What is the recommended treatment for meibomian gland dysfunction?

Treatment of Meibomian Gland Dysfunction

Begin with warm compresses applied to the eyelids for several minutes once or twice daily, followed immediately by vertical eyelid massage to express meibomian gland secretions, combined with lid margin cleaning using diluted baby shampoo or commercial eyelid cleaners. 1, 2

Step 1: First-Line Conservative Management

Thermal Therapy and Physical Expression

• Apply warm compresses to the eyelids for 5-10 minutes, once or twice daily to liquefy thickened meibum 1, 2
• Perform vertical eyelid massage immediately after warming to mechanically express meibomian gland secretions 1, 2
• This combination addresses the primary pathophysiology of MGD: terminal duct obstruction and altered glandular secretions 3

Lid Hygiene

• Clean eyelid margins by gently rubbing the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a cotton pad, ball, or swab 1, 2
• Hypochlorous acid eye cleaners at 0.01% provide strong antimicrobial effects for anterior blepharitis when present 2
• Daily lid hygiene must be maintained long-term to achieve sustained remission 4

Environmental and Lifestyle Modifications

• Educate patients to blink completely and frequently (>10 times/minute) when using computers or watching television, as staring reduces blink frequency 1
• Avoid dry environments, wind exposure, and air-conditioned spaces that increase evaporative stress 1
• Consider Mediterranean diet modifications and oral omega-3 essential fatty acid supplementation 1, 5

Ocular Lubrication

• Use lipid-containing artificial tear supplements when MGD is present 1
• Preservative-free formulations are preferred, especially if using more than 4 times daily 1
• Preserved artificial tears are acceptable at ≤4 times/day frequency 1

Step 2: Escalation for Inadequate Response

Topical Antibiotic Therapy

• Apply topical antibiotic ointment (bacitracin or erythromycin) to eyelid margins one or more times daily or at bedtime for several weeks 1, 2, 5
• Topical azithromycin offers both antimicrobial and anti-inflammatory benefits 5, 6
• Rotate between different antibiotics with different mechanisms of action to prevent resistant organisms 2

Demodex Treatment (If Present)

• Apply tea tree oil treatment, specifically the terpinen-4-ol component, which is highly effective for Demodex-associated MGD 1, 5
• Scrubs with 50% tea tree oil are recommended by international expert groups for tick-borne infestation 4

Tear Conservation Strategies

• Consider temporary punctal occlusion to preserve existing tears 1
• Use moisture chamber spectacles or goggles 1
• Apply overnight treatments such as ointments or moisture chamber devices 1

In-Office Physical Therapies

• Perform in-office physical heating and expression of meibomian glands, including device-assisted therapies such as LipiFlow or thermal pulsation systems 1, 6
• Intense pulsed light (IPL) therapy is effective for moderate-to-severe MGD, though caution is needed in darkly pigmented individuals (Fitzpatrick skin type >IV) due to burn and pigmentation risks 1, 2

Step 3: Pharmacological Anti-Inflammatory Therapy

Oral Antibiotics for Moderate-to-Severe Disease

• For adults and children ≥8 years: Prescribe oral tetracyclines (doxycycline, minocycline, or tetracycline) which improve MGD through both antimicrobial and anti-inflammatory mechanisms 1, 5, 3
• For children <8 years: Tetracyclines are contraindicated due to tooth staining; use oral erythromycin 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 2
• Alternative for children: Azithromycin 5 mg/kg daily for 2 months has shown clinical improvement in small case series 2

Topical Anti-Inflammatory Agents

• Short-term topical corticosteroids: Use limited-duration therapy with preservative-free dexamethasone 0.1%, prednisolone 0.5%, or hydrocortisone 0.335% for moderate-to-severe disease 1
• For children, loteprednol etabonate 0.5%/tobramycin 0.3% suspension is safer than dexamethasone due to lower risk of intraocular pressure elevation or cataract progression 2
• Limit steroid courses to avoid complications including glaucoma and cataracts 2, 5

Topical Immunomodulatory Therapy

• Initiate topical cyclosporine for patients with severe symptoms refractory to other medications, particularly when superficial punctate keratitis is present 1
• Consider early introduction of corticosteroid-sparing agents (cyclosporine) concurrently with corticosteroids to facilitate tapering 1
• Topical cyclosporine is effective as a therapeutic adjunct in patients with concurrent dry eye 5, 6

Other Prescription Options

• Topical secretagogues can be considered 1
• Topical LFA-1 antagonist drugs (such as lifitegrast) are options for refractory cases 1

Step 4: Advanced Interventions for Refractory Disease

Extended Anti-Inflammatory Therapy

• Use stronger potency steroids such as betamethasone for severe cases 1
• Long-term low-dose topical steroids are reserved for patients with autoimmune diseases or moderate-to-severe DED 1

Surgical Options

• Amniotic membrane grafts, with combination contact lens application being superior to grafts alone 1
• Surgical punctal occlusion for permanent tear conservation 1
• Other surgical approaches including tarsorrhaphy or salivary gland transplantation for extreme cases 1

Critical Caveats and Pitfalls

Realistic Expectations: Patients must understand that cure is usually not possible; treatment focuses on symptom control and requires long-term maintenance 2, 7

Avoid Mechanical Irritation: Frequent eyelid manipulation may lead to mechanically induced irritation, so tailor the therapeutic plan based on the patient's ability to safely perform home treatments 2

Trial-and-Error Approach: The optimal treatment regimen often requires persistence and experimentation, as response varies significantly between individuals 2, 7

Preservative Toxicity: Caution patients against independently purchasing over-the-counter eye drops, as many contain preservatives or vasoconstricting agents that worsen ocular surface disease 1

Cosmetic Considerations: Educate patients to avoid certain cosmetics that may exacerbate MGD 1