Begin with the Lid in Mind

A frothy tear film indicating saponified oils in a patient with early MGD.

Research has shown that 86% of dry eye disease
(DED) has an evaporative or meibomian gland dysfunction (MGD) component.¹

As such, one of the most important DED
pearls in this entire series is to be a great observer
of the eyelids.



Eye care providers must:

• Look for collarettes, the clear sleeves at the base of the lashes, as this is an indication of Demodex blepharitis and will lead to lash loss, inflammation and MGD.

• Scan for debris and discharge in the lashes, and especially biofilm along the lid margins indicating bacterial/Staphylococcal blepharitis.

• Express the meibomian glands of the lower nasal to central eyelid to ensure that clear oil is easily expressed. You can use a meibomian gland evaluator or a Mastrota paddle to assist. Abnormal expression is turbid, gelatinous/thickened, or paste-like; no expression is also abnormal.

• Look for froth on the eyelid margins or in the tear film, which would indicate saponified oils and a diagnosis of MGD.

• Watch the patient’s blink at the slit lamp to see if there is partial or incomplete closure.

• Determine if the patient’s eyelids don’t close properly at night by performing the K-B test. This involves having the patient close their eyes as if sleeping (not squeezing) and shining a penlight at the top of the closed eyelid to see if light escapes inferiorly.

• Finally, check for lid laxity, entropion, or ectropion.

Know that inflammation is often present when hyperosmolarity occurs, and almost all of the findings above will eventually lead to MGD, hyperosmolarity, and inflammation.

Thanks to colleagues like Donald Korb and Kelly Nichols, who have been decades ahead in the field of dry eye and meibomian gland dysfunction, we have come to understand the importance of the eyelids in dry eye disease.

In the next few clinical pearls, we’ll delve into a number of the above-mentioned eyelid contributors.