H00.021-025 Meibomian Gland Disease

Meibomian gland disease is also called posterior blepharitis.  It refers to those manifestations primarily affecting the meibomian glands and the meibum they secrete.  The condition is characterized by the following abnormal signs and symptoms:

• Puffy eyelids
• Ocular redness
• Crusty debris in the eyelashes
• Inflammed, erythematous eyelid margins
• Eyelid involvement is usually bilateral and symmetric
• Associated evaporative dry eye syndrome in 50-75% of patients 
• Abnormal signs and symptoms that are usually worse in the morning 
• Severe cases can produce corneal scarring, corneal neovascularization and marginal keratitis

Functional Damage to the Eye

• Fluctuating vision from the effects of an unstable tear film
• Blurred vision from corneal epitheliopathy

The main goal of the diagnostic evaluation in a patient with meibomian gland disease is to accomplish the following:

1.  Stage the disease based on it’s clinical features

• Patient symptoms
• Eyelid appearance and meibomian gland secretions
• Ocular surface staining

2.  Relieve ocular pain and discomfort

• Prescribe a treatment program to treat the posterior blepharitis
• Prescribe a treatment program to treat any associated dry eye syndrome

Patient History

Patients may present with any or all of the following clinical signs and symptoms:

• None
• Mild ocular discomfort
• Itching
• Photophobia
• Ocular redness
• Puffy eyelids

External Ocular Examination with Biomicroscopy

• Meibomian gland orifice plugging
• Meibomian gland duct obstruction
• Meibomian gland atrophy and dropout
• Qualitive changes in the expressed secretions
• Eyelid margin hyperemia
• Eyelid vessel telangiectasia
• Tear film frothing

DIAGNOSTIC TESTS

External Ocular Photography

• Document clinical appearance of the eyelid margin
• Document clinical appearance of the inferior cornea
• Help to plan treatment of meibomian gland disease

Meibomian gland disease can be categorized into four subtypes:

Primary meibomian gland disease 

• Meibomian gland dropout
• Altered meibomian gland secretion
• Changes in eyelid morphology

Meibomian gland disease associated with ocular surface damage

• Staining of the cornea
• Staining of the conjunctiva

Meibomian gland disease-related evaporative dry eye

• Reduced tear-film stability
• Abnormal tear film spreading pattern
• Increased loss of water from the tear film secondary to evaporation

Meibomian gland disease associated with other ocular disorders

• Contact lens wear
• Seborrhea sicca
• Acne rosacea
• Seborrheic dermatitis
• Atropy

CHRONIC PRESENTATIONS

Best practices treatment guidelines from The International Workshop on Meibomian Gland Dysfunction suggest the following treatment options:

• Improve patient symptoms
• Reduce chronic gland inflammation
• Improve the quality of the meibum secretion
• Prevent damage to the ocular surface
• Prevent meibomian gland dropout

Palliative Treatment

• Artificial tears (non-preserved is preferred for frequent use)
• Topical emollient lubricant
• Liposomal spray
• Warm compress therapy

Topical cyclosporine (e.g., Restasis ophthalmic emulsion)

• If concurrent corneal epitheliopathy is present
• If concurrent aqueous deficiency dry eye syndrome is present 

Oral tetracyclines

• Tetracycline 250 mg (4x per day for 30 days)
• Doxycycline 50-100 mg (2x per day for 30 days)
• Minocycline 50-100 mg (2x per day for 30 days)

Nutritional Treatment

• Omega-3 fatty acid dietary supplementation to decrease inflammation in the eyelids

In 2003, research presented  at the 2003 Annual meeting of the Association for Research in Vision and Ophthalmology found that high dietary intake of omega-3 essential fatty acids decrease the risk of dry eye syndrome. The anti-inflammatory effects of omega-3’s also help the reduce inflammation in the eyelids.

Mechanical Treatment

• Meibomian gland therapeutic expression

Surgical Treatment

• Ductal probing of the meibomian gland

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