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Meibography improves care of patients with meibomian gland dysfunction
When patients see images of their own glands, they may be more likely to comply with their treatment regimen.
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Meibomian gland dysfunction, or MGD, is one of the most common causes of an abnormal tear film lipid layer and evaporative dry eye, with numerous risk factors reported. Its prevalence varies among countries from 20% to 60%, with one of the highest rates in Japan. It is characterized by terminal duct inspissation, truncation, obstruction and gland dropout, and/or qualitative and quantitative changes in the secretion of the glands.
Meibography — the imaging of the meibomian glands — is now a quick, comfortable point-of-care test that is becoming popular in practices that have made the diagnosis and treatment of ocular surface disease a priority. There are three systems in widespread use: the LipiScan from Johnson & Johnson Vision, the Keratograph 5M from Oculus and the HD Analyzer from Visiometrics.
The units are small in footprint. They differ in regard to other features, but they are all able to take sharp images that are quickly and easily interpreted.
First, a little history. Meibography is the only clinically in vivo and noninvasive technique to visualize the morphology of the meibomian glands. Tapie was probably the first to describe the evaluation of the meibomian glands by transilluminating glands with white light in 1977, a procedure that is somewhat uncomfortable for patients. Tapie also captured images of the glands using infrared film. Later, Jester and his colleagues adapted biomicroscopic and photographic techniques to improve upon Tapie’s work. Numerous scientists and clinicians improved upon the original meibography systems so that we have the quick, noncontact, patient-friendly units that are available today.
Meibography images
The importance of meibography in educating patients and encouraging compliance cannot be overstated. A picture is truly worth a thousand words. When you tell a patient that he has advanced MGD and paint a verbal picture of his future if it is left untreated, he will usually listen politely and then disregard your little speech as so much white noise.
But show him an image of his own glands, and his reaction is completely different. Of course, the doctor must first give him a point of reference; the companies provide laminated photos that we keep in each exam lane, illustrating normal glands, moderately advanced MGD and severe MGD.
We perform meibography on any patient who checks off one or more of the typical dry eye/MGD symptoms on our questionnaire and any patient with a known history of dry eye/MGD who has not had an image taken within the last 6 months.
As the psychometric questionnaire, meibography, tear osmolarity (TearLab) and MMP-9 testing (Quidel) have been performed before I enter the exam room, I can perform my slit lamp exam and quickly summarize the findings.
When I show the patient his meibography images, I use the aforementioned trio of photos, all on one laminated sheet, to educate the patient. I explain that the normal photo shows healthy glands: tall, straight, tightly packed. I explain that they are producing the clear oil that prevents evaporation of the tear film.
The second image, moderately advanced disease, shows diseased glands that are serpentine and truncated. I explain that the clear oil has been changed by the disease process into a toxic yellow-white “goo” (altered meibum) that causes the gland loss, and, for half of the patients, the symptoms they know so well.
The last image, advanced disease, shows truncation and loss of virtually all glands. I explain that these patients are virtual house prisoners, with blurred vision and extreme light sensitivity. It is well documented that 50% of ocular surface disease patients have no symptoms; I explain that even if the patient has no symptoms now, he will when the gland loss is this advanced.
After a 20-second review of these three images, we show patients their own images. Often, jaws drop and gasps are heard.
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For clinical trials, we study both the upper and lower lids with meibography. In routine clinical practice, however, we only image the lower lids. Why? Patients do not enjoy having their upper lids everted, many technicians feel uncomfortable doing this, it takes more time, and we have found that the patient’s pathology is virtually always present, to nearly equal degree, in both the upper and lower lids. If anything, there is slightly less dropout of glands in the upper lids than in the lower lids. In other words, you are not missing any pathology by imaging lower lids only.
Treatment compliance
My patients’ compliance with my suggested regimen has improved dramatically since the introduction of meibography to our practice. Whether it is a medical regimen, or an in-office lid cleaning by the ophthalmologist with OcuSoft Swabstix, or a thorough biofilm debridement of the lid margin (BlephEx), or thermal pulsation therapy (J&J Vision), the conversion and compliance rate has soared.
At the moment, we are not billing for these images. Soon there should be a specific code for meibography. We nevertheless remain enthusiastic about meibography. It takes only seconds to capture the images, and they motivate so many patients to accept our recommended treatment regimens that it is worth it for our practice to continue performing meibography.
- For more information:
- Marguerite B. McDonald, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 360 Merrick Road, Lynbrook, NY 11563; email: margueritemcdmd@aol.com.
Disclosure: McDonald reports she is a consultant for Johnson & Johnson Vision, BlephEx, OcuSoft and TearLab.