Meibomian gland inversion: under‐recognized entity

Abstract

Objective: To describe a clinical entity of upper eyelid margin and meibomian gland inversion (MGI) sequential to meibomian gland dysfunction (MGD), in the absence of eyelash ptosis, trichiasis or manifest marginal entropion. We highlight its clinical features, surgical management and outcomes. Methods: We performed a retrospective analysis of symptomatic MGI cases refractory to conservative management who underwent surgery in our centre over a 4-year period. Anatomical correction, resolution of symptoms and possible complications are reported. Results: A total of 21 eyelids of 13 patients (mean age: 68.5 AE 15.4, range: 32-88 years) were analysed. Symptomatic MGI patients were operated only if they have noted immediate comfort when we corrected the lid margin position with a cotton tip. Those with refractory superior punctate corneal staining (n = 14 eyes), blink-related discomfort (n = 8) and pseudo-blepharospasm (n = 3) reported complete postoperative resolution. Milder symptoms showed partial improvement: gritty feeling (79%), sore eye (80%) and watery eye (86%). However, symptoms of dry eye disease (DED) persisted in 88% of patients. One case recurred in 6 weeks and was offered revision surgery. Median follow-up was 5 (range: 3-12) months. Conclusion: Meibomian gland inversion (MGI) is a subtle clinical entity that can be easily overlooked. Symptoms are often attributed to DED or MGD alone. It is likely that MGI represents early upper lid margin anatomical changes secondary to MGD before cicatricial marginal entropion becomes clinically apparent. Recommended treatment is conservative with intensive lid hygiene and topical MGD management. However, refractory symptomatic cases who respond positively to a 'cotton-tip test' (reversal of lid margin malposition with a rolling cotton-tip) may benefit from surgical intervention with favourable anatomical and functional outcome.

Quantitative analysis of morphological and functional alterations of the meibomian glands in eyes with marginal entropion

“…Therefore, surgical correction of marginal entropion could have additional benefits in improving dry eye syndrome and MGD. Similarly, Siah et al [ 23 ] reported improved signs and symptoms of MGD after corrective surgery for meibomian gland inversion. The effect of entropion repair for dry eye syndrome and MGD is thought to be sustained throughout the 5-month follow-up.…”

“…Another major finding of the present study is the increase of LLT after surgical correction of marginal entropion. Siah et al [ 23 ] postulated that marginal entropion is a result of MGD, as the chronic subclinical inflammatory processes of MGD result in tarsal contraction and MG inversion. Our finding supposes that marginal entropion could also cause or exacerbate MGD.…”

“…Persistent contact between MG orifices and the ocular surface could aggravate corneal and conjunctival epithelial cell shedding and obstruction of the MG orifice. Distorted MG ducts could inhibit the secretion of meibum [ 23 ]. Damming back of MG secretions causes inflammation and cystic dilatation of the duct, and ultimately atrophy of the acini.…”

Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion

“…However, the study done by Potemkin et al [1] had not examined changes in the status of MGD after the surgical correction of involutional eyelid malposition. Although the study done by Siah et al [19] noted improvement in ocular signs and symptoms after surgery, both of those previous studies [1,19] did not evaluate or compare the status of MGD before and after surgery.…”

“…A previous study by Potemkin et al [1] showed that MGD was significantly worse in patients with involutional eyelid malposition, including entropion, ectropion, and punctal ectropion, than in controls. Another recent study done by Siah et al [19] presented a new clinical entity of meibomian gland inversion in the upper eyelid, which is associated with MGD. The results of these studies were similar to the findings of our study noticed preoperatively.…”