Topic- ''Eyelid/Meibomian Gland Evaluation'' Speaker: Dr Christine W. Sindt Hello Everyone, Namaste!! We would like to notify you all that Mero Eye Foundation is going to conduct an "EYE TALKS-Webinar", and we will be having our session live broadcasted on YouTube (Session No. 90) DATE – Thurs, 08:00 p.m NPT, 07:45 p.m IST, July 23th, 2020 YouTube LIVE : https://youtu.be/FBwoRQuDYlU

1. COMPREHENSIVE
MEIBOMIAN GLAND
EVALUATION
Christine W Sindt OD FAAO
Clinical Professor
Director, Contact Lens Service
University of Iowa

2. Disclosure
■ Consultant:
– Allergan
– NovaBay Pharmaceuticals
■ President and Owner
– EyePrint Prosthetics

3. Objective
Understanding how to evaluate the
Meibomian Glands is the first step
in an effective treatment plan.
This course reviews the
definitions, structure/ anatomy
and diagnosis of Meibomian gland
dysfunction and how to effectively
incorporate it into everyday
practice.

4. Learning objectives
1) Understand the lexicon of Meibomian gland dysfunction
2) Understand the Meibomian gland structure: both normal and transformation to
abnormal
3) Understand diagnostic techniques necessary for differentiation, treatment and
follow up.

5. Meibum
■ The meibomian glands are the main
source of lipids for the human tear
film.
■ The meibomian gland secretions
consist of a complex mixture of
various polar and nonpolar lipids
containing cholesterol and wax
esters, diesters, triacylglycerol, free
cholesterol, free fatty acids, and
phospholipids.
Invest Ophthalmol Vis Sci. 2011 Mar; 52(4): 1930–1937

6. The Functions of Healthy Meibomian Lipids
■ Provide a smooth optical surface for the cornea at the air-lipid interface
■ Reduce evaporation of the tear film
■ Enhance the stability of the tear film
■ Enhance spreading of the tear film
■ Prevent spillover of tears from the lid margin
■ Prevent contamination of the tear film by sebum
■ Seal the apposing lid margins during sleep
Invest Ophthalmol Vis Sci. 2011 Mar; 52(4): 1930–1937

7. ANATOMY OF THE
MEIBOMIAN GLAND

8. The Normal EyeLid Margin
■ Large sebaceous glands located in the tarsal plates of the eyelids
■ No contact with hair follicles
■ Synthesize and secrete lipids and proteins that are delivered at the upper and lower eyelid
margins just anterior to the mucocutaneous junctions
■ Glandular lipids spread onto the tear film, promote its stability, and prevent its evaporation.

9. ■ Length
– Follows the Tarsus
■ 5.5- 10mm long in upper
■ 2-5mm long in lower
■ Number
– More in the Upper lid (30-40)
– Less in the Lower lid (20-30)
■ Volume
– Higher in the upper lid
■ 26ul vs. 13ul
■ Relative functional contribution
(upper vs lower) to the tear film lipid
is unknown

10. Acini
■ Each gland contains 10-15 acini filled
with secretory cells
■ readily be judged in young,
uninflamed lids
■ the visibility of the acini decreases
with:
– age
– chronic conjunctival
inflammation.
■ Acini empty into a central duct
– Holocrine secretions
– Meibocyte nuclei shrink and
disintegrate- forming oil product
■ Constant secretions

11. DEFINITIONS AND
TERMINOLOGY

12. Anterior Blepharitis
■ Inflammation of the lid margin
anterior to the gray line and
centered around the lashes
■ Gray line represents the location of
the marginal region of the
orbicularis muscle (the muscle of
Riolan) seen through the lid skin
■ May be accompanied by squamous
debris or collarettes around the
base of the lashes and vascular
changes of the lid skin
Invest Ophthalmol Vis Sci. 2011 Mar; 52(4): 1930–1937

13. Posterior Blepharitis
■ Term used to describe inflammatory
conditions of the posterior lid margin,
of which MGD is only one cause
– Other causes include infectious
or allergic conjunctivitis and
systemic conditions such as
acne rosacea
■ Posterior lid margin contains:
– marginal mucosa
– mucocutaneous junction
– meibomian gland orifices and
associated terminal ductules
– neighboring keratinized skin
Invest Ophthalmol Vis Sci. 2011 Mar; 52(4): 1930–1937

14. Meibomian gland dysfunction (MGD)
■ Chronic, diffuse abnormality of the meibomian
glands
■ Characterized by
– terminal duct obstruction and/or
– qualitative/quantitative changes in the
glandular secretion.
■ Result in
– alteration of the tear film
– symptoms of eye irritation
– clinically apparent inflammation
– ocular surface disease.
International Workshop on Meibomian Gland Dysfunction
Invest Ophthalmol Vis Sci. 2011 Mar; 52(4): 1930–1937

15. PHYSIOLOGY, AND
PATHOPHYSIOLOGY

17. ■ Meibomian glands are densely innervated, and their function is regulated by
androgens, estrogens, progestins, retinoic acid, and growth factors, and possibly by
neurotransmitters.
■ Meibum delivery onto the lid margin occurs with muscular contraction during lid
movement.
■ The obstruction may lead to intraglandular cystic dilatation, meibocyte atrophy,
gland dropout, and low secretion, effects that do not typically involve inflammatory
cells.
■ The outcome of MGD is a reduced availability of meibum to the lid margin and tear
film.
– The consequence of insufficient lipids may be increased evaporation,
hyperosmolarity and instability of the tear film, increased bacterial growth on
the lid margin, evaporative dry eye, and ocular surface inflammation and
damage.

18. HOWEVER…recent literature suggests
atrophy may be the cause not the result.
■ In both mouse and humans
– There is an anterior displacement of the mucocutaneous junction
– Loss of fully keratinized epithelium around the meibomian gland orifice
■ Desiccating stress induces proliferative changes in the gland leading to retention of
protein the meibomian gland lipid that could alter lipid fluidity and stiffness.
– BMC Ophthalmol. 2015; 15(Suppl 1): 156
■ Clinically non-apparent inflammation may affect MG function and pain
– Eye (Lond). 2015 Aug; 29(8): 1099–1110.

19. Associated Risk factors
■ Ophthalmic factors:
– anterior blepharitis
– contact lens wear
– Demodex folliculorum
■ Medications:
– Antiandrogens
– medications used to treat BPH
– postmenopausal hormone therapy
(e.g., estrogens and progestins)
– Antihistamines
– Antidepressants
– retinoids.
– Glaucoma drops
■ The ω-3 fatty acids may be protective.
■ Systemic factors:
– androgen deficiency
– Menopause
– Aging
– Sjögren's syndrome
– cholesterol levels
– Psoriasis
– Atopy
– Rosacea
– Hypertension
– benign prostatic hyperplasia (BPH)

20. EVALUATION AND
DIAGNOSIS

21. BIOMICROSCOPY

22. Lid margin
■ Thickness
– 2 mm thick
■ Thickening of the lid is a common feature
of meibomian gland disease
– difficult to measure because of the
rounded contour of the anterior
margin.
– best measured from the posterior
margin to the posterior lash line,
■ Rounding of the posterior lid margin is
often associated with thickening and
interferes with the normal apposition of lid
to globe.

23. Lid margin
■ Telangectasia
■ Vascularization increases with age.
– telangiectasia, and cutaneous
hyperkeratinization are
significantly more common in
the lower lid.
■ Increased inflammatory cytokines:
– interleukin-1β)
– tumor necrosis factor-α
– matrix metalloproteinase-9.

24. Lid margin
■ Irregularity of the lid
– often in the region of
obliterated meibomian orifices
– will occur with more gross
distortions of lid architecture in
cicatricial and ulcerative lid
disease.

25. Mucocutaneous junction
■ Immediately posterior to the
meibomian gland orifices.
– at the junction of the anterior
two thirds and posterior one
third of the lid
– No significant age-related
changes in the position or form
of the MCJ have been noted.
– Changes are seen in disease
states, such as MGD, acne
rosacea, and severe atopic eye
disease.
■ Best identified by specular reflection

26. Mucocutaneous junction
■ In MGD, the mucosa may spread
forward, so that the orifices appear
to lie in mucosal tissue.

27. Mucocutaneous junction
■ Ridging.
– ridgelike elevation of the MCJ
or of tissue between the
orifices.

28. Orifices
■ Orifices are located anterior to the MCJ.
– Round

29. Orifices
■ Capping.
– Dome of oil with a tough
■ underlying orifice may be ulcerated and the cap epithelialized.
■ Capping usually affects only occasional orifices and may be found in otherwise
normal lids.

30. Orifices
■ Pouting or plugging- minimal expression of oil
– Can be early sign of MGD
– Orifice not flush with the surface.
– May eventually lead to obliteration of orifices with atrophy of gland and duct.

31. Orifices
■ Obliteration narrowing.
– The punctum of the orifice may not be visible.
– The appearance of narrowing is accompanied by absent expressability of lipid.

32. Concretions
■ deposits of lime salts within acini
■ follow the line of the meibomian
glands.
■ corresponding ductile orifice is
occluded, with no oil being
expressible.
■ Cystoid dilatation of duct

33. Chalazia
■ Chalazia
– meibomian gland
lipogranuloma
– More frequently under the
upper than the lower lid
Before Chalazion After Chalazion

34. Secretions
■ Decrease in the quantity of secretion
occurs with age
– fewer orifices freely expressing
meibomian secretions
– not accompanied by an increased
opacity or viscosity of the secretions
■ Changes in secretions represent markers
of disease
■ Assessed indirectly by compressing the
tarsal plate locally in relation to individual
groups of orifices.
– may be performed with finger
pressure, a cotton tip, or a glass rod
or with the Korb expression device
– Nasal more active than temporal

35. Assessment scale
■ Number of glands expressed on lower lid
– 4(or more) = normal
– 3 = mildly reduced
– 2 = moderately reduced
– 1 (or less) = severely reduced

36. Secretion Quality
■ Clear (i.e., normal).
■ Cloudy: diffusely turbid fluid
secretions.
■ Granular: usually turbid fluid
secretions, but contains particulate
matter. The color of these secretions
varies from whitish-gray to yellow.
■ Inspissated: a semisolid plug or a
substance of toothpaste-like
consistency; may be extruded as a
plug or curled thread. Expression is
usually delayed or requires extra
pressure. The material contains
keratinized epithelial cells

37. Tear break up time (TBUT)
■ Measure of tear film instability
■ Level 0: break-up (average) >=14s
(stable tear film)
■ Level 1: break-up (average) >=7s
bis <14s (critical tear film stability)
■ Level 2: break-up (average) <7s
(unstable tear film/dry eye)

38. Meibomography
■ Transillumination
■ Infrared imaging
– Lipiview
– Keratograph 5M
■ Laser confocal microscopy
– Can evaluate dendritic cells
– Not clinically applicable

39. Tortuosity
■ The glands of the upper lid are
more bent (tortuosity) than that of
the lower lid, which might be a more
anatomical issue than impacted
due to dysfunction of these glands.
– H. Pult, B.H. Riede-Pult and J.J. Nichols, Optom. Vis.
Sci., 2012;89:310–315
■ People with repeated allergic
reaction of the tarsal conjunctiva
showed more bent glands than
normal patients
– R. Arita et al., Jpn J. Ophthalmol., 2012;56:14–19.

40. Upper vs Lower
■ Lower lid glands are significantly
wider than of the upper lid
– might be due to having less
space
– the number of glands is larger
in the upper lid.
– H. Pult, B.H. Riede-Pult and J.J. Nichols, Optom. Vis. Sci.,
2012;89:310–315
■ Meibography of the lower eyelid
seemed to offer the greatest
effectiveness as a single measure.
– L.C. McCann et al., Eye Contact Lens, 2009;35:203–208.
■ FBUT better correlation to the upper
lid
– Eye Contact Lens. 2016 Jul 27
Same patient

41. Meibomian Gland Loss (Dropout)
■ MGL is significantly higher in contact
lens wearers than in non-lens wearers
– R. Arita et al., Ophthalmology, 2009;116:379–384
■ MGL occurs in Ocular Rosacea
– Curr Eye Res. 2015 Dec 7:1-6
■ MGL occurs normally with age
– accompanied by reduced quality
and quantity of the meibum
produced
■ MGL not significantly correlated to
symptoms unless there is tear film
disruption.
– Invest Ophthalmol Vis Sci. 2016 Aug 1;57(10):3996-4007

42. Meibomian Atrophy

43. Meiboscale
■ Area of loss of MG (MGL) is significantly
correlated to lipid layer thickness,
noninvasive break-up time and dry eye
symptoms
– H. Pult and B.H. Riede-Pult, Cont. Lens Anterior Eye,
2011;2012:77–80.
– H. Pult and B. Riede-Pult, Invest. Ophthalmol. Vis. Sci.,
2012;ARVO E-Abstract 53:588
■ Threshold of dry eye.
– Loss of 16.9% of the upper lid MG
– Loss of 28.7% of the lower lid MG
– R. Arita et al., ARVO E-Abstract, 2012;53:1283

44. Best Meibo-Images
■ Flat images
■ All in the same plane
■ No reflections
■ Entire lid
■ No obstructions in the way
– fingers

46. How to Get the Best Meibo-Images

48. Infection
■ Hordeolum/Chalazion
– Demodicosis more prevalent
than in controlgroup (69.2% vs
20.3%)
– D Brevis more common than D
Folliculorum (2.82:1)
– 33% recurrence
Am J Ophthalmol. 2014 Feb;157(2):342-348

50. ■ 8 legged mite which lives in hair follicles and oil glands.
■ 65+ species of Demodex,
– only 2 live on humans (folliculorum and brevis)
– not the same mites which affect pets.
■ spread either through direct contact or in dust and towels
containing eggs.
■ eat skin cells, hormones and oils in the follicles and glands
■ Major cause, if not the cause, of rosacea, seborrheic
dermatitis and other skin conditions.
What is Demodex?

51. Brevis
■ 0.2mm long
Folliculorum
■ 0.4mm long
Demodex Species

52. ■ Life span 2-3 weeks
■ Light sensitive
– Come out at night to breed
■ Prevalence:
– Acquired shortly after birth
– 25% age 25 to near 100% age
70
– Bioload increases with age

53. Signs
Anterior blepharitis
■ Studies show nearly 100% if people
with blepharitis have Demodex
– Statistically significant
correlation
■ Cylindrical dandruff
■ “volcano-like” lash base
■ folliculitis

54. Signs
Posterior blepharitis
■ MGD
■ telangectasia

55. Symptom
Dry Eye
■ Increased Demodex with increased
OSDI
■ Normal shirmer’s with mite
infestation
■ >85% of patients with evaporative
dry eye have demodex (MGD)

56. Symptoms
Allergy
■ Positive correlation to Demodex and
conjunctival papillary changes
■ Itching
■ DR’s and patients often treat for
allergies when actually mites
■ Mite debris and waste elicit
inflammatory response

57. Associated with other ocular disease
states
■ Salzman nodular degeneration
■ Ocular rosacea
– Stem cell failure
■ Peripheral ulcers
– Aka clpu, staph marginal
keratitis

58. 1. Dryness
2. Blurred vision
3. Itching
4. FBS/ irritation
5. Glare
6. Crusting, redness
7. Many people have lived with their Demodex symptoms for so long that they consider
them normal.
Symtoms

59. Past History
■ Patients may have a history of trying treatments with little to no success
■ Drop out of contact lens wear
■ Past treatments may include:
– Artificial tears
– Cyclosporine
– Antihistamines
– Doxycycline/ tetracycine
■ Oral
■ Topical
– Lid hygiene (baby shampoo)
– Steroids – increases mite counts

60. How do mites cause symptoms
■ Demodex is colonized with bacteria
■ Decaying mite bodies elicit inflammation
■ Increasing mite counts
■ Immune response to mites
■ IL-17 tear concentrations higher in demodex colonized
patient than non-colonized patients
– IL-17 causes inflammation of ocular surface and lid margins

61. Looking for Mites

62. ■ Demodex associated with CL drop out/ dry eye
– May be a major cause!
– I have successfully treated Demodex and patient regained CL
wear
■ Confused with seasonal allergy
– Pt self treating allergy
■ Need better treatment/ awareness
– Cliradex
– Long time course for improvement- months
– Need quality patient instructions
■ No procedure codes for in office diagnosis o treatment
■ Need more studies
Challenges

63. ■ Nearly impossible to eradicate
■ All members of household should be checked
■ Heat kills mites in bedding
■ Scrubbing off debris (baby shampoo very bad) helps
■ Tea tree oil?
■ Manuka honey?
■ Colloidal silver?
■ Other Essential oils?
■ Hypochlorous acid?
■ High patient compliance once they see their own mites
Treatment

64. Treatment
■ Ivermectin
– Antiparasitic
– Paralyzes and kills parasites
– Oral
■ Single dose 3mg tabs)
■ Based on weight
■ Call pharmacist
– Topical
■ 1% ivermectin
■ Hard to find for humans.
■ OTC for pets (1.87%)

65. Treatment
skin- not eyes
■ Permethrin cream 5%
– BID
– More effective the 0.75% metroidazole
– No eye indication
■ Eurax cream (crotamiton) 10%

66. EyeLid Hygiene
■ Reasons not to use baby shampoo
– Dermatitis
■ JAMA Ophthalmol. 2014 Mar;132(3):357-9
– Excessive drying
– Burning
– Damage lipid layer
■ Clin Ophthalmol. 2012; 6: 1689–1698.
– Does not effect bacterial colinization of eyelids
■ Can J Ophthalmol. 2010;45(6):637–641
– Dermatologists won’t use it on their babies!

67. Hot Compresses
■ Warm compresses applied to the outer lid must maintain a temp of 113oF in order to
reach the MG, 4-6 minutes.
■ Cornea temperature increases
– Cornea. 2013 Jul;32(7):e146-9
■ Moisture help soften collarettes
■ Hot water increases evaporation off periorbital skin
– Increased drying and discomfort

69. Cleansing Oils
■ Reduce surfactant induced
skin irritation
– Polar oils bond with proteins
and protect skin
– Sunflower oil better than
mineral oil
– Int J Cosmet Sci. 2015 Feb
6.
■ Coconut oil has higher
saponification
■ Improved epidermal
barrier loss and cutaneous
inflammation
– Int J Dermatol. 2014
Jan;53(1):100-8

70. Coconut oil
■ Coconut oil is a polar oil
– J Cosmet Sci. 2001 May-Jun;52(3):169-84
■ Antibacterial
– Changes bacterial cell membrane activity
– J Med Food. 2013 Dec;16(12):1079-85
■ Anti- candida
– J Med Food. 2007 Jun;10(2):384-7
■ Lowers lipid peroxide levels
■ Antioxidant
– Skin Pharmacol Physiol. 2010;23(6):290-7

71. Coconut oil
■ Clinically: what I have found
■ Adds oil to the tear film
– Severe evap dry eye patients report improved comfort while using it
■ No need to hot soaks to remove scurf
■ Reduced collarettes
■ Reduced lid inflammation
■ Better long term compliance

72. Coconut oil regime
■ Apply small amount to lid margin
■ Let soak in about 20 minute
– Brush teeth
– Get in jammies
– Etc…
■ Wipe off with dry wash cloth or gauze pad
– Apply firm but not excessive pressure
■ If patient complains of lingering blurred vision: used too much

73. Coconut oil scrubs
Before
After 1 month of
treatment

74. Before
After 1 month of
treatment

75. Tea Tree Oil
■ Tea tree treatments with
50% lid scrubs in office
■ 5-15% TTO at home
■ Multiple Properties
– Anti-microbial
– Anti-inflammatory
– Anti-protozoal
– Anti-viral
■ Toxic to the Ocular surface!

76. Cliradex
■ Melaleuca alternifolia
– a special variety of tea tree oil
■ Preservative free

77. Manuka honey
■ Made in New Zealand by bees that
pollinate the native manuka bush.
■ UMF (Unique Manuka Factor)
determines antibiotic effectiveness.
■ Manuka honey used is
pharmaceutical/medical grade and
highly sterilized.

78. Manuka Honey
■ principle antibacterial components
– methylglyoxal and hydrogen
peroxide
Manuka-type honeys can eradicate biofilms produced by Staphylococcus aureus strains with different biofilm-f
PeerJ. 2014 Mar 25;2

79. Betadine
■ Betadine 5% Ophthalmic Prep
Solution
– Povidone-Iodine
■ Normal surgical scrub is 10%
■ Intended for:
– Irrigation of cornea, conj.
– Periocular antiseptic
■ Wide range of bacteria
– Effective against biofilm
– Inhibits release of exotoxins
■ Possible Treatment for EKC

80. Hypochlorous Acid .01%
•Excellent activity
against a broad
range of
pathogens
•Fast acting onset
of activity
•Effective against
pathogens
commonly found
on the lids &
lashes
80
*Data on file

81. DRY EYE SPA

82. ■ All lid care discussions
happen in the SPA
■ Set up 3 appointments
■ Charge SPA prices
– Self pay
■ Product recommendations

83. Expression
Iowamade.org Sindt Ophthalmic lid spatula

84. Home Care
■ Cleansing oils
– No surfactants
■ Disinfectant
– TTO
– Hypochlorus acid
■ Mechanical Debridement
■ Heat
– 108 for 15-30 minutes
■ Artificial tears with oil

85. Summary
■ Lashes
– Demodex
■ Lid Margin
– Thickness/ regularity
– Telangiectasia
– Placement of MCJ
– Ridging/ hyperkeratinization
■ Orifices
– Round/ oval
– Location
– Plugging/ capping/ pouting
■ Secretions/ Expression
– Clear
– Cloudy
– Granular
– Inspissated
■ Meibography
– Drop out/ atrophy
– Central duct dilation
– Tortuosity
■ Consider MG monitoring in anyone
with an associated risk factor

86. SEND EVERYONE TO
“THE SPA”
Christine W Sindt OD FAAO
Christine-sindt@uiowa.edu