Management Of Meibomian Gland Dysfunction Research Articles

Intense pulsed light treatment for the management of meibomian gland dysfunction.

Meibomian gland dysfunction (MGD) is one of the most common disorders encountered by ophthalmologists, and its management can prove challenging for both clinicians and patients. Intense pulsed light (IPL), which has been historically used in the field of dermatology, has emerged as a tool to help improve meibomian gland function. The goal of this review is to assess the clinical efficacy, utility, and safety of IPL for the treatment of MGD. In recent randomized controlled trials, IPL has been shown to improve meibomian gland function, and subsequently tear film quality and dry eye symptoms. The mechanism of action still remains unclear. Recent literature suggests that IPL may also be used in conjunction with other therapies, such as meibomian gland expression, low-level light therapy, and thermal pulsation. Careful attention should be placed on each patient's Fitzpatrick skin type, as well as protecting the ocular structures to reduce the risk of adverse effects. Cost, accessibility, as well as a limited duration of efficacy may be drawbacks. There is significant evidence supporting that IPL may be used as a potential well tolerated and effective treatment for MGD, though there are certain caveats regarding its long-term efficacy, accessibility, and cost.

Dip eyes in water technique (Akshi Nimanjjana): Efficacy of a simple technique in the management of meibomian gland dysfunction

Abstract Background: Dip eyes in water (DEW) is an ancient technique to improve eye hygiene. Conventionally, the eyes are cleaned by splashing water on them. However, splashing is not very effective as the eyes get closed reflexly when the water is splashed onto the eyes. On the other hand, in the DEW technique, it is conveniently possible to keep eyes fully open when dipped inside the water in the eye cup. Meibomian gland dysfunction (MGD) is a chronic, frustrating disease for which there is no gold standard, and eye hygiene is presumed to play an important role. Aim: The present study was tested in a cohort of MGD patients using the DEW technique. Materials and methods: DEW was prescribed to seven patients who were symptomatic for a period ranging from 6 months to 2 years. The main four symptoms were irritation in the eyes, persistent watering of the eyes, burning sensation, and foreign-body sensation. The scale of assessment of these four symptoms was severe (+++), moderate (++), mild (+), and no symptoms (−). The outcome assessment criteria were complete relief in these four symptoms and were assessed after 1 year of starting treatment. The DEW technique was performed 3–4 times per day. It was added to the ongoing conservative treatment. Once complete relief was obtained, other conservative management measures were stopped, and only the DEW treatment continued. It was advised that the DEW treatment be continued as a part of the regular eye hygiene daily routine. Results: Five out of seven patients reported complete relief in outcome criteria (four symptoms), one had partial relief, and there was no relief in one of the patients. After a follow-up of 1 year, one patient (the one with partial relief) was lost to follow-up. Five out of seven patients had significant relief, and 5/6 patients had sustained relief on long-term follow-up. No adverse effects were reported by any of the patients. Conclusion: The DEW technique is promising in providing significant relief in patients with MGD. The encouraging results of DEW in this series can help prescribe and extend the indications of DEW in managing MGD and other eye disorders, in which eye hygiene plays a therapeutic role and as a daily routine eye-care practice to prevent various eye disorders.

Chinese expert consensus on meibomian gland dysfunction: diagnosis and management (2023)

Meibomian gland dysfunction (MGD) is a common ocular surface disease. In recent years, the meibomian gland-related examination and treatment technologies have evolved rapidly. In order to further optimize the diagnostic process of MGD in China and improve the treatment efficiency of MGD, the Chinese Branch of the Asian Dry Eye Society has organized relevant experts to discuss the clinical characteristics of MGD in China and the progress of research at home and abroad. Based on the expert consensus formed in 2017, the updated consensus opinions have been developed for clinical physicians to refer to in the diagnosis and management of MGD.

Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology

To review the literature to determine the efficacy and safety of thermal pulsation technologies in improving signs or symptoms of meibomian gland dysfunction (MGD) and dry eye compared with no therapy or with conventional warm compress therapy or eyelid hygiene. A literature search was conducted in the PubMed database in June 2022 and again in March 2023 to identify all studies in the English language on the use of thermal pulsation to treat MGD or dry eye. The search yielded 59 citations, and 11 articles metall of the inclusion criteria. The panel methodologist then assigned a level of evidence rating for each study; 8 studies were rated level I evidence and 3 studies were rated level II evidence. All included studies evaluated a single 12-minute session using the LipiFlow automated thermal pulsation system (TearScience, Inc, or Johnson & Johnson). Improvements were detected in subjective and objective metrics of MGD or dry eye in patients within 1 to 12 months of thermal pulsation treatment compared with nontreatment. Most of the studies (9/11) reported greater efficacy with thermal pulsation than with standard warm compress therapy and eyelid hygiene. Four of these studies showed relevant industry conflicts of interest. Two of the 4 level I studies without direct industry participation concluded that thermal pulsation treatment was not significantly different from conventional hygiene or warm compress therapy control treatments (in symptoms in one of the studies and in objective findings in the second study). No serious adverse events were reported in any of the 11 studies. According to the current literature, a single thermal pulsation session may improve subjective or objective parameters of MGD and dry eye safely. However, industry support and participation were present in 4 of the 8 level I studies. The durability beyond several months and cost efficacy remain uncertain. Because the inclusion parameters of this assessment captured only the LipiFlow system, the conclusions are limited to that product. High-quality independent studies are needed to assess the long-term benefits of this intervention. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Preoperative Treatment of Meibomian Gland Dysfunction with a Vectored Thermal Pulsation System Prior to Extended Depth of Focus IOL Implantation.

Patients implanted with a range-of-vision intraocular lens (IOL) (multifocal or extended depth of focus, EDOF) may be more susceptible to visual disturbances from poor tear film quality, and prophylactic treatment of meibomian gland dysfunction (MGD) has been recommended. The purpose was to evaluate whether vectored thermal pulsation (LipiFlow™) treatment prior to cataract surgery with a range-of-vision IOL safely improves postoperative outcomes. This is a prospective, randomized, open-label, crossover, multicenter study of patients with mild-to-moderate MGD and cataract. The test group underwent LipiFlow treatment prior to cataract surgery and implantation of an EDOF IOL, while the control group did not. Both groups were evaluated 3months postoperatively, after which the control group received LipiFlow treatment (crossover). The control group was re-evaluated 4months postoperatively. A total of 121 subjects were randomized, with 117 eyes in the test group and 115 eyes in the control group. At 3months after surgery, the test group had a significantly greater improvement from baseline in total meibomian gland score compared with the control group (P = 0.046). At 1month after surgery, the test group had a significant decrease in corneal (P = 0.04) and conjunctival (P = 0.002) staining compared to the control group. At 3months after surgery, the test group had significantly lower incidence of being bothered by halos compared with the control group (P = 0.019). The control group had a significantly lower incidence of being bothered by multiple or double vision compared with the test group (P = 0.016). After crossover, patients had significant improvement in vision (P = 0.03) and total meibomian gland score (P < 0.0001). No safety concerns or relevant safety findings were uncovered. Presurgical LipiFlow treatment of patients implanted with range-of-vision IOLs improved meibomian gland function and postoperative ocular surface health. This supports guidelines recommending proactive diagnosis and management of MGD in patients with cataracts to improve patient experience. The study was registered on www. gov (NCT03708367).

A Deep Learning Approach for Meibomian Gland Appearance Evaluation

To develop and evaluate a deep learning algorithm for Meibomian gland characteristics calculation. Evaluation of diagnostic technology. A total of 1616 meibography images of both the upper (697) and lower (919) eyelids from a total of 282 individuals. Images were collected using the LipiView II device. All the provided data were split into 3 sets: the training, validation, and test sets. Data partitions used proportions of 70/10/20% and included data from 2 optometry settings. Each set was separately partitioned with these proportions, resulting in a balanced distribution of data from both settings. The images were divided based on patient identifiers, such that all images collected for one participant could end up only in one set. The labeled images were used to train a deep learning model, which was subsequently used for Meibomian gland segmentation. The model was then applied to calculate individual Meibomian gland metrics. Interreader agreement and agreement between manual and automated methods for Meibomian gland segmentation were also carried out to assess the accuracy of the automated approach. Meibomian gland metrics, including length ratio, area, tortuosity, intensity, and width, were measured. Additionally, the performance of the automated algorithms was evaluated using the aggregated Jaccard index. The proposed semantic segmentation-based approach achieved average aggregated Jaccard index of mean 0.4718 (95% confidence interval [CI], 0.4680-0.4771) for the 'gland' class and a mean of 0.8470 (95% CI, 0.8432-0.8508) for the 'eyelid' class. The result for object detection-based approach was a mean of 0.4476 (95% CI, 0.4426-0.4533). Both artificial intelligence-based algorithms underestimated area, length ratio, tortuosity, widthmean, widthmedian, width10th, and width90th. Meibomian gland intensity was overestimated by both algorithms compared with the manual approach. The object detection-based algorithm seems to be as reliable as the manual approach only for Meibomian gland width10th calculation. The proposed approach can successfully segment Meibomian glands; however, to overcome problems with gland overlap and lack of image sharpness, the proposed method requires further development. The study presents another approach to utilizing automated, artificial intelligence-based methods in Meibomian gland health assessment that may assist clinicians in the diagnosis, treatment, and management of Meibomian gland dysfunction. The authors have no proprietary or commercial interest in any materials discussed in this article.

Morphology of Meibomian Glands in a 65-Year-Old Norwegian Population without Dry Eye Disease.

Analyses of meibography may help in the diagnosis, prevention, and management of meibomian gland dysfunction (MGD). However, there is currently a paucity of data regarding meibography analyses in the young elderly populations in the Nordic countries. In the current study, meibography of the upper and lower eyelids of 117 65-year-old residents in Oslo, Norway, who did not fulfil the diagnosis of dry eye disease (DED) were analysed. Meibomian gland (MG) dropout and tarsal areas were measured semi-automatically using ImageJ software. The relationship between morphological features of the MGs and clinical dry eye tests was examined. The median percent MG dropout was 26.1% and 40.7% in the upper and lower eyelids, respectively. There was no significant difference between males and females. None of the MG morphological parameters demonstrated significant values in discriminating abnormal dry eye symptom loads or MGD diagnosis from the normal loads. We therefore concluded that moderate MG atrophy was common among the Norwegian population of 65-year-olds without DED and showed no sexual differences. Meibography alone cannot discriminate MGD from non-MGD; thus, both morphological and functional MG tests are necessary when screening for MGD.

Quantifying Meibomian Gland Morphology Using Artificial Intelligence.

Quantifying meibomian gland morphology from meibography images is used for the diagnosis, treatment, and management of meibomian gland dysfunction in clinics. A novel and automated method is described for quantifying meibomian gland morphology from meibography images. Meibomian gland morphological abnormality is a common clinical sign of meibomian gland dysfunction, yet there exist no automated methods that provide standard quantifications of morphological features for individual glands. This study introduces an automated artificial intelligence approach to segmenting individual meibomian gland regions in infrared meibography images and analyzing their morphological features. A total of 1443 meibography images were collected and annotated. The dataset was then divided into development and evaluation sets. The development set was used to train and tune deep learning models for segmenting glands and identifying ghost glands from images, whereas the evaluation set was used to evaluate the performance of the model. The gland segmentations were further used to analyze individual gland features, including gland local contrast, length, width, and tortuosity. A total of 1039 meibography images (including 486 upper and 553 lower eyelids) were used for training and tuning the deep learning model, whereas the remaining 404 images (including 203 upper and 201 lower eyelids) were used for evaluations. The algorithm on average achieved 63% mean intersection over union in segmenting glands, and 84.4% sensitivity and 71.7% specificity in identifying ghost glands. Morphological features of each gland were also fed to a support vector machine for analyzing their associations with ghost glands. Analysis of model coefficients indicated that low gland local contrast was the primary indicator for ghost glands. The proposed approach can automatically segment individual meibomian glands in infrared meibography images, identify ghost glands, and quantitatively analyze gland morphological features.

Meibography Phenotyping and Classification From Unsupervised Discriminative Feature Learning

PurposeThe purpose of this study was to develop an unsupervised feature learning approach that automatically measures Meibomian gland (MG) atrophy severity from meibography images and discovers subtle relationships between meibography images according to visual similarity.MethodsOne of the latest unsupervised learning approaches is to apply feature learning based on nonparametric instance discrimination (NPID), a convolutional neural network (CNN) backbone model trained to encode meibography images into 128-dimensional feature vectors. The network aims to learn a similarity metric across all instances (e.g. meibography images) and groups visually similar instances together. A total of 706 meibography images with corresponding meiboscores were collected and annotated for the use of network learning and performance evaluation.ResultsFour hundred ninety-seven meibography images were used for network learning and tuning, whereas the remaining 209 images were used for network model evaluations. The proposed nonparametric instance discrimination approach achieved 80.9% meiboscore grading accuracy on average, outperforming the clinical team by 25.9%. Additionally, a 3D feature visualization and agglomerative hierarchical clustering algorithms were used to discover the relationship between meibography images.ConclusionsThe proposed NPID approach automatically analyses MG atrophy severity from meibography images without prior image annotations, and categorizes the gland characteristics through hierarchical clustering. This method provides quantitative information on the MG atrophy severity based on the analysis of phenotypes.Translational RelevanceThe study presents a Meibomian gland atrophy evaluation method for meibography images based on unsupervised learning. This method may be used to aid diagnosis and management of Meibomian gland dysfunction without prior image annotations, which require time and resources.

Proposed Algorithm for Management of Meibomian Gland Dysfunction Based on Noninvasive Meibography.

Although the pathophysiology of meibomian gland dysfunction (MGD) remains incompletely understood, many treatment options have recently become available. According to an international workshop report, treatment selection for MGD should be based on a comprehensive stage classification dependent on ocular symptoms, lid margin abnormalities, meibum grade, and ocular surface staining. However, it is often difficult to evaluate all parameters required for such classification in routine clinical practice. We have now retrospectively evaluated therapeutic efficacy in MGD patients who received five types of treatment in the clinic setting: (1) meibocare (application of a warm compress and practice of lid hygiene), (2) meibum expression plus meibocare, (3) azithromycin eyedrops plus meibocare, (4) thermal pulsation therapy plus meibocare, or (5) intense pulsed light (IPL) therapy plus meibocare. Patients in each treatment group were classified into three subsets according to the meiboscore determined by noncontact meibography at baseline. Eyes in the IPL group showed improvement even if the meiboscore was high (5 or 6), whereas meibocare tended to be effective only if the meiboscore was low (1 or 2). The meiboscore may thus serve to guide selection of the most appropriate treatment in MGD patients. Prospective studies are warranted to confirm these outcomes.

Intense pulsed light for the treatment of Meibomian gland dysfunction: A systematic review and meta-analysis.

Meibomian gland dysfunction (MGD) is frequently encountered by eye care practitioners. It is characterised by obstruction of the Meibomian glands and/or alterations in the consistency of glandular secretions. At present, no definitive treatment exists for this condition. The present meta-analysis was performed to assess the efficacy of intense pulsed light (IPL) therapy in the management of MGD. Databases including EMBASE, PubMed, Cochrane Central, MEDLINE and Google Scholar were systematically searched to identify clinical trials that assessed the efficacy of IPL in the treatment of MGD. Outcome measures were described as the standardized mean difference (SMD). The fixed- or random-effects model was selected for analysis based on the Cochrane I2 values representing heterogeneity. Publication bias was visually inspected using Begg's funnel plot. Data were synthesized from four randomized controlled trials (RCTs) comprising 122 subjects in the IPL group and 120 subjects in the control group. Pooled analysis indicated no statistically significant difference in the Standard Patient Evaluation of Eye Dryness (SPEED) scores between the two groups [SMD -0.16 (95% CI, -0.41 to 0.10)] but a significant increase in Non-Invasive Tear Break-Up Time (NIBUT) scores in the IPL group (SMD, 0.90; 95% CI, 0.40-1.40). To conclude, the results of the present study did not provide any conclusive evidence for the efficacy of IPL therapy in the management of MGD. The analysis indicated that IPL therapy may result in an improvement of objective NIBUT scores but has no effect on subjective SPEED scores. Given the limited number of studies performed to date, there is a requirement for more well-designed prospective RCTs with a larger sample size to provide further evidence on the efficacy of IPL therapy.

Randomised trial of the clinical utility of an eyelid massage device for the management of meibomian gland dysfunction

PurposeTo compare the single application and two week treatment effects of device-applied (Eyepeace) and manually-applied eyelid massage techniques, as an adjunct to warm compress therapy, on ocular surface and tear film parameters. MethodsTwenty participants (11 females, 9 males; mean age, 27 ± 11 years) with dry eye symptoms were recruited in a two week, investigator-masked, randomised, contralateral-eye trial. Following 10 min of warm compress therapy application (MGDRx EyeBag®) on both eyes, eyelid massage therapy was applied to one eye (randomised) by device, and to the fellow eye by manual eyelid massage, once daily for 14 days. Ocular surface and tear film measurements were conducted at baseline, and 15 min post-application by a clinician, then again after 14 days of self-administered daily treatment at home. ResultsBaseline clinical measurements did not differ between the treatment groups (all p > 0.05). Following two weeks of treatment, tear film lipid layer grade improved significantly with device massage (p = 0.008), and was marginally greater than manual massage by less than 1 grade (p = 0.03). Although immediate post-treatment improvements in tear film stability were observed in both groups (both p < 0.05), no significant long-term cumulative effects or inter-treatment differences in stability measures were detected (all p > 0.05). Visual acuity, tear meniscus height, conjunctival hyperaemia, ocular surface staining, and meibomian gland dropout did not change during the treatment period (all p > 0.05). ConclusionsTwo weeks of treatment with the eyelid massage device, as an adjunct to warm compress therapy, effected marginally greater improvements in tear film lipid layer thickness than the conventional manual technique, which were statistically but not clinically significant. Future parallel group trials with longer treatment periods and a greater range of disease severity are required.

A hot new treatment for MGD

Bill Harvey tries out a new approach to the management of meibomian gland dysfunction.

In-vivo heat retention comparison of eyelid warming masks.

Meibomian gland dysfunction (MGD) is one of the most common causes of evaporative dry eye. Warm compresses (WC) are recommended as adjunct therapy to slowly transfer heat to the meibomian glands to melt or soften the stagnant meibum with targeted temperatures of 40-45°C. This clinical study evaluated the heat retention profiles of commercially available eyelid warming masks over a 12-min interval. Five eyelid-warming masks (MGDRx Eyebag(®), EyeDoctor(®), Bruder(®), Tranquileyes XR™, Thera°Pearl(®)) were heated following manufacturer's instructions and heat retention was assessed at 1-min intervals for 12min. A facecloth warmed with hot tap water was used as comparison. Twelve (n=12) subjects participated in the study (10F:2M, ranging in age from 21 to 30 with an average of 23.2±3.8years). Each mask demonstrated a unique heat retention profile, reaching maximum temperature at different times and having a different final temperature at the end of the 12-min evaluation. After heating, all eyelid warming masks reached a temperature near 37°C within the first minute. The facecloth was significantly cooler than all other masks as of the 2-min mark (p<0.05). Reusability, availability and heat retention profiles should be considered when selecting an eyelid warming masks for adjunct WC therapy in the management of MGD. All masks tested, with the exception of the facecloth, demonstrated stable heat retention throughout the 12min, bringing further awareness that patient education is required to discuss the shortcomings of the heat retention of the facecloth, if only heated once.

Utilisation de la lentille thérapeutique dans l’ulcère perforé

Meibomian gland dysfunction (MGD) is one of the most common causes of evaporative dry eye. Warm compresses (WC) are recommended as adjunct therapy to slowly transfer heat to the meibomian glands to melt or soften the stagnant meibum with targeted temperatures of 40−45° C. This clinical study evaluated the heat retention profiles of commercially available eyelid warming masks over a 12-min interval.Five eyelid-warming masks (MGDRx Eyebag®, EyeDoctor®, Bruder®, Tranquileyes XR™, Thera°Pearl®) were heated following manufacturer's instructions and heat retention was assessed at 1-min intervals for 12 min. A facecloth warmed with hot tap water was used as comparison.Twelve (n = 12) subjects participated in the study (10F:2 M, ranging in age from 21 to 30 with an average of 23.2 ± 3.8 years). Each mask demonstrated a unique heat retention profile, reaching maximum temperature at different times and having a different final temperature at the end of the 12-min evaluation. After heating, all eyelid warming masks reached a temperature near 37° C within the first minute. The facecloth was significantly cooler than all other masks as of the 2-min mark (p < 0.05).Reusability, availability and heat retention profiles should be considered when selecting an eyelid warming masks for adjunct WC therapy in the management of MGD. All masks tested, with the exception of the facecloth, demonstrated stable heat retention throughout the 12 min, bringing further awareness that patient education is required to discuss the shortcomings of the heat retention of the facecloth, if only heated once.

Effects of a New Eyelid Shampoo on Lid Hygiene and Eyelash Length in Patients with Meibomian Gland Dysfunction: A Comparative Open Study.

Purpose. Meibomian gland dysfunction (MGD) can lead to abnormalities in the composition and function of tear film, resulting in dry eye. Eyelid hygiene is a key to management of MGD. We tested a novel eyelid shampoo (Eye Shampoo Long, ESL) for its ability to maintain lid hygiene. This shampoo is nonirritating and can potentially lengthen eyelashes. This study was aimed to evaluate the efficacy of ESL in the treatment of MGD and its effects on eyelash length. Methods. Ten patients with MGD and 10 healthy subjects without MGD applied ESL twice daily for 8 weeks. Patients were examined for lid margin and dry eye before and after the trial. Subjective symptoms were evaluated. Eyelash length was measured at baseline and at the end of the trial. Results. In the MGD group, significant improvements were observed in subjective symptoms obstruction of the meibomian orifice, secretion of meibum, eyelashes contamination, eyelid margin foam, and SPK. Eyelash length became significantly longer. Conclusions. Maintaining eyelid hygiene using ESL improved the eyelid margins and symptoms of dry eye in MGD patients and increased eyelash length. These findings are promising and warrant confirmation in a larger randomized controlled study.

Évaluation des moyens modernes de prise en charge du dysfonctionnement meibomien

To evaluate a thermal pulsation treatment compared to a warming eyelid device for the management of meibomian gland dysfunction. Thirty patients were randomized into two groups: the first had a treatment with MeiboPatch(®) on a daily basis for three months while the second had a single treatment with LipiFlow(®). The evaluation focused on a classical approach but also on a modern approach of the ocular surface (interferometry lipid layer LipiView(®)), analysis of the tear film by Oquas(®) (osmolarity by TearLab(®)) before treatment, then a month and three months later. Both treatments proved to be effective with almost three times more functional meibomian glands at 3 months in the LipiFlow group and almost twice more in the MeiboPatch group (P<0.05) but the LipiFlow allows a more rapid improvement at the first month of treatment. Functional scores and classic exploration of the ocular surface except the Schirmer test also undergo a significant improvement in both groups after three months of treatment. The combination of heat applied to the inner eyelid surface, together with simultaneous expression of the glands, during a single 12-minute treatment shows to be highly effective in treating cases of meibomian gland disease. Whilst results were excellent, and continued lid hygiene remains advised, the benefit of being able to simultaneous address potential compliance issues relating to ongoing treatment is significant. The convenience of a single 12-minute treatment versus an ongoing daily heating regime was shown to be highly desirable and a welcome relief in our patients' busy lifestyles.

Improving Awareness, Identification, and Management of Meibomian Gland Dysfunction

Ocular surface disorder--and dry eye, in particular--is a leading reason for visits to eye care professionals. It has been generally accepted that meibomian gland dysfunction (MGD) is a leading cause of evaporative dry eye, as well as being associated with aqueous-deficient dry eye. Yet, researchers and clinicians have lacked a global consensus on the definition of MGD, its epidemiology, pathophysiology, and management. Various systemic diseases and medications have been associated with the progression of both dry eye and MGD, as have several ocular disorders beyond those directly affecting the surface. It is in the best interest of patients for clinicians to be able to better identify and diagnose MGD, differentiating it from other ocular surface disorders, and to recognize the effects of MGD on the ocular surface, and thus initiate appropriate therapy. This CME activity provides expert insight into the Tear Film and Ocular Surface Society's International Workshop on MGD consensus report, offering practical application of its findings to better manage MGD patient care, particularly for those patients facing or undergoing ocular surgery.

Physical therapy in MGD as a cornerstone for improvement of signs and symptoms &amp; The British perspective on MGD

AbstractPurpose This talk will present the typical management of meibomian gland dysfunction (MGD) that is currently implemented in British primary eye care, and where the current focus lies in newer diagnostic techniques and therapies.Methods Recent focus on MGD has highlighted this condition as one that is under‐estimated and under‐managed, particularly amongst contact lens wearers. This renewed appreciation for the major cause of dry eye has resulted in parallel interest amongst eye care practitioners for an evidence‐based approach to management. The most common approaches are reviewed, alongside some emerging popular choices.Results There is robust evidence to support modern approaches, and to discourage some of the old‐fashioned management strategies.Conclusion Whilst there is still a lot to understand about MGD, there is no doubt that eye care practitioners can do more to help patients manage this highly prevalent problem.

The role of heat in rubbing and massage-related corneal deformation

To examine the role of elevated corneal temperature in the development of rubbing/massage-related corneal deformation and the possibility that warm compresses in the management of meibomian gland dysfunction or chalazion could contribute to such adverse responses. With reference to reports of corneal deformation associated with meibomian gland dysfunction, chalazion, dacryocystoceles and post-trabeculectomy, the mechanisms for increased corneal temperature due to ocular massage, especially when combined with warm compresses are examined. Several mechanisms for rubbing/massage to elevate corneal temperature have been described, apart from the application of warm compresses or other forms of heat. Raised corneal temperature helps to explain corneal deformation which develops in association with rubbing or massage in conditions such as keratoconus, chalazion, post-trabeculectomy, post-laser assisted in situ keratomileusis, post-graft and dacryocystoceles. When combined with warm compresses or other methods of heat delivery to the eye, the elevation of corneal temperature appears to explain how meibomian gland dysfunction treatment involving warm compresses and massage could induce rubbing-related deformation. Patients whose management involves iatrogenic ocular massage appear to require screening for risk of corneal deformation. Risk may be increased for patients with a concurrent habit of rubbing their eyes abnormally in response to allergic itch for example. It appears to be possible to modify ocular massage techniques to reduce the risk of corneal deformation. Careful tutoring and follow-up using corneal topography appears to be required when massage is prescribed, especially when used in conjunction with heat application.