The 2017 International Workshop in Meibomian Gland Dysfunction (MGD)

The international workshop in Meibomian Gland Dysfunction (MGD) gave us the blueprint for success for diagnosis and management for MGD.  It has been defined as:  “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/ quantitative changes in the glandular secretion.

It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.”

Types of Testing

Suggested testing by general clinicians included a symptom questionnaire, measurement of blink rate and calculation of the blink interval, lower tear meniscus height, measurement of tear osmolarity, use of fluorescein to measure tear break up time and ocular protection index, grading of staining patterns, and Schirmer or similar tear secretion testing.i

Eyelid characteristics and gland expression were performed using the slit lamp.  Meibography was recommended.

Expression was described as digital pressure over the central and/or nasal third of the lower and upper lids using moderate digital pressure or by a standardized technique.

Diagnostic evaluation of the glands may be done using a finger, swab, meibomian gland evaluator, while expression as treatment is performed using a single paddle, double paddles forceps, Tearse or similar forceps, or rollers.

How do you document your MGD findings?

In light of this information, documenting “(+) MGD” or “Grade 2 insippation with frothing” seems woefully inadequate.  After reading a discussion about recording of slit lamp findings, I realized I am, I hate to say, slacking in this area.

I barely have the room to write a description on my paper form, a typical table built for check boxes.  My other office uses Exam writer, where I can custom type to my heart’s content, but I am currently obsessed with MIPS compliance and dependent upon a cheat sheet to code my exams correctly.

I asked some seasoned colleagues, “How do you document your MGD findings?” Several colleagues, including Dr. Laura Periman, Dr. Anith Pillai, and Dr. Leslie O’Dell, were quite willing to share their best practices and participate in the discussion.  Dr. Periman currently uses paper charts by choice (although not tech adverse), while the others use electronic.

I wanted to put that blueprint into practice in the real world.  All agree that during the slit lamp exam, expression should be performed on the lid in three sections: nasal, central and temporal.

Expression may be performed using a Korb Meibomian Gland Evaluator (aka Tearscience Meibomian Gland Evaluator), or similar device.  The results of the expression are graded.  All three examine the glands using transillumination or with a device.

My expert panel suggested a two-step process: expression and transillumination of the glands. Using the Korb Meibomian Gland Evaluator to express each section, the results are evaluated.

Describe the quality of meibum expressed on a scale of 1-3, as well as the number of expressing glands per third section of lid. The scale used to describe the meibum is as follows:  1 = toothpaste like discharge (bad), 2 = cloudy, turbid discharge, and 3 = clear oil (good).

For example, if upon gland expression, 3 glands were expressed with clear oil nasally, 2 glands with turbid discharge were expressed centrally, and 4 glands with toothpaste like discharge were expressed temporally, then correct documentation is shown below.

In another example, a diseased lower lid would be described as “temporally, 2 glands expressed thick white meibum, centrally 1 gland expressed thick, white meibum, and nasally only one gland expressed thick white meibum”.  The total number is obtained from the sum of the three products.  For example, [(2×1) + (1×1) + (1×1)] = 4. The higher the composite score, the healthier the glands.

Eye Temporal Central Nasal Total:
Healthy 4×1 2×2 3×3 (4+4+9) = 17
Diseased 2×1 1×1 1×1 (2+1+1) = 4

 

Option 2 is to note the number of functional glands. A gland was considered functional if standard expression yields a clear liquid secretion. This is less precise, but still be better than general comments checked the “Bleph, Staph” checkbox and involves less math.  Korb refers to this as the Meibomian Glands Yielding Liquid Secretion (MGYLS) Score.

Expressible Glands
Healthy Eye 12/15
Diseased Eye 3/15

 

Slit Lamp Transillumination is performed using a muscle light prepped with an alcohol pad.  Using the light, gently evert the eyelid by placing the light at the lash line and pushing in and up to roll the lid margin anteriorly.

This allows a quick examination of the number and quality of the glands. Examine the glands.  Look for terminal obstruction (TO) of the duct, gland Hypertension (HT) (aka constipated meibum), gland Foreshortening (FS), gland Tortuosity(T), gland atrophy (A), percent gland Drop Out (DO) and Tylosis (Tyl) (the ‘golf divot’ look at the lid margin).  A table using these descriptors is shown below.

Eyelid: TO: HT: FS: T: A: DO: Tyl: Overall Pult Score
RLL 3+ 3+ 2+ 10% 10% 50% # observed Grade 3+
LLL

 

It is important to look for nasal drop out in patients with punctal plugs.  Several doctors have observed a high degree of total gland drop out nasally in patients with punctual plugs.

Educate your patient

While your patient may not be nearly as excited as we are about the findings of the MGD Workshop they do understand numbers. These numbers can be used to educate the patients.

For example, “Mrs. Jones, we all start with about 20-30 glands on the upper and lower lids. Over time these glands can scar over due to inflammation and obstruction. Once they die, I can’t revive them. You currently have 18 glands left on the lower lid in your right eye, and out of the 18, only 3 of them are working. My goal is to get at least half 18 of those glands working effectively to relieve your symptoms.” These tables can enable clinicians to quantitatively track treatment effectiveness and disease progression.

Other characteristics to evaluate include lipid layer thickness, partial blinking, and lid seal.  When evaluating for lid seal, (+) means they have microlag present, and (-) means microlag is absent.

Using a paper form, these tables are easy to use. Electronic documentation is more difficult.  Dr. Anith Pillai and Dr. Leslie O’Dell are both EMR users, as I am.

While EMR systems are improving their options for clinical dry eye findings, they are not including the standards described here. Custom testing is typically required. The special testing section may be used to document these findings.  Tables similar to those above can be saved as a template and copied to the EMR.

Standardizing your impression and treatment sections will also facilitate documentation.  For example, the Impression section could include the custom text, “Mixed, Aqueous or Evaporative DED – level (1-4)”.  The total non-atrophied number of glands and the total score could be included here to facilitate future evaluation.

I am off to create templates and hope that my scribe won’t have a meltdown.  Special thanks to my panel of colleagues Dr. Laura Periman, Dr. Anith Pillai, and Dr. Leslie O’Dell for their expert guidance.

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