January 09, 2026
4 min read
Key takeaways:
- Upper lid assessment can help identify disease earlier than lower lid meibography.
- Innovative instruments make everting the upper eyelid easier and more consistent.
Despite a decade of growing attention to dry eye disease, millions of patients remain undiagnosed — whether symptomatic or asymptomatic — highlighting an opportunity to enhance comprehensive care, provide relief and support practice growth.
One persistent gap in comprehensive exams is the frequent omission of a simple 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 shows that evaluating the upper meibomian glands provides critical clinical insight. These glands often demonstrate structural changes earlier than the lower glands, giving clinicians an opportunity to diagnose and proactively treat dry eye disease (DED) across a broad patient population, including asymptomatic patients who may already have gland loss (Gupta et al.; Grue et al.). With innovative lid eversion instruments now available, upper lid assessment has become substantially easier and more consistent, reducing previous barriers and enabling clinicians to capture high-quality images that support earlier, more confident diagnosis.
Why MGD deserves a closer look
Asymptomatic meibomian gland dysfunction (MGD) is remarkably common and may be even more prevalent than symptomatic disease (Grue et al.; Viso et al.). Traditional diagnostic methods often fail to detect early-stage MGD, as compensatory mechanisms can maintain tear film stability and mask underlying pathology (Adil et al.). Approaches that rely primarily on gland dropout capture only later-stage disease, further delaying detection (Vunnava et al.).
Meibography enables clinicians to visualize structural gland abnormalities and assess early morphologic changes, such as thickening and tortuosity, allowing earlier identification of disease onset and progression (Gupta et al.; Adil et al.). Research also shows that many evaluations omit the upper eyelid (Gupta et al.), yet these longer, slender glands are particularly susceptible to early structural damage that may precede symptoms, underscoring the importance of including upper lid assessment in comprehensive exams.
Ever-expanding pool of patients
The opportunity to capture more patients with DED continues to grow. Gupta and colleagues suggested that the diagnostic and prognostic value of upper lid meibography extends across multiple patient populations with distinct clinical profiles.
- Contact lens wearers: Early upper lid changes help predict discomfort and discontinuation (Pucker et al.; Pucker et al.), allowing proactive management to maintain comfortable, long-term lens use and improve retention.
- Preoperative cataract surgery: Upper lid meibography can reveal baseline gland loss that predicts higher risk for postoperative dry eye symptoms, supporting presurgical risk stratification and informed patient planning (Gupta et al.; Fujimoto et al.).
- Autoimmune disorders: Patients with autoimmune and endocrine diseases show more pronounced MGD (Gupta et al.; Foulks et al.). Upper lid gland dropout is significantly greater in patients with Sjögren’s disease than in non-Sjögren’s dry eye (Zang et al.), and thyroid eye disease is likewise associated with more severe upper lid loss (Park et al.).
Value: Efficiency, practice impact
Historically, the upper eyelid has been more difficult to evert adequately for imaging, leading to a higher percentage of missing or poorly everted images (Daniel et al.; Wolffsohn et al.). Less efficient lid eversion techniques can increase chair time and patient discomfort (Wolffsohn et al.). Gupta and colleagues underlined the importance of effective eversion for meibography: “Notably, proper eyelid eversion is crucial for ensuring image quality and accurate assessment, especially for long-term monitoring.”
Meibography sets practices apart in their ability to identify and treat MGD effectively. Upper lid imaging uncovers 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 (eg, OptiLight from Lumenis) and thermal pulsation (eg, 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.
The implementation of specialized instruments (eg, Meivertor from Meivertor, LidVue eyelid everter from VisuScience or LidStick from Oculus) reduces chair time, streamlines procedures and simplifies lid eversion while supporting efficient workflows, maintaining patient comfort and offering a superior alternative to cotton applicators or finger-only eversion.
The Meivertor is a multiuse stainless steel instrument for upper and lower lid eversion with disposable silicone tips to improve hygiene, provide secure eyelash handling and enhance patient comfort. Its single-handed design leaves the clinician’s other hand free to operate the imaging camera or perform other tasks.
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 sustainable. Whether lid eversion is performed by a clinician or a technician, these tools simplify the process and help ensure that clinical time is directed toward 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 opportunities for revenue, making meibography a practical and impactful component of routine eye exams.
Reaching patients
There is no need to market for MGD patient encounters — these patients are already in your practice. Equipped with the knowledge 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.
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