Co-Management

How the Decision to Do (or not do) Meibography Impacts Your Dry Eye Services

Co-author Jessica Heinke, OD, in her office performing meibography, which she and her co-authors of this article note greatly impacts overall dry eye services in an OD's office.

Co-author Jessica Heinke, OD, in her office looking over OCT findings of a dry eye patient. Her treatment also typically includes meibography, which she and her co-authors of this article note greatly impacts overall dry eye services in an OD’s office.

Importance of meibography in dry eye treatment

By James E. Grue, OD,
Ronald P. Snyder, OD, FAAO,
and Jessica Heinke, OD

Jan. 15, 2025

There is significant variation in the frequency with which eyecare providers order in-office thermal treatments or other advanced dry eye therapies.

Some eyecare providers rarely perform or refer patients for advanced dry eye treatments while others order them on a wide range of patients.

The key differentiator between these diverse groups is meibography.

How Meibography Impacts Dry Eye Treatment

Offices that infrequently order in-office thermal treatments are unlikely to perform meibography as part of the dry eye workup on a patient. The findings that drive clinical decision-making in these offices is most likely to be:

Patient symptoms
Corneal staining
Tear break-up time
Shirmer’s

Offices that frequently order in-office thermal treatments almost always perform meibography as part of any dry eye workup. Analytics show that in these offices, the findings that are most likely to drive clinical decision making are:

Meibomian gland function testing
Meibography
Presence of demodex or blepharitis
Corneal staining
Tear break-up time

These offices also tend to treat dry eye associated blepharitis and demodex more aggressively. There certainly is variation between offices in what testing is done. There are also many additional tests that are done more frequently in some offices and less frequently in others.

When a clinical registry was asked to look at the frequency of tests completed in dry eye workups to see if there were any trends, it was almost immediately obvious that the biggest differentiator was in the frequency in which meibography is performed.

When providers who regularly do meibography were asked when they order meibography, there were a consistent set of reasons:

Patient symptoms is not a reliable predictor of meibomian gland loss
1. Most patients who are symptomatic have meibomian gland loss on meibography
2. Many patients who are asymptomatic or mildly symptomatic have extensive meibomian gland loss on meibography
3. Many practices report adopting meibography as part of their wellness screenings and many recommend meibography to patients as part of their annual eye exam

Expansion of Dry Eye Analytics

These observations have resulted in an expansion of dry eye analytics within the registry that did the original data review. There are now analytics that:

Study the frequency and extent of meibomian gland loss when dry eye symptoms first appear, so all providers are aware of the risk of meibomian gland dysfunction in these patients.
1. It is expected that the data from these analytics will indicate that all patients with dry eye symptoms should have meibography and likely suggest patients without symptoms should be screened with meibography.
2. This has implications for other providers as well since some patients present to primary care physicians with symptoms and others self-medicate with over-the-counter medications. These are two groups that represent potential referral sources
Analytics are also looking at the percentage of patients in each age group that are asymptomatic, but have significant meibomian gland loss on meibography
1. An alarming finding is the amount of meibomian gland loss (MGD) in children who are either asymptomatic or mildly asymptomatic.
2. There is growing concern that extended use of near devices may be the cause.
3. In preliminary analytics, the number of children with over 75 percent meibomian gland loss is concerning.
4. If an association is determined analytically between the use of near devices and MGD, we may be seeing a future public health crisis developing right in front of us that is going largely undetected.
5. A major emphasis of the registry currently is to establish frequency data on the extent of meibomian gland loss in children.
6. Preliminary data is strong enough to suggest that any symptoms that could be related to dry eye in children justify meibography being completed to rule out MGD.

Reconsidering Role of Meibography

As more data is accumulated for the registry analytics, the data will drive the future use of meibography. Preliminary data suggests that the role of meibography be reconsidered. Currently, many eyecare providers consider meibography a test performed by dry eye clinics, so only consider it necessary if they are deciding to expand dry eye management.

Why is Meibography So Important?

When providers who regularly order meibography on patients were asked why it seems to be such an important test in driving more aggressive dry eye management, the responses were pretty consistent.

The feeling is that most of the other dry eye tests are findings that individually are difficult for both the patient and provider to quantify and relate to significant changes that will likely occur if not addressed. Since meibography involves images, the findings tend to be more tangible.

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When a provider sees significant meibomian gland loss, it is a finding they feel compelled to show the patient. When the patient is shown the images, they almost immediately agree that it is a finding that needs to be addressed. It also provides a powerful finding to compare over time to show how effectively any management approach is working.

If a provider does not have access to a meibographer and cannot afford to invest in one, they can utilize an alternative approach by everting the lower eyelid behind the slit lamp to observe the meibomian glands and assess their length. With proper lighting, the meibomian glands are visible.

If gland dropout is observed, the patient should be referred for appropriate treatment, regardless of the presence or severity of symptoms. Early referral ensures proper management and helps prevent further complications.

James E. Grue, OD, is a health-care reform speaker and consultant. To contact him: JimGrue@HealthCareRegistries.com