How do I know if I have meibomian gland dysfunction?

You cannot diagnose meibomian gland dysfunction from the outside, but you can recognise the pattern that should send you for an examination. The picture is grittiness rather than dryness, worse as the day goes on and worse again during screen work, with vision that smears and then clears with a blink, sometimes watering, often a lid margin that looks red or thickened, and a history of styes or chalazia.

What settles the question is an eyelid examination. An optometrist looks at the lid margin under magnification, presses the glands deliberately to see what comes out, times how long your tear film lasts, and in many practices photographs the glands with infrared meibography. None of that can be done at home, and the last part matters most: MGD is often silent, so feeling fine is not evidence that your glands are.

The symptom pattern that points at the glands

Dry eye symptoms are non-specific, so it is the shape of them that carries information.

Worse late in the day. Glands that deliver poorly still deliver something. Early on the tear film usually holds up; by mid-afternoon the lipid layer is thin and the surface starts to complain. Symptoms that are worst on waking are a different pattern, and worth mentioning to your optometrist, because lids that do not close fully overnight and anterior lid margin disease both produce it.

Worse on screens. Concentrating on a screen reduces how often and how completely you blink, and blinking is what pumps meibum onto the lid margin. A blocked gland has less reserve to cope with that.

Vision that fluctuates. Blurring that clears for a second or two after a blink, then creeps back, comes from an unstable tear film rather than from a change in your prescription.

Foamy tears and a changed lid margin. Frothy debris along the lower lid, small visible vessels along the rim behind the lashes, and lid edges that look thickened or irregular are all worth reporting.

Styes and chalazia. A chalazion is a blocked meibomian gland that has become inflamed. More than one, or one that keeps returning in the same place, is a reason to have the whole row assessed rather than just the lump treated.

Why symptoms are an unreliable guide on their own

Blackie and colleagues described what they named nonobvious obstructive MGD, a form in which inflammation and the other classic signs may be entirely absent unless the examiner uses specific techniques — above all, deliberate expression of the glands. Their review argued this may be the most common form of obstructive MGD, that its prevalence appears very high, and that it is significantly underdiagnosed.

The TFOS DEWS II classification report makes room for the same problem from the other direction, recognising non-obvious disease with ocular surface signs but no related symptoms, and separately, symptoms with no demonstrable signs. Comfort and gland health are only loosely coupled.

What an optometrist actually looks at

The MGD workshop's diagnosis report is explicit that the order of tests matters, because each disturbs the surface for the ones that follow: questions first, then the least invasive measurements, then anything that touches the lids.

Symptoms, formally. TFOS DEWS II recommends screening with a validated questionnaire such as the OSDI or DEQ-5 before any test is done, so that the symptom score is not coloured by the examination.

The lid margin. Under the slit lamp the examiner looks for plugging of the gland orifices, which the workshop calls a pathognomonic sign of MGD, along with rounding, notching or dimpling of the lid edge, telangiectasia and increased vascularity of the posterior margin, and displacement of the mucocutaneous junction.

Gland expression. Firm, standardised pressure is applied to the lid and the examiner grades what emerges. Meibum quality runs from 0 for clear fluid, through 1 for cloudy and 2 for cloudy with particles, to 3 for inspissated secretion with the consistency of toothpaste. Expressibility is scored as the number of glands out of eight yielding liquid secretion, using a standardised-force instrument. A second, coarser scale graded 0 to 3 over five glands is used for staging, so the number your optometrist quotes depends on which scheme they work from. Korb and Blackie found that this count in the lower lid correlated with dry eye symptoms, and that it varies markedly across the lid: in their sample the nasal third averaged 3.10 glands yielding secretion, the central third 2.14 and the temporal third only 0.27, with 86% of temporal thirds yielding nothing at all against 6% of nasal thirds. Where the examiner presses changes what they find.

Tear film break-up time. A short break-up time is the signature of an unstable film and points towards the evaporative side of dry eye.

Meibography. Infrared imaging shows the glands as pale structures inside the everted lid, so shortening, dropout and distortion become visible. Arita's grading scores each lid from 0 for no loss to 3 for more than two-thirds lost; a later paper from the same group summed the two lids into a single meibo-score running from 0 to 6. In a normal population of 236 people aged 4 to 98, that score rose with age and correlated with lid margin abnormality. Our article on what meibography shows goes into what the images mean.

Arita and colleagues later proposed a practical rule using three of these: the ocular symptom score, the lid margin abnormality score and the meiboscore. Obstructive MGD should be suspected when any two are abnormal, and is very likely when all three are. In their comparison the symptom score had the highest diagnostic power as a single parameter, followed by the lid margin score, the meiboscore and break-up time.

What you can check yourself, and what you cannot

Some home observation is genuinely useful; some of it is not.

Home checks are good at raising the question and useless at answering it. For a fuller account of the clinical measurements, see dry eye tests explained, and for how findings get turned into a severity grade, the stages of MGD.

When to book an examination

Book if the pattern above sounds like your day, if lubricating drops help for twenty minutes and no longer, if you have had more than one chalazion, or if you have rosacea, take isotretinoin, wear contact lenses or are past 50 and have not had your lids assessed. Ask specifically for a lid margin assessment with gland expression, and for meibography if the practice has it. A general eye examination does not always include them.

Book sooner, and do not start heat therapy on your own, if you have an active eye infection, have had eye surgery recently, have glaucoma, or notice any change in your vision. Speak to your optometrist or ophthalmologist first.

If the examination does show obstructive MGD, warming the lids is where guideline treatment starts, and the difficulty is holding the eyelid at a useful temperature for long enough. The Meibocare E-Heated Eye Mask is designed to bring the eyelids to about 42 °C on the recommended setting and timer, with three settings each paired to a timer — 20 minutes on Low, 15 on Medium, 10 on High. It is notified to Medsafe on the New Zealand WAND database (240927-WAND-746QNT), a register that records notification rather than assessing the device, and is the test device in a registered randomised trial at the University of Auckland (ACTRN12625000997459). What it cannot do is tell you whether you have MGD, which is the point of the examination. Our overview of what meibomian gland dysfunction is covers the condition itself.

Frequently asked questions

How do I know if I have meibomian gland dysfunction?

You cannot confirm it yourself. The pattern that should prompt an examination is grittiness and heaviness that worsen through the day and during screen work, vision that blurs and clears with a blink, a red or thickened lid margin, and a history of styes or chalazia. Diagnosis needs a slit lamp examination with deliberate gland expression, and often meibography.

Can you have meibomian gland dysfunction without symptoms?

Yes, and it is common. A review describing nonobvious obstructive meibomian gland dysfunction found that inflammation and the usual signs may be entirely absent unless the examiner deliberately expresses the glands, and argued the condition is significantly underdiagnosed. The TFOS DEWS II classification also recognises ocular surface signs occurring without related symptoms.

What does an optometrist check for meibomian gland dysfunction?

A symptom questionnaire first, then the lid margin for plugged orifices, notching, telangiectasia and displacement of the mucocutaneous junction. Then gland expression, grading meibum from clear fluid to a toothpaste-like consistency and counting how many glands out of eight yield liquid secretion. Tear break-up time and infrared meibography complete the picture.

Should I try to express my own meibomian glands?

No. Diagnostic expression uses standardised pressure and a graded scale, and squeezing your own lids risks bruising the lid or pressing on the eyeball without producing any information you can interpret. If your optometrist has taught you a specific massage technique after a warm compress, follow their instructions rather than improvising.

Educational information only, not medical advice. References: Tomlinson A, et al. Invest Ophthalmol Vis Sci. 2011;52:2006–2049; Nichols KK, et al. Invest Ophthalmol Vis Sci. 2011;52:1922–1929; Blackie CA, et al. Cornea. 2010;29:1333–1345; Korb DR, Blackie CA. Cornea. 2008;27:1142–1147; Arita R, et al. Ophthalmology. 2008;115:911–915; Arita R, et al. Ophthalmology. 2009;116:2058–2063; Wolffsohn JS, et al. Ocul Surf. 2017;15:539–574; Craig JP, et al. Ocul Surf. 2017;15:276–283.