Upper Lid Assessment: A Critical Step in Dry Eye Disease Diagnosis
Despite a decade of growing attention to dry eye disease (DED), millions of patients remain undiagnosed – whether symptomatic or asymptomatic – highlighting a important opportunity to enhance complete care, provide relief, and support practice growth. One persistent gap in comprehensive exams is the frequent omission of a simple, yet crucial, diagnostic step: evaluating the upper eyelids. Historically, lower lid meibography was considered sufficient, and the practical challenges of upper lid eversion led many clinicians to forgo upper lid imaging altogether.
Emerging research demonstrates that evaluating the upper meibomian glands provides critical clinical insight. These glands often exhibit structural changes earlier than the lower glands, offering clinicians an opportunity to diagnose and proactively treat DED across a broad patient population, including those who are asymptomatic but may already have gland loss (Gupta et al.; Grue et al.). The advent of innovative lid eversion instruments has made upper lid assessment substantially easier and more consistent,reducing previous barriers and enabling clinicians to capture high-quality images that support earlier,more confident diagnoses.
Why a Closer Look at Meibomian Glands is Essential
Asymptomatic meibomian gland dysfunction (MGD) is remarkably common, perhaps even more prevalent than symptomatic disease (Grue et al.; Viso et al.). Conventional diagnostic methods often fail to detect early-stage MGD because compensatory mechanisms can maintain tear film stability and mask underlying pathology (Adil et al.). Methods relying primarily on gland dropout only capture later-stage disease, further delaying detection (Vunnava et al.).
Meibography allows clinicians to visualize structural gland abnormalities and assess early morphologic changes, such as thickening and tortuosity, enabling earlier identification of disease onset and progression (Gupta et al.; Adil et al.). Research indicates that upper eyelid evaluations are frequently omitted (Gupta et al.), despite these longer, slender glands being particularly susceptible to early structural damage that may precede symptoms. This underscores the importance of incorporating upper lid assessment into comprehensive exams.
Expanding the Patient Pool for DED Evaluation
The potential to identify more patients with DED continues to grow. Gupta and colleagues suggest that the diagnostic and prognostic value of upper lid meibography extends across diverse patient populations with distinct clinical profiles:
- Contact Lens wearers: Early upper lid changes can predict discomfort and discontinuation (Pucker et al.; Pucker et al.), allowing for proactive management to maintain comfortable, long-term lens use and improve retention.
- Preoperative Cataract Surgery Patients: Upper lid meibography can reveal baseline gland loss, predicting a higher risk of postoperative dry eye symptoms.This supports presurgical risk stratification and informed patient planning (Gupta et al.; Fujimoto et al.).
- Patients with Autoimmune Disorders: Individuals with autoimmune and endocrine diseases frequently enough exhibit more pronounced MGD (Gupta et al.; Foulks et al.).Upper lid gland dropout is significantly greater in patients with Sjögren’s disease compared to those with non-Sjögren’s dry eye (Zang et al.), and thyroid eye disease is also associated with more severe upper lid loss (Park et al.).
Efficiency and Practice Impact
Historically, upper eyelid eversion for imaging has been challenging, resulting in a higher percentage of missing or poorly everted images (Daniel et al.; wolffsohn et al.). Less efficient eversion techniques can increase chair time and patient discomfort (Wolffsohn et al.). gupta and colleagues emphasize the importance of effective eversion for accurate meibography: “Notably, proper eyelid eversion is crucial for ensuring image quality and accurate assessment, especially for long-term monitoring.”
Meibography differentiates practices by demonstrating their ability to effectively identify and treat MGD. Upper lid imaging reveals more patients with gland loss, and sharing these images helps patients understand the need for intervention. This facilitates in-office therapies such as intense pulsed light (e.g., optilight from Lumenis) and thermal pulsation (e.g., LipiFlow from Johnson & Johnson or iLux from Alcon), which are typically paid out-of-pocket and recommended periodically, providing both improved patient outcomes and additional revenue opportunities.
Implementing specialized instruments – such as the Meivertor from Meivertor, LidVue eyelid everter from VisuScience, or LidStick from Oculus – reduces chair time, streamlines procedures, simplifies lid eversion, and supports efficient workflows while maintaining patient comfort. These tools offer a superior alternative to traditional methods like cotton applicators or finger-only eversion.
The Meivertor is a multiuse stainless steel instrument for both upper and lower lid eversion, featuring disposable silicone tips to improve hygiene, provide secure eyelash handling, and enhance patient comfort. Its single-handed design allows the clinician to operate the imaging camera or perform other tasks simultaneously.
LidVue assists with lower lid eversion for meibomian gland imaging,featuring smooth,rounded edges for easy handling and patient comfort.
For clinicians who prefer single-use tools, the LidStick is a disposable, multiuse instrument made of medical-grade silicone and plastic, providing a convenient and hygienic option for routine exams.
These innovations enhance efficiency, support patient flow, and optimize revenue per patient, making comprehensive meibography a sustainable practice component. Whether lid eversion is performed by a clinician or a technician, these tools simplify the process and allow clinical time to be focused on image interpretation and patient management.
By combining efficient lid eversion tools with comprehensive upper lid imaging, practices can streamline workflows, enhance patient care, and unlock new revenue opportunities, making meibography a practical and impactful component of routine eye exams.
Reaching and Treating Patients
There is no need to actively market for MGD patient encounters – these patients are already within your practice. Equipped with the knowlege that upper lid meibography is a critical diagnostic procedure and that new tools improve efficiency, clinicians can diagnose and treat DED earlier while supporting practice growth.
Over the past 6 months, I have refined my dry eye workflow in response to emerging meibography data. Incorporating upper gland imaging into initial consultations has become essential, providing insights into cases with unexpected therapy outcomes and prompting adjustments to treatment protocols for better patient care.
For More Information
Janelle L. Davison, OD, founder and clinical director of brilliant Eyes Vision Center in Smyrna, Georgia, can be reached at info@dryeyeinstituteofga.com.
Sources/Disclosures
Source:
Expert Submission
References:
- Adil MY, et al.Am J Ophthalmol. 2019;doi:10.1016/j.ajo.2018.12.006.
- Daniel E, et al. Ocul Surf. 2020;doi:10.1016/j.jtos.2020.07.014.
- Foulks GN, et al. Ocul Surf.2015;doi:10.1016/j.jtos.2014.12.001.
- Fujimoto H, et al.Clin Ophthalmol. 2022;doi:10.2147/OPTH.S346606.
- Grue JE, et al. https://www.reviewob.com/how-the-decision-to-do-or-not-do-meibography-impacts-your-dry-eye-services/. Published jan. 15, 2025. Accessed Sept. 24, 2025.
- Gupta PK, et al. Cornea. 2025;doi:10.1097/ICO.0000000000003729.
- Park J, et al. Acta Ophthalmol. 2018;doi:10.1111/aos.14000.
- Pucker AD, et al. Cont Lens Anterior Eye. 2019;doi:10.1016/j.clae.2018.12.002.
- Pucker AD, et al. Cont Lens Anterior Eye. 2019;doi:10.1016/j.clae.2019.06.004.
- Viso E, et al. Invest Ophthalmol Vis Sci. 2012;doi:10.1167/iovs.11-9228.
- Vunnava KP, et al. Indian J Ophthalmol. 2023;doi:10.4103/IJO.IJO_2930_22.
- Wolffsohn JS, et al. Cont Lens Anterior Eye. 2019;doi:10.1016/j.clae.2019.07.002.
- Zang S,et al. Eye (Lond).2018;doi:10.1038/s41433-018-0149-5.
Disclosures:
Davison reports being on the American Optometric Association aesthetic task force and consulting for AbbVie,Alcon,Orasis,Tarsus and Virtual Field.
Published: 2026/01/10 06:33:12
