meibomian gland dysfunction ( mgd ) is a chronic , diffuse abnormality of the meibomian glands . it is commonly characterized by obstruction of the terminal ducts and qualitative and/or quantitative changes in glandular secretions . these can cause changes in tear film , eye irritation , clinically apparent inflammation , and diseases of the ocular surface . mgd can be divided into low - delivery and high - delivery states based on meibomian gland secretions . obstructive mgd is the most common form of dry eye and is categorized as a low - delivery state . it is also a major cause of evaporative dry eye disease . in this condition , eyelid hygiene is essential in the management of mgd and plays a fundamental role in decreasing the load of lipolytic bacteria and the amount of potentially toxic lipids on the ocular surface originating from products that cause tear film spoilage ( e.g. , free fatty acids ) [ 48 ] . several lid scrubs are commercially available and have been shown to be effective for managing dry eye disease [ 711 ] . baby shampoo is one such lid scrub and for many physicians is the treatment of choice for chronic blepharitis . however , even though it is gentle and ph - balanced , ocular surface irritation can still occur when this conventional shampoo contacts the ocular surface . in this study the purpose of this study was to evaluate the effects of this newly developed eye - cleansing formulation on mgd and eyelash length . the study protocol was prospectively reviewed and approved by the minamiaoyama eye clinic internal review board and was conducted according to the tenets of the declaration of helsinki . all subjects provided written informed consent to participate after receiving a detailed explanation of the study . ten patients ( 2 men , 8 women ) with dry eye associated with mgd were enrolled into the study . the patients in the mgd - related dry eye group were diagnosed according to the 2006 guidelines published by shimazaki . to determine whether the trial shampoo ( eye shampoo long [ esl ] , mediproduct co. , ltd . , tokyo , japan ) had an effect on eyelash growth , we included 10 healthy subjects ( 4 men , 6 women ) for measurement of eyelash length . esl is a nonirritating , eye - cleansing formulation ( figure 1(a ) ) with a ph of 7.4 and an osmolality of 300  mosm / l , which is similar to that of normal tear film . the product contains components that are anti - inflammatory ( dipotassium glycyrrhizate , cholecalciferol [ vitamin d3 ] ) and moisturizing ( blends of ceramide , kjellmaniella gyrate extract ) and promote hair growth ( cholecalciferol [ vitamin d3 ] , panax ginseng root extract , kjellmaniella gyrate extract , and amino acids ( see table 1  ) ) [ 1418 ] . all participants used esl twice a day for 8 weeks according to the prescribed study washing regimen , which entailed pumping the shampoo onto one hand or a piece of cotton and spreading it gently around the eyes . next , the study participants lightly massaged their eyelids to remove impurities located at the eyelash roots and rinsed their eyes with water ( figure 1(b ) ) . during the study , examinations were performed in 10 patients with mgd - associated dry eye and in 10 healthy subjects to check for a possible effect on eyelash growth . all subjects completed a background survey ( table 3 ) at the time of enrollment ( baseline ) and at the end of the 8-week treatment period . the examinations ( table 4 ) included tear breakup time , fluorescein staining score , and lipid layer thickness ( lipiview , tearscience , inc . , eyelid margin findings ( meibomian gland blockage , eyelash contamination , eyelid margin foam , and decreased meibum secretion ) were graded on a 5-point scale ranging from 0 to 4 ( table 5 ) . the change in meibum secretion was evaluated by extruding meibum from the lower eyelid using mge-100 ( tearscience , inc . ) . the severity of superficial punctate keratopathy ( spk ) was evaluated using a 4-point scale ranging from 0 to 3 . the corneal surface was divided into nasal , temporal , and central regions , and spk was graded in each area . visual acuity , intraocular pressure ( iop ) , and refractive error were measured at each study visit . the longest eyelash on the left eye was identified , pulled , and taped to a piece of paper for measurement . dry eye symptoms were evaluated using a questionnaire administered at baseline and after 8 weeks of using esl . responses of  none ,   mild ,   moderate ,  and  severe  were scored as 0 , 1 , 2 , and 3 , respectively . differences in subjective symptoms and findings at the eyelid margin ( meibomian gland blockage , eyelash contamination , lid margin foam , and decreased meibum secretion ) were tested for statistical significance using the mann differences in ocular surface findings ( including spk ) and eyelash length were tested for statistical significance using the wilcoxon signed rank test . the patients with mgd showed a significant improvement from baseline in subjective symptoms after 8 weeks using esl . sensation of dryness , bleary eyes ( foreign body sensation ) , grittiness ( foreign body sensation ) , sore eyes ( burning sensation ) , and heat ( burning sensation ) improved significantly ( p < .05 ) during this time ( table 7 , figure 2 ) . patients with mgd showed a significant improvement ( p < .05 ) in meibomian gland blockage , eyelash contamination , and eyelid margin foam , as well as decreased meibum secretion ( table 7 , figures 36 ) . eyelashes were significantly longer after 8 weeks of using esl than they were at baseline in the patients with mgd and in the healthy subjects ( p < .05 ; table 7 , figure 7 ) . spk significantly improved in the mgd group ( p < .05 ) during the 8-week study period . however , no significant changes were observed in tear breakup time or lipid layer thickness this time ( table 7 , figure 8) . our results indicate that the condition of the eyelids improved markedly after using esl for 8 weeks . the objective findings for mgd and the ocular surface improved , subjective dry eye symptoms ( e.g. , chronic ocular discomfort ) lessened , and eyelash length increased . it was suspected that esl would not be effective because a mild shampoo is likely to have limited cleansing ability . however , we found improvements in the cleanliness of the eyelashes and meibomian blockage . in general , lid hygiene regimens consist of application of warm compresses and lid massage to clear meibomian gland blockage . antibiotics and anti - inflammatory agents can also be used to improve the quality of the meibum . however , the treatments available have somewhat variable effects and must be continued over long periods to achieve a satisfactory reduction of symptoms . as a result , patients often discontinue treatment [ 6 , 7 ] . the patients in this study were compliant with the lid hygiene regimen partly because of improvements in their mgd symptoms , such as eyelash contamination , and subjective symptoms . esl is believed to improve compliance because the regimen is less complicated than that required when using conventional baby shampoo regimens ; for example , unlike baby shampoo , this product does not need to be diluted . no treatments for mgd that are effective in long - term use have been described in the literature . however , esl is easy to handle and reduces irritation ; therefore patients using it may be more likely to continue their treatment . the eyelash - lengthening effect of esl maybe due to its vitamin d and hair growth - promoting components and/or the effects of better hygiene [ 14 , 15 ] . it is possible that lengthening of the eyelashes occurred once the eyelashes were cleaned by washing and the condition of the eyelash roots improved . the mrna encoding 25-hydroxylase , the vitamin d activation enzyme , was recently shown to be present in some ocular cells . however , expression of this gene in the meibomian glands of epithelial cells has not been confirmed . it is possible that vitamin d3 is activated in the meibomian gland epithelium and induces eyelash growth , as has been demonstrated on the scalp [ 1416 , 19 ] . future studies should be performed to determine whether the vitamin d activation enzyme is expressed in the epithelium of the meibomian glands . lastly , lid massage may have promoted eyelash growth because of the presence of panax ginseng extract and kjellmaniella gyrate extract , both of which are known to stimulate hair growth [ 17 , 18 ] . the effect of esl on lid hygiene was similar to that of already available commercial products . however , esl is less irritating and has the additional benefit of lengthening the eyelashes . the lash - lengthening effect of esl may further improve compliance with the lid hygiene regimen and encourage patients with mgd to wash their eyelids regularly , just as they brush their teeth . esl can also be used as a make - up remover , so it can reduce mgd caused by residual eye make - up . in the present study , no adverse events such as redness , discharge , pupillary formation of congestive , and edema were observed and good results were obtained using esl . moreover , no participants reported irritation using esl . in addition , participants reported that esl was easily available and that they felt reduced mgd symptoms and 30% of the subjects continue to use the esl . these suggest that continued use of esl could have additional favorable effects on the meibomian gland ; however , we have to admit that the sample size is small . , esl is the first product in japan which can take care of eyelashes as well as mgd treatment . esl effectively improved the signs and symptoms of mgd and lengthened eyelashes , which may encourage patients to continue using the product .
purpose . meibomian gland dysfunction ( mgd ) can lead to abnormalities in the composition and function of tear film , resulting in dry eye . 
 eyelid hygiene is a key to management of mgd . 
 we tested a novel eyelid shampoo ( eye shampoo long , esl ) for its ability to maintain lid hygiene . 
 this shampoo is nonirritating and can potentially lengthen eyelashes . 
 this study was aimed to evaluate the efficacy of esl in the treatment of mgd and its effects on eyelash length . 
 methods . 
 ten patients with mgd and 10 healthy subjects without mgd applied esl twice daily for 8 weeks . 
 patients were examined for lid margin and dry eye before and after the trial . 
 subjective symptoms were evaluated . 
 eyelash length was measured at baseline and at the end of the trial . 
 results . in the mgd group 
 , significant improvements were observed in subjective symptoms obstruction of the meibomian orifice , secretion of meibum , eyelashes contamination , eyelid margin foam , and spk . 
 eyelash length became significantly longer . 
 conclusions . maintaining eyelid hygiene using esl improved the eyelid margins and symptoms of dry eye in mgd patients and increased eyelash length . 
 these findings are promising and warrant confirmation in a larger randomized controlled study .