Published in Ocular Surface

How to Perform Meibomian Gland Expression

Preeya K. Gupta, MD

Preeya K. Gupta, MD

This is editorially independent content
5 min read
Dr. Preeya K. Gupta walks through the basics of how to express meibomian glands.
In this video from Interventional Mindset, Preeya K. Gupta, MD, offers clinical pearls for meibomian gland expression.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

Background on meibomian gland dysfunction

In the 17th century, German professor of medicine Heinrich Meibom was the first to dissect and describe meibomian glands, thereby becoming their namesake in time (he originally termed them “Glandulae tarsales” or tarsal glands).1 Flash forward to 2023, meibomian glands and specifically their dysfunction (MGD) have become a part of nearly every dry eye conversation. 
With simultaneous rising rates of prevalence and increased understanding of the role, the toll of MGD in the dry eye equation has led eyecare providers to make screening and treatment a top priority. According to several studies, up to 86% of patients with dry eye,2 39% of asymptomatic patients,3 80% of glaucoma patients taking long-term intraocular pressure (IOP) lowering medications,4 and 63% of pre-cataract surgical patients exhibit MGD.5
Amidst the many treatments, both at-home—warm compresses, lid hygiene, antibiotic or steroid eye drops, artificial tear eye drops—and in-office—TearCare, intense pulsed light therapy (IPL), iLux2,  and LipiFlow—the most straightforward way to address blocked glands is through meibomian gland expression.
Regardless of whether you are performing the procedure or training your staff to do so, there are six key steps that will allow you to achieve the maximum results.

Step 1: Place one drop of topical anesthetic in each eye.

This local anesthetic, sold under the brand names Alcaine, Ocu-Caine, Ophthetic, and Parcaine, blocks the pain signals in the nerve endings of the eye, making the procedure more comfortable.

Step 2: Instruct the patient to look away from the point of expression.

Prior to performing meibomian gland expression, instruct the patient to look in the opposite direction of the lid where the procedure is set to take place. For example, if expressing the left lower eyelid, have them look to the right and up. If expressing the right upper eyelid, have them look down and left.

Step 3: Place the expression forceps behind the eyelid.

Whether you choose to use expression forceps or a cotton tip applicator, it is important that you practice and become comfortable with the tool you choose. I prefer the ease of use of the Clearance Assistant forceps by Sight Sciences.
In addition, the flat and smooth design of the paddles proves comfortable for most patients. Patients often feel less irritation with these forceps compared to the cotton tip, which can abraid the tarsal conjunctiva. Additionally, the forceps allow titration and also fixation of the lid without damaging the glandular structures.

Step 4: Apply gentle pressure at the base of the glands.

Using the forceps, gently squeeze the lid to relieve meibum. Throughout the expression, titrate to the patient's comfort as well as to which glands are effectively relieving adequate amounts of material. If the secretions are inspissated, you may need to attend to the eyelid tissue multiple times.
In patients with floppy eyelids, use the thumb of your non-dominant hand to gently straighten or pull the lid down and away from the globe so that it becomes less slippery and more manageable.

Step 5: For difficult-to-reach spots, angle forceps vertically.

Some areas of the quadrants along the lower and upper eyelids are more challenging to express. For these spots, consider flipping the forceps vertically to be able to hone in on the problematic glands. Also, in patients who have tighter eyelid fissures, if you have difficulty slipping the entire width of the forceps, utilize the vertical placement technique.

Step 6: Repeat steps 1 to 5 for the upper eyelid.

A short summary of performing meibomian gland expression

Performing meibomian expression is an important aspect of dry eye care. It is important for both you and your trained technicians to become as proficient and efficient with this procedure as possible. Follow these three adages.

Two hands are better than one

To this end, become comfortable using two hands at the slit lamp.

Practice makes perfect

As with any procedure, practice breeds proficiency, so have staff practice on one another until they have developed their technique and feel at ease.

Variety is the spice of life

Take every opportunity to perform expression on a variety of different patients with different eyelids and varied levels of MGD.

Conclusion

Remember, the more comfortable you feel performing meibomian gland expression, the more comfortable the patient will feel in receiving it. This simple in-office treatment often yields excellent results, leading to a reduction of some of the most annoying dry eye symptoms.
  1. Ocular Surface Center Berlin. History of the Meibomian Glands. Ocular Surface Center Berlin. https://oscb-berlin.org/overview-of-the-meibomian-gland-dysfunction-2. Accessed May 19, 2023.
  2. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous deficient and evaporative dry eye in a clinic based patient cohort: a retrospective study. Cornea. 2012; 31(5):472-478.
  3. Korb DR, Blackie CA. "Dry Eye" Is the Wrong Diagnosis for Millions. Optom Vis Sci. 2015;92(9):e350-e354.
  4. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
  5. Uzunosmanoglu E, Mocan MC, Kocabeyoglu S, et al. Meibomian Gland Dysfunction in Patients Receiving Long-Term Glaucoma Medications. Cornea. 2016;35(8):1112-1116.
Preeya K. Gupta, MD
About Preeya K. Gupta, MD

Dr. Gupta earned her medical degree at Northwestern University’s Feinberg School of Medicine in Chicago, and graduated with Alpha Omega Alpha honors. She fulfilled her residency in ophthalmology at Duke University Eye Center in Durham, North Carolina, where she earned the K. Alexander Dastgheib Surgical Excellence Award, and then completed a fellowship in Cornea and Refractive Surgery at Minnesota Eye Consultants in Minneapolis. She served on the faculty at Duke University Eye Center in Durham, North Carolina as a Tenured Associate Professor of Ophthalmology from 2011-2021.

Dr. Gupta has authored many articles in the peer-reviewed literature and serves as an invited reviewer to journals such as Ophthalmology, American Journal of Ophthalmology, and Journal of Refractive Surgery. She has also written several book chapters about corneal disease and ophthalmic surgery, as well as served as an editor of the well-known series, Curbside Consultation in Cataract Surgery. She also holds several editorial board positions.

Dr. Gupta serves as an elected member of the American Society of Cataract and Refractive Surgery (ASCRS) Refractive Surgery clinical committee, and is also is the Past-President of the Vanguard Ophthalmology Society. She gives presentations both nationally and internationally, and has been awarded the National Millennial Eye Outstanding Female in Ophthalmology Award, American Academy of Ophthalmology (AAO) Achievement Award, and selected to the Ophthalmologist Power List.

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