The Importance of Identifying Meibomian Gland Inversion in Patients With Floppy Eyelid Syndrome

Abstract

Background: Floppy eyelid syndrome (FES) is a common and underdiagnosed condition characterized by eyelid hyperlaxity with reactive palpebral conjunctivitis that can cause ocular irritation. It may be associated with meibomian gland dysfunction (MGD) and secondary tarsal curling, resulting in upper eyelid meibomian gland inversion (MGI) in the absence of obvious marginal entropion.Purpose: To highlight the possible significance of MGI in patients with FES and report findings and outcomes in patients with concomitant MGI and FES undergoing correction of MGI with or without upper eyelid horizontal tightening.Methods: Retrospective, 5-year, noncomparative, singlecenter study of patients with FES and MGI, treated with MGI correction, with or without upper eyelid horizontal tightening, under the supervision of a single surgeon. Preoperative symptoms, surgical outcomes, complication rates, and postoperative symptoms were recorded.Results: A total of 13 eyes of 9 patients were treated with MGI surgery over the study period. Seven were male. Mean age at the surgery was 63 (range 42-81) years. Two OSs, 3 ODs, and 4 OUs were treated. All patients were "cotton-tip test" positive, and 77% (10/13) had MGI-related superior corneal fluorescein staining. Three patients (33%) had previous standard tightening procedures with recurrence of symptoms within 5 to 24 (mean 16) months. Repeat horizontal tightening had been considered in all these cases before referral to our unit. Mean follow-up was 20 months. Eight patients (88.9%) had improvement of symptoms (n = 3, full resolution; n = 5, partial resolution). All patients demonstrated restoration of the normal anatomical position of the meibomian glands. Superior punctate staining resolved in all eyes. Conclusion:This study provides a proof of concept that upper eyelid MGI can be present and symptomatic in patients with FES. It may help explain cases where symptoms persist or recur early following standard upper eyelid horizontal tightening. Where superior corneal punctate staining and a positive cotton-tip test exist, surgical correction of MGI, alongside horizontal tightening, may provide better, and longerlasting symptomatic relief. This study provides evidence for the need for a prospective study to evaluate the contribution of MGI in patients with FES.

Improvement in Epiphora Using TEARS Grading Following Surgical Treatment of Meibomian Gland Inversion in Patients With Facial Nerve Palsy

“…This test was found to be a positive indicator for the benefit of correcting MGI with surgery. 1,2,4 Patients. Clinical records of 160 patients with FNP who underwent correction of MGI during the 5-year study period were examined using operating theater logbooks.…”

“…A slight eversion of the eyelid margin with a cotton bud demonstrated the posterior migration of the gland orifices. All patients undergoing MGI correction reported a positive cotton tip test 1,2,4 preoperatively with an improvement in symptoms with correction of MGI (see below).…”

“…M eibomian gland inversion (MGI) is a common but underdiagnosed condition characterized by the posterior migration of the meibomian glands in the absence of eyelid entropion. 1,2 It is thought to be triggered by chronic meibomian gland dysfunction (MGD), whereby the inflammatory changes lead to tarsal curling. The abnormal glands are then in contact with the cornea, resulting in blink-related microtrauma.…”

“…Surgery involving anterior lamella repositioning (ALR) with or without gray line split (GLS) can effectively improve signs and symptoms of MGI. 1,3 The authors have previously demonstrated an association between MGI and facial nerve palsy (FNP). 4 Patients with FNP and concomitant MGI were treated with ALR and GLS and were noted to have an improvement in clinical features, including corneal staining, static asymmetry, and dynamic function.…”

“…Surgery involving anterior lamella repositioning (ALR) with or without gray line split (GLS) can effectively improve signs and symptoms of MGI. 1,3…”