Meibomianitis (Meibomitis): Causes and Treatments

Meibomianitis refers to inflammation of the meibomian glands, a subtype of posterior blepharitis. It is classified as a form of meibomian gland dysfunction (MGD) and is the most common cause of evaporative dry eye diseaseClayton JA, NEJM 2018.

The International Workshop on Meibomian Gland Dysfunction defines MGD as a “chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion”Onghanseng et al., Cochrane 2021. When MGD is accompanied by clinically apparent inflammation — visible lid margin redness, telangiectasia, and turbid or thickened secretions — it is termed meibomitis or meibomianitisSuzuki T, IOVS 2018.

• Hyperkeratinization of the meibomian gland duct epithelium leads to terminal duct obstruction, reduced meibum secretion, cystic dilation, and eventual acinar atrophyCote et al., Cochrane 2020.*
• Stagnation of meibum within obstructed glands promotes bacterial proliferation and secondary inflammationSuzuki T, IOVS 2018.

• Bacterial colonization — Proliferation of commensal bacteria (e.g., Staphylococcus spp.) within the meibomian glands produces lipolytic enzymes that alter meibum composition and drive inflammationUpaphong et al., JAMA Ophthalmology 2023.
• Demodex mite infestation — Demodex brevis inhabits the meibomian glands and can block gland orifices, inducing MGD and secondary meibomitis. Demodex folliculorum infests the eyelash follicles and may cause anterior blepharitis that coexists with posterior disease. Cylindrical dandruff at the lash base is highly suggestive of Demodex infestationOnghanseng et al., Cochrane 2021Rabensteiner et al., AJO 2019.

• Acne rosacea — One of the most important systemic associations; ocular rosacea frequently manifests as posterior blepharitis/meibomitisClayton JA, NEJM 2018.
• Seborrheic dermatitis — Oily, greasy scaling of the lid margin with overlap into MGDOnghanseng et al., Cochrane 2021.
• Fibrosing conjunctival disorders — Trachoma, erythema multiforme, and ocular cicatricial pemphigoid can cause secondary MGDClayton JA, NEJM 2018.

• Androgen deficiency reduces meibocyte lipid production via downregulation of androgen receptor (AR) and PPARγ signaling, contributing to altered meibum composition and gland atrophyYang & Li, Exp Eye Res 2026.
• Prevalence of MGD increases significantly with age, particularly above 50 yearsKam et al., Cochrane 2026.

• Use of isotretinoin (causes meibomian gland atrophy)Onghanseng et al., Cochrane 2021.*
• Contact lens wear, giant papillary conjunctivitis, and environmental factors (low humidity, prolonged screen use).

• Warm compresses — Soften meibum, relieve duct obstruction, and improve gland function. Recommended as the mainstay of treatment.
• Lid hygiene — Mechanical cleansing of the eyelid margins (eyelid scrubs, baby shampoo, or commercial lid wipes) reduces bacterial load.
• Meibomian gland expression/massage — Manual expression of inspissated meibum from the glands.
• Artificial tears — Lipid-containing lubricants to supplement the deficient tear film lipid layer.

• Topical antibiotics — Azithromycin ophthalmic solution has both antibacterial and anti-inflammatory properties.
• Topical corticosteroids — Short courses of low-dose glucocorticoids (e.g., loteprednol etabonate) for acute flares; requires monitoring for steroid-induced glaucoma and cataracts.
• Antibiotic–steroid combinations — Topical combination drops/ointments for moderate-to-severe disease.
• Topical cyclosporine A (Restasis, Cequa) — Immunomodulatory agent approved for dry eye disease; may be used as an adjunct, though evidence for superiority over placebo in MGD specifically is limited].
• Lifitegrast 5% (Xiidra) — LFA-1/ICAM-1 antagonist approved for dry eye; has shown benefit in inflammatory MGD, with improvement in eye dryness, corneal staining, and eyelid redness compared with thermal pulsation in one RCT.

• Oral tetracyclines — Doxycycline (e.g., 50–100 mg daily for 6–12 weeks) or minocycline; exert anti-inflammatory, lipid-modulating, and anti-bacterial effects on the meibomian glands.
• Oral azithromycin — Pulsed regimens (e.g., 500 mg day 1, then 250 mg days 2–5) offer a shorter course with fewer gastrointestinal side effects; one RCT showed comparable or superior efficacy to doxycycline.
• Omega-3 fatty acid supplementation — May improve MGD symptoms and tear film stability.

• Tea tree oil (terpinen-4-ol) — Effective for MGD associated with Demodex infestation; applied as lid scrubs.
• Lotilaner 0.25% ophthalmic solution (Xdemvy) — FDA-approved for Demodex blepharitis.

• Thermal pulsation (LipiFlow) — Automated device applying controlled heat (41–43°C) and pulsatile pressure to the eyelids for 12 minutes; may improve meibomian gland function and dry eye symptoms compared with warm compresses, though long-term durability is uncertain.
• Intense pulsed light (IPL) therapy — Broad-spectrum light applied to the periocular skin; when combined with meibomian gland expression, may improve tear film stability, ocular surface staining, and lipid layer thickness.
• Meibomian gland probing — Intraductal probing to relieve obstruction in refractory cases.
• Other thermal devices — TearCare, MiBoFlo, and Systane iLux systems offer alternative in-office heat/expression modalities.

If left untreated, meibomitis can cause inflammation of the adjacent ocular surface, leading to:

• Meibomian keratoconjunctivitis — corneal cellular infiltrates, neovascularization, and superficial punctate keratopathy.
• Progressive meibomian gland dropout (acinar atrophy), which is considered a permanent pathological change.
• Chronic evaporative dry eye disease.

1. Oral Antibiotics for Chronic Blepharitis. Onghanseng N, Ng SM, Halim MS, Nguyen QD. The Cochrane Database of Systematic Reviews. 2021;6:CD013697. doi:10.1002/14651858.CD013697.pub2.
2. Dry Eye. Clayton JA. The New England Journal of Medicine. 2018;378(23):2212-2223. doi:10.1056/NEJMra1407936.
3. Inflamed Obstructive Meibomian Gland Dysfunction Causes Ocular Surface Inflammation. Suzuki T. Investigative Ophthalmology & Visual Science. 2018;59(14):DES94-DES101. doi:10.1167/iovs.17-23345.
4. Molecular Mechanisms and Pathophysiology of Meibomian Gland Dysfunction. Yang L, Li Z. Experimental Eye Research. 2026;267:110970. doi:10.1016/j.exer.2026.110970.
5. A 6-Week, Prospective, Randomized, Single-Masked Study of Lifitegrast Ophthalmic Solution 5% Versus Thermal Pulsation Procedure for Treatment of Inflammatory Meibomian Gland Dysfunction. Tauber J. Cornea. 2020;39(4):403-407. doi:10.1097/ICO.0000000000002235.
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7. Pulsed Oral Azithromycin vs 6-Week Oral Doxycycline for Moderate to Severe Meibomian Gland Dysfunction: A Randomized Clinical Trial. Upaphong P, Tangmonkongvoragul C, Phinyo P. JAMA Ophthalmology. 2023;141(5):423-429. doi:10.1001/jamaophthalmol.2023.0302.
8. Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A Report by the American Academy of Ophthalmology. Wladis EJ, Bradley EA, Bilyk JR, Yen MT, Mawn LA. Ophthalmology. 2016;123(3):492-6. doi:10.1016/j.ophtha.2015.10.062.
9. Interventions for Dry Eye: An Overview of Systematic Reviews. McCann P, Kruoch Z, Lopez S, et al. JAMA Ophthalmology. 2024;142(1):58-74. doi:10.1001/jamaophthalmol.2023.5751.
10. Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology. Tao JP, Shen JF, Aakalu VK, et al. Ophthalmology. 2023;130(12):1336-1341. doi:10.1016/j.ophtha.2023.07.009.
11. Intense Pulsed Light (IPL) Therapy for the Treatment of Meibomian Gland Dysfunction. Cote S, Zhang AC, Ahmadzai V, et al. The Cochrane Database of Systematic Reviews. 2020;3:CD013559. doi:10.1002/14651858.CD013559.