Alisha Regmi, M. Optom

Postgraduate in Optometry (M.Optom), The Sankara Nethralaya Academy, Chennai, India


Meibomian Gland Dysfunction (MGD) is a chronic and diffuse abnormality of the Meibomian Glands which is commonly characterized by terminal meibomian duct obstruction and/or qualitative/quantitative changes in the glandular secretion” as defined by International Workshop on MGD. (1) The prevalence of MGD ranges from 3.6% to 68.0%. (2-5)  Evaporative dry eye, the most common type of dry eye (6) is mainly caused due to MGD, unstable lipid layer due to changes in quality and quantity of meibomian gland secretion. (7)   It can further increase the evaporation of the underlying aqueous layer too. (8)  


Table 1: Conventional Diagnostic Criteria for MGD proposed by Japanese MGD working group (9)


International Workshop on MGD recommended the following tests for diagnosis of MGD-related disease in the general clinical setting: symptom questionnaire, blink rate, tear meniscus height, tear osmolality, and tear breakup time, fluorescein staining, Schirmer test, and slit-lamp findings (lid changes, meibum expressibility / quality). (10)


Table 2: Recent Diagnostic tools for MGD

Lipiview-II interferometer(11) Lipiscan(12) In Vivo Confocal Microscopy (IVCM) (13)
Its main working principle is white light interferometry It uses dynamic Meibomian Imaging (DMI) mode It is a non-invasive and powerful tool that evaluates on a cellular level
The tear film is measured using interferometry colour assessment by specular reflection It is the first dedicated meibomian gland imager with a small footprint and user-friendly design It allows detection of changes in the ocular surface epithelium, immune and inflammatory cells, and meibomian gland structures
It measures:
-Lipid layer thickness,
-Captures blink rate and partial blinks
-Images Meibomian gland structure
It captures:
-HD image of gland structure
It evaluates:
-acinar unit density and acinar unit longest diameter
-acinar unit shortest diameter
-cell density of inflammatory cells of Meibomian glands in MGD


    Figure-1: Lipiview-II interferometer (11)


Figure-2: Lipiscan (12)


Figure-3: Vivo confocal microscopy (IVCM) showing the stage of MGD. (a) Normal meibomian glands; (b) lumen obstruction with minimal inflammation; (c)Intra-epithelial, and inter-glandular  inflammation; (d) fibrosis with epithelium destruction. (13)


Management of MGD

 Table 3: Showing sequence of treatment addition algorithm proposed by International Workshop on MGD (14) (added based on the severity of MGD)


Table 4: Recent therapeutic modalities

Lipiflow thermal pulsation system (15) Intense Pulse Light (IPL) therapy(16)
It is used for dry eye treatment It is used for dry eye treatment It is a new instrumental treatment modality for MGD
A single-use activator has 2 components:
-one insulated lid warmer provides precision-controlled heat to the tissue of the internal eyelid
-another cup that provides intermittent pressure to the outer eyelid surface
The emission wavelength discharged from flashlamps, ranges from 500–1200 nm, which is within the visible light and infrared radiation wavelength of the electromagnetic spectrum for IPL therapy
It helps to release the lipids from the meibomian glands which are responsible for producing meibum using heat and pressure technique It helps to improve tear film stability, meibomian gland functionality, as well as patient’s feeling of ocular dryness


Figure-4: Lipiflow thermal pulsation system (15)


Figure-5: Intense pulsed light treatment in Meibomian gland dysfunction (16)



  1. Nelson, J. D., Shimazaki, J., Benitez-del-Castillo, J. M., Craig, J. P., McCulley, J. P., Den, S., & Foulks, G. N. (2011). The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Investigative ophthalmology & visual science52(4), 1930-1937.
  2. Schein, O. D., MUÑO, B., Tielsch, J. M., Bandeen-Roche, K., & West, S. (1997). Prevalence of dry eye among the elderly. American journal of ophthalmology124(6), 723-728.
  3. Viso, E., Rodríguez-Ares, M. T., Abelenda, D., Oubina, B., & Gude, F. (2012). Prevalence of asymptomatic and symptomatic meibomian gland dysfunction in the general population of Spain. Investigative ophthalmology & visual science53(6), 2601-2606.
  4. Lekhanont, K., Rojanaporn, D., Chuck, R. S., & Vongthongsri, A. (2006). Prevalence of dry eye in Bangkok, Thailand. Cornea25(10), 1162-1167.
  5. Jie, Y., Xu, L., Wu, Y. Y., & Jonas, J. B. (2009). Prevalence of dry eye among adult Chinese in the Beijing Eye Study. Eye23(3), 688-693.
  6. Stapleton, F., Alves, M., Bunya, V. Y., Jalbert, I., Lekhanont, K., Malet, F., … & Viso, E. (2017). Tfos dews ii epidemiology report. The ocular surface15(3), 334-365.
  7. Nichols, K. K., Foulks, G. N., Bron, A. J., Glasgow, B. J., Dogru, M., Tsubota, K., … & Sullivan, D. A. (2011). The international workshop on meibomian gland dysfunction: executive summary. Investigative ophthalmology & visual science52(4), 1922-1929.
  8. Bron, A. J., de Paiva, C. S., Chauhan, S. K., Bonini, S., Gabison, E. E., Jain, S., … & Uchino, Y. (2017). Tfos dews ii pathophysiology report. The ocular surface15(3), 438-510.
  9. Amano, S. (2018). Meibomian gland dysfunction: recent progress worldwide and in Japan. Investigative ophthalmology & visual science59(14), DES87-DES93.
  10. Tomlinson, A., Bron, A. J., Korb, D. R., Amano, S., Paugh, J. R., Pearce, E. I., … & Dogru, M. (2011). The international workshop on meibomian gland dysfunction: report of the diagnosis subcommittee. Investigative ophthalmology & visual science52(4), 2006-2049.
  11. Lee, Y., Hyon, J. Y., & Jeon, H. S. (2021). Characteristics of dry eye patients with thick tear film lipid layers evaluated by a LipiView II interferometer. Graefe’s Archive for Clinical and Experimental Ophthalmology259(5), 1235-1241.
  12. Waring, G. O. (2018, April). Johnson & Johnson: LipiScan™ and LipiFlow®. In 2018 ASCRS ASOA Annual Meeting. ASCRS.
  13. Matsumoto, Y., & Ibrahim, O. M. (2018). Application of in vivo confocal microscopy in dry eye disease. Investigative ophthalmology & visual science59(14), DES41-DES47.
  14. Geerling, G., Tauber, J., Baudouin, C., Goto, E., Matsumoto, Y., O’Brien, T., … & Nichols, K. K. (2011). The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Investigative ophthalmology & visual science52(4), 2050-2064.
  15. In, W. R. D. I. P., & Eye, D. Guide to Using LipiFlow® To Treat Meibomian Gland Dysfunction.
  16. Craig, J. P., Chen, Y. H., & Turnbull, P. R. (2015). Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Investigative ophthalmology & visual science56(3), 1965-1970.