 scale for each gland: 0=clear meibum; 1=cloudy meibum; 2=cloudy with debris (granular); Increased conjunctival and corneal staining, includ- 3=thick, like toothpaste (range 0–24). ing central staining (DEWS grade 24–33; Oxford grade Expressibility of meibum is assessed from 5 glands: 0= all 11–15) glands expressible; 1=3–4 glands expressible; 2=1–2 glands h Signs of inflammation: e.g., > moderate conjunctival expressible; 3=no glands expressible. This can be assessed in hyperemia, phlyctenules the lower or upper lid. Numerical staining scores refer to a summed score of staining of the exposed cornea and conjunctiva. The Oxford scale has a Go to www.iovs.org/content/52/4.toc for the full report. range of 0–15 and the DEWS scale has a range of 0–33. geerling, g. et al. the international workshoptreatment on meibomian of meibomian gland dysfunction: gland dysfunction. report invest of the subcommittee ophthalmol on management vis sci 2011;52:2050–2064, and table arvo. © 2011 1.

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