Meibography: A Japanese Perspective

Comprehensive Assessment of the Meibomian Glands by Meibography: Why the Upper Eyelids Matter

ABSTRACT

The clinical value of upper eyelid meibographic imaging remains relatively underexplored; consequently, it is not commonly used in clinical assessments. However, its significance could be particularly important for the early detection of various ocular diseases and systemic conditions related to the eyes. An analysis of the current literature from the PubMed database, covering the years 2005 to 2023, with additional relevant papers added from cited references was conducted. Failure to diagnose dry eye disease and meibomian gland dysfunction associated with conditions such as Sjögren syndrome or thyroid eye disease in the early stages and taking appropriate action may result in persistent signs and symptoms. This could potentially lead to the development of chronic conditions that directly affect a patient's visual quality, functionality, and overall well-being. Therefore, this review aimed to demonstrate the potential clinical significance of upper eyelid examination as an integral component of comprehensive meibomian gland evaluation.

Meibomian gland dropout of upper eyelids as a novel biomarker for early diagnosis of primary Sjögren's syndrome: a pilot study

Background

Early diagnosis of primary Sjögren's syndrome (pSS) remains difficult due to its insidious onset.

Objectives

To identify whether meibomian gland dropout (MGD) is a sensitive and noninvasive predictor of pSS by studying its association with histopathology in labial salivary gland biopsy in patients with clinically suspected pSS.

Design

Prospective, randomized, multicenter, comparative effectiveness study.

Methods

The study was conducted from July 2022 to July 2023. In all, 56 eligible participants with clinically suspected pSS were recruited from three combined ophthalmology medicine/rheumatology SS clinics. All participants with suspected pSS were evaluated and diagnosed by ophthalmology and rheumatology consultants and underwent infrared imaging of the meibomian glands using Keratograph 5M and histopathological evaluation of labial salivary gland biopsies. The length, width, and tortuosity of the meibomian glands were measured; the dropout rate in the nasal, temporal, and total eyelids was analyzed; and the dropout score was calculated using meibography grading scales.

Results

Among the 56 participants, 34 were identified with pSS, and 22 were diagnosed with non-SS dry eye (NSSDE) and served as the control group. We recorded significant differences in the temporal and total MGD rates of the upper eyelids between the pSS and NSSDE groups (all p < 0.01). Improved prediction accuracy was achieved with the temporal and total MGD rates in the upper eyelids, with area under the curve values of 0.94 and 0.91, and optimal cutoff points of 0.78 and 0.75, respectively.

Conclusion

MGD in the upper eyelids, especially in the temporal portion, is strongly associated with the histopathological outcome of labial salivary gland biopsy in pSS and is proposed as a highly predictive and noninvasive biomarker for the early diagnosis of pSS.

Trial registration

ClinicalTrials.gov identifier: ChiCTR2000038911.

Evaluation of Meibomian Gland Structure and Function in Patients with Vernal Keratoconjunctivitis Using Non Contact Meibography and Lipid Layer Interferometry

PURPOSE

This study evaluated the structural and functional impact of vernal keratoconjunctivitis (VKC) on meibomian glands (MGs) using a combination of noncontact meibography and lipid layer interferometry.

METHODS

In this observational study 50 patients with moderate persistent or severe VKC and 50 age-matched controls underwent MG imaging and lipid layer thickness (LLT) measurements with Lipiview II. Image J software was used to assess MG loss (meibograde) in both lids. All patients underwent dry eye evaluation comprising tear break-up time (TBUT), ocular surface staining (OSS), Schirmer I scoring, and meiboscoring (expressibility and quality of meibum secreted).

RESULTS

Meibograde, OSS score, and meiboscore was higher in cases (2.68 ± 0.96, 0.580 ± 1.07, and 0.56 ± 0.95 respectively) than controls (1.80 ± 0.67, 0.00 ± 0.00, 0.22 ± 0.47 respectively) (p < 0.001, 0.001, 0.025 respectively). LLT and TBUT was lower in cases (54.58 ± 9.43 nm and 4.92 ± 3.09 sec respectively) than controls (70.14 ± 22.50 nm and 12.02 ± 2.73 sec respectively) (both p's = 0.001). Both groups had comparable Schirmer I scores.

CONCLUSION

Children with VKC have significant MG dropouts, deterioration in meibum quality and a thinner and less stable tear film. VKC patients are thus prone to a vicious cycle of inflammation attributable both to the allergic component and to deterioration in MG structure and function. Co-management of MG dysfunction warrants as much attention as the allergic component itself.

Temporal variations in meibomian gland structure-A pilot study

PURPOSE

To investigate whether there is a measurable change in meibomian gland morphological characteristics over the course of a day (12 h) and over a month.

METHODS

The study enrolled 15 participants who attended a total of 11 study visits spanning a 5-week period. To assess diurnal changes in meibomian glands, seven visits were conducted on a single day, each 2 h apart. For monthly assessment, participants attended an additional visit at the same time of the day every week for three consecutive weeks. Meibography using the LipiView® II system was performed at each visit, and meibomian gland morphological parameters were calculated using custom semi-automated software. Specifically, six central glands were analysed for gland length ratio, gland width, gland area, gland intensity and gland tortuosity.

RESULTS

The average meibomian gland morphological metrics did not exhibit significant changes during the course of a day or over a month. Nonetheless, certain individual gland metrics demonstrated notable variation over time, both diurnally and monthly. Specifically, meibomian gland length ratio, area, width and tortuosity exhibited significant changes both diurnally and monthly when assessed on a gland-by-gland basis.

CONCLUSIONS

Meibomian glands demonstrated measurable structural change over short periods of time (hours and days). These results have implications for innovation in gland imaging and for developing precision monitoring of gland structure to assess meibomian gland health more accurately.

Meibomian Gland Shortening Is Associated With Altered Meibum Composition

Purpose

The purpose of this study was to investigate differences in the composition of meibum extracted from human meibomian glands displaying different morphological characteristics.

Methods

Adult participants with evidence of meibomian gland shortening were enrolled. Glands were observed using infrared meibography, and meibum was collected from one short and one long gland from the lower eyelid of the same eye. Total protein concentration was evaluated using the detergent compatible (DC) protein assay and lipid analysis was performed using liquid chromatography mass spectrometry.

Results

Fifteen participants (8 women and 7 men) completed the study (mean age = 34.7 ± 7.7 years). The average volume of meibum collected from the short and long glands was 0.02 ± 0.01 and 0.05 ± 0.03 µL, respectively (P = 0.01). Average protein concentration in the short glands was significantly higher compared to the long glands (0.10 ± 0.03 vs. 0.08 ± 0.02 mg/mL, P = 0.01). Among the non-polar lipids, the mole percent of cholesterol esters (CEs; P = 0.02), triacylglycerols (TAGs; P = 0.04), and ceramide (Cer; P = 0.03) was significantly lower in short glands compared with long glands. Among the polar lipids, the mole percent of (O-acyl)-ω-hydroxy fatty acid (OAHFA; P = 0.01) was significantly lower in short glands, whereas phosphatidylcholine (PC; P = 0.02) and sphingomyelin (SM; P = 0.01) were significantly higher in short glands than long glands.

Conclusions

Meibum composition differed between short and long glands. The lower mole percent of CE, TAG, OAHFA, and Cer and a higher mole percent of PC and SM among short glands may indicate disease activity. This information may clarify the natural history of meibomian gland dysfunction and future targets for therapy.

Exploring Sjögren's syndrome through interdisciplinary perspectives: a concise review

Dr. Henrik Sjögren after whom Sjögren's Syndrome is named, was a Swedish ophthalmologist who identified the syndrome which had three main symptoms namely, dry eyes, dry mouth, and arthritis. His contributions also highlighted the systemic complications of the syndrome which made our understanding of this disease better. Since then, there have been several studies on Sjögren's Syndrome (SS) of which two of them have changed the perception of the disease's prevalence. The first was a British study in the late 1990s which indicated this syndrome was no more a rare condition. The second is a 2008 study in the US which placed the syndrome as the second most prevalent autoimmune disease after rheumatoid arthritis (RA). Being one of the most prevalent autoimmune disease, there is a pressing need for a more profound and comprehensive understanding of the syndrome. This review endeavors to offer a comprehensive overview of the disease, encompassing its prevalence, manifestations, mechanisms, genetic factors, diagnostic methods, and treatment options. This review additionally offers the āyurvedic viewpoint on SS and its symptoms. This supplementary insight has the potential to contribute to the development of an integrated and holistic approach to managing the condition.

One Soul and Several Faces of Evaporative Dry Eye Disease

The ocular surface system interacts with, reacts with, and adapts to the daily continuous insults, trauma, and stimuli caused by direct exposure to the atmosphere and environment. Several tissue and para-inflammatory mechanisms interact to guarantee such an ultimate function, hence maintaining its healthy homeostatic equilibrium. Evaporation seriously affects the homeostasis of the system, thereby becoming a critical trigger in the pathogenesis of the vicious cycle of dry eye disease (DED). Tear film lipid composition, distribution, spreading, and efficiency are crucial factors in controlling water evaporation, and are involved in the onset of the hyperosmolar and inflammatory cascades of DED. The structure of tear film lipids, and subsequently the tear film, have a considerable impact on tears' properties and main functions, leading to a peculiar clinical picture and specific management.

2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management

ABSTRACT

Detailed clinical assessment is critical to allow sensitive evaluation of the eye and its management. As technology advances, these assessment techniques can be adapted and refined to improve the detection of pathological changes of ocular tissue and their impact on visual function. Enhancements in optical medical devices including spectacle, contact, and intraocular lenses have allowed for a better understanding of the mechanism and amelioration of presbyopia and myopia control. Advancements in imaging technology have enabled improved quantification of the tear film and ocular surface, informing diagnosis and treatment strategies. Miniaturized electronics, large processing power, and in-built sensors in smartphones and tablets capacitate more portable assessment tools for clinicians, facilitate self-monitoring and treatment compliance, and aid communication with patients. This article gives an overview of how technology has been used in many areas of eye care to improve assessments and treatment and provides a snapshot of some of my studies validating and using technology to inform better evidence-based patient management.

Morphologic variants of Meibomian glands: age-wise distribution and differences between upper and lower eyelids

Purpose

To evaluate the distribution of various Meibomian gland morphologies across different age groups in healthy individuals.

Methods

The infrared meibographic morphologies of the Meibomian glands from the upper and lower eyelids of 236 healthy individuals (472 eyes; mean age 38.4 ± 17.5 years; 80 female participants: 156 male participants) were evaluated for their prevalence and differences across six decades of life, from 10 to 80 years. A linear mixed-effects modeling test was performed for statistical analysis.

Results

Of 14,452 glands, 8,830 (61%) glands were located in the upper eyelid. No significant differences in frequency were noted between different age groups for distorted, tortuous, hooked, overlapping, abnormal gap, fluffy areas, dropout (except for 51-60 vs. 10-20 years, P = 0.023), and thick and thin morphologies. Short glands were significantly more common in individuals aged over 30 years (P = 0.015), whereas moderately short and severely short glands were more common in the upper eyelids of individuals older than 50 years compared to those aged 10-20 years (P = 0.035). The frequency of distorted, hooked, tortuous, overlapping, and tadpole-shaped Meibomian glands was significantly higher in the upper eyelids than in the lower eyelids for all age groups. Dropout glands were more common in the lower eyelids of individuals younger than 50 years, but no difference was observed in the upper and lower eyelids of individuals over 50 years. Dropout (P = 0.006) and severely short glands (0.026) of the lower eyelid were associated with low non-invasive tear break-up time (NIBUT) values.

Conclusion

Various morphologic characteristics of the Meibomian glands that are considered abnormal can be present in healthy individuals, and only moderate to severely short glands display an increase in abnormal morphologic characteristics of the Meibomian glands with age.

Meibomian gland stem/progenitor cells: The hunt for gland renewal

Meibomian glands (MGs) secrete lipid (meibum) onto the ocular surface to form the outermost layer of the tear film. Proper meibum secretion is essential for stabilizing the tear film, reducing aqueous tear evaporation, and maintaining the homeostasis of the ocular surface. Atrophy of MG as occurs with aging, leads to reduction of meibum secretion, loss of ocular surface homeostasis and evaporative dry eye disease (EDED). Since MGs are holocrine glands, secretion of meibum requires continuous self-renewal of lipid-secreting acinar meibocytes by stem/progenitor cells, whose proliferative potential is dramatically reduced with age leading to MG atrophy and an age-related meibomian gland dysfunction (ARMGD). Understanding the cellular and molecular mechanisms regulating meibocyte stem/progenitor cell maintenance and renewal may provide novel approaches to regenerating MG and treating EDED. Towards that end, recent label retaining cell and lineage-tracing experiments as well as knock-out transgenic mouse studies have begun to identify the location and identities of meibocyte progenitor cells and potential growth and transcription factors that may regulate meibocyte renewal. In addition, recent reports have shown that ARMGD may be reversed by novel therapeutics in mice. Herein, we discuss our current understanding of meibocyte stem/progenitor cells and the hunt for gland renewal.

Intraobserver Repeatability Assessment of the S390L Firefly WDR Slitlamp in Patients With Dry Eye Disease: Objective, Automated, and Noninvasive Measures

OBJECTIVES

To assess the intraobserver repeatability of automated, objective, and noninvasive measures obtained with the S390L Firefly WDR slitlamp.

METHODS

This cross-sectional study included 50 eyes of patients with dry eye disease with a mean age of 55.06±12.96 years. Three consecutively repeated measures of the following variables were obtained: first noninvasive break-up time (F-NIBUT), average noninvasive break-up time (A-NIBUT), tear meniscus height, tear meniscus area (TMA), nasal ciliary hyperemia (NCIH), temporal ciliary hyperemia (TCIH), nasal conjunctival hyperemia (NCOH), temporal conjunctival hyperemia (TCOH), upper loss area meibomian gland (U-LAMG), lower loss area meibomian gland (L-LAMG), upper meibomian gland dysfunction grade (U-MGD grade), and lower meibomian gland dysfunction grade (L-MGD grade). Intraobserver repeatability was estimated with coefficient of variation (CoV), intrasubject standard deviation (SD) (S w ), and Bland-Altman plots.

RESULTS

All variables showed no statistically significant differences in the repeated-measures analysis except for L-MGD grade ( P =0.045). F-NIBUT and A-NIBUT obtained the highest CoV with an average value of 0.48±0.41 [0.02-1.00] and 0.34±0.25 [0.02-1.00], respectively. The remaining variables showed CoVs between 0.04±0.11 [0.00-0.43] and 0.18±0.16 [0.00-0.75]. A-NIBUT, TMA, NCOH, and L-LAMG obtained an S w of 2.78s, 0.21 mm 2 , <0.001, and 4.11%, respectively. Bland-Altman plots showed a high level of agreement between pairs of repeated measures.

CONCLUSION

The S390L Firefly WDR slitlamp has moderate intraobserver repeatability for F-NIBUT and A-NIBUT, which suggests that F-NIBUT and A-NIBUT are tests with high variability. The remaining variables show satisfactory intraobserver repeatability.

Development of Artefact-Free Imaging System for Accurate Meibomian Gland Reflectivity Assessment

Purpose

To develop and evaluate a custom imaging system to provide high-resolution, wide depth-of-field, reflection-free, multispectral infrared (IR) imaging of the Meibomian glands.

Methods

Lower eyelids of 15 volunteers were everted to obtain multispectral images of the Meibomian glands with custom imaging setup. Photographs were captured at 10 different ISO settings (from underexposure to overexposure) and using nine IR imaging filters (ranging from 600 nm to 1000 nm in 50-nm steps). Meibomian gland contrast (simple and Michelson) was calculated for the images to choose an optimal wavelength for Meibomian gland imaging and to determine differences in contrast across individuals.

Results

The overall linear regression model showed a significant effect of wavelength on Meibomian gland contrast (Simple contrast: F = 7.24, P < 0.0001; Michelson contrast: F = 7.19, P < 0.0001). There was a significant negative correlation between Meibomian gland contrast and Meibomian gland depth for 750-nm IR filter (ρs= -0.579; P = 0.026).

Conclusions

Meibomian gland contrast varies across individuals and depends on Meibomian gland depth. IR filter of 750 nm is the optimal choice for Meibomian gland imaging because it provides images of greatest contrast.

Translational Relevance

This study adds to our understanding of Meibomian gland imaging. It has successfully demonstrated that Meibomian glands that are deeper in the tarsal plate require longer wavelengths for imaging.

Clinical parameters obtained during tear film examination in domestic rabbits

Background

One of the contributing factors to ocular surface health is a stable precorneal tear film. Considering the increasing interest in rabbits as pets and the limited literature available on domestic rabbit tearing, the aim of this study was to establish normative data for examination of the tear film in domestic rabbits.

Results

The study included 75 client-owned domestic Holland Lop rabbits (150 eyes). The following examinations were performed in each eye: Schirmer tear test-1, tear osmometry, interferometry, tear meniscus height measurement and meibography (quantifying meibomian gland loss as a percentage). The resulting median (95% central range) values were 10.0 (5.0–17.3) mm/min for the Schirmer tear test-1, 345.0 (280.5–376.1) mOsm/L for tear osmolarity, grade 2 (1–4) of interferometry, 0.28 (0.20–0.47) mm for tear meniscus height and 0.0 (0.0–67.6) % meibomian gland loss. A significant association was found between tear osmolarity and age, with an estimated decrease of − 4.0 mOsm/L with each additional year of age (p < 0.001). The distributions of interferometry grades were significantly different between males and females (p < 0.001), with grade 1 and grade 2 being the most frequent in females and males, respectively. A weak negative correlation was also observed between interferometry grade and the percentage of meibomian gland loss (r = − 0.22, p = 0.006).

Conclusions

This is an original study that documents extensive tear film parameters in healthy Holland Lop rabbits. The results can be used as normative data for the examination of the tear film in this lagomorph breed.

Relationship between meibomian gland loss in infrared meibography and meibum quality in dry eye patients

Background

In the present study, we evaluated the correlation between meibomian gland dropout and meibum quality in the same central 8 meibomian glands of the eyelid.

Methods

Ninety-nine eyes of 91 patients with dry eye were included in the study. Dropout of the 8 central meibomian glands of the eyelids was graded as 0, 1, 2, or 3, according to the dropout area. The meibum quality was graded as follows: grade 0, no secretion; 1, inspissated/toothpaste consistency; 2, cloudy liquid secretion; and 3, clear liquid secretion. For 68 eyes of 68 patients, correlation analysis between dropout and meibum quality was performed. To precisely analyze the direct correlation between meibomian gland dropout in meibography and meibum quality, we evaluated 31 eyes of 23 patients with focal dropout in meibography.

Results

The median (interquartile range) meiboscore was 1.0 (2.0) in the upper eyelids and 0.0 (1.0) in the lower eyelids. The median (interquartile range) meibum quality grade was 3.0 (1.0) in the upper eyelids and 1.0 (1.0) in the lower eyelids. No significant correlation between the meiboscore and meibum quality grade was detected in the upper (p =0.746) or lower (p =0.551) eyelids. Analysis of the direct correlation between meibomian gland dropout in meibography and meibum quality in patients with focal dropout (loss of 1 or 2 adjacent meibomian glands), however, indicated that meibomian glands with dropout secreted little to no meibum.

Conclusions

Overall analysis revealed no relationship between meibomian gland dropout and meibum quality, but more detailed investigation of each meibomian gland alone revealed that meibomian glands with dropout secrete little to no meibum.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02509-5.

Bevacizumab Eye Drops Vs. Intra-meibomian Gland Injection of Bevacizumab for Meibomian Gland Dysfunction-Associated Posterior Blepharitis

Aims

This study aimed to evaluate the efficacy and safety of bevacizumab eye drops compared with those of an intra-meibomian gland (MG) injection of bevacizumab when performed in conjunction with standard lid hygiene in patients with meibomian gland dysfunction (MGD)-associated posterior blepharitis.

Methods

This prospective, open-label, observer-blinded randomized controlled trial included 60 eyes of 30 patients with MGD-associated posterior blepharitis who exhibited lid margin telangiectasia, treated at the Chula Refractive Surgery Center of King Chulalongkorn Memorial Hospital. Patients were randomized to receive lid hygiene plus 0.05% bevacizumab eye drops or a single intra-MG injection of 2.5% bevacizumab. All patients were instructed to perform routine lid hygiene care as demonstrated in an instructional video. Primary outcomes included telangiectasia grading and the lid margin neovascularized area (LMNA). Secondary outcomes included the Ocular Surface Disease Index (OSDI) score, corneal staining, meibum quality, meiboscore, conjunctival redness, fluorescein break-up time (FBUT), lipid layer thickness, treatment compliance, and adverse events. All parameters were evaluated before and 3 months after treatment.

Results

After treatment, there were no significant differences in telangiectasia grade and LMNA between groups (mean difference, −0.14, 95% CI −0.42 to 0.15, p = 0.338, −0.1, 95% CI −1.1 to 0.8, p = 0.761, respectively); however, the injection group exhibited significant improvements in both telangiectasia grade and LMNA, while, in the eye drop group, only telangiectasia grade showed a significant improvement relative to baseline. The injection group also exhibited significant improvements in corneal staining (mean difference, −0.78, 95% CI −1.29 to −0.27, p = 0.003), meiboscores (mean difference, −0.37, 95% CI −0.52 to −0.21, p <0.001), and FBUT (mean difference, 1.25, 95% CI 0.21–2.29, p = 0.019) compared to the eye drop group. OSDI scores, corneal staining, meibum quality, meiboscores, and conjunctival redness significantly improved relative to baseline in both groups. No local and systemic adverse event was observed at month 3 in both groups.

Conclusion

When performed with regular lid hygiene, intra-MG injection and topical application of bevacizumab are safe and effective for improving lid margin telangiectasia and the signs and symptoms of MGD-associated posterior blepharitis. This therapy may represent an alternative or adjunctive treatment for patients with MGD-associated posterior blepharitis.

Latest developments in meibography: A review

Meibography is a visualisation technique that has been used for over 40 years. There have been significant improvements in image quality, examination technique and image interpretation over this period. Although meibography has received sporadic reviews in the past, an updated review is timely due to the rapid recent rise of relevant technology and advances in both image processing and artificial intelligence. The primary aim of this paper is to review recent research into Meibomian gland imaging and update the community about the most relevant technologies and approaches used in the field.

Candidate Molecular Compounds as Potential Indicators for Meibomian Gland Dysfunction

Meibomian gland dysfunction (MGD) is the leading cause of dry eye disease throughout the world. Studies have shown that several molecules in meibum, including but not limited to interleukins, amino acids, cadherins, eicosanoids, carbohydrates, and proteins, are altered in meibomian gland dysfunction compared with healthy normal controls. Some of these molecules such as antileukoproteinase, phospholipase A2, and lactoperoxidase also show differences in concentrations in tears between meibomian gland dysfunction and dry eye disease, further boosting hopes as candidate biomarkers. MGD is a complex condition, making it difficult to distinguish patients using single biomarkers. Therefore, multiple biomarkers forming a multiplex panel may be required. This review aims to describe molecules comprising lipids, proteins, and carbohydrates with the potential of serving various capacities as monitoring, predictive, diagnostic, and risk biomarkers for meibomian gland dysfunction.

Management Strategies for Evaporative Dry Eye Disease and Future Perspective

Dry eye disease (DED) is a common disorder that remains challenging from a clinical perspective. Unstable or deficient tear film is a major factor contributing to DED and the inability to resolve the loss of tear film homeostasis that accompanies DED can result in a vicious circle of inflammation and treatment-refractory disease. Recently recognized as a multifactorial disease, the main etiological subtypes of DED are aqueous-deficient and evaporative which exist on a continuum, although evaporative dry eye (EDE) is the more frequent classification. Although attaining greater recognition in recent years, there is currently no consensus and no clear recommendation on how to manage EDE. Clarity on the early diagnosis and treatment of EDE may facilitate the avoidance of progression to chronic inflammation, permanent damage to the ocular surface, and treatment-refractory disease. The purpose of this review was to identify current best practice for management of EDE in order to help clinicians in providing accurate diagnosis and optimized treatment. We summarize recent literature considering the role of the lipid layer on tear film stability, the importance of its composition and of its dynamic behavior, and the link between its malfunction and the insurgence and maintenance of tear film-related diseases. We have provided an assessment of the best management of lipid-deficient EDE based upon an understanding of disease pathophysiology, while indicating the flow of current treatments and possible future evolution of treatment approaches. Lipid containing eye drops may be considered as a step closer to natural tears from artificial aqueous tears because they more closely mimic the aqueous and lipid layers and may be used in combination with other management approaches. As a next step, we recommend working with a wider expert group to develop full guidelines to enable patient-centered management of EDE. Key pointsDry eye is a multifactorial disease of variable presentation with the tendency to become a chronic disease for which it is essential to identify and treat the main pathogenic mechanisms involved and tailor the treatment to the individual patient.Early intervention is needed to prevent the vicious cycle of DED and may require a multi-faceted management approach.EDE is not just a problem of MGD but can be the result of anything affecting blinking, mucin spreading, aqueous layer volume and content.Lipid-containing eye drops may provide significant relief of symptoms by improving the lipid layer and its spreading ability and, as such, are an appropriate component of the overall management of lipid-deficient EDE; natural lipid-containing eye drops should be the preferred treatment.

A Practical Approach to Severity Classification and Treatment of Dry Eye Disease: A Proposal from the Mexican Dry Eye Disease Expert Panel

Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.

Evaluation of the meibomian glands using the tear interferometer wearing orthokeratology lenses

Background

To investigate the impact of orthokeratology wear on meibomian glands in Korean pediatric population using the tear interferometer.

Methods

Fifty-three orthokeratology wearers and 79 non-lens wearers were evaluated using the LipiView® II ocular surface interferometer which shows incomplete blink rate, average lipid layer thickness, and meiboscores.

Results

No significant differences in the incomplete blink rate and meiboscores for upper eyelids, but the lipid layer thickness and meiboscores for lower eyelids were significantly higher in the Ortho-K group than in the control group (p = 0.024 and 0.007, respectively). Correlation analysis showed no significant correlation between the duration of orthokeratology wear and the parameters measured by LipiView® (p > 0.05 for all). Among subgroups based on average duration of lens wear, the longer duration (≥ 24 months) subgroup showed higher meiboscores of lower eyelids (p = 0.011), but no other significant differences.

Conclusions

Ortho-K wearers showed no significant differences in the incomplete blink rate and meiboscores of upper eyelids, but they were associated with increased LLT and higher meiboscores of lower eyelids. Thorough examination and close monitoring of orthokeratology wearers is necessary. Prospective and observational studies are needed to further elucidate the relationship between Orthokeratology and meibomian glands.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02365-3.

Evaluation of ocular psoriasis with meibography

Background

Previous studies has shown that dry eye test abnormalities, meibomian gland dysfunction (MGD), may occur in psoriasis.

Objectives

The authors aimed to evaluate the dry eye disease (DED), MGD, in psoriasis patients with meibography which is a current, objective, noninvasive method for patients with meibomian gland diseases, to investigate the relationship between disease severity and ocular involvement.

Methods

This study included 50 participants with psoriasis and 50 healthy individuals. All subjects were examined by the same dermatologist and referred for ophthalmological examination including meibomian gland obstruction, lid margin alterations assessment, ocular surface disease index assessment, tear film break-up time test, Schirmer test, corneal conjunctival fluorescein staining assessment. Additionally, upper and lower lids were evaluated for meibomian gland loss with meibography.

Results

MGD (28%), meibomian gland loss (MGL) (29.5%), upper meiboscore (0.61 ± 0.81), lower meiboscore (0.46 ± 0.61), DED (22%) were significantly higher in the psoriasis group compared with the control group (p = 0.008, p < 0.001, p = 0.027, p = 0.041, p = 0.044, respectively). There was a significant relationship between MGD and psoriasis area severity index (PASI) (p = 0.015, Odds Ratio = 1.211). There was a significant positive relationship between MGL with PASI (p < 0.001, r = 608) and psoriasis duration (p < 0.001, r = 0.547).

Study limitations

Smaller study group and inability to detect quality changes of meibum with meibography were limitations of the study.

Conclusions

Psoriasis may affect the meibomian gland morphology, may cause structural changes in meibomian glands, and as a result of these may cause MGD and DED. Therefore, ophthalmologists and dermatologists should be aware of this situation and co-evaluate the patients in this respect.

Advances in the Noninvasive Diagnosis of Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease that represents one of the most common ophthalmologic conditions encountered in everyday clinical practice. Traditional diagnostic tests for DED, such as subjective questionnaires, tear film break-up time and the Schirmer test, are often associated with poor reproducibility and reliability, which make the diagnosis, follow-up, and management of the disease challenging. New advances in imaging technologies enable objective and reproducible measurements of DED parameters, thus making the diagnosis a multimodal imaging-based process. The aim of this review is to summarize all the current and emerging diagnostic tools available for the diagnosis and monitoring of DED, such as non-invasive tear breakup time, thermography, anterior segment optical coherence tomography, meibography, interferometry, in vivo confocal microscopy, and optical quality assessment. Although there is not a gold standard imaging technique, new multi-imaging-integrated devices are precious instruments to help clinicians to better cope with the diagnostic complexity of DED.

Update on ocular graft-versus-host disease

Ocular graft-versus-host disease (oGVHD) occurs as a complication following hematopoietic stem cell transplantation and is associated with significant ocular morbidity resulting in a marked reduction in the quality of life. With no current consensus on treatment protocols, management becomes challenging as recurrent oGVHD often refractory to conventional treatment. Most authors now diagnose and grade the disease based on criteria provided by the National Institutes of Health Consensus Conference (NIH CC) or the International Chronic oGVHD (ICCGVHD) consensus group. This article will provide an insight into the diagnostic criteria of oGVHD, its classification, and clinical severity grading scales. The inflammatory process in oGVHD can involve the entire ocular surface including the eyelids, meibomian gland, corneal, conjunctiva, and lacrimal system. The varied clinical presentations and treatment strategies employed to manage them have been discussed in the present study. The recent advances in ocular surface imaging in oGVHD patients such as the use of meibography and in vivo confocal microscopy may help in early diagnosis and prognostication of the disease. Researching tear proteomics and identification of novel potential tear biomarkers in oGVHD patients is an exciting field as they may help in objectively diagnosing the disease and monitoring the response to treatment.

Grading reliability of the tear film viscosity examination

PURPOSE

To assess the reliability of a tear film (TF) viscosity video grading system.

METHODS

Thirty-four dynamic TF viscosity videos were obtained by a clinically available TF analyzer and objectively sorted according to the movement speed of three arbitrary reflective light particles. A 4-grade system was constructed on a specially designed window for simultaneous comparison with the three standard videos. Two masked graders were invited to grade these videos under a randomized procedure. Observer reliabilities were determined by Spearman's correlation analysis and Bland-Altman agreement analysis.

RESULTS

For this four-grade system, the intra-observer correlation was very strong in the two graders (ρ = 0.96 and 0.82; both P < 0.0001). However, the inter-observer correlation showed moderate strength in normal playback speed (ρ = 0.53, P = 0.002 and ρ = 0.52, P = 0.003 for 1st and 2nd gradings, respectively). In slower playback videos, the inter-observer correlation of the two graders was higher (ρ = 0.70 and P < 0.0001) when reduced to 0.8-times playback speed. Moreover, the 0.8-times mode was also significantly better than normal playback mode (P = 0.0204) in terms of inter-observer agreement.

CONCLUSIONS

The dynamic 4-grade system has an excellent intra-observer reliability and a good inter-observer reliability under 0.8-times playback speed. The grading system established in this study provides a promising solution for rapidly determining the level of TF viscosity.

Imaging Biomarkers for Dry Eye Disease

The clinical, scientific, economic, and regulatory impact of validated biomarkers and surrogate endpoints has the potential to revolutionize the approach to ocular surface diseases. At present, there is a growing interest in developing biomarkers for dry eye disease, and other ocular surface disorders and imaging are of the most promising approaches to this issue. Among the several and constantly evolving imaging technologies, some tools that are aimed to assess tear film stability and volume, meibomian gland morphology and function, and ocular surface microanatomy are now supported by a good body of evidence. To date, clinical trials on ocular surface diseases have slowly started incorporating imaging biomarkers for disease diagnosis and stratification and as surrogate endpoints. Major efforts are still needed, mainly aimed to improve automatic acquisition and quantitative analysis, standardization (standard operating procedures, normative databases etc.), and validation of imaging biomarkers.

Effect of meibomian gland morphology on functionality with applied treatment

PURPOSE

To determine how Meibomian gland (MG) morphology affects MG function by means of gland expression with the effect of treatment.

METHODS

Fifteen patients (aged 31.6 ± 13.1 years) from a dry eye clinic diagnosed with MG dysfunction had their 365 lower lid MGs visualised with a slit-lamp biomicroscopy. Using infrared meibography (Oculus K5m), MG length, width and tortuosity were objectively measured. Each MG was expressed and the meibum graded (0=clear fluid, 1=cloudy fluid, 2= particulate fluid, 3=inspissated, or 4 = no expression) to determine its functionality. Participants had functionality repeated each time following a sequence of a warm compress, debridement, and forcible expression after 5 min.

RESULTS

Just over 10 % of complete length MGs gave clear expression, while about 5% did not express at all, with most expressed meibum being particulate in nature. In contrast, the majority of partial length glands gave inspissated expression (38 %), with 32 % not expressing at all. No MG of <10 % length expressed. MG gland length was correlated with gland expression (r=-0.507, p < 0.001) and MG tortuosity (r=-0.129, p < 0.001), but not MG width (r=-0.090, p = 0.167). Regardless of MG length, warm compress increased the quality of expression (p < 0.002). Debridement further improved expression in partial MGs (p = 0.003), but not forcible expression (p = 0.529).

CONCLUSIONS

Length is the key functional morphology metric of lower lid MGs. Warm compress and massage increase the quality of expression in all, but the shortest glands and patients with partial length glands also benefit from debridement.

Proposed Algorithm for Management of Meibomian Gland Dysfunction Based on Noninvasive Meibography

Although the pathophysiology of meibomian gland dysfunction (MGD) remains incompletely understood, many treatment options have recently become available. According to an international workshop report, treatment selection for MGD should be based on a comprehensive stage classification dependent on ocular symptoms, lid margin abnormalities, meibum grade, and ocular surface staining. However, it is often difficult to evaluate all parameters required for such classification in routine clinical practice. We have now retrospectively evaluated therapeutic efficacy in MGD patients who received five types of treatment in the clinic setting: (1) meibocare (application of a warm compress and practice of lid hygiene), (2) meibum expression plus meibocare, (3) azithromycin eyedrops plus meibocare, (4) thermal pulsation therapy plus meibocare, or (5) intense pulsed light (IPL) therapy plus meibocare. Patients in each treatment group were classified into three subsets according to the meiboscore determined by noncontact meibography at baseline. Eyes in the IPL group showed improvement even if the meiboscore was high (5 or 6), whereas meibocare tended to be effective only if the meiboscore was low (1 or 2). The meiboscore may thus serve to guide selection of the most appropriate treatment in MGD patients. Prospective studies are warranted to confirm these outcomes.

<p>A Retrospective Data Review Confirms That Topical Preservative-Free Hydrocortisone Improves Inflammation in Dry Eye Disease</p>

Background

Inflammation is among the most important mechanisms in the pathogenesis of dry eye disease (DED), triggering the vicious circle of the disease. Reducing inflammation is an important target in dry eye disease treatment. Hydrocortisone is a low-potency corticosteroid with a low ocular penetration potential.

Aim

To document the effect of topical preservative-free hydrocortisone 0.335% (PFH, Softacort^®, Laboratoires Théa, France) on DED.

Methods

Retrospective data review of patients with mild to moderate DED, treated with PFH for 15 days. Clinical evaluations at Days 0 and 15 included the assessment of the central precorneal tear film thickness (CPTFT), fluorescein tear breakup time, Schirmer test, corneal grading staining (Oxford schema), ocular surface disease index (OSDI) spatial distribution of the precorneal tear film thickness, intraocular pressure (IOP) and local tolerance.

Results

Data from 13 women and 2 men were collected. Mean age±SD was 51±5 years for women and 53±4 years for men. Clinical signs and symptoms significantly (all p<0.05) improved after 15 days of treatment. A significant positive correlation between the percentage of change in left eye CPTFT and that in the contralateral eye CPTFT was observed (p=0.003) as well as for both eyes and the left eye FTBUT (p=0.03). For the percentage of change in OSDI, the only significant correlation was with the percentage of change in right eye and FTBUT (p=0.03). IOP remained unchanged. No adverse events were recorded.

Conclusion

This retrospective data review confirms that topical PFH twice daily for 2 weeks significantly improves clinical signs and symptoms in patients with mild to moderate DED with no safety issues.

Latest evidences on meibomian gland dysfunction diagnosis and management

Meibomian gland dysfunction (MGD) can be considered the leading cause of dry eye disease (DED) and one of the most common ophthalmic disorders found in clinical practice. The growing body of literature provides a substantial amount of information on this condition, but more efforts are needed to better interpret research data and to properly apply them to daily clinical practice., In this article, we reviewed the most recent publications on MGD diagnosis and management, focusing on the highest available level of evidence, provided by well-designed and well-reported studies on humans., Latest evidences on MGD diagnosis are mainly focused on imaging techniques, including meibography, optical coherence tomography (OCT), and in vivo confocal microscopy. Meibographic parameters, such as drop-out and glands' distortion, show great diagnostic accuracy, which accounts for their widespread use in clinical practice and research., Recent randomized controlled clinical trials on MGD treatment provided data on the role of antibiotics, steroids, essential fatty acids, intraductal meibomian gland probing, electronic heating devices and intense pulsed light therapy.

Novel Approaches for Imaging-Based Diagnosis of Ocular Surface Disease

Imaging has become indispensable in the diagnosis and management of diseases in the posterior part of the eye. In recent years, imaging techniques for the anterior segment are also gaining importance and are nowadays routinely used in clinical practice. Ocular surface disease is often synonymous with dry eye disease, but also refers to other conditions of the ocular surface, such as Meibomian gland dysfunction or keratitis and conjunctivitis with different underlying causes, i.e., allergies or infections. Therefore, correct differential diagnosis and treatment of ocular surface diseases is crucial, for which imaging can be a helpful tool. A variety of imaging techniques have been introduced to study the ocular surface, such as anterior segment optical coherence tomography, in vivo confocal microscopy, or non-contact meibography. The present review provides an overview on how these techniques can be used in the diagnosis and management of ocular surface disease and compares them to clinical standard methods such as slit lamp examination or staining of the cornea or conjunctiva. Although being more cost-intensive in the short term, in the long term, the use of ocular imaging can lead to more individualized diagnoses and treatment decisions, which in turn are beneficial for affected patients as well as for the healthcare system. In addition, imaging is more objective and provides good documentation, leading to an improvement in patient follow-up and education.

Objective Imaging Diagnostics for Dry Eye Disease

Traditional diagnostic tests for dry eye disease (DED), such as fluorescein tear film break-up time and the Schirmer test, are often associated with poor reproducibility and reliability, which make the diagnosis, follow-up, and management of the disease challenging. Advances in ocular imaging technology enables objective and reproducible measurement of changes in the ocular surface, tear film, and optical quality associated with DED. In this review, the authors will discuss the application of various imaging techniques, such as, noninvasive tear break-up time, anterior segment optical coherence tomography, in vivo confocal microscopy, meibography, interferometry, aberrometry, thermometry, and tear film imager in DED. Many studies have shown these devices to correlate with clinical symptoms and signs of DED, suggesting the potential of these imaging modalities as alternative tests for diagnosis and monitoring of the condition.

Meibomian gland dysfunction is the primary determinant of dry eye symptoms: Analysis of 2346 patients

PURPOSE

To determine relative contributions of various ocular surface clinical signs and predisposing factors to the magnitude of dry eye symptoms.

METHODS

Clinical audit data were prospectively collected for newly referred dry eye patients. All 2346 patients had an initial visit evaluation of the Ocular Surface Disease Index (OSDI), and a detailed ophthalmic examination including tear breakup time (TBUT), ocular surface fluorescein staining, Schirmer's I test. Among the participants, 1414 had number of liquid meibum expressing glands (NLMEG) evaluated on standard force expression. Other variables collected included history of glaucoma or glaucoma surgery, and history of allergies.

RESULTS

In patients aged 46.2 ± 14.8 years, 77.4% were women and 87.1% Chinese. The mean ± SD OSDI was 35.2 ± 21.7. On univariate analysis, higher OSDI was associated with glaucoma diagnosis (p = 0.003), glaucoma surgery (p = 0.002), greater temporal corneal staining (p = 0.002), reduced NLMEG (p < 0.001), and higher inferior forniceal papillary grade (p < 0.001). OSDI was not significantly associated with gender, TBUT, Schirmer's I test values, or the use of cyclosporine eyedrops. On multivariate regression, higher OSDI scores were associated with fewer NLMEG (p = 0.002) and increased lower eyelid forniceal papillary grading (p = 0.002). Corneal staining, glaucoma status and glaucoma surgery were not significantly associated with OSDI. Logistic regression showed that severe symptoms (OSDI>32) was associated with <2 NLMEG [OR(95%CI): 1.34(1.08-1.66)], and presence of inferior eyelid forniceal papillae [1.50(1.17-1.91)].

CONCLUSIONS

Meibomian gland dysfunction (MGD) and lower forniceal papillary reaction had significant contributions to the severity of symptoms, in contrast to traditional dry eye signs. MGD should be objectively assessed and treated to improve symptoms.

The role of meibography in ocular surface diagnostics: A review

The meibomian glands are lipid-secreting glands located in the tarsal plates, whose secretory products cover the tear film, thereby reducing evaporation as well as ensuring lubrication of the ocular surface. The meibomian glands can be visualized at different levels of magnification by infrared meibography, laser confocal microscopy, and optical coherence tomography. These imaging modalities have been subject to much research and progress in clinical practice and have shaped our current understanding of meibomian glands in health and disease. In this review, we explore the evolution of meibography over the past decades, the major contributions of various meibographic modalities, and discuss their clinical significance.

Meibomian Gland Dropout, not Distortion, Can Distinguish Dry Eyes from Normal Eyes in Contact Lens Wearers

PURPOSE

To examine the effectiveness of using meibomian gland (MG) dropout and distortion for dry eye disease (DED) diagnosis in a young population with long-term contact lens (CL) wear.

METHODS

Seventy-three CL-wearers and 68 non-CL-wearers (20-28 years old) participated in the study. The diagnosis of DED was based on an ocular surface disease index ≥ 13, and a noninvasive breakup time < 10 seconds or positive corneal fluorescein staining. The MG dropout and distortion in each subject were quantified with non-invasive meibography. Receiver operating characteristic (ROC) curves were created to evaluate the effectiveness of using MG dropout and distortion to determine the presence of DED in CL-wearers and non-CL-wearers.

RESULTS

In non-CL-wearers, the MG distortion was significantly higher in DED subjects than in normal subjects (3.83 ± 1.81 versus 1.59 ± 1.04). In CL-wearers, MG distortion was not significantly different (5.12 ± 4.11 versus 5.51 ± 3.15 in normal and DED subjects respectively). The area under the ROC curve (AUC) for MG distortion was 0.783 in the non-CL-wearers, but 0.507 in CL-wearers. In non-CL-wearers, MG dropout was significantly higher in DED subjects than in normal subjects (0.22 ± 0.08 versus 0.15 ± 0.06). In CL-wearers, MG dropout was also significantly higher in DED subjects than in normal subjects (0.29 ± 0.11 versus 0.22 ± 0.08). The AUC for MG dropout used to classify DED was 0.740 in the non-CL-wearers and 0.715 in CL-wearers.

CONCLUSIONS

MG dropout was effective in distinguishing subjects with DED from normal subjects in both CL wearers and non-CL wearers. MG distortion can only distinguish DED subjects from normal ones in non-CL wearers, but not in CL wearers.

Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion

PURPOSE

To examine postoperative changes in the status of meibomian gland dysfunction in patients with involutional entropion.

METHODS

This prospective, interventional study included 10 eyelids of 8 patients with involutional entropion who underwent posterior layer advancement of the lower eyelid retractors and either a lateral tarsal strip or transcanthal canthopexy procedure. The following features were examined for evaluation of meibomian gland dysfunction and dry eye: the presence or absence of eyelid abnormalities (irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices), Marx line score, meibum expression score, loss of the meibomian glands, A (area) and D (density) scores for corneal fluorescein staining, and tear breakup time. All the measurements were performed before and 6 months after surgical correction of involutional entropion.

RESULTS

Regarding the findings of meibomian gland dysfunction, irregular eyelid margin, vascular engorgement, and plugged meibomian gland orifices improved only in 1 eyelid of 1 patient (P = 0.317, P = 1.000, and P = 1.000, respectively) postoperatively. The scores of Marx line, meibum expression, and loss of meibomian glands did not statistically change after surgery (P = 0.157, P = 0.705, and P = 0.317, respectively). The D score was statistically improved after surgery (P = 0.046), although the difference between the pre- and postoperative A score was not statistically significant (P = 0.083). Tear breakup time did not change after surgery (P = 0.705).

CONCLUSIONS

Our study indicates that meibomian gland dysfunction does not resolve after surgical correction of involutional entropion.

[Modified meibography in malignant eyelid tumors of epithelial origin]

INTRODUCTION

Eyelid tumors can be diagnosed using various diagnostic techniques. However, capability of existing methods for determining the type and margins of the tumor at the preoperative stage remains insufficiently studied.

PURPOSE

To improve the noncontact infrared meibography technique and determine its diagnostic capabilities for studying structural changes in meibomian glands in malignant eyelid tumors of epithelial origin.

MATERIAL AND METHODS

The study included 49 people (66 eyelids), among which 21 (21 eyelids) with malignant eyelid tumors, 11 - with benign eyelid tumors (11 eyelids), and 17 (34 eyelids) comprised the control group. The mean age of patients was 64.8±1.56 years. Meibomian glands of the lower eyelids were photographed in infrared light. Receiver-operating characteristic (ROC) curves were constructed to estimate the sensitivity and specificity of the method.

RESULTS

Modified meibography showed 100% sensitivity and 90% specificity in the differential diagnosis of malignant and benign eyelid tumors in 32 patients. Unlike other methods, the modified meibography technique can clarify the margins of tumor growth, which is considered when planning the resection volume.

CONCLUSION

Modified meibography can indicate the margins of tumor invasion; it can be successfully used in the differential diagnostics of malignant eyelid tumors of epithelial origin and benign eyelid tumors.