Evaluation of Dry Eye and Meibomian Gland Dysfunction
After Cataract Surgery
KYUNG EUN HAN, SANG CHUL YOON, JI MIN AHN, SANG MIN NAM, R. DOYLE STULTING,
EUNG KWEON KIM, AND KYOUNG YUL SEO

PURPOSE: To evaluate dry eye and meibomian gland
dysfunction after cataract surgery.

DESIGN: Prospective observational case series.

METHODS: We studied 58 eyes of 48 patients who un-
derwent phacoemulsification and evaluated them preop-
eratively and at 1 month and 3 months postoperatively.
Ocular symptom scores, lid margin abnormalities, super-
ficial punctate keratopathies (SPKs), tear film break-up
time (TBUT), Schirmer test, lower tear meniscus height,
depth, and area using Fourier domain optical coherence
tomography, meibum expressibility and images of the
meibomian glands using meibography were measured.

RESULTS: The ocular symptom scores were worse at
1 month and 3 months postoperatively (P < 0.001 and
P < 0.001, respectively). Lid margin abnormalities
were significantly increased (P < 0.001 and P <
0.001, respectively) and TBUT decreased postopera-
tively (P < 0.001 and P < 0.001, respectively).
Meibum expressibility decreased at 3 months postopera-
tively (P [ 0.016); however, meibography score, SPK,
lower tear meniscus height, depth and area and the
Schirmer test did not change significantly postoperatively
(all P values >0.05).

CONCLUSION: Meibomian gland function may be
altered without accompanying structural changes after
cataract surgery. (Am J Ophthalmol 2014;157:
1144–1150. Ó 2014 by Elsevier Inc. All rights reserved.)
M
ODERN CATARACT SURGERY IS ONE OF THE
most successful surgical procedures performed
today. In spite of excellent postoperative dis-
tance visual acuity obtained for most patients, some are
distracted and dissatisfied because of tear film dysfunc-
tion,1–4 poor near vision5 or reduced contrast sensitivity.6
Accepted for publication Feb 11, 2014.
From the Department of Ophthalmology, Hallym University College of
Medicine, Chuncheon Sacred Heart Hospital, Chuncheon, South
Korea (K.E.H.); the Institute of Vision Research, Department of
Ophthalmology, Yonsei University College of Medicine, Seoul, South
Korea (S.C.Y., E.K.K., K.Y.S.); the Siloam Eye Hospital, Seoul, South
Korea (J.M.A.); the Department of Ophthalmology, CHA Bundang
Medical Center, CHA University College of Medicine, Sungnam,
South Korea (S.M.N.); and the Stulting Research Center, Woolfson Eye
Institute, Atlanta, Georgia, USA (R.D.S.).
Inquiries to Kyoung Yul Seo, Department of Ophthalmology, Yonsei
University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, CPO Box
8044, Seoul 120-752, South Korea; e-mail: seoky@yuhs.ac
1144 Ó 2014 BY ELSEVIER INC. ALL
Tear film dysfunction due to the use of topical medications,
reduced corneal sensitivity or conjunctival goblet cell loss
have been most widely investigated.2,7–9 Changes in tear
volume or production after surgery have been observed
inconsistently.2,8–10 Some patients complain of ocular
discomfort in spite of normal tear production and normal
corneal surfaces.
Obstructive meibomian gland dysfunction (MGD) is the
most common cause of evaporative dry-eye disease11,12 and
is characterized by stagnation of meibomian gland lipids
with or without qualitative or quantitative changes in
meibum. Hyposecretion of lipids may result in tear film
instability, ocular irritation and ultimately ocular surface
disease.13 Multiple ocular and systemic factors, such as con-
tact lens wear,14–16 giant papillary conjunctivitis,17,18
atopy,19 menopause,20,21 and psoriasis22 have been
reported to cause MGD; however, the influence of cataract
surgery on meibomian gland function has not been investi-
gated.
Regarding blepharitis after ocular surgery, 1 study has
been published. The authors reported that more than
30% of patients after post-laser in situ keratomileusis who
complained of ocular symptoms had dry eye or blephari-
tis.23 However, they did not classify the blepharitis as ante-
rior or posterior (MGD) blepharitis, and changes in ocular
parameters related to blepharitis were not discussed. The
purpose of this study was to evaluate whether cataract sur-
gery affects meibomian gland function and to investigate
potential associated changes in ocular surface parameters.
PATIENTS AND METHODS
THIS STUDY WAS PERFORMED IN ACCORDANCE WITH THE
tenets of the World Medical Association of Helsinki.
The prospective study protocol was approved by the Sever-
ance Hospital Institutional Review Board, Seoul, South
Korea, and registered at http://www.clinicaltrials.gov
(identification no. NCT01942642). Informed consent
was obtained from all subjects after explanation of the pur-
pose and possible consequences of the study.
We evaluated 55 patients (66 eyes) for inclusion in this
study. Of them 7 patients (8 eyes) were lost to follow-up.
The remaining 48 patients (58 eyes) are the subject of
this report. The mean age of the 48 patients was 68.3 6
11.7 years, and 27 were female.
RIGHTS RESERVED. 0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2014.02.036
 Eyes were categorized according to whether they had
anterior or posterior blepharitis. Anterior blepharitis was
further categorized as staphylococcal or seborrheic, and
posterior blepharitis was further characterized as seborrheic
or obstructive.13,24,25 Anterior staphylococcal blepharitis
was diagnosed by the presence of eyelid crusting and
collarettes. Anterior seborrheic blepharitis was diagnosed
by the presence of greasy scales on lid margins and
around the eyelashes. Seborrheic posterior blepharitis
(MGD) was diagnosed by excessive, thickened meibum
secretion with expression. Obstructive MGD was
diagnosed when there was plugging of the meibomian
gland orifices and hyposecretion of meibum with
expression. None of the patients had had staphylococcal
or seborrheic anterior blepharitis or seborrheic MGD
preoperatively.
Patients who had other comorbid ocular diseases, such as
ocular allergies, continuous use of topical ocular medica-
tions before surgery, or histories of ocular surgery or ocular
injury, were excluded. Patients who already had severe
obstructive MGD before surgery, abnormal findings on
the lid margin (>3 positive findings),19 reduced meibum
expression (>grade 2),26 or obstructed gland dropout
(meibography score >3)26 were also excluded.
Of the patients, the 10 who received cataract surgery in
both eyes had a period of at least 2 weeks between surgical
procedures.

CATARACT SURGERY: All cataract surgery was performed
by phacoemulsification through a 3.2 mm clear corneal
temporal incision under topical anesthesia by one of the
authors (KYS). The intraocular lens implant was either
the Tecnis 1-piece ZCB00 (Abbott Medical Optics, Santa
Ana, California), or the Acrysof IQ SN60WF (Alcon Lab-
oratories, Fort Worth, Texas). At the end of surgery, the
corneal incision was sealed with stromal hydration. There
were no intraoperative or postoperative complications.
Postoperatively, topical levofloxacin 0.5% (Cravit; Santen
Pharmaceutical, Osaka, Japan) and prednisolone acetate
1% (PredForte, Allergan, Irvine, California) were instilled
4 times daily for 4 weeks.
Patients were instructed to wash their faces as usual after
1 week postoperatively and to avoid pressing on the oper-
ated eyes for 1 month postoperatively. No special instruc-
tions for lid massage or lid hygiene were given.

CLINICAL EXAMINATIONS: Ocular symptoms, including
ocular fatigue, discharge, foreign-body sensation, dryness,
uncomfortable sensation, sticky sensation, pain, epiphora,
itching, redness, heavy sensation, glare, excessive blinking,
and history of chalazion or hordeolum, were evaluated by a
questionnaire.26 The total scores of symptoms ranged from
0 to 14, with higher scores representing greater severity.
Lid margin abnormalities were scored as 0 (absent) or
1 (present) for the following 4 parameters: vascular
engorgement, plugged meibomian gland orifices, anterior
VOL. 157, NO. 6 MEIBOMIAN GLAND DYSFUNCTION AFTER CATARACT SURGERY
or posterior displacement of the mucocutaneous junction,
and irregularity of lid margin.26 The sum was recorded as
0 through 4.
Tear film break-up time (TBUT) was evaluated by
placing a single fluorescein strip over the inferior tear
meniscus after instilling a drop of normal saline. Time
from the last blink to the first appearance of a randomly
distributed dry spot on the cornea was recorded in seconds.
The mean time for 3 attempts was recorded. After
measuring TBUT, SPK was graded as 0 (no staining); 1
(less than one third of the corneal surface); 2 (between
one third and half of the corneal surface); or 3 (half or
more of the corneal surface).
Lower tear meniscus status was evaluated using Fourier
domain optical coherence tomography (OCT) (RTVue;
Optovue, Fremont, California). Vertical 2 mm scan images
at the middle of the lower eyelid were obtained 3 times per
eye. The patients were asked to refrain from blinking dur-
ing the scanning. The tear meniscus height, depth and
area were measured using virtual calipers provided by Four-
ier domain OCT software. Tear meniscus height was
defined as the distance between the upper meniscus on
the cornea and the lower meniscus on the lid. The tear
meniscus depth was defined as the distance from the
midpoint of the air/meniscus interface to the cornea/lower
eyelid junction, and the tear meniscus area was defined as
the area consisting of the boundaries of the cornea, the
lower eyelid and the tear meniscus.
Expressibility of the meibum was scored by the applica-
tion of digital pressure to the central third of the upper
tarsus. The ease of meibum secretion was graded as follows:
0 (clear meibum easily expressed); 1 (cloudy meibum
expressed with mild pressure); 2 (cloudy meibum expressed
with more than moderate pressure); and 3 (meibum not
expressed, even with heavy pressure)27; higher scores repre-
sented a more obstructive status.
The morphology of meibomian glands was evaluated by
meibography (BG-4M; Topcon, Tokyo, Japan) using a
noncontact recording system that consists of an infrared
transmitting filter (IR-83; Hoya, Tokyo, Japan) and an
infrared charge-coupled video camera (XC-EI50; Sony,
Tokyo, Japan). The upper and lower eyelids were everted
and images were obtained. Meibography scores, which
quantitate obstruction of the meibomian glands, were
obtained using the following grades for each eyelid: 0 (no
loss of meibomian glands); 1 (meibomian gland loss
involving less than one third of the total meibomian gland
area); 2 (area lost between one third and two thirds of the
total meibomian gland area); and 3 (area lost more than
two thirds of the total meibomian gland area). The total
meibography score was the sum of the scores of the upper
and lower lids and was recorded as 0 to 6.28
The Schirmer test was performed without topical anes-
thesia as the final step in the examination by placing
a standard paper strip in the mid-lateral portion of the
lower fornix. The amount of wetting was recorded after
1145
 TABLE. Mean (6 standard deviation) of Ocular Surface Parameters Measured Preoperatively and at 1 Month and 3 Months After
Cataract Surgery

P Value

Parameters Baseline 1 month 3 months Overall Baseline vs 1 month Baseline vs 3 months

a
Ocular symptom score 1.5 6 1.1 3.6 6 1.1 3.9 6 1.7 <0.001 <0.001 <0.001
Lid margin abnormalityb 1.5 6 1.1 2.1 6 1.1 2.3 6 0.9 <0.001 <0.001 <0.001
Meibum expressibilityb 1.7 6 0.8 1.8 6 0.8 2.1 6 0.7 0.009 0.490 0.016
Meibography scoreb
Upper lid 0.5 6 0.8 0.5 6 1.0 0.6 6 1.0 0.714 >0.999 >0.999
Lower lid 1.1 6 0.8 1.2 6 1.0 1.2 6 1.1 0.220 0.264 0.689
Total 1.5 6 1.5 1.7 6 1.8 1.7 6 1.8 0.229 0.262 0.432
TBUT (sec)a 6.7 6 3.0 4.2 6 1.9 4.1 6 2.0 <0.001 <0.001 <0.001
SPKb 0.4 6 0.8 0.4 6 0.7 0.5 6 0.9 0.558 0.924 0.924
Schirmer test (mm)a 10.0 6 3.8 10.9 6 7.0 11.0 6 6.7 0.672 >0.999 >0.999
Lower tear meniscus assessment by
FD-OCTa
Height (mm) 261.2 6 77.43 267.2 6 75.96 268.3 6 68.84 0.892 >0.999 >0.999
Depth (mm) 186.1 6 50.78 183.0 6 64.80 200.0 6 69.16 0.529 >0.999 >0.999
Area (109 mm2) 25.8 6 13.2 26.2 6 15.2 29.2 6 17.0 0.638 >0.999 >0.999

FD-OCT ¼ Fourier domain optical coherence tomography; SPK ¼ superficial punctuate keratopathy; TBUT ¼ tear film break-up time.
a
Continuous values were analyzed by linear mixed model with Bonferroni post hoc analysis.
b
Noncontinuous values were analyzed by generalized linear mixed model analysis with Bonferroni post hoc analysis.

5 minutes. Patients were asked to blink normally during
the test.
All measurements were performed by one of the authors
(KYS) preoperatively, at 1 month postoperatively, and at
3 months postoperatively. Unoperated fellow eyes were
not examined for the study.

STATISTICS: Normal distribution of the data was verified
using the Kolmogorov-Smirnov test. A linear mixed model
with Bonferroni post hoc analysis was used to evaluate
repeated measurements of continuous values, such as ocular
symptom score, TBUT, SPK, Schirmer test, and tear
meniscus height, depth and area. A generalized linear
mixed model analysis was used for repeated measurements
of noncontinuous values, including lid margin abnormal-
ity, each parameter of lid margin abnormality, meibum
expressibility, and meibography score. Statistical analyses
were performed using SPSS for Windows (v 20.0, SPSS,
Chicago, Illinois). P values less than 0.05 were considered
significant.
RESULTS
OCULAR SYMPTOM SCORES WERE SIGNIFICANTLY WORSE
postoperatively than they were preoperatively (1.5 6 1.1
preoperatively, 3.6 6 1.1 at 1 month postoperatively and
3.9 6 1.7 at 3 months postoperatively; P < 0.001 and
P < 0.001, respectively) (Table). Lid margin abnormalities
were significantly increased at 1 month and 3 months
postoperatively (P < 0.001 and P < 0.001, respectively)
(Table). Vascular engorgement was observed in 23 eyes
(39.7 %) preoperatively, 42 eyes (72.4 %) at 1 month post-
operatively, and 41 eyes (70.7 %) at 3 months postopera-
tively (P < 0.001 and P < 0.001, respectively) (Figure 1).
Plugging of meibomian gland orifices was observed in 30
eyes (51.7 %) preoperatively, 43 eyes (74.1 %) at 1 month
postoperatively, and 49 eyes (84.5 %) at 3 months postop-
eratively (P ¼ 0.007 and P < 0.001, respectively) (Figure 1
and Figure 2, left and right). The mucocutaneous junction
was displaced in 16 eyes (27.6 %) preoperatively, in 18 eyes
(31.0 %) at 1 month postoperatively, and in 20 eyes
(34.5 %) at 3 months postoperatively (P ¼ 0.488, P ¼
0.285, respectively) (Figure 1 and Figure 3, left and right).
Lid margin irregularity was noted in 16 eyes (27.6 %) pre-
operatively and in 20 eyes (34.5 %) at 1 month and
3 months postoperatively (P ¼ 0.303, P ¼ 0.491, respec-
tively) (Figure 1).
Meibum expressibility was unchanged at 1 month post-
operatively (P ¼ 0.490) but worsened at 3 months postop-
eratively (P ¼ 0.016) (Table). However, the meibography
score of the upper lid, the lower lid and the sum of upper
and lower lids did not change significantly postoperatively
(all P values >0.05) (Table).
TBUT decreased at 1 month and 3 months postopera-
tively (P < 0.001 and P < 0.001, respectively) (Table).
However, measurements of SPK and tear meniscus height,
depth and area and the Schirmer test did not show signifi-
cant differences postoperatively (all P values >0.05)
(Table).

1146 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2014


FIGURE 1. Changes in lid margin abnormalities after cataract
surgery. An asterisk indicates a P value less than 0.05 by gener-
alized linear mixed model with Bonferroni correction method
when compared with baseline.
DISCUSSION
WE OBSERVED A STATISTICALLY SIGNIFICANT INCREASE IN
ocular symptom scores, worsening of lid margin abnormal-
ities, decrease in meibum expressibility, and decreased
TBUT in patients after cataract surgery but no change in
the Schirmer test, lower tear meniscus volume or meibog-
raphy score. These results suggest that cataract surgery
may influence meibomian gland function without causing
structural changes in the meibomian glands.
Cataract surgery using clear corneal incisions produces
rapid wound healing, little postoperative inflammation
and early refractive stability.29 In spite of uneventful and
successful surgery by a skilled surgeon, the majority of
patients in this study noted ocular discomfort that persisted
for at least 3 months postoperatively. To date, ocular
discomfort after cataract surgery has been attributed pri-
marily to the development or aggravation of dry-eye
syndrome.2–4,8,9,30 Changes in tear meniscus height
measured by slit-lamp examination or tear production
measured by the Schirmer test have been inconsistent.2,8–10
For objective, quantitative evaluation of tear meniscus
volume, we assessed the lower tear meniscus using Fourier
domain-OCT, which has shown low intraindividual vari-
ability31 and high intervisit reproducibility.32,33 With this
advanced technology, we were unable to detect differences
in tear production and tear meniscus volume between the
time points examined, suggesting that ocular discomfort
after cataract surgery cannot be explained by a decrease in
aqueous tear production alone. Other reports indicate that
corneal sensitivity recovers to normal levels within 1 to
3 months after cataract surgery,7,8 making this an unlikely
explanation of the persistent ocular symptoms seen
3 months postoperatively.
In patients with MGD, an erythematous, irregular or
thickened lid margin; plugging or capping of meibomian
gland orifices; reduction in the number of visible orifices;
and changes in the mucocutaneous junction can be
VOL. 157, NO. 6 MEIBOMIAN GLAND DYSFUNCTION AFTER CATARACT SURGERY
observed.11,19,34,35 Arita and associates have suggested
that ocular symptom score, lid margin abnormality score
and meibography score differentiate patients with MGD
from the normal population.26 They reported that lid
margin abnormality scores had the best predictive value,
followed by ocular symptom scores. Consistent with this
report, changes in lid margin abnormalities were apparent
in our study. More than 70 % of eyes showed plugging of
meibomian gland orifices and vascular engorgement of
the lid margin at 1 month postoperatively. These changes
did not resolve by 3 months postoperatively. In some
patients, irreversible morphologic changes in lid margin
anatomy such as displacement of the mucocutaneous junc-
tion were observed (Figure 3, right).
Lid margin abnormalities, such as vascular engorgement,
displacement of the mucocutaneous junction and irregular-
ities of the lid margin can also be observed in patients with
anterior blepharitis. However, we observed an increase in
the plugging of meibomian gland orifices (Figure 2), along
with a decrease in meibomian gland expressibility, without
the development of collarettes or crusting of eyelashes.
Taken together, it is more reasonable to conclude that
the changes in lid margin morphology were signs of changes
in meibomian gland function, rather than the development
of anterior blepharitis.
Many elderly patients who are candidates for cataract
surgery also have MGD with or without significant symp-
toms.28 We excluded patients with severe obstructive
MGD preoperativelyso as to maximize our ability to deter-
mine whether cataract surgery produced MGD.
MGD results in stagnation of meibomian gland secretion
inside the glands, dilation of the ductal system and loss of
glandular tissue. We hypothesized that cataract surgery
caused or exacerbated meibomian gland obstruction; how-
ever, only functional changes in meibomian glands,
including a decrease of meibum expressibility, were
observed without accompanying structural changes, as
seen by meibography. We suspect that structural changes
in the meibomian glands are a result of chronic meibomian
gland dysfunction rather than the short-term effect of cata-
ract surgery. To evaluate possible structural changes related
to cataract surgery, a longer duration of follow-up would be
necessary.
Inflammation and bacterial colonization have been
implicated in the pathogenesis of MGD. Subjective and
objective improvement of MGD through the use of topical
antibiotics and steroids such as those routinely used after
cataract surgery would be consistent with this hypothe-
sis.36–42 On the other hand, preservative-containing post-
operative medications have shown conflicting results.2,8
In this study, all patients used topical medications until
1 month postoperatively, possibly influencing clinical
outcomes. Discrimination between the effects of surgery
and those of medications would require the study of
patients undergoing cataract surgery with and without
postoperative medications.
1147
FIGURE 2. Anterior-segment photographs of the right eye of a 77-year-old female who developed meibomian gland dysfunction after
cataract surgery. (Left) Preoperatively, the lid margin was normal, without any signs of meibomian gland dysfunction. (Right) Three
months postoperatively, plugging of meibomian gland orifices (white arrows) was observed. A black arrowhead indicates cosmetic
powder residue.

FIGURE 3. Anterior segment photographs of the left eye of 45-year-old female who developed meibomian gland dysfunction after
cataract surgery. (Left) Preoperatively, the lid margin was normal, without any signs of meibomian gland dysfunction. (Right) Three
months postoperatively, vascular engorgement (white arrows) and anterior displacement of the mucocutaneous junction (white
arrowheads) were observed.

The exact mechanism by which cataract surgery pro-
duces MGD could not be elucidated by this study. For
example, ocular surface inflammation related to the surgery
itself; a decrease in blink rate resulting from a decrease in
corneal sensation; topical medications; lid dysfunction
due to the use of a lid speculum; or coincident development
of dry-eye syndrome might influence meibomian gland
function. MGD increases evaporative tear film dysfunc-
tion, which is probably the mechanism through which it
produces symptoms. Questionnaires cannot distinguish
between symptoms of evaporative dry eye (MGD) and
aqueous-deficient dry eye.43
This study has some drawbacks. First, this study was con-
ducted in a relatively small number of subjects and did not
have a control group that had not undergone cataract sur-
gery. Second, the lid hygiene status was not studied. Third,
meibum expressibility was not objectively measured using a
device that delivers standardized pressure on the lid.44
In spite of these drawbacks, our results provide important
information showing that patients without pre-existing
MGD tend to develop it after routine, uncomplicated cata-
ract surgery and that it persists for at least 3 months,
perhaps explaining some of the symptoms of ocular discom-
fort noted in the immediate postoperative period.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE FOR POTENTIAL CONFLICTS OF INTER-
est, and none were reported. This study was supported by a grant from the Korea Healthcare technology R&D Project, Ministry of Health & Welfare,
Republic of Korea (Grant No. A121861). Involved in design of study (K.E.H., K.Y.S); Conduct of study (K.E.H., S.C.Y., K.Y.S); Collection, management,
analysis, and interpretation of data (K.E.H., S.C.Y., S.M.N., J.M.A., K.Y.S); Preparation of manuscript (K.E.H., K.Y.S); Critical revision of article; (K.E.H.,
S.M.N., R.D.S., K.Y.S.); Final approval of manuscript (K.E.H., R.D.S., E.K.K., K.Y.S).

1148 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2014

 REFERENCES
1. Hardten DR. Dry eye disease in patients after cataract surgery.
Cornea 2008;27(7):855.
2. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease
and analysis of the pathogenic factors in patients after cata-
ract surgery. Cornea 2007;26(9 Suppl 1):S16–S20.
3. Ram J, Gupta A, Brar G, Kaushik S. Outcomes of phacoemul-
sification in patients with dry eye. J Cataract Refract Surg
2002;28(8):1386–1389.
4. Ram J, Sharma A, Pandav SS, Gupta A, Bambery P. Cataract
surgery in patients with dry eyes. J Cataract Refract Surg 1998;
24(8):1119–1124.
5. Pager CK. Expectations and outcomes in cataract surgery: a
prospective test of 2 models of satisfaction. Arch Ophthalmol
2004;122(12):1788–1792.
6. Trueb PR, Albach C, Montes-Mico R, Ferrer-Blasco T. Visual
acuity and contrast sensitivity in eyes implanted with aspheric
and spherical intraocular lenses. Ophthalmology 2009;116(5):
890–895.
7. Kim J, Chung J, Kang S, Kim S, Seo K. Change in corneal
sensitivity and corneal nerve after cataract surgery. Cornea
2009;28(Suppl 1):S20–S25.
8. Oh T, Jung Y, Chang D, Kim J, Kim H. Changes in the tear
film and ocular surface after cataract surgery. Jpn J Ophthalmol
2012;56(2):113–118.
9. Sanchez MA, Arriola-Villalobos P, Torralbo-Jimenez P, et al.
The effect of preservative-free HP-Guar on dry eye after
phacoemulsification: a flow cytometric study. Eye (Lond)
2010;24(8):1331–1337.
10. Cho YK, Kim MS. Dry eye after cataract surgery and associ-
ated intraoperative risk factors. Korean J Ophthalmol 2009;
23(2):65–73.
11. Foulks GN, Bron AJ. Meibomian gland dysfunction: a clin-
ical scheme for description, diagnosis, classification, and
grading. Ocul Surf 2003;1(3):107–126.
12. Bron AJ, Tiffany JM. The contribution of meibomian disease
to dry eye. Ocul Surf 2004;2(2):149–165.
13. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The
international workshop on meibomian gland dysfunction:
report of the definition and classification subcommittee.
Invest Ophthalmol Vis Sci 2011;52(4):1930–1937.
14. Arita R, Itoh K, Inoue K, Kuchiba A, Yamaguchi T,
Amano S. Contact lens wear is associated with decrease of
meibomian glands. Ophthalmology 2009;116(3):379–384.
15. Ong BL, Larke JR. Meibomian gland dysfunction: some clin-
ical, biochemical and physical observations. Ophthalmic Phys-
iol Opt 1990;10(2):144–148.
16. Molinari JF, Stanek S. Meibomian gland status and preva-
lence of giant papillary conjunctivitis in contact lens wearers.
Optometry 2000;71(7):459–461.
17. Martin NF, Rubinfeld RS, Malley JD, Manzitti V. Giant
papillary conjunctivitis and meibomian gland dysfunction
blepharitis. CLAO J 1992;18(3):165–169.
18. Mathers WD, Billborough M. Meibomian gland function and
giant papillary conjunctivitis. Am J Ophthalmol 1992;114(2):
188–192.
19. Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease:
classification and grading of lid changes. Eye (Lond) 1991;
5(Pt 4):395–411.
VOL. 157, NO. 6 MEIBOMIAN GLAND DYSFUNCTION AFTER CATARACT SURGERY
20. Sullivan DA, Sullivan BD, Evans JE, et al. Androgen defi-
ciency, meibomian gland dysfunction, and evaporative dry
eye. Ann N Y Acad Sci 2002;966:211–222.
21. Sullivan DA, Sullivan BD, Ullman MD, et al. Androgen in-
fluence on the meibomian gland. Invest Ophthalmol Vis Sci
2000;41(12):3732–3742.
22. Knop E, Knop N, Millar T, Obata H, Sullivan DA. The inter-
national workshop on meibomian gland dysfunction: report
of the subcommittee on anatomy, physiology, and pathophys-
iology of the meibomian gland. Invest Ophthalmol Vis Sci 2011;
52(4):1938–1978.
23. Levinson BA, Rapuano CJ, Cohen EJ, Hammersmith KM,
Ayres BD, Laibson PR. Referrals to the Wills Eye Institute
Cornea Service after laser in situ keratomileusis: reasons for
patient dissatisfaction. J Cataract Refract Surg 2008;34(1):
32–39.
24. Jackson WB. Blepharitis: current strategies for diagnosis and
management. Can J Ophthalmol 2008;43(2):170–179.
25. McCulley JP, Dougherty JM, Deneau DG. Classification of
chronic blepharitis. Ophthalmology 1982;89(10):1173–1180.
26. Arita R, Itoh K, Maeda S, et al. Proposed diagnostic criteria
for obstructive meibomian gland dysfunction. Ophthalmology
2009;116(11):2058–2063.e1.
27. Shimazaki J, Sakata M, Tsubota K. Ocular surface changes
and discomfort in patients with meibomian gland dysfunc-
tion. Arch Ophthalmol 1995;113(10):1266–1270.
28. Arita R, Itoh K, Inoue K, Amano S. Noncontact infrared
meibography to document age-related changes of the meibo-
mian glands in a normal population. Ophthalmology 2008;
115(5):911–915.
29. Dick HB, Schwenn O, Krummenauer F, Krist R, Pfeiffer N.
Inflammation after sclerocorneal versus clear corneal tunnel
phacoemulsification. Ophthalmology 2000;107(2):241–247.
30. Chung YW, Oh TH, Chung SK. The effect of topical cyclo-
sporine 0.05% on dry eye after cataract surgery. Korean J
Ophthalmol 2013;27(3):167–171.
31. Qiu X, Gong L, Sun X, Jin H. Age-related variations of hu-
man tear meniscus and diagnosis of dry eye with Fourier-
domain anterior segment optical coherence tomography.
Cornea 2011;30(5):543–549.
32. Zhou S, Li Y, Lu AT, et al. Reproducibility of tear meniscus
measurement by Fourier-domain optical coherence tomogra-
phy: a pilot study. Ophthalmic Surg Lasers Imaging 2009;40(5):
442–447.
33. Shen M, Li J, Wang J, et al. Upper and lower tear menisci in
the diagnosis of dry eye. Invest Ophthalmol Vis Sci 2009;50(6):
2722–2726.
34. Yamaguchi M, Kutsuna M, Uno T, Zheng X, Kodama T,
Ohashi Y. Marx line: fluorescein staining line on the inner
lid as indicator of meibomian gland function. Am J Ophthal-
mol 2006;141(4):669–675.
35. Driver PJ, Lemp MA. Meibomian gland dysfunction. Surv
Ophthalmol 1996;40(5):343–367.
36. Akyol-Salman I, Azizi S, Mumcu UY, Ates O, Baykal O.
Comparison of the efficacy of topical N-acetyl-cysteine and
a topical steroid-antibiotic combination therapy in the treat-
ment of meibomian gland dysfunction. J Ocul Pharmacol Ther
2012;28(1):49–52.
37. Bloom PA, Leeming JP, Power W, Laidlaw DA, Collum LM,
Easty DL. Topical ciprofloxacin in the treatment of
1149
 blepharitis and blepharoconjunctivitis. Eur J Ophthalmol
1994;4(1):6–12.
38. Jackson WB, Easterbrook WM, Connolly WE, Leers WD.
Treatment of blepharitis and blepharoconjunctivitis: com-
parison of gentamicin-betamethasone, gentamicin alone
and placebo. Can J Ophthalmol 1982;17(4):153–156.
39. Rubin M, Rao SN. Efficacy of topical cyclosporin 0.05% in
the treatment of posterior blepharitis. J Ocul Pharmacol Ther
2006;22(1):47–53.
40. Shulman DG, Sargent JB, Stewart RH, Mester U. Compara-
tive evaluation of the short-term bactericidal potential of a
steroid-antibiotic combination versus steroid in the treat-
ment of chronic bacterial blepharitis and conjunctivitis.
Eur J Ophthalmol 1996;6(4):361–367.
1150 AMERICAN JOURNAL OF OPHTHALMOLOGY
41. Yactayo-Miranda Y, Ta CN, He L, et al. A prospective study
determining the efficacy of topical 0.5% levofloxacin on bac-
terial flora of patients with chronic blepharoconjunctivitis.
Graefes Arch Clin Exp Ophthalmol 2009;247(7):993–998.
42. Yalcin E, Altin F, Cinhuseyinoglue F, Arslan MO. N-acetyl-
cysteine in chronic blepharitis. Cornea 2002;21(2):164–168.
43. Arita R, Itoh K, Maeda S, Maeda K, Tomidokoro A,
Amano S. Efficacy of diagnostic criteria for the differential
diagnosis between obstructive meibomian gland dysfunction
and aqueous deficiency dry eye. Jpn J Ophthalmol 2010;
54(5):387–391.
44. Korb DR, Blackie CA. Meibomian gland diagnostic expressi-
bility: correlation with dry eye symptoms and gland location.
Cornea 2008;27(10):1142–1147.
JUNE 2014
 Biosketch
Kyung Eun Han, MD is a clinical assistant professor of Cornea and External Eye Disease Service at the Hallym University
College of Medicine, Chuncheon, South Korea. Dr Han received her medical degree from the Ewha Womans University
School of Medicine, Seoul, South Korea, and then completed her internship and residensy at the Department of
Ophthalmology of the same university. She completed a fellowship at Yonsei University Severance Hospital. Her main
research interests are pathophysiology of dry eye disease and meibomian gland dysfunction.

VOL. 157, NO. 6 MEIBOMIAN GLAND DYSFUNCTION AFTER CATARACT SURGERY 1150.e1