Eyeworld

Integrating meibography into practice Meibography is expected to take a more significant role in diagnostics T he 2017 ASCRS Clin- ical Survey showed that less than 20% of respondents are using meibography. "I think we are going to see some amazing changes in these numbers over the next 5 or 10 years," said Eric Donnenfeld, MD. "I predict that this is going it yields more information than the slit lamp examination alone; plus, I can show the mei- bography photographs to the patient," he said (Figure 1). "We do point-of-care test- ing and meibography imaging as initial tests for all cataract and refractive surgery patients," said Marjan Farid, MD. "This ensures that we catch all occult cases of ocular surface disease and start treatment on them prior to surgery. These patients then also become aware of their dry eye and MGD prior to to be a big change, particularly around cataract surgery." "To truly assess meibomian gland dysfunction (MGD), it is equally important to have meibography for structural analysis as well as a functional exam of the lid margin and put that together," said Elizabeth Yeu, MD. 1,2 Role of meibography John Sheppard, MD, uses mei- bography as a point-of-care test before examination. "I like to have the meibography done be- fore I see the individual because 4 Meibography Summit: Translating knowledge into practice you immediately know whether there is MGD or not." Before the examination, Edward Holland, MD, observes the patient's blink rate, whether the patient has an incomplete blink, and whether there is entropion or ectropion. He examines the lids for anterior blepharitis and MGD, and then he examines the tear film quality. He expresses the glands laterally, centrally, and medially with a cotton tip applicator, inspecting the orifices and meibum quality. John Sheppard, MD, flips the upper lid to directly evalu- ate the superior tarsus, especial- ly in chronic cases. "We usually look at the inferior tarsus quite readily, and we can glean some useful information from the inferior tarsal examination. There's a lot more information in the superior tarsal conjuncti- va, and it is much more tightly adherent to the underlying car- tilaginous plate, which contains the meibomian glands," he said. He explained that this enables clinicians to assess acute vs. chronic inflammation, cu- mulative inflammatory damage by the presence of scarring, and anatomical abnormalities indicative of parallel collateral damage. During meibography, however, the lower tarsal plate is far more readily accessible to surgery and are more motivated and compliant with treatment." Marguerite McDonald, MD, explained that in her prac- tice meibography is performed for all patients evaluated for surgery, new patients with pos- itive responses on the psycho- metric test, or well-established dry eye patients who have not had meibography in 6 months. "I typically have techni- cians perform meibography on my refractive cataract patients and symptomatic patients," said Alice Epitropoulos, MD. "This the photographer and yields es- sentially the same information as the superior tarsus, he said. Marguerite McDonald, MD, said her practice used to image the upper and lower lids with meibography but realized findings were similar in both lids. 3 "So, on a routine basis, unless you are in a clinical trial, you do not have to flip that lid," she said. The 2011 International Workshop on Meibomian Gland Dysfunction indicated MGD may be diagnosed based on a single affected gland. 1 Assessing structure Some practices use meibogra- phy as a point-of-care test in cataract or refractive patients and others in those with signs or symptoms of dry eye. 3 Slight- ly more than half of Meibogra- phy Summit participants think meibography diagnoses the condition earlier. Marjan Farid, MD, looks for dilation of the glands, shortening and disorganization of the glands, or atrophy and dropout as distinguishing signs of progressive MGD. Alan Carlson, MD, has a low threshold for performing meibography and asking about symptoms in patients having cataract surgery. 2 "Not only is MGD non-obvious to the exam- iner in many cases, it's non-ob- vious to the patient," he said. "These are typically older patients who tend to have a relatively neurotrophic cornea, so they may not feel the symp- toms," said D. Rex Hamilton, MD. "Functional effects may not be seen until the loss is more significant," Dr. Farid said. "I have been impressed by how many younger patients that I would not expect to have MGD have significant MGD and do not know it," she said. "So now, with the younger corneal refrac- tive or LASIK evaluation patients that come in, I make it a point to perform meibography." If tear breakup time is abnormal, the chance of MGD is high, said W. Barry Lee, MD. "If you do not recognize this before your cataract surgery, you are going to see them after their cataract surgery and they are going to be complaining of this," he said. "There is so much we are learning about MGD, and mei- bography is an area that we are going to learn more about over the next decade," said Preeya Gupta, MD. "It is critical as a tool to assess meibomian gland structure. Meibography adds value in terms of helping to set patient expectations and help- ing me to be a better diagnosti- cian. I would love to see more people use it." References 1. Tomlinson A, et al. The Internation- al Workshop on Meibomian Gland Dysfunction: report of the diagnosis subcommittee. Invest Ophthalmol Vis Sci. 2011;52:2006–49. 2. Cochener B, et al. Prevalence of mei- bomian gland dysfunction at the time of cataract surgery. J Cataract Refract Surg. 2018;44:144–148. 3. Finis D, et al. Evaluation of meibomian gland dysfunction and local distribu- tion of meibomian gland atrophy by non-contact infrared meibography. Curr Eye Res. 2015;40:982–9. continued on page 5 continued from page 3 " Not only is MGD non-obvious to the examiner in many cases, it's non-obvious to the patient. " —Alan Carlson, MD

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