From automated refracting technology to autocapturing non-mydriatic fundus cameras, state-of-the-art diagnostic devices provide the finest and most updated eye care experience. Most recently, another device is taking the spotlight, aiding in the diagnosis of meibomian gland dysfunction (MGD): the meibographer. 
In our boutique clinic in Beverly Hills, Calif., we’ve found the meibographer to be a tool that resonates with dry eye clients—particularly those middle-aged and younger. Its ability to put measurable results in the hands of our patients offers tremendous value, as it supports our patients’ understanding of their condition and, hopefully, encourages their compliance with treatments. 
This article reviews how we use the meibographer, the benefits it’s brought us and how you can incorporate one into your clinic—whether you run a boutique practice or a traditional family practice.
This 35-year-old female patient developed gland atrophy as a result of contact lens overwear. Click image to enlarge.
Meibography Basics
Conventional meibography—also called “contact” meibography—used a transilluminating light probe and an infrared camera system to evaluate a small central region of the lid margin.1 But the time-consuming and invasive nature of the test made it impractical. Approximately nine years ago, however, a non-contact method was introduced that used an infrared charge-coupled device attached to a slit lamp biomicroscope, without the need for a probe. Additionally, it expanded the area of observation to the upper and lower lids, providing the ability to perform extensive examination.1 This is when the meibographer as we know it really took off. As manufacturers sought to distinguish their contributions, the market began to produce a variety of meibographers, each with unique capabilities (Table 1). But for the most part, meibographers expose the meibomian glands, which, under healthy circumstances, have a piano-key-like appearance. Abnormal glands, on the other hand, will appear tortuous, dilated, congested or atrophied. 
This patient, a 27-year-old female, displayed an abnormal tear break-up time. Click image to enlarge.
Dysfunction Defined
The meibomian glands of the upper and lower eyelids play a valuable role in secreting the lipid layer of the tear film. Disturbances in their function may result in MGD. This can alter secretion and variations in tear composition, eventually leading to evaporative dry eye, which patients report as ocular discomfort.2 
MGD can be classified as primary or secondary to systemic diseases; it can be focal or diffuse and may lead to symptoms of lid discomfort, neovascularization, ocular irritation, alteration of the tear film or inflammation of the meibomian gland orifices. Numerous structural changes can take place in MGD that will result in the functions of the glands being altered.1,3 When the glands are blocked, there is not enough oil to coat the tear film, and the aqueous layer may evaporate rapidly. Without adequate lubrication between them, the eyelids and cornea can abrade each other, causing inflammation and cell damage.
As MGD progresses, structural changes within the eyelid margin may occur, such as thickening, rounding or distortion secondary to the destruction of the meibomian gland orifices. Even eyelash misdirection and weakness may occur as a side effect.
 Other changes occur to the mucocutaneous junction of the lid, which may become irregular, displaced posteriorly or elevated. Additionally, meibomian gland orifices may change in number, representing a potentially permanent loss of these glands. Salvageable glands may be expressed (by applying digital pressure to the lids) and the secretions assessed; the secretions may be classified as clear, cloudy, granular or inspissated (toothpaste consistency). These changes can be seen in MGD, where the meibomian glands do not function efficiently or where a disturbance exists within the functional mechanisms of these glands.4 
This 35-year-old patient was given a treatment plan of switching to daily, single-use contact lenses. We also advised her to avoid makeup near or around the eyelash margin, and started her on our dry eye kit. Click image to enlarge.
MGD Drivers
According to the prestigious MGD Workshop report, researchers suggest that MGD may be the leading cause of dry eye disease (DED) throughout the world.5 With more than 50% of patients knowingly or unknowingly suffering from signs or symptoms of DED, eye care professionals must educate patients on the causes, symptoms and treatment of this highly prevalent condition.5 Patients who could benefit from screening for MGD include, but are not limited to, contact lens wearers, patients living in dry climates and those with ocular allergies, blepharitis, marginal staphylococcal keratitis, ocular rosacea, dermatitis (eczema) or psoriasis. Even patients who are considering refractive surgery (i.e., LASIK) should consider testing for MGD to improve post-op outcomes. 
Additionally, many common prescription and over-the-counter systemic medications may contribute to dry eye symptoms, including antihistamines, decongestants, hormone replacement therapy, contraceptives, antidepressants, diuretics, beta blockers, acne medicine and sleeping pills.6 Often, patients may leave one or more of these off their list of current medications because they are not aware of the ocular side effects.6 Be sure to specifically probe about these medications, as well as their frequency, dosage and duration of use.
Unfortunately, DED also affects young, healthy patients. In a national survey polling 1,000 optometrists, approximately 90% agree the use of modern technology contributes to dry eye symptoms. Furthermore, DED is becoming more common because of today’s digital device use with an increase in patients between the ages of 18 and 34 with dry eye symptoms.7

Table 1. Meibographers on the Market

Keratograph 5M (Oculus)Offers a relatively comprehensive DED analysis that shows the rate of tear evaporation, measures the tear meniscus height, scans for conjunctival hyperemia, analyzes lipid layer thickness and evaluates the structure of the glands. 
Lipiview II (TearScience)Provides a high-definition images for accurate visualization of the gland structures, measures lipid layer thickness and evaluates a patient’s blink rate and pattern. 
LipiScan (TearScience)Offers rapid imaging of the glands using the company’s dynamic meibomian imaging; the device is limited to just this feature.
Meibox (Box Medical Solutions)Works as an efficient, lightweight option that still offers high-resolution image of the glands.  

Seeing is Believing

In my practice, I commonly diagnose MGD patients in their 20s, 30s and 40s. Some may present with no symptoms while others display vision fluctuation, contact lens intolerance, photosensitivity, ocular hyperemia, epiphoria or any combination of these. 
Whatever their age or symptoms, the goal is the same: to address the signs and symptoms of MGD before they become irreversible. All patients should be educated on the importance of early detection and prevention to avoid chronic issues later in life. Here, meibography is a powerful tool in MGD diagnosis. The key is to image the patient’s meibomian glands (MG), then review any changes in anatomical structures. If changes exist, offer alternative lifestyle solutions as well as treatment options to increase the likelihood of MGD relief. When patients recognize the difference between their glands and healthy ones, they tend to be genuinely concerned and open to a custom treatment plan.
This is how the meibomian glands of a healthy, pre-LASIK patient should appear. Click image to enlarge.
Our Workup
Properly diagnosing, educating and treating MGD patients is key to satisfaction. To start, ask the appropriate questions with the SPEED II questionnaire for ocular surface disease.8 Next, assess the anatomy of the glands using infrared imaging with a meibographer, looking for destruction of glandular tissue vs. normal appearance. Non-invasive keratograph break-up time (NIKBUT) or tear break-up time (TBUT) can be helpful in assessing the stability of the tear film and therefore the severity of MGD. Another test provides early presence of ocular surface disease for an inflammatory marker. The InflammaDry (Quidel)detects matrix metalloproteinase-9 (MMP-9), a cytokine produced by epithelial cells experiencing inflammation.9 Knowing if a patient’s MGD is exacerbated by inflammation (i.e., elevated MMP-9 levels) can guide the treatment plan. 
When evaluating the anterior segment at the slit lamp, we use a Korb Meibomian Gland Evaluator (TearScience) to assess the function of the oil glands. The MGE exerts pressure on the outer eyelids consistent with a deliberate blink, allowing evaluation of gland secretion.10 The glands are classified as one of the three following grades: no secretion, inspissated (or cloudy) secretions or normal secretions. 
These diagnostics collectively tell a story that ultimately leads to a customized and favorable treatment protocol.
This patient displays significant gland atrophy. Click image to enlarge.
Happier Patients, Happier Doctors
For our patient base, we offer both in-office and at-home solutions. In the office, patients are presented with BlephEx (RySurg), LidPro (Mibo Medical), Lipiflow (TearScience),  Mibo ThermoFlo (Mibo Medical) and meibomian gland expression. BlephEx and LidPro are handheld devices used in-office to gently exfoliate the eyelid at the lash line and remove the inflammatory biofilm that leads to chronic lid disease and discomfort.6 
Another in-office procedure is thermal pulsation (Lipiflow), which provides controlled, safe heat (~108º F) for 12 minutes to the inner eyelid surface while pulsating pressure is simultaneously applied to the outer lids.11 This intermittent pressure combined with the effective heating allows the meibomian gland oils to release without causing injury to the eye itself.12 One of the few drawbacks of Lipiflow is its high out-of-pocket cost.
An alternative, economical approach incorporates the in-office heating device Mibo ThermoFlo, which is applied at the same constant 108º F but only externally to the eyelids. In my practice, many patients—even denizens of Beverly Hills—find the latter more cost effective, as well as quite soothing. This is immediately followed by manual massage with a meibomian gland expressor to release the stagnant oils, unclogging the glands.
To complement these in-office services, we offer our 60-day dry eye kit (or MGD kit) with premium eye care products. Three key items included are a high-quality warm compress with medical grade beads to maintain and deeply penetrate, such as Bruder’s Medibeads mask; a gentle, anti-inflammatory lid wash from Ocusoft or Zocular; and pharmaceutical grade omega-3 supplements (we prefer Nordic Naturals or PRN). If the patient has a positive MMP-9 result, we consider starting Restasis (cyclosporine 0.05%, Allergan), Xiidra (lifitegrast 5%, Shire) or a steroid drop prior to punctal occlusion. Inserting a punctal plug in the presence of active inflammation may cause an increase in ocular surface disease symptoms. 
Another option that may prove valuable is a higher viscosity, preservative-free artificial tear such as Retaine MGD (Ocusoft) or Oasis Plus (Oasis) to provide instant as well as longer lasting relief. These drops may sooth the ocular surface both directly by providing lubrication and reducing friction between the lid and the eye, as well as indirectly by diluting inflammatory cells until they are eliminated.
Not every patient will want or need the somewhat indulgent, spa-like treatments often favored by those who live in the 90210 zip code. Cheaper, simpler alternatives can often suffice. But educating patients about the role of the meibomain glands through direct visualization does impress upon them the importance of good lid hygiene. I consider it a foundational step that sets the patient up for success. An educated patient will be more amenable to working with you to develop a treatment regimen that fits their lifestyle, budget and clinical picture. 
Dr. Silani is the chief clinical director at Beverly Hills Optometry in Beverly Hills, Calif.