Clinicians continue to better define the overlap between dry eye, meibomian gland dysfunction (MGD) and blepharitis. MGD is likely to be the primary cause of evaporative dry eye1 but may occur in combination with aqueous deficiency dry eye. The MGD workshop has recommended two additional states: low delivery and high delivery MGD. Low delivery is further sub-divided into hyposecretory (ie, gland atrophy) and obstructive (the most common form of MGD). Hypersecretory MGD (high delivery) is linked to dermatological disorders (ie, acne and seborrheic dermatitis). Hyperkeratinisation has been described as a primary cause of obstructive MGD.2 Obstructive MGD may be linked to prosthetic eye wear just as it is linked to contact lens (CL) intolerance. CL wearers have a higher level of meibomian gland drop-out on meibography than non-CL wearers,3 and this appears to correlate with the amount of time subjects wear CLs.4 The presence of a prosthesis may increase the potential for hyperkeratinisation due to a combination of tear deficiency,5 ,6 deposit build-up and microtrauma (mechanical rubbing of the prosthesis on the tarsus and posterior surface of lid margin), causing excretory duct obstruction. Healthy meibomian secretions are clear, and unhealthy secretions are cloudy, turbid, insipated or toothpaste-like. Age-related changes also lead to a decline in function.4 Just as contact lens intolerance has been shown to improve by meibomian gland expression and opening of plugged orifices,4 perhaps this should be encouraged in prostheses wearers. The study by Jang et al7 in this current issue investigated the morphologic changes in meibomian glands associated with wearing a prosthetic eye using non-contact meibography, a relatively new technique, and demonstrated a new finding, that eyelids with an ocular prosthesis were significantly associated with a greater degree of meibomian gland loss compared with the normal paired eyelids. …