Meibomian glands are large sebaceous glands located in the eyelids and secrete lipid (meibum) that prevents excessive evaporation of the tear film [1]. Meibomian gland dysfunction (MGD) is defined as a chronic abnormality of meibomian glands characterized by terminal duct obstruction or qualitative or quantitative changes in the glandular secretion that can result in changes to the tear film, inflammation, ocular surface disease, or symptoms of eye irritation [2]. MGD is a leading cause of the entire dry eye, not only the evaporative dry eye [3]. The ocular symptoms of MGD are similar to those of aqueous-deficient dry eye and include fatigue as well as foreign body, burning, and itchy sensations. However, the clinical findings of MGD differ from those of aqueous-deficient dry eye [4]. The first line of treatment for MGD has been proposed to include patient education, the application of a warming compress, and the practice of lid hygiene [5]. In clinical practice, many ophthalmologists also tend to prescribe eye drops developed for aqueous-deficient dry eye as a result of the similarity in symptoms with MGD.

In the present study, we administered a questionnaire regarding the diagnosis and treatment of MGD to physicians with an interest in this condition in order to evaluate the perceived usefulness of noncontact meibography and the efficacy of self-care consisting of the application of a warming compress or the practice of lid hygiene. Our results suggest that appropriate diagnosis and management not only contribute to the success of MGD treatment but also avoid unnecessary prescription of eye drops.

The Lid and Meibomian Gland Working Group (LIME; http://www.lime.jp) was established in 2012 for ophthalmologists in Japan with an interest in MGD. Its purpose is to educate not only physicians but also patients with regard to the high prevalence of MGD and the importance of its proper diagnosis and treatment (http://www.lime.jp/en/about). We made available a questionnaire in Google format to be completed by LIME members on a volunteer basis and with complete anonymity between April and June 2018. A total of 121 LIME members (87 men and 34 women with a mean ± SD age of 51.9 ± 11.2 years; 99 employed in private clinics and 22 in public hospitals) responded to the Web-based questionnaire. The content of questionnaire is described in Figures 1 and 2.

Figure 1: Responses to questions regarding the efficacy of meibography.

Figure 2: Responses to questions regarding the efficacy of eyelid warming and lid hygiene.

Meibography

First, we asked ophthalmologists the efficacy of meibography in their clinics. Meibography is an observation device to visualize meibomian gland in upper and lower eyelids. Recently we developed a non-invasive meibography, and this triggered the expansion of meibomian gland research and clinics. Out of 121 ophthalmologists who belong to LIME, 25 use noncontact meibography, a morphological diagnostic tool [6,7], for the diagnosis of MGD in clinical practice. These 25 physicians were asked about the usefulness of meibography for the diagnosis of MGD and for the education of MGD patients (Figure 1). Of the 22 respondents to the question regarding the usefulness of meibography for diagnosis of MGD, 16 (72.7%) replied “notably” and 6 (27.3%) replied “some.” Of the 22 respondents to the question regarding the usefulness of meibography images for the education of MGD patients, 18 (81.8%) replied “notably” and 4 (18.2%) “some.” All respondents thus provided a positive response to both questions on the usefulness of meibography, indicating that meibography is recognized as a tool not only for diagnosis but also for patient education.

Eyelid warming

Then we asked ophthalmologists the efficacy of eyelid warming. Eyelid warming is a basic treatment for MGD recommended by Tear Film & Ocular Surface Society (TFOS). It is well-known that eyelid warming improved the tear film condition and ocular symptoms in MGD patients. Among the 121 ophthalmologists, 89 recommend a warming compress for the initial treatment of MGD in clinical practice. These 89 respondents were asked additional questions regarding this treatment, with 74 providing answers (Figure 2). With regard to the usefulness of eyelid warming as an initial treatment for MGD, 38 of the 74 respondents (51.4%) replied “valuable” and 36 (48.6%) selected “partly,” with all responses thus being positive. As to whether the use of a warming compress reduces the frequency of administration of eyedrops for dry eye, “notably,” “some,” “rarely,” and “none” were selected by 3 (4.1%), 50 (67.6%), 18 (24.3%), and 3 (4.1%) respondents, respectively, with most responses thus again being positive. Of the 71 respondents who thought that a warming compress did reduce the frequency of eyedrop use, 2 (2.8%), 12 (16.9%), 27 (38.0%), and 30 (42.3%) estimated that it did so by >80%, 50-80%, 30-50%, or 10-30%, respectively, with ~60% of respondents thus estimating a reduced frequency of eyedrop administration of at least 30%. With regard to whether eyelid warming reduces the prescription of eyedrops by physicians, none of the 71 respondents selected “notably,” with 47 (66.2%), 21 (29.6%), and 3 (4.2%) selecting “some,” “rarely,” and “none,” respectively. Finally, of the 68 respondents who did not answer “none” to the previous question, 8 (11.8%), 24 (35.3%), and 36 (52.9%) thought that the use of a warming compress reduced the frequency of eye drop prescription by 50-80%, 30-50%, or 10-30%, respectively.

Lid hygiene

Finally, we asked the efficacy of lid hygiene to the ophthalmologists. Lid hygiene is a procedure to clean eyelids up with using shampoo or something like that. Lid hygiene is also recommended by TFOS as a basic care procedure as well as eyelid warming. Among the 121 ophthalmologists, 89 recommend the practice of lid hygiene for the initial treatment of MGD. These 89 respondents were asked additional questions regarding this treatment, with 60 providing answers (Figure 2). With regard to the usefulness of lid hygiene as an initial treatment for MGD, 38 (63.3%), 19 (31.7%), 3 (5.0%), and 0 (0%) of the 60 respondents answered “valuable,” “partly,” “elective,” or “unnecessary,” respectively, with all responses thus being positive. As to whether the practice of lid hygiene reduces the frequency of eyedrop use, 5 (8.3%), 36 (60.0%), 19 (31. 7%), and 0 (0%) of the 60 responders selected “notably,” “some,” “rarely,” or “none,” respectively, with again all responses being positive. The extent of the reduction in the rate of eyedrop use was estimated as >80%, 50–80%, 30–50%, or 10–30% by 1 (3.2%), 9 (29.0%), 13 (41.9%), and 8 (25.8%) of the 31 respondents, respectively, with ~75% of respondents thus thinking that lid hygiene has the potential to reduce the frequency of eyedrop use by 30% or more. Two (3.3%), 39 (65.0%), 19 (31.7%), and 0 (0%) of 60 responders selected “notably,” “some,” “rarely,” or “none,” respectively, when asked whether lid hygiene reduces the prescription of eyedrops. Finally, 1 (3.2%), 9 (29.0%), 14 (45.2%), and 7 (22.6%) of 31 respondents selected >80%, 50–80%, 30–50%, or 10–30%, respectively, with regard to by how much lid hygiene reduces the frequency of eyedrop prescription, with ~80% of respondents thus estimating that the practice of lid hygiene has the potential to reduce the frequency by 30% or more.

Combination of eyelid warming and lid hygiene

We also asked physicians how often they recommend the combination of a warming compress and lid hygiene. Among the 60 responders, 31 (51.7%), 9 (15.0%), 9 (15.0%), and 11 (18.3%) selected >80%, 50–80%, 30–50%, or 10–30% of cases, respectively.

With the use of a questionnaire, we evaluated the efficacy of meibography, eyelid warming, and lid hygiene for the diagnosis or management of MGD as estimated by ophthalmologists in clinical practice. The results indicated that meibography is a valued tool both for the diagnosis of MGD and for patient education. In addition, home care for MGD consisting of eyelid warming or lid hygiene was considered effective with regard to reducing the use and prescription of eyedrops for dry eye. Our data thus suggest that adequate management of MGD independent of eyedrop treatment is beneficial for patients.

Self-care that includes patient education, eyelid warming, lid hygiene, and diet modification has been recommended as initial treatment for MGD [5], to be attempted before the prescription of eyedrops for amelioration of ocular symptoms. Our data now show that adequate self-care for MGD has the potential to reduce the frequency of eyedrop use and prescription. In our personal experience, the prescription of eyedrops for MGD patients without self-care is often ineffective in clinical practice. The recommendation of self-care for MGD reduces time spent by patients in the clinic as well as the cost of treatment, and thus has the potential to reduce national healthcare costs overall.

Our data indicate that noncontact meibography is a valuable tool for the diagnosis of MGD. This tool has been approved by the Ministry of Health, Labor, and Welfare and is widely applied in ophthalmic clinics in Japan, although it is not covered by national insurance. Meibography is also used to educate MGD patients with regard to their condition and to motivate them to administer self-care, with this application also being supported by the results of our questionnaire.

The impressions of ophthalmologists with regard to the efficacy of eyelid warming and lid hygiene as revealed in our questionnaire support the recommendation of self-care for MGD patients [5]. In addition to other options such as eyedrops and oral tetracycline, several new approaches such as exposure to intense pulsed light [8] or thermal pulsation [9] have recently been introduced as treatment regimens for MGD. Although its recommendation may be hindered in some cases because it does not generate repeated income for ophthalmologists, our data suggest that self-care is an effective and low-cost treatment option for MGD. The assessment for the efficacy of eyelid warming and lid hygiene in multi-center would be performed in the future study to support the current results.