Meibomian Gland Dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands that leads to qualitative or quantitative changes in glandular secretions. It is recognized as the most common cause of evaporative dry eye disease, contributing to ocular surface instability, inflammation, and patient discomfort (1). The meibomian glands, located within the tarsal plates of the eyelids, secrete lipids that form the outermost layer of the tear film, preventing evaporation and maintaining a stable optical surface (2). Dysfunction of these glands alters tear film composition, resulting in increased evaporation, hyperosmolarity, and a cascade of ocular surface damage. Globally, the prevalence of MGD varies widely, ranging from 30% to 70%, depending on diagnostic criteria, ethnicity, and environmental factors (3). Asian populations have been reported to have a higher prevalence and more severe forms of MGD compared to Western populations, likely due to anatomical and climatic differences (4). Increasing digital screen exposure, air pollution, aging, and dietary changes have been identified as key contributors to the rising incidence of MGD worldwide. The clinical grading of MGD is traditionally based on lid margin abnormalities, gland orifice plugging, and meibum expressibility. Although useful, these assessments are often subjective and prone to inter-observer variability. In recent years, infrared meibography has emerged as an objective, non-contact imaging tool that enables visualization and quantification of meibomian gland structure, dropout, and distortion (5). This imaging modality provides valuable insights into the morphologic changes within the glands and helps correlate structural loss with functional severity. Studies conducted across various countries have shown a significant correlation between clinical severity and meibography grades. Arita et al. (2008) demonstrated that meibomian gland loss increases with age and correlates with clinical findings of MGD (5). Finis et al. (2015) further validated that meibography offers a reliable, reproducible method for quantifying gland dropout and can serve as a biomarker for disease progression (6). Such correlations support the integration of meibography into routine MGD evaluation for both research and clinical purposes. In the Indian context, MGD has gained prominence as a major ocular morbidity due to the country’s tropical climate, increased pollution, and rising screen exposure among younger individuals. Studies from India have reported a prevalence of 55–60% in outpatient ophthalmology settings (7). Infrared meibography has been introduced in select tertiary centers, demonstrating that Indian patients with higher clinical grades of MGD also show greater degrees of gland dropout on imaging (7). However, most Indian studies are limited by small sample sizes and lack of standardized grading comparisons. Considering the significant burden of MGD and the potential for meibography to serve as a structural correlate of disease severity, this study aims to compare the clinical grades of MGD with meibography degrees of gland loss in an Indian population. Establishing this correlation can help in early diagnosis, monitoring of disease progression, and guiding targeted therapy for meibomian gland dysfunction. Aim and Objectives Aim To compare the clinical grades of Meibomian Gland Dysfunction (MGD) with the meibography degrees of gland loss. Objectives 1. To assess the correlation between clinical grades of MGD and meibography findings. 2. To determine whether higher clinical grades of MGD are associated with greater meibomian gland dropout on meibography.

Study Design and Setting This was a cross-sectional observational study conducted at Sankara Eye Hospital, Shimoga, between August 2019 and October 2020. Study Population A total of 115 patients clinically diagnosed with Meibomian Gland Dysfunction (MGD) were included in the study. Inclusion Criteria • Patients aged 18 years and above. • Clinically diagnosed cases of MGD. Exclusion Criteria • Patients with ocular infections, allergic conjunctivitis, or other lid disorders. • History of ocular surgery within 6 months. • Use of topical or systemic medications affecting tear film or lipid metabolism. • Systemic diseases such as Sjögren’s syndrome, rosacea, or thyroid disorders. Clinical Examination All patients underwent detailed slit-lamp examination of the eyelids and meibomian glands. MGD was graded clinically as: • Grade 0: Clear secretion on mild pressure • Grade 1: Clear secretion on firm pressure • Grade 2: Cloudy secretion on firm pressure • Grade 3: Inspissated or no secretion on pressure Meibography Assessment Infrared non-contact meibography was performed using the Sirius topographer (CSO, Italy). Meibomian gland loss was graded based on the meiboscale as follows: • Grade 0: No loss of glands • Grade 1: <33% gland loss • Grade 2: 33–66% gland loss • Grade 3: >66% gland loss Data Analysis: Data were analyzed using SPSS. The correlation between clinical grades of MGD and meibography degrees of gland loss was assessed using the Chi-square test and Spearman’s correlation coefficient. A p-value ≤ 0.05 was considered statistically significant.

A total of 115 patients with clinically diagnosed Meibomian Gland Dysfunction (MGD) were included in this study. The mean age of the study population was 60.3 ± 10.4 years, with 70.4% males and 29.6% females. The majority of patients were in the 61–70 years age group (36.5%). Table 1. Age-wise Distribution of Study Population Age Group (years) Number of Patients (n=115) Percentage (%) 31–40 6 5.2 41–50 20 17.4 51–60 37 32.2 61–70 42 36.5 >70 10 8.7 Total 115 100.0 Observation: Most patients belonged to the 51–70 years age group. Fig 1. Age-wise Distribution of Study Population Table 2. Distribution According to Gender Gender Number of Patients (n=115) Percentage (%) Male 81 70.4 Female 34 29.6 Total 115 100.0 Observation: Males constituted the majority of the study population. Fig 2. Distribution According to Gender Table 3. Distribution According to Clinical Grades of MGD Clinical Grade Number of Patients Percentage (%) Grade 0 14 12.17 Grade 1 23 20.00 Grade 2 37 32.17 Grade 3 41 35.65 Total 115 100.00 Observation: Most patients had moderate to severe MGD (Grades 2 and 3). Fig 3. Distribution According to Clinical Grades of MGD Table 4. Distribution According to Meibography Degrees of Gland Loss Meibography Grade Gland Loss (%) Number of Patients Percentage (%) Grade 0 0% 6 5.2 Grade 1 <33% 24 20.9 Grade 2 33–66% 48 41.7 Grade 3 >66% 37 32.2 Total 115 100.0 Observation: Most patients showed moderate gland loss (Grade 2) on meibography. Table 5. Correlation Between Clinical Grades of MGD and Meibography Grades Clinical Grade Meibography Grade 0 Grade 1 Grade 2 Grade 3 Total p-value Grade 0 5 (83.3%) 1 (16.7%) 0 (0%) 0 (0%) 6 Grade 1 1 (4.3%) 14 (60.9%) 7 (30.4%) 1 (4.3%) 23 Grade 2 0 (0%) 8 (21.6%) 21 (56.8%) 8 (21.6%) 37 Grade 3 0 (0%) 1 (2.4%) 20 (48.8%) 20 (48.8%) 41 <0.001 Total 6 24 48 37 115 Interpretation: A strong, statistically significant correlation (p < 0.001) was found between clinical severity of MGD and degree of gland loss on meibography. Table 6. Correlation Strength Between Clinical Grade and Meibography Grade Parameter Correlation Test Correlation Coefficient (r) p-value MGD Grade vs Meibography Grade Spearman’s Rank Correlation 0.892 <0.001 Interpretation: There was a strong positive correlation between clinical and meibography grades of MGD. Summary of Findings • The majority of MGD patients were aged 51–70 years, with male predominance. • Most eyes showed moderate to severe MGD (Grades 2–3) both clinically and on meibography. • Meibography grades strongly correlated with clinical grades (r = 0.892, p < 0.001). • Higher clinical grades of MGD corresponded to greater meibomian gland dropout, confirming the structural-functional relationship.

This study was undertaken to evaluate the relationship between clinical grades of Meibomian Gland Dysfunction (MGD) and meibography degrees of gland loss using non-contact infrared meibography. The results revealed a strong and statistically significant positive correlation (r = 0.892, p < 0.001) between the two grading systems, indicating that higher clinical grades of MGD were associated with greater meibomian gland dropout on imaging. MGD remains one of the most common ocular surface disorders worldwide, and its chronic nature often leads to progressive glandular atrophy and evaporative dry eye symptoms. Traditionally, MGD has been evaluated using slit-lamp findings such as lid margin irregularity, vascular telangiectasia, gland orifice plugging, and meibum quality or expressibility (8). However, such parameters are largely subjective, varying with examiner experience, gland pressure, and environmental conditions (9). Therefore, there is an increasing shift toward the use of objective imaging modalities like meibography to assess the structural integrity of meibomian glands. The present findings align with the work of Arita et al. (2008), who introduced non-contact infrared meibography and reported that meibomian gland loss increased with age and clinical severity (10). Similarly, Eom et al. (2014) demonstrated that quantitative assessment of gland dropout using meibography strongly correlates with clinical signs such as meibum expressibility and tear film breakup time (11). Finis et al. (2015) also found that patients with higher clinical MGD grades had greater structural loss of glands on imaging, reinforcing that gland morphology reflects functional decline (12). In our study, mild MGD (Grades 0–1) typically showed little or no gland loss, while moderate to severe cases (Grades 2–3) showed significant dropout. This pattern supports the progressive nature of MGD, where long-standing obstruction and inflammation cause acinar atrophy and gland shortening. Over time, this structural damage becomes irreversible, leading to persistent ocular surface symptoms despite medical management. The pathophysiology of meibomian gland loss involves chronic obstruction of gland ducts, accumulation of inspissated secretions, and localized inflammation. The resultant pressure leads to gland dilation, epithelial hyperkeratinisation, and eventual acinar destruction (13). Infrared meibography captures these changes as areas of gland shortening, distortion, or complete dropout. As shown in the present study, these morphological alterations correlate closely with the patient’s clinical grade, confirming that functional impairment and structural damage progress in parallel. Globally, studies have demonstrated the clinical utility of meibography in quantifying glandular health. Arita et al. reported that more than 60% of elderly individuals show some degree of gland dropout, even in the absence of overt symptoms (10). Similarly, Finis et al. emphasized that infrared meibography can serve as a biomarker for early glandular damage, aiding in screening and disease monitoring (12). The TFOS DEWS II report also recommended incorporating structural assessment using meibography for a comprehensive evaluation of MGD (9). In the Indian population, environmental factors such as high ambient temperature, dust exposure, low humidity, and increased screen time have been shown to accelerate gland dysfunction. Guliani et al. (2018) and Banait & Hada (2019) reported that Indian patients exhibited higher grades of gland loss compared to Western counterparts, possibly due to chronic exposure to tropical environmental stressors (13,14). The findings of the present study corroborate these results, confirming that Indian patients with severe clinical MGD have extensive gland dropout, detectable by meibography. The significant correlation between clinical and meibography grades underscores the importance of combining functional and structural evaluation for accurate diagnosis. Meibography enables early detection of subclinical gland loss before severe symptoms arise, allowing timely interventions such as lid hygiene, warm compresses, and lipid-based lubricants. It can also serve as a monitoring tool to assess treatment response and disease progression. Furthermore, meibography findings can help differentiate between MGD-related dry eye and other ocular surface disorders, improving diagnostic precision. In severe cases, where gland dropout exceeds 66%, conventional medical therapy may have limited efficacy, and these patients can be counselled for long-term management strategies.

This study demonstrated a strong and statistically significant correlation between clinical grades of Meibomian Gland Dysfunction (MGD) and meibography degrees of gland loss, confirming that higher clinical severity is associated with greater structural damage to the meibomian glands. Meibography provides an objective and reliable method to assess gland morphology and should be used as a complementary tool to clinical grading for accurate diagnosis and monitoring. Early detection of gland dropout may help in initiating timely management and preventing irreversible gland atrophy. Incorporating meibography into routine evaluation can enhance the understanding and treatment of MGD, especially in high-prevalence regions such as India.

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