Abnormal meibum secretions that
meibomian gland disease

ICD-10 Diagnosis Codes:

H00.021–Internal hordeolum, Right upper eyelid
H00.022–Internal hordeolum, Right lower eyelid
H00.024–Internal hordeolum, Left upper eyelid
H00.025–Internal hordeolum, Left lower eyelid


Meibomian Gland Disease


Inflammation Of Eyelids


An abnormality of the meibomian glands commonly characterized by duct obstruction and/or changes in duct secretions.

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
Structural Damage to the Eyelid and Eye

  • Hyperkeratinization of the terminal ductules within the meibomian gland
  • Accumulation of cellular and lipid material within meibomian duct lumina
  • Meibomian duct obstruction
  • Cystic dilatation of the meibomian ducts and acini
  • Secondary diffuse atrophy of the meibomian acini
  • Unstable tear film develops
  • Inferior corneal epitheliopathy occurs
  • Periglandular inflammatory changes (seen at right) indicate gland atrophy and end stage disease

Eyelid notch indicates meibomian gland atrophy


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
37312PostBleph4 Clinical Appearance of the Eyelid

  • No apparent eyelid pathology
  • No apparent corneal pathology
  • No apparent tear film abnormalities
Digital pressure on the eyelid margin results in the expression of meibum that is turbid. Clinical Appearance of Meibomian Gland Expression

  • Meibomian gland expression performed with index finger
  • Digital pressure applied to tarsal plate
  • Release of cloudy meibum with digital expression

Epressed meibum can be graded as follows:

  • Clear fluid
  • Cloudy fluid
  • Viscous fluid containing particulate matter
  • Densely opaque, inspissated, toothpaste-like material
37300MixedBleph (6) Clinical Appearance of the Meibomian Orifice

  • Capped meibomian gland orifices
DG37312Pic20 Clinical Appearance of the Meibomian Orifice

  • Meibomian orifice capped by a lipid globule
  • Cap is hypothesized to be oxidized lipid and epithelial material
DG37312Pic76 Clinical Appearance of the Eyelid

  • Dimpling of the posterior eyelid margin due to tissue absorption in the area of the meibomian gland orifices
  • Additional eyelid features include notching, rounding, epithelial ridging between gland orifices, telangiectasia, increase vascularity of the posterior eyelid margin and anterior migration of the mucocutaneous junction
37312PostBleph2 Clinical Appearance of the Eyelid Margin

  • Telangiectasia of the eyelid margin correlates with the presence of meibomian gland disease
DG37312Pic77 Clinical Appearance of the Mucocutaneous Junction

  • The location of the mucocutaneous junction is called Marx’s line
  • This junction forms the watershed between the lipid-friendly skin of the eyelid marginandthe hydrophilic mucosa of the conjunctiva
  • Anterior migration of Marx’s line correlates with the presence of meibomian gland disease
  • The line of conjunctival epithelial staining directly behind Marx’s line is revealed with Lissamine green dye
37312PostBleph3 Clinical Appearance of the Tear Film

  • Frothing of the tear film along the eyelid margin
  • The “foamy” appearance seen is a clinical sign of posterior blepharitis
37312PostBleph1a Clinical Appearance of the Cornea

  • Inferior punctate epitheliopathy associated with blepharitis is called meibomian keratoconjunctivitis
  • Epithelial damage in this location is usually from the toxins released by bacteria residing in the eyelid margin or the meibomian gland


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
8 5 (1) 7

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
DG17310AB Sebaceous Gland Carcinoma

  • Inflammation and distortion of the normal eyelid anatomy are common findings in malignant tumors of the eyelid
  • Chronic, unilateral or asymmetric meibomian gland disease is a rare manifestation of sebaceous gland carinoma
  • Clinical signs of tumor include loss of eyelashes or whitening of eyelashes over the lesion


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

1.  Pitts J. Lievens C.  Put The Squeeze on Meibomian Gland Disease.  16 Sept 2009.  RevOptom. http://www.revoptom.com/content/c/15811/.  Last accessed August 17, 2014.
2.  Stephenson M.  Blepharitis:  The Cause Guides to Treatment.  Review of Ophthalmology.  5 Sept 2013. http://www.revophth.com/content/c/42801/.  Last accessed August 17, 2014. 
3.  Stuart A.  Managing Blepharitis:  Tried-and-True and New Approaches.  American Academy of Ophthalmology. http://www.aao.org/publications/eyenet/201207/cornea.cfm.  Last accessed August 17, 2014.
4.  Lowery S.  Adult Blepharitis.  Medscape/EMedicine.  20 Feb 2014. http://emedicine.medscape.com/article/1211763-overview.  Last accessed August 17, 2014. 
5.  Kabat A. Shechtman D.  Current Therapeutic Approaches to Blepharitis Management.  RevOptom.  3 Mar 2011. http://www.revoptom.com/content/c/27049/.  Last accessed August 17, 2014.