Meibomian Gland Dysfunction: What Does It Mean James P. McCulley, MD, FACS, FRCOph(UK)

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1 Meibomian Gland Dysfunction: What Does It Mean James P. McCulley, MD, FACS, FRCOph(UK) David Bruton, Jr. Professor of Ophthalmology Chairman, Department of Ophthalmology The University of Texas Southwestern Medical School Dallas, Texas

2 No relevant financial relationships to disclose.

3 Primary e.g. Hypersecretory Secondary/Contributory e.g. with ADDE Epiphenomenon/Marker for disease e.g. IOSD with induction of hyper keratinization Aging normal vs contribute to dry eye All/Each of the above

4 Tear Film Instability Lipid Deficiency Cause: meibomian gland dysfunction (MGD) causing insufficient or unhealthy lipid production Sign: irregular meibomian gland expression, fast tear film break-up time (TFBUT) Aqueous Deficiency Cause: insufficient tear production by accessory and primary lacrimal glands Sign: low Schirmer (tear volume/flow) score Mucin Deficiency Cause: insufficient or unhealthy mucin production Sign: TFBUT

5 Lipid Layer The Antievaporative Layer Outermost layer of the tear film Approximately 0.1 m thick Primary function = prevent evaporation & overflow of tears Produced by meibomian glands along the lower and upper lids. OCULAR SURFACE

6 Definition of MGD Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of meibomian glands, characterized by an alteration in the qualitative and/or quantitative secretion of the meibomian glands that may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.

Lid margin neovascularization Clinical Characteristics of MGD Burning

meibomian gland orifices Granular sensation and scratchiness or

changes in visual clarity due to poor tear film Eyelids stuck together upon

eye lashes, especially upon waking Eyelids red, especially upon waking

and Justin Kwan, MD., 2010. Preferred Practice Pattern Guidelines.

7 Lid margin neovascularization Clinical Characteristics of MGD Burning Itching Excessive tearing SYMPTOMS of dry eyes Squamous metaplasia of meibomian gland orifices Granular sensation and scratchiness or foreign-body sensation due to crusted debris or dryness Decreased vision or changes in visual clarity due to poor tear film Eyelids stuck together upon waking Meibum alterations (color / composition) Crusty debris around the eye lashes, especially upon waking Eyelids red, especially upon waking Gland drop out Short TFBUT Photos courtesy of Richard Yee, MD, Don Korb, MD and Justin Kwan, MD., Preferred Practice Pattern Guidelines. Blepharitis. San Francisco, CA: American Academy of Ophthalmology; Available at:

8 Meibomian Gland Dysfunction (MGD)? Evaporation Anatomic Definition: Meibomian gland dropout on meibography. Slit lamp Definition: Difficult to express meibum or turbid meibum on expression. Wojtowicz, JC, Butovich, IA. McCulley, JP. Historical Brief on Composition of Human Meibum Lipids. Ocular Surface 2009 July;(7)3:

9 Primary Hyposecretory MGD Obstructive/Hyposecretory MGD Hypersecretory MGD AKA Meibomian Seborrhea Turbid MGD

10 Meibomian Gland Disease

11 Photos courtesy of Justin Webb, OD, Alcon Research Ltd., Non-obvious MGD

12 MKC Posterior Blepharitis Inflammation of the posterior lid margin

13 Photo Courtesy of JP McCulley, MD Zero Drop Out

14 Photo Courtesy of JP McCulley, MD 50.0 % Drop out

15 Clinical Significance of MGD Theory: associated with increased tear evaporation resulting in (hyperevaporative) KCS and in (frequent) association with aqueous secretory deficiency (hyposecretory) KCS combined mechanism KCS. McCulley JP, Uchiyama E, Aronowicz J.D, Butovich I.A, Impact of Evaporation on Aqueous Tear Loss. Trans Am Ophthalmol Soc 2006;104: KCS: Keritoconjuntivitis Sicca

16 Evaporative Contribution to Tear Loss Evaporative Contribution to Tear Loss at 20-25% RH Evaporative Contribution to Tear Loss at 40-45% RH % P value % P value Normals Mean ± (.187) * ± (.376) * Dry Eye Classic KCS Mean ± (.114) ± (.227) KCS / MGD Mean ± (.417) ± (.725) * Normals versus All Dry Eye Compared to Normals McCulley JP, Uchiyama E., Aronowicz JD, Butovich IA, Impact of Evaporation on Aqueous Tear Loss. Trans Am Ophthalmol Soc 2006;104: RH: Relative Humidity

17 Survey of Etiological Classification of Dry Eye 50% % of Overall Patient Population 40% 30% 20% 10% 0% 39% 30% 31% Aqueous Deficiency MGD Mixed N = 40 Data on File, Alcon. Market research interviews with 40 eye care professionals asking for subjective description of the percentage of patients seen that fall into each category. Mixed refers to an unclear etiology that may contain aspects of both aqueous deficiency and lipid deficiency/mgd.

18 Primary e.g. Hypersecretory Secondary/Contributory e.g. with ADDE Epiphenomenon/Marker for disease e.g. IOSD with induction of hyper keratinization Aging normal vs contribute to dry eye All/Each of the above

19 Other autoimmune diseases Sjogren s syndrome Aging/Menopause Flora changes Goblet cell loss Blepharitis/MGD LPS release Toxins-Lipases Tear film instability Imbalance Eyelid inflammation Cell hyperosmolarity Chalasis/lid margin irregularities Lipidic changes Rosacea Toxic drugs/ preservatives Allergy Systemic drugs/ Antidepressants Cytokine release MMP activation Neurogenic inflammation Lacrimal hypersecretion INFLAMMATION Cell damage Conjunctiva Cornea APOPTOSIS Contact lens wear Ocular surgery LASIK/ refractive surgery Nerve stimulation Neurotrophic Viral/bacterial conjunctivitis Environment Baudouin C. Un nouveau schéma pour mieux comprendre les maladies de la surface oculaire. J Fr. Ophtalmol., 2007; 30, 3,

20 An Integrated Ocular Surface Complex in Health & Disease Many interactions & cascades Complex mechanisms in disease states No simple approach to pathophysiology or Rx The more we learn the more we realize how little we truly know

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