Cornea · 3 authors, 3 centres
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This retrospective study found that 95.1% of patients presenting for cataract surgery had some degree of meibomian gland atrophy, with 44.7% having moderate to severe atrophy. Notably, 31% of patients without a prior dry eye diagnosis had moderate or severe atrophy, suggesting significant underdiagnosis. Routine meibography during preoperative cataract evaluation may improve detection and treatment of meibomian gland dysfunction, potentially enhancing surgical outcomes.
**Background:** Meibomian gland dysfunction (MGD) is the most common cause of dry eye disease (DED), affecting up to 86% of DED patients. MGD is progressive and can lead to meibomian gland (MG) atrophy, which is common in older adults. Cataract surgery is frequently performed in this population, and preoperative MGD can affect tear film stability, leading to inaccurate keratometric measurements and intraocular lens (IOL) calculations. Cataract surgery itself may exacerbate DED. The MGD Workshop recommends baseline meibography, but data on MG atrophy prevalence in US cataract surgery patients are limited. This study aimed to determine the prevalence of MG atrophy in this population and evaluate associated factors.
**Methods:** This retrospective study included 391 patients aged ≥50 years who underwent preoperative cataract surgery evaluation with meibography (LipiScan) at Virginia Eye Consultants between June and December 2020. MG atrophy in the lower eyelid was graded using the Arita scale: grade 0 (no atrophy), grade 1 (1%-33%), grade 2 (34%-66%), and grade 3 (>66%). MG function was assessed via meibum expressibility (easy, moderate, difficult), meibum grade (1-4), and telangiectasia score (0-4). Associations between MG atrophy and age, sex, ethnicity, comorbidities (glaucoma, hypertension, diabetes, autoimmune disease), prior DED diagnosis, cyclosporine/lifitegrast use, and smoking were evaluated using logistic regression. Only one eye per patient was analyzed.
**Key Results:** The mean age was 68.5 ± 7.8 years (range 50-90); 60.1% were female. Overall, 95.1% (372/391) had MG atrophy ≥grade 1: 50.4% grade 1, 25.8% grade 2, and 18.9% grade 3. MG atrophy showed a statistically significant but weak positive correlation with meibum expressibility (R = 0.22; P = 0.001) but not with meibum grade (R = 0.103; P = 0.123) or telangiectasia (R = 0.014; P = 0.787). The combined score of expressibility and meibum grade was also significantly correlated (R = 0.175; P = 0.007). In a subset with complete functional data (n=236), 93.2% had MG atrophy ≥grade 1, while 75.4% had moderate/difficult expressibility or meibum grade ≥2, indicating that 18% had structural changes without significant functional impairment. No significant differences in MG atrophy prevalence were found by age, sex, ethnicity, or comorbidities (glaucoma, hypertension, autoimmune disease, diabetes). Among patients with prior DED diagnosis (n=190), 96.9% had MG atrophy, with 59% having grade 2/3; among those without prior DED (n=194), 93.8% had atrophy, but only 30.9% had grade 2/3. Notably, 18% of patients without prior DED had moderate (grade 2) and 13% had severe (grade 3) atrophy.
**Clinical Implications:** MG atrophy is highly prevalent (95.1%) in patients presenting for cataract surgery, with nearly half having moderate to severe atrophy. The finding that 31% of patients without a prior DED diagnosis had moderate or severe atrophy highlights significant underdiagnosis. Since structural changes can occur without functional impairment (18% of patients), meibography provides critical information beyond standard functional tests. Preoperative identification of MG atrophy allows for timely treatment (e.g., thermal pulsation) to optimize ocular surface health, improve IOL calculation accuracy, and enhance patient satisfaction, especially for premium IOLs. The study's limitations include its retrospective, single-center design and semiquantitative grading. Nonetheless, the results support routine meibography in all cataract surgery candidates to improve MGD diagnosis and management.