The prevalence of meibomian gland dysfunction, tear film and ocular surface parameters in an Austrian dry eye clinic population

Sex Differences in the Prevalence of Meibomian Gland Dysfunction: A Mini Review

PURPOSE

In this review, we aimed to investigate the literature on sex-specific prevalence of meibomian gland dysfunction (MGD) and to determine whether women or men are more at risk for MGD.

METHODS

A search was conducted on PubMed using the terms: (Sex OR Gender OR prevalence) AND (Meibomian gland).

RESULTS

Twenty-four relevant studies on MGD prevalence were identified, including 10 population-based and 14 hospital-based studies. Among the population-based studies, five studies reported higher rates among men, three studies found no differences, and one study observed higher rates among women. In the hospital-based studies, 10 studies reported no difference, two found higher rates among men, and one found higher among women. In the reviewed literature, there was a considerable variation between studies in terms of quality, sample size, age ranges, diagnostic criteria.

CONCLUSIONS

While most of the population-based studies suggest a higher prevalence among men, the majority of clinic-based studies show no significant difference. Further research with larger samples and standardized criteria is needed to determine whether men are indeed more susceptible to MGD.

Exploring Signs and Symptoms Associated with Meibomian Gland Dysfunction for Use as Clinical Trial Endpoints

Purpose: Dry eye disease is attributed to impaired tear production and/or evaporative dry eye. Evaporative dry eye is frequently associated with meibomian gland dysfunction (MGD). The objective of this study was to identify clinical study endpoints related to MGD. Methods: This 22-day, noninterventional, case-control clinical study involved three cohorts with increasing MGD severity: no MGD, mild/moderate MGD, and severe MGD. Symptoms were assessed with an ocular symptom questionnaire grading blurred vision, eye burning, eye dryness, eye pain, light sensitivity, eye itching, eye foreign body sensation, and overall ocular discomfort. Sign assessments included the maximum meibum quality score (MMQS), tear breakup time, Schirmer tear tests, biomicroscopy, and corneal staining. Signs and symptoms were compared between cohorts and study visits. Results: Seventy-five study participants were assigned to the cohorts (25 per cohort). MMQS scores increased with increasing MGD severity, reflecting the selection criteria for the cohorts. Between-visit scores showed a weighted kappa statistic of 0.72 indicating substantial agreement. Mean scores of all assessed symptoms increased with increasing MGD severity. Scores for symptoms showed moderate (κ = 0.41-0.60) to substantial (κ = 0.61-0.80) agreement between visits. Overall ocular discomfort demonstrated the strongest correlation with the MMQS. Conclusion: The MMQS was a reproducible sign of MGD showing good agreement with ocular symptoms. Overall ocular discomfort was well correlated with typical dry eye symptoms and could potentially be used as a single measure of MGD symptoms. The findings from this observational study may inform endpoints for future clinical trials. ClinicalTrials.gov NCT01979887.

Recent advances in age-related meibomian gland dysfunction (ARMGD)

Meibomian glands (MGs), located within the tarsal plate of the eyelid, secrete meibum which is the lipid-rich secretion necessary for stabilizing the tear film and preventing tear evaporation. Changes in the quality and quantity of meibum produced causes MG dysfunction (MGD), the leading cause of evaporative dry eye disease (EDED). MGD is an underdiagnosed disease and it is estimated that, in the US, approximately 70 % of the population over 60 have MGD. Three forms of MGD occur based on their meibum secretion: hyposecretory, obstructive, and hypersecretory MGD. The pathophysiology of MGD remains poorly understood, however aging is the primary risk factor. With age, MGs undergo various age-related changes, including decreased acinar basal cell proliferation, hyperkeratinization, MG atrophy, and eventual MG drop-out, leading to age-related MGD (ARMGD). Additionally, studies have suggested that MGs can suffer inflammatory cell infiltration and changes innervation patterns with aging, which could also contribute towards ARMGD. This review focuses on how the aging process affects the MG, and more importantly, how age-related changes to the MG can lead to MG atrophy and MG drop-out, ultimately leading to ARMGD. This review also highlights the most recent developments in potential therapeutic interventions for ARMGD.

Prevalence of meibomian gland dysfunction at a tertiary centre in Taiwan

CLINICAL RELEVANCE

Meibomian gland dysfunction and dry eye disease are closely related conditions that often coexist and can contribute to the development of each other. Understanding the similarities and differences between these diseases can assist clinicians in implementing effective treatments for both conditions in a clinical setting.

BACKGROUND

Dry eye disease is a multifactorial disease of the tears and ocular surface. This study aimed to evaluate the demographic characteristics of patients with meibomian gland dysfunction in Taiwan, investigate the association between meibomian gland dysfunction and dry eye parameters, and estimate the prevalence of meibomian gland dysfunction among patients with dry eye symptoms at a tertiary referral centre.

METHODS

This cross-sectional study enrolled patients aged ≥20 years who complained of dry eye symptoms and visited a tertiary centre between September 2019 and March 2020. The patients completed the Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness questionnaires before undergoing ocular examination. The lipid layer thickness and meiboscale scores were recorded. In addition, the study measured tear film break-up time, examined corneal staining, and evaluated the number of meibomian glands yielding liquid secretions using a slit lamp.

RESULTS

The study evaluated 202 eyes of 202 patients with a mean age of 58.05 ± 13.34 years. The prevalence of meibomian gland dysfunction was 93%. Mean meiboscale score and age were negatively associated, and tear film break-up time was positively associated with the mean number of meibomian glands yielding liquid secretions. Hyperlipidaemia and smoking were the main risk factors for Meibomian gland dysfunction.

CONCLUSIONS

The prevalence of meibomian gland dysfunction among patients with dry eye symptoms was extremely high at the tertiary centre, highlighting the strong relationship between Meibomian gland dysfunction and dry eye disease. Clinicians should consider meibomian gland dysfunction as a possible cause of dry eye.

NOV03 for Signs and Symptoms of Dry Eye Disease Associated With Meibomian Gland Dysfunction: The Randomized Phase 3 MOJAVE Study

PURPOSE

To evaluate the efficacy and safety of NOV03 (perfluorohexyloctane) ophthalmic drop for the treatment of signs and symptoms of dry eye disease (DED) associated with meibomian gland dysfunction (MGD).

DESIGN

Randomized, double-masked, controlled trial.

METHODS

Patients ≥18 years of age with a history of DED and signs of MGD were randomly assigned 1:1 to treatment with NOV03 or hypotonic saline (0.6%) 4 times daily for 8 weeks. The primary sign and symptom endpoints were change from baseline to week 8 in total corneal fluorescein staining (tCFS; National Eye Institute scale) and eye dryness score (0-100 visual analog scale), respectively.

RESULTS

A total of 620 patients (NOV03, n = 311; saline, n = 309) were randomized and treated. Least-squares (LS) mean change from baseline to week 8 was statistically significantly greater for NOV03 compared with saline for both tCFS (-2.3 vs -1.1; LS mean treatment difference, -1.2 [95% confidence interval -1.7 to -0.8]; P < .001) and visual analog scale dryness score (-29.4 vs -19.2; LS mean treatment difference, -10.2 [95% CI -14.4 to -6.1]; P < .001), with statistically significant between-group differences observed as early as week 2. The incidence of ocular adverse events was similar for NOV03 (12.9%) and saline (12.3%). There were no serious adverse events and no adverse events leading to treatment discontinuation.

CONCLUSIONS

In this randomized controlled trial of patients with DED associated with MGD, NOV03 significantly reduced both signs and symptoms of DED compared with hypotonic saline control. NOV03 was well tolerated, with an adverse event profile similar to that of saline.

Differential characteristics among asymptomatic and symptomatic meibomian gland dysfunction and those with dry eye

PURPOSE

To identify the characteristics of asymptomatic meibomian gland dysfunction (MGD), symptomatic MGD, and MGD coexisting with dry eye disease (DED).

METHODS

This cross sectional study enrolled a total of 153 eyes of 87 MGD patients. Participants filled in ocular surface disease index (OSDI) questionnaires. Age, gender, Schirmer's test, meibomian gland (MG) related parameters, lipid layer thickness (LLT) and blinking were compared among patients with asymptomatic MGD, symptomatic MGD, and MGD with DED. Multivariate regression was used to analyze the significant factor of DED in MGD. Spearman's rank correlation analysis was used to evaluate the association between the significant factors and MG function.

RESULTS

There was no difference in age, Schirmer's test, lid changes, MG secretion, and MG morphology among three groups. The OSDI of asymptomatic MGD, symptomatic MGD and MGD coexisting with DED were 8.5 ± 2.9, 28.5 ± 12.8 and 27.9 ± 10.5, respectively. Patients with MGD coexisting with DED exhibited more frequent eye blinking than that of patients with asymptomatic MGD (8.1 ± 4.1 vs. 6.1 ± 3.5 blinks/20 sec, P = 0.022), and reduced LLT than that of patients with asymptomatic MGD (68.6 ± 17.2 vs. 77.6 ± 14.5 nm, P = 0.010) and symptomatic MGD (78.0 ± 17.1 nm, P = 0.015). Multivariate analysis identified LLT (per nm, OR = 0.96, 95% CI = 0.93-0.99, P = 0.002) as a significant factor associated with DED development in MGD. The number of expressible MG was positively correlated with LLT (Spearman's correlation coefficient = 0.299, P = 0.016) but negatively correlated with the number of blinking (Spearman's correlation coefficient = -0.298, P = 0.016) in MGD patients with DED, and these findings were not identified in those without DED.

CONCLUSIONS

Asymptomatic MGD, symptomatic MGD, and MGD coexisting with DED share similar characteristics, including meibum secretion and morphology, but MGD patients coexisting with DED exhibited significantly reduced LLT.

Dry Eye Disease Associated with Meibomian Gland Dysfunction: Focus on Tear Film Characteristics and the Therapeutic Landscape

Meibomian gland dysfunction (MGD) is highly prevalent and is the leading cause of evaporative dry eye disease (DED). MGD is characterized by a reduction in meibum secretion and/or a change in meibum composition that results in the disruption of the tear film lipid layer and an increase in the tear film evaporation rate. Excessive evaporation causes tear film instability, desiccation, tear hyperosmolarity, inflammation, and apoptosis of ocular surface cells, resulting in a continuous cycle of DED. The primary treatment goal for DED associated with MGD is to restore the tear film lipid layer and decrease evaporation, thereby reducing ocular signs and symptoms. The management of MGD includes home care options (eyelid hygiene, warming eye masks, ocular lubricants) and office-based treatments (manual expression, microblepharoexfoliation, thermal pulsation, intense pulsed light, intraductal probing). Topical ophthalmic prescription medications attempt to alter various factors that may contribute to DED (e.g., inflammation, bacterial growth, inadequate tear production). In this review, clinical evidence regarding available treatments and emerging therapies from randomized studies in patients with DED associated with MGD is summarized. Although some treatment modalities have been evaluated specifically for DED patients with MGD, large-scale randomized controlled trials are needed to confirm efficacy and safety in this patient population. Currently, there are no approved prescription pharmacologic treatments specifically indicated for DED associated with MGD, and those medications approved for the treatment of DED do not target the key driver of the disease (i.e., excessive evaporation). NOV03 (perfluorohexyloctane; under review with the US Food and Drug Administration) is the most advanced emerging therapy for DED associated with MGD and has demonstrated statistically significant improvements in both signs and symptoms in randomized controlled trials. Development of novel pharmacotherapies will improve therapeutic options and allow for a more individualized approach for patients with DED associated with MGD.

NOV03 for Dry Eye Disease Associated with Meibomian Gland Dysfunction: Results of the Randomized Phase 3 GOBI Study

PURPOSE

To evaluate the efficacy and safety of NOV03 (perfluorohexyloctane) ophthalmic drop in patients with dry eye disease (DED) associated with meibomian gland dysfunction (MGD).

DESIGN

Eight-week, phase 3, multicenter, randomized, double-masked, saline-controlled study.

PARTICIPANTS

Adults ≥ 18 years with a history of DED for ≥ 6 months, tear film breakup time of ≤ 5 seconds, Schirmer I test (without anesthesia) score ≥ 5 mm, MGD score ≥ 3 (0-15 scale), and total corneal fluorescein staining (tCFS) score ≥ 4 and ≤ 11 (0-15 National Eye Institute [NEI] scale).

METHODS

Patients were randomized 1:1 to NOV03 or hypotonic (0.6%) saline 4 times daily.

MAIN OUTCOME MEASURES

The primary sign and symptom end points were change from baseline in tCFS and eye dryness score (0-100 visual analog scale [VAS]) at week 8. Key secondary end points were change from baseline in eye dryness score at week 2, tCFS at week 2, eye burning or stinging score (0-100 VAS) at week 8, and central corneal fluorescein staining (cCFS; 0-3 NEI scale) at week 8.

RESULTS

Of the 599 patients randomized, 597 were treated (NOV03, n = 303; saline, n = 294). At week 8, improvement from baseline was significantly greater (P < 0.001) with NOV03 versus saline for tCFS (least square [LS] mean treatment difference, -0.97; 95% confidence interval [CI]: -1.40, -0.55) and VAS dryness score (-7.6; 95% CI: -11.8, -3.4). Improvement from baseline also significantly (P < 0.01) favored NOV03 on all key secondary end points: LS mean treatment difference (95% CI) was -4.7 (-8.2, -1.2) for VAS dryness score at week 2, -0.6 (-0.9, -0.2) for tCFS at week 2, -5.5 (-9.5, -1.6) for VAS burning or stinging score at week 8, and -0.2 (-0.4, -0.1) for cCFS at week 8. Most ocular adverse events (AEs) were mild in severity; no serious ocular AEs occurred. One patient discontinued NOV03 because of an AE (eye irritation).

CONCLUSIONS

In patients with DED associated with MGD, NOV03 demonstrated statistically significant and clinically meaningful improvements versus hypotonic saline in signs and symptoms of DED and was well tolerated.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Outcomes of serial sessions of Activa mask combined with intense pulsed light therapy in patients with Meibomian gland dysfunction

Background

To evaluate the effects on ocular surface signs and symptoms of serial sessions of heating and vibrating eye mask followed by intense pulsed light (IPL) therapy for the treatment of dry eye disease owing to meibomian gland dysfunction (MGD).

Methods

Consecutive patients with MGD whose signs and symptoms were not satisfactorily controlled with conventional therapy were included. Patients received 3 treatments performed at day 1, 15, and 45 incorporating a session with a newly-developed eye mask (Activa, SBS Sistemi, Turin, Italy) immediately followed by IPL therapy (E > Eye device, E-Swin, Paris, France). Patients were examined before the first session (T0) and 30 days after the last session (T1) for the measurement of: noninvasive break-up time (NIBUT); lipid layer thickness (LLT); tear meniscus height (TMH); meibomian gland loss (MGL); tear osmolarity. Ocular discomfort symptoms were ascertained by ocular surface disease index (OSDI) questionnaire.

Results

Thirty patients were ultimately included in the study. At T1, all objective ocular surface parameters improved significantly, except for TMH: NIBUT and LLT increased from 6.4 ± 1.7 to 8.6 ± 1.7 s and from 57.7 ± 15.5 to 81.3 ± 12.0 μm (all P < 0.001), while MGL and tear osmolarity decreased from 21.1 ± 17.3 to 17.0 ± 14.1% and from 302.0 ± 8.5 to 295.7 ± 6.9 mOsm/L (respectively, P = 0.004 and P < 0.001). In parallel, OSDI score decreased significantly from 49.8 ± 13.5 to 29.8 ± 10.6 (P < 0.001). In the historical control group of patients who underwent only IPL, NIBUT, LLT, tear osmolarity and OSDI improved significantly but not MGL and TMH.

Conclusions

Serial sessions incorporating the application of an eye mask producing heating and vibration immediately followed by IPL therapy are able to improve all ocular surface parameters as well as ocular discomfort symptoms in MGD patients.

Efficacy of the Systane iLux Thermal Pulsation System for the Treatment of Meibomian Gland Dysfunction After 1 Week and 1 Month: A Prospective Study

OBJECTIVES

To assess 1-week and 1-month efficacy of Systane iLux thermal pulsation treatment for meibomian gland dysfunction (MGD).

METHODS

This prospective, nonrandomized, open-label, multicenter study enrolled 30 adult patients (60 eyes) who had a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire score greater than 6 and total meibomian gland secretion (MGS) score equal to or less than 12 in each eye. All participants received thermal pulsation treatment bilaterally. Primary efficacy measures included MGS score (sum of grades for 15 glands graded on a scale of 0-3; 0 [no secretion], 1 [inspissated], 2 [cloudy], and 3 [clear liquid]) and tear breakup time (TBUT). Secondary efficacy measures were SPEED and Ocular Surface Disease Index (OSDI) scores.

RESULTS

The mean age of patients was 52.9±11.9 years. After 1 week, the mean MGS score improved significantly from 4.1±3.1 to 15.8±7.1 (right eye, OD) and 3.7±3.1 to 16.7±7.6 (left eye, OS); mean TBUT improved significantly from 4.9±4.1 to 8.4±3.6 (OD) and 5.2±4.2 to 8.9±3.9 (OS); and mean SPEED and OSDI scores improved significantly from 16.1±5.3 to 7.2±6.1 and 45.2±21.3 to 19.0±16.8, respectively (all P<0.001). After 1 month, the mean MGS score improved to 18.3±8.2 (OD) and 18.6±7.3 (OS); mean TBUT improved to 9.7±3.8 (OD) and 9.6±3.5 (OS); and mean SPEED and OSDI scores improved to 7.0±5.6 and 16.7±14.5, respectively (all P<0.001). No adverse events were reported.

CONCLUSIONS

Systane iLux thermal pulsation treatment for MGD resulted in a statistically significant increase in meibomian gland secretion, improvement in tear film stability, and reduction in dry eye symptoms as early as both 1 week and 1 month.

Prevalence of symptomatic dry eye disease with associated risk factors among medical students at Chiang Mai University due to increased screen time and stress during COVID-19 pandemic

Dry eye disease (DED) is one of the most common ophthalmological disorders, resulting from several systemic and ocular etiologies including meibomian gland dysfunction (MGD). During the COVID-19 pandemic, medical students are among the high-risk group for DED, mainly due to the increasing use of a visual display terminal (VDT) for online lectures and psychological stress from encountering several changes. Our study aimed to explore the prevalence of DED using the symptom-based definition and potential risk factors in medical students. This is a prospective cross-sectional study that included medical students at Chiang Mai University between November 2020 and January 2021. All participants were assessed using the Ocular Surface Disease Index (OSDI) questionnaire, the Thai version of the 10-Item Perceived Stress Scale-10 (T-PSS-10), the LipiView® II interferometer, and an interview for other possible risk factors. Overall, 528 participants were included in the study; half of the participants were female. The prevalence of DED was 70.8%. In the univariate analysis, female sex, contact lens wear, and T-PSS-10 stress scores were significantly higher in the DED group (P = 0.002, 0.002, and <0.001, respectively). Moreover, participants with severe DED were likely to have higher meibomian gland tortuosity but not statistically significant. In the multivariate analysis, contact lens use and T-PSS-10 score were significant risk factors associated with the severity of DED. In conclusions, the prevalence of DED in medical students was as high as 70.8%. Contact lens use and psychological stress evaluated using the T-PSS-10 questionnaire had a significant correlation with a risk of DED. Female gender and duration of VDT use were also associated. Most of the risk factors were modifiable and may be used as initial management in patients with DED.

Periplocin ameliorates mouse age-related meibomian gland dysfunction through up-regulation of Na/K-ATPase via SRC pathway

Age-related meibomian gland dysfunction (MGD) is the main cause of evaporative dry eye disease in an aging population. Decreased meibocyte cell renewal and lipid synthesis are associated with age-related MGD. Here, we found an obvious decline of Ki67, ΔNp63, and Na+/K+ ATPase expression in aged meibomian glands. Potential Na+/K+ ATPase agonist periplocin, a naturally occurring compound extracted from the traditional herbal medicine cortex periplocae, could promote the proliferation and stem cell activity of meibocyte cells in vitro. Moreover, we observed that periplocin treatment effectively increased the expression of Na+ /K+ ATPase, accompanied with the enhanced expression of Ki67 and ΔNp63 in aged meibomian glands, indicating that periplocin may accelerate meibocyte cell renewal in aged mice. LipidTox staining showed increased lipid accumulation after periplocin treatment in cultured meibomian gland cells and aged meibomian glands. Furthermore, we demonstrated that the SRC pathway was inhibited in aged meibomian glands; however, it was activated by periplocin. Accordingly, the inhibition of the SRC signaling pathway by saracatinib blocked periplocin-induced proliferation and lipid accumulation in meibomian gland cells. In sum, we suggest periplocin-ameliorated meibocyte cell renewal and lipid synthesis in aged meibomian glands via the SRC pathway, which could be a promising candidate for age-related MGD.

Meibomian gland dysfunction is highly prevalent among first-time visitors at a Norwegian dry eye specialist clinic

To investigate the prevalence of meibomian gland dysfunction (MGD) in patients presenting with subjective dry eye-related symptoms at their first-time consultation in a Norwegian specialized ocular surface clinic. Additionally, to explore the accuracy of the ocular surface disease index score (OSDI) as an extensively applied tool to assess the severity of dry eye symptoms and MGD diagnosis. Patients with subjective dry eye-related complaints (n = 900) attending the clinic for the first time, from 2012 to 2016, were included in the study. At the baseline, patients completed the OSDI questionnaire. Subsequently, objective clinical tests, including fluorescein break-up time (FBUT), Schirmer-I test, ocular surface staining (OSS), and meibomian gland function assessment using gland expressibility and meibum quality were performed. The association between MGD and its severity in relation to symptom severity defined by OSDI-score was examined. MGD was found in 93.8% of the study group. MGD prevalence was not significantly different between groups based on age (p = 0.302) or sex (p = 0.079). There was a significant association between severity of MGD and dry eye-related symptoms (p = 0.014). OSS was significantly higher in patients with severe symptoms (p = 0.031). Sensitivity and specificity of positive symptom-score (OSDI ≥ 13) for disclosing MGD were 85.5% and 30.4%, respectively. MGD was highly prevalent, not associated with age and sex. OSDI ≥ 13 had high sensitivity and high positive predictive value (PPV), but low specificity and negative predictive value (NPV) for disclosing MGD. This underscores the importance of meibomian gland assessment in patients with dry eye-related symptoms.

Comparison of intense pulsed light and near-infrared light in the treatment of dry eye disease: a prospective randomized study

PURPOSE

To compare the efficacy of intense pulsed light (IPL) and near-infrared light (NIL) treatments in alleviating symptoms and signs of dry eye disease (DED).

METHODS

Patients diagnosed with DED at the Peking University Third Hospital Eye Center from January 2019 to October 2019 were randomized to undergo either NIL therapy combined with meibomian gland expression (MGX; NIL Group) or IPL combined with MGX (IPL Group). Treatments were performed three times at 1-month intervals. DED signs and symptoms were evaluated before every treatment. We compared the clinical improvement within and between the groups. Additional comparisons were made according to the meibomian gland (MG) dropout grade.

RESULTS

A total of 260 eyes of 130 patients (mean age, 49.68 ± 18.01 years) were included. The dryness and total symptom scores and the MG expressibility and secretion quality (upper and lower eyelids) significantly improved after the three treatments in both groups (p < 0.05). However, IPL had superior efficacy in improving blurred vision, photophobia, burning, increased secretions and the total symptom score at 2 months in patients with more severe MG dropout.

CONCLUSIONS

Both IPL and NIL treatments were effective in the treatment of DED, but IPL provided greater symptom improvement, particularly in patients with severe MG dropout. NIL can be a new therapeutic option for the treatment of DED.

Update on the Management and Treatment of Demodex Blepharitis

ABSTRACT

Demodex blepharitis is a common ophthalmologic disease that is often overlooked in the workup of blepharitis. Demodex infestation occurs in both symptomatic and asymptomatic individuals at similar rates; consequently, its role in the development of blepharitis has not been well elucidated. Two species have been confirmed to inhabit the human eyelid-Demodex folliculorum and Demodex brevis. These species differ in their preferred location of infestation, with D. folliculorum occupying the base of the eyelash and D. brevis inhabiting the meibomian glands, contributing to anterior and posterior Demodex blepharitis, respectively. A clinical index of suspicion must be developed from the history when blepharitis, conjunctivitis, or keratitis in adults and blepharoconjunctivitis or chalazia in children are resistant to treatment. The diagnosis can be strongly suspected by the presence of cylindrical dandruff at the base of the eyelash and confirmed by light microscopy of an epilated lash or by in vivo confocal microscopy. No cure is currently available. Management most frequently includes topical tea tree oil and its active ingredient terpinen-4-ol, both of which have produced good clinical outcomes. Topical tea tree oil is typically applied by a professional due to risk of toxicity. Several second-line treatment options have been studied, including ivermectin, metronidazole, selenium sulfide, microblepharoexfoliation, and lid hygiene. Novel, targeted therapies such as TP-03 (Tarsus Pharmaceuticals) are also currently being investigated in phase 2b/3 clinical trials. The purpose of this review purpose is to characterize Demodex blepharitis in detail, including its historical perspective and various classifications, and describe the latest diagnostic and management strategies.

Meibomian Gland Dysfunction and Lipid Profile: A Study Among Pregnant Women

PURPOSE

This study aimed to estimate the frequency of meibomian gland dysfunction (MGD) and its associated factors among pregnant women.

METHODS

This was a hospital-based cross-sectional study of consecutive pregnant women visiting the University of Cape Coast hospital's antenatal clinic. Meibomian gland assessment and tear function test were performed along with the administration of a symptom questionnaire. Correlation, analysis of variance, and logistic regression analyses were used to examine predictors of MGD.

RESULTS

All 201 pregnant women who met the inclusion criteria and gave informed consent were included in the study. The mean age of the entire sample was 29.96 (±4.74) years. The frequency of MGD among the cohort of pregnant women was 22.9% (95% confidence interval, 17.4%-28.9%). Univariate logistic regression revealed that the following factors were significantly associated with MGD: high-density lipoprotein (HDL) (odds ratio [OR] 1.017; 95% confidence interval [CI], 1.001-1.034; P=0.042), total cholesterol (TC) (OR 1.009; 95% CI, 1.003-1.016; P=0.006), and low-density lipoprotein (LDL) (OR 1.008; 95% CI, 1.00-1.016; P=0.049). In multivariate analysis, the model confirmed that MGD was not significantly associated with TC, LDL, and HDL.

CONCLUSIONS

In summary, this study showed a high frequency of MGD in pregnant women but comparable with that reported in the normal population. Clinicians examining pregnant women for dry eye disease may need to pay attention to other causative instigators aside MGD to enable the clinicians to make an appropriate etiology-based diagnosis.

The Association Between Risk Factors for Metabolic Syndrome and Meibomian Gland Disease in a Dry Eye Cohort

Purpose

Risk factors for metabolic syndrome include abdominal obesity, insulin resistance, hypertension, high triglycerides and/or low high-density lipoprotein cholesterol, and hyperglycemia. Risk factors for metabolic syndrome have been associated with dry eye disease; however, their association with meibomian gland disease (MGD), a subtype of dry eye, is unclear. In the present study, we investigated risk factors for metabolic syndrome in a dry eye cohort with and without MGD.

Methods

This retrospective case-control study evaluated electronic medical records at a major urban outpatient medical center to identify patients with a known diagnosis of dry eye disease with and without MGD. Males and females were matched for age, smoking status, race, ethnicity, and body mass index (BMI). Patient demographics, anthropometric measurements, medical history, clinical findings, and serologies were analyzed. A diagnosis of MGD was based on clinical signs noted in the medical record.

Results

MGD was not associated with BMI, smoking, type 2 diabetes mellitus, hypertension or hyperlipidemia in this dry eye cohort. MGD was associated with male sex and increasing age. While increasing age was weakly correlated with decreased low density lipoprotein cholesterol and non-high density lipoprotein cholesterol, serum lipid levels were not associated with MGD.

Conclusion

Importantly, we found that risk factors for metabolic syndrome are not specifically associated with an increase in MGD when compared to non-MGD dry eye subjects. While risk factors for metabolic syndrome are associated with dry eye disease, they likely reflect a chronic systemic state of low-grade inflammation that negatively impacts the function of both lacrimal and meibomian glands.

Tear film interferometry assessment after intense pulsed light in dry eye disease: A randomized, single masked, sham-controlled study

BACKGROUND

Inadequate meibomian glands (MGs) secretion can lead to dry eye signs and symptoms. Tear film lipid layer (TFLL) secreted by MGs protects and prevents rapid evaporation of tear film. The purpose was to assess TFLL alteration and function in patients with evaporative dry eye (EDE) using tear interferometry after optimal pulse light technology (OPT) intense pulsed light (IPL).

METHODS

This prospective randomized examiner-masked sham- controlled study included 86 participants (142 eyes) with DED. IPL or sham procedure was performed on day 0, 21, and 42. Ocular Surface Disease Index (OSDI), non-invasive breakup time (NITBUT), interferometric fringe pattern determined TFLL quality, fluorescein staining (FS), and meibum gland (MG) were assessed at day 0, 21, 42 and 3-month.

RESULTS

At 3-month, TFLL, NITBUT, MG drop-out, MG quality, MG expressibility, FS and OSDI improved significantly (P < 0.05) in the IPL group, while the sham group had no significant improvements. Except for Meibo-score and FS, all parameters significantly correlated with the improvement in TFLL following IPL treatment. Additionally, artificial tears usage was significantly less in the IPL group from D-42 onwards.

CONCLUSION

IPL treatment demonstrated the ability to improve TFLL quality and clinically reduced sign and symptoms of DED thereby reducing the frequency of artificial tears use.

A Single-center Retrospective Trial of a Blink-assisted Eyelid Device in Treating the Signs and Symptoms of Dry Eye

SIGNIFICANCE

The clinical features of meibomian gland disease include altered tear film stability, damage to the ocular surface, symptoms of ocular surface irritation, and visual fluctuations. Finding an adequate treatment to alleviate a patient's signs and symptoms is vital to caring for those with dry eye disease resulting from meibomian gland disease.

PURPOSE

The purpose of this analysis was to determine whether the controlled heating of meibomian glands with the SmartLid devices (TearCare) combined with evacuation of the liquefied meibum using a handheld clearance assistant would improve a patient's dry eye symptoms (as measured by the Standardized Patient Evaluation of Eye Dryness [SPEED] questionnaire) and signs (as measured by meibomian gland expression [MGE] scores).

METHODS

This study involved a retrospective analysis of data gathered in a single-center ophthalmology/optometry practice. The symptom frequency and severity were assessed using the SPEED questionnaire, and the signs were assessed via MGE scores before and after (8 to 12 weeks) treatment. A further analysis evaluating efficacy in subgroups based on age, race, and sex was performed. A statistical analysis was performed with t tests for group comparisons.

RESULTS

A SPEED questionnaire was answered by 92 patients with dry eye disease. In addition, each patient's meibomian gland function was recorded as MGE scores for each eye (176 eyes). These procedures were completed before and approximately 8 weeks after a single bilateral TearCare treatment. The median total SPEED score was reduced from 16 to 9, and the total MGE scores improved from 5.0 to 9.0 in the right eye and 4.0 to 9.0 in the left eye after a single TearCare treatment.

CONCLUSIONS

A single TearCare treatment was effective in reducing both the signs and symptoms of dry eye in all subjects.

Meibomian gland dysfunction in geriatric population: tehran geriatric eye study

PURPOSE

To determine the prevalence of Meibomian gland dysfunction (MGD) and its risk factors in an elderly Iranian population METHODS: This cross-sectional study was conducted in 2019. The target population was the subjects aged 60 and over living in Tehran. Multistage cluster sampling was done to select the subjects from all Tehran districts. After an initial interview, all subjects underwent complete ophthalmic examinations including the measurement of visual acuity and refraction as well as slit lamp biomicroscopy to evaluate Meibomian glands.

RESULTS

Of 3791 selected subjects, 3310 participated in the study. The data of 3284 participants were analyzed. The mean age of the subjects was 68.24 ± 6.53 years (range: 60-97 years) and 57.8% of them were female. The total prevalence of MGD was 71.2% (68.3-74.1), and 38.1% (8.35-40.4), 30.3% (27.4-33.2), and 2.8% (2-3.6) of the subjects had MGD stage 2, 3, and 4, respectively. The prevalence of MGD was significantly higher in men (p < 0.001) and increased with age from 64.4% in the age group 60-64 years to 82.4% in subjects aged 80 years and over. There was no significant difference in the prevalence of MGD between smokers and nonsmokers; however, severe MGD was more common in smokers. The prevalence of MGD was 76.3% and 68.52% in subjects with and without a history of ocular surgery, respectively. The prevalence of MGD stage 3 and 4 was higher in subjects with a history of ocular surgery.

CONCLUSIONS

In line with the results of other studies in Asian countries, this study found a high prevalence of MGD in an elderly population of Iran. It was found that male gender and advanced age were risk factors of MGD and smoking and history of ocular surgery might worsen this disease in MGD patients.

Evaluation of dry eye disease in children with blepharokeratoconjunctivitis

OBJECTIVE

To evaluate the symptoms and signs of dry eye disease (DED) in children diagnosed with blepharokeratoconjunctivitis (BKC).

DESIGN

Prospective case-controlled study PARTICIPANTS: Consecutive patients with BKC and normal controls.

METHODS

All participants underwent a comprehensive dry eye assessment including the Canadian Dry Eye Assessment (CDEA) questionnaire, tear film osmolarity test, Schirmer's test without anesthesia, slit lamp examination, tear film break-up time, corneal fluorescein staining (CFS), and lissamine green conjunctival staining (LGCS), according to the Sjögren's International Collaborative Clinical Alliance ocular staining score. For each test the result of the more severe eye was included in the statistical analysis.

RESULTS

Twenty-five patients were recruited-11 with BKC and 14 healthy controls. No difference in symptoms was found between children with BKC (CDEA score 6.1 ± 5.5) and normal controls (CDEA score 3.6 ± 3.2; p = 0.16). Children with BKC had significantly higher mean CFS (1.1 ± 1.6 vs 0.1 ± 0.4; p = 0.04) but similar mean LGCS (1.4 ± 1.8 vs 1.5 ± 2.1; p = 0.81) than normal controls. No statistically significant differences were observed in other tests between the 2 groups. CDEA scores were significantly correlated to CFS in normal controls (r = 0.59, p = 0.03), and approached significance in children with BKC (r = 0.56, p = 0.07).

CONCLUSIONS

The only test that can distinguish DED in patients with BKC from children without BKC is the CFS score. This should guide management and monitoring of this unique patient population with DED symptoms and signs.

Preoperative Management of MGD with Vectored Thermal Pulsation before Cataract Surgery: A Prospective, Controlled Clinical Trial

Purpose: To investigate the efficacy of preoperative monocular treatment in elderly cataract patients with Meibomian Gland Dysfunction (MGD) utilizing vectored thermal pulsation treatment.Materials and Methods: This study was a prospective, examiner-masked contralateral eye clinical trial. Patients previously diagnosed with MGD undergoing uncomplicated cataract surgery in two eyes were enrolled. The eye perceived by the patient to be more symptomatic of MGD received a 12 min vectored thermal pulsation treatment using the LipiFlow Thermal Pulsation System, and was referred to as the LipiFlow-surgery eye. The contralateral eye then served as the nonLipiFlow-surgery eye. Patients with MGD not undergoing cataract surgery were enrolled as the control group. Within the control group, the eye that received LipiFlow treatment was considered the LipiFlow-nonsurgery eye, while the contralateral eye served as the nonLipiFlow-nonsurgery eye. All patients were examined before treatment and at one-week, one-month, and three-month intervals after treatment. Clinical parameters included dry eye symptoms, average lipid layer thickness (LLT-ave), tear breakup time (TBUT), corneal staining, Schirmer I tests, Meibomian glands yielding liquid secretion (MGYLS), and meibomian gland dropout.Results: A total of 32 patients (64 eyes) were examined during the three-month follow-up. There was a significant reduction in dry eye symptoms in non-surgery patients with monocular treatment of MGD, while no change in surgery patients was observed. Significant improvement of MGYLS in LipiFlow-surgery and LipiFlow-nonsurgery eyes during the follow-up time (p < .001) was reported, while no difference was observed in nonLipiFlow-surgery and nonLipiFlow-nonsurgery eyes. A statistically significant difference was seen in TBUT between LipiFlow-surgery and nonLipiFlow-surgery eyes at one-week and one-month intervals (p = .019 and 0.019, respectively). Differences in other clinical parameters were not statistically significant.Conclusions: Our findings suggest that although subjective symptoms were not alleviated, a single application of LipiFlow treatment before cataract surgery is effective in alleviating blockage of meibomian glands and preventing the decline of TBUT after cataract surgery.

Metagenomic Profiling of Ocular Surface Microbiome Changes in Meibomian Gland Dysfunction

Purpose

Ocular surface microbiome changes can affect meibomian gland dysfunction (MGD) development. This study aimed to delineate differences among the microbiome of eyelid skin, conjunctiva, and meibum in healthy controls (HCs) and patients afflicted with MGD.

Methods

Shotgun metagenomic analysis was used to determine if there are differences between the microbial communities in ocular sites surrounding the meibomian gland in healthy individuals and patients afflicted with MGD.

Results

The meibum bacterial content of these microbiomes was dissimilar in these two different types of individuals. Almost all of the most significant taxonomic changes in the meibum microbiome of individuals with MGD were also present in their eyelid skin, but not in the conjunctiva. Such site-specific microbe pattern changes accompany increases in the gene expression levels controlling carbohydrate and lipid metabolism. Most of the microbiomes in patients with MGD possess a microbe population capable of metabolizing benzoate. Pathogens known to underlie ocular infection were evident in these individuals. MGD meibum contained an abundance of Campylobacter coli, Campylobacter jejuni, and Enterococcus faecium pathogens, which were almost absent from HCs. Functional annotation indicated that in the microbiomes of MGD meibum their capability to undergo chemotaxis, display immune evasive virulence, and mediate type IV secretion was different than that in the microbiomes of meibum isolated from HCs.

Conclusions

MGD meibum contains distinct microbiota whose immune evasive virulence is much stronger than that in the HCs. Profiling differences between the meibum microbiome makeup in HCs and patients with MGD characterizes changes of microbial communities associated with the disease status.

Prevalence of meibomian gland dysfunction in staffs and faculty members of a Chinese university

AIM

To assess the prevalence of meibomian gland dysfunction (MGD) in staffs and faculty members of Sichuan University, China.

METHODS

The records of the annually systemic physical examination of 4404 consecutive staffs and faculty members of Sichuan University were analyzed retrospectively. Ocular symptoms and signs of ocular surface were evaluated.

RESULTS

MGD was diagnosed in 1424 participants (32.3%), with a mean age of 43.0±9.6y. Of these, 718 (50.4%) were females and no significant difference was found between males and females. The highest prevalence was found in the age 50-59y (36.0%). Logistic regression analysis showed that age is an impact factor of MGD (P<0.001, odds ratio=1.014).

CONCLUSION

The prevalence of MGD in staffs and faculty members of a Chinese university is 32.3%, and increases with age.

A Review on Evidence-Based Treatments for Meibomian Gland Dysfunction

OBJECTIVES

To evaluate recent studies on available therapies for meibomian gland dysfunction (MGD).

METHODS

A literature search on recent publications, within the last five years, concerning treatment options for MGD was performed.

RESULTS

A total of 35 articles were reviewed after curation by the authors for relevance. In general, all modalities of treatments were shown to have clinical efficacy in alleviating dry eye signs and symptoms, although the extent of improvement and persistency of outcomes varied between the different treatments. Evidence from published studies demonstrate that thermal pulsation produces the longest lasting effect per treatment, but it also incurs the highest per-treatment cost. Reusable methods for warm compress with lipid/semi-fluorinated alkane-containing eye drops are recommended as first-line treatment for mild-to-moderate dry eye patients, because this option is most technically feasible and cost-effective in clinical practice. Intense pulsed light (IPL) therapy and thermal pulsation may be suitable as second line for patients unresponsive to warm compress therapy; however, their respective limitations need to be considered. For refractory MGD with features of periductal fibrosis or severe blepharitis, supplementary treatment with meibomian gland probing or oral antibiotics may be used.

CONCLUSIONS

All eight forms of treatments, including self-applied eyelid warming, thermal pulsation, IPL, MG probing, antibiotics, lipid-containing eye drops, and perfluorohexyloctane, were effective against MGD, although with varying extent of clinical improvements. A better understanding on the mechanisms of actions may guide physicians to make better treatment decisions targeting the root causes.

Intense pulsed light for meibomian gland dysfunction: a systematic review and meta-analysis

BACKGROUND

Intense pulsed light therapy (IPL) is a new method being used to treat meibomian gland dysfunction (MGD) globally. With an increasing number of studies being published, it is necessary to consider additional factors related to treatment. This review aims to investigate the efficacy and safety of IPL for the treatment of MGD.

METHODS

The PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, and SinoMed databases were searched through February 24, 2020. Randomized clinical trials and cohort studies comparing IPL+ meibomian gland expression (MGX) or IPL alone with control groups were included. The weighted mean difference (WMD) was calculated to analyze the Ocular Surface Disease Index (OSDI) score and Standard Patient Evaluation of Eye Dryness (SPEED) score, and the standard mean difference (SMD) was calculated to analyze the tear breakup time (TBUT). Heterogeneity was quantified by the I² statistic ranging from 0 to 100%, and a random effects model was used in this meta-analysis. All analyses were performed by RevMan 5.3. All p values were calculated by the t test, and p values were regarded as statistically significant at p < 0.05. The Cochrane Collaboration's tool for assessing risk of bias was used to identify and evaluate bias in the literature.

RESULTS

Nine studies with a total of 539 patients were included. Eight studies examined TBUT, six examined OSDI scores, and four examined SPEED scores. IPL combined with MGX showed superiority regarding the TBUT (SMD 2.33, 95% CI 1.04-3.61), and OSDI scores (WMD 11.93, 95% CI - 17.10 to - 6.77), with high heterogeneity. The SPEED scores were not significantly different.

CONCLUSIONS

IPL combined with MGX may be an effective and safe treatment for MGD, but it cannot improve all symptoms. IPL alone is not superior to MGX. The efficacy is also affected by the number and average frequency of treatments. The efficacy of IPL may decrease within 6 months after the last treatment, so it should be considered a long-term adjuvant therapy combined with MGX. When patients receive 3 or 4 treatments (once every 3-4 weeks), a return visit at 6 months after the last treatment is required.

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.

Clinical results of Intraductal Meibomian gland probing combined with intense pulsed light in treating patients with refractory obstructive Meibomian gland dysfunction: a randomized controlled trial

Background

This study aims to optimize the therapeutic regimen for refractory obstructive meibomian gland dysfunction (o-MGD) patients by combining intraductal meibomian gland probing (MGP) and intense pulsed light (IPL) to enhance their positive effects and reduce their limitations.

Methods

This randomized, assessor blind study includes 45 patients (90 eyes) with refractory o-MGD who were divided into 3 groups via allocation concealment: IPL (group I, received an IPL treatment course: 3 times at 3-week intervals), MGP (group II, received MGP one time), and combined MGP-IPL (group III, MGP first followed by an IPL treatment course). Standard Patient Evaluation of Eye Dryness score (SPEED), tear break-up time (TBUT), corneal fluorescein staining (CFS), meibum grade, and lid margin finding results were assessed at baseline, 3 weeks after final treatment for groups I and III, 3 and 12 weeks after MGP for group II. Six months after final treatment, the SPEED and willingness to receive any treatment again were also collected for all groups. Paired Wilcoxon, Mann-Whitney U with Bonferroni correction, and Kruskal-Wallis tests were used for data analysis.

Results

For all 3 groups, all previously mentioned indexes improved significantly following treatment (P<0.01). MGP-IPL was better than IPL and MGP in terms of post-treatment SPEED, TBUT, meibum grade, and lid telangiectasia (P<0.05/3). Furthermore, the MGP-IPL was better than IPL in terms of lid tenderness and better than MGP in terms of orifice abnormality (P< 0.05/3). Six months later, the SPEED for the MGP-IPL was also significantly lower than other groups (P<0.05/3). Moreover, no patients in the MGP-IPL group expressed the need to be treated again compared to 35.7% or 20% of patients in the IPL or MGP groups, respectively.

Conclusions

Compared with IPL or MGP alone, the combination MGP-IPL produced best results in relieving all signs and symptoms and helping patients attain long-lasting symptom relief.

Trial registration

http://clinicaltrials.gov, ChiCTR1900021273 (retrospectively registered February 9, 2019).

Evaluation of ocular surface impairment in meibomian gland dysfunction of varying severity using a comprehensive grading scale

This study aimed to propose a comprehensive grading scale to evaluate different clinical manifestations in patients with varying severity of meibomian gland dysfunction (MGD) and analyze the correlations between the parameters of ocular surface impairment in MGD.A total of 63 patients with MGD were enrolled. Ten specific symptoms were evaluated each with a subjective score and total score was applied to grade the severity of MGD. Thirty-seven patients were diagnosed with mild, 19 with moderate, and 7 with severe MGD. Slit-lamp and keratography were used to assess the signs of ocular surface and meibomian gland (MG). In vivo confocal microscopy (IVCM) was performed to evaluate the corneal nerves and dendritic cells. The differences and correlations between symptoms, signs, and IVCM parameters were analyzed.Dryness, foreign body sensation, asthenopia, and photophobia were the most common and severe symptoms in our patients. The severe MGD group showed worse MG expressibility, Meibum score, Meiboscore, MG score, and higher nerve reflectivity (P < .05). The mild MGD group showed higher nerve density (P < .05). Total symptom score was negatively correlated with nerve density (r = -0.374, P < .05), while positively correlated with nerve reflectivity and dendritic cell density (r = 0.332 and 0.288, respectively, P < .05). MG score was correlated with nerve reflectivity (r = 0.265, P < .05).The comprehensive grading scale was suitable for evaluating clinical manifestations in MGD of varying severity. The relationship between the specific symptoms, signs, and IVCM results concerning whole ocular surface impairment could help elucidate MGD pathophysiology and benefit evaluation or treatment in the future.

Intense pulsed light therapy: A promising complementary treatment for dry eye disease

OBJECTIVE

To propose the Intense Pulsed Light (IPL) therapy as a helpful supplementary treatment in patients with dry eye disease.

MATERIAL AND METHODS

Retrospective cross sectional design. Medical records of patients in whom dry eye disease symptoms were not satisfactorily controlled with medical therapy alone and who underwent additional IPL with at least three sessions completed. Data were analyzed before therapy and 3weeks after its completion to asses improvement. Determination of symptoms, through a visual analog scale; tear film stability, through tear Break Up Time (tBUT); measurement of tear secretion, through Schirmer Test; and ocular surface staining with Van Bijsterveld score were evaluated. SPSS software and nonparametric analysis of repeated measures were used. The study was approved by the ethics committee.

RESULTS

50 eyes from 25 subjects were reviewed. There were 9 males (36%) and 16 females (64%), with a median age of 59years (IQR 52-64). The median of the symptoms scale was 8 (IQR 8-9) and 3 (IQR 2-4) before and after the therapy respectively (P<.05). The median of BUT was 4 (IQR 3-5) and 10 (IQR 8-11), Schirmer test was 13 (IQR 12-15) and 15 (IQR 13-20), and Van Bijsterveld score was 3 (RIC 3-4) and 2 (IQR 2-3) before and after the therapy respectively (P<.05, for all measurements).

CONCLUSION

IPL treatment has excellent results regarding both: dry eye disease symptoms improvement and in office objective tests such as tBUT, Schirmer test and Van Bijsterveld score; IPL could be considered as an effective adjunct for dry eye disease.