Warm Compresses: Should You Use Them 2x/day for 10-15minutes or Not—The Controversy

 

Warm Compresses: Why Eye Surgeons Hate Them, Why We Fight About Them, and How to Do Them Right

Sandra Lora Cremers, MD, FACS

I am an eye surgeon, and like most eye surgeons, I hate talking about warm compresses. We like to cut things out and cure patients instantly. We like the dopamine hit of making the blind see, or, in the case of my sister who is head of oculoplastics at Stanford, of removing a blinding tumor.

But now every eye surgeon I know, even my sister, has to talk about warm compresses.

So why are warm compresses so important, and why are they so incredibly controversial among surgeons? I want to walk you through all of it, including the data and the references, so you can decide for yourself.

Why warm compresses matter at all

For years the published literature has held up warm compresses as the cheapest and easiest way to prevent the daily misery of dry eye. That misery shows up as tired eyes, swelling, dryness, aching or burning pain, a gritty or foreign body sensation, redness, and over time even eyelash loss. Behind most of these symptoms sit the meibomian glands, roughly thirty oil glands lining each upper and lower eyelid. These glands secrete meibum, the oily outer layer of the tear film that keeps your tears from evaporating too quickly.

When meibum thickens and the gland openings clog, a cascade begins. Tears evaporate too fast, the ocular surface becomes inflamed, and the inflammation further damages the glands. Left long enough, the glands atrophy and drop out. This is the crucial point that drives everything else. A meibomian gland that has withered away does not grow back. The entire logic of a warm compress is to melt the thickened oil, keep it flowing, and protect the glands before they are lost.

This is not a fringe idea. The cornerstone of managing meibomian gland dysfunction across the major guidelines is lid hygiene with warm compresses combined with gentle cleansing and massage of the lid margins. The TFOS DEWS III Management and Therapy Report from 2025, the American Academy of Ophthalmology Blepharitis Preferred Practice Pattern from 2024, the New England Journal of Medicine review, and multiple systematic reviews all endorse warm compresses as first line therapy. Beyond compresses, the evidence based ladder includes in office thermal pulsation such as LipiFlow, intense pulsed light therapy with gland expression, oral antibiotics like doxycycline or azithromycin for their anti inflammatory effect, omega 3 supplementation, and lid hygiene measures including blepharoexfoliation and treatment for Demodex mites.

The temperature problem, in detail

The single most important number in this entire discussion is 40 degrees Celsius. That is the temperature the inner surface of the eyelid, the palpebral conjunctiva, must reach for meibum to melt. Borchman established the science of this in 2019. Heating normal meibum to 40 degrees disorders its lipids to about 90 percent of maximum, which is the state you want. In meibomian gland dysfunction the oil is stiffer, so a slightly higher temperature near 41.5 degrees is needed to reach the same degree of melting. In severe disease the target can climb even higher, into a range that begins to approach the safety limits of the tissue.

Now the practical catch. The heat has to travel from the outer skin of the lid, through the lid, to the inner surface where the glands empty. Heat dissipates along the way. That is why a starting compress temperature around 45 to 47 degrees on the outer lid is usually needed just to get the inner lid to the therapeutic threshold. Murakami, Blackie, and Korb tested this directly in 2015. They compared eight different compress methods and found that only the bundled wet or moist warm towel reliably heated all three lid surfaces, outer upper, outer lower, and inner palpebral, to 40 degrees or higher. Dry heat packs and chemically activated masks frequently fell short at the inner lid, which is precisely where the heat needs to arrive. The blunt conclusion is that a large number of patients are diligently doing warm compresses that never reach the temperature required to do anything at all.

The evidence chart

Below is a summary of the published warm compress protocols, what temperature and schedule they used, and what they found. Reading it end to end shows both the real promise of warm compresses and the very real gaps in the evidence.

Published warm compress protocols and findings for meibomian gland dysfunction

Study or Source	Year	Compress Type	Starting Temp	Target Inner Lid Temp	Duration and Frequency	Key Findings
AAO Blepharitis Preferred Practice Pattern	2024	Hot washcloth, heat pack, or microwaveable rice or bean bag	Not specified (hot tap water)	Not specified	Several minutes, once or twice daily	Long term treatment often required. Avoid burns. Caution in advanced glaucoma.
Borchman (Ocular Surface)	2019	Any eyelid warming device (theoretical study)	Not applicable	40C for normal meibum, 41.5C for MGD meibum	Not applicable	40C achieves about 90 percent lipid disorder in normal meibum. MGD meibum needs about 41.5C. Severe dry eye may need temperatures above safety limits.
Murakami, Blackie and Korb (Optom Vis Sci)	2015	8 methods tested, including wet towel bundle, dry heat packs, chemically activated masks	About 47C (microwaved compresses)	40C or higher therapeutic threshold	10 minutes, measured every 2 minutes	Only the bundled wet or moist towel heated all three lid surfaces to 40C or higher. Dry and chemical heat compresses were inferior at the inner lid.
Mori (via Cochrane)	2003	Disposable eyelid warming device	Not specified	Not specified	5 minutes, once daily for 2 weeks	Improved tear breakup time by about 1 second. Reduced obstructed gland orifices from 26 of 34 to 14 of 34 eyes. 56 percent improvement in dryness sensation.
Ishida (via Cochrane)	2008	Orgahexa eye warmer mask	Not specified	Not specified	Worn overnight, nightly for 2 weeks	Significant improvement in tear breakup time, fluorescein staining, rose bengal staining, and lipid expression on DR-1 interferometry.
Olson (via Cochrane)	2003	Warm wet compress versus room temperature compress	Not specified	Not specified	30 minutes, single session	Evaluated tear film lipid layer thickness changes during and after compress therapy.
Lane (LipiFlow comparator arm)	2012	Conventional warm compresses	Not specified	Not specified	Daily for 1 month	A single LipiFlow session gave significantly greater improvement in gland secretion, tear breakup time, SPEED, and OSDI than warm compresses at 2 and 4 weeks.
Finis	2014	Eyelid warming plus massage	Not specified	Not specified	Twice daily for 3 months	A single LipiFlow session was at least as effective as 3 months of twice daily lid hygiene for OSDI improvement.
Zhao	2016	Warm compresses	Not specified	Not specified	Twice daily for 3 months	LipiFlow improved outcomes over baseline but was similar to 3 months of twice daily warm compresses (P equals 0.88).
VIEW Trial (Hu, PLoS One)	2025	Eyelid warm compress (method not specified)	Not specified	Not specified	Twice daily for 15 months	Ongoing randomized trial comparing warm compress, LipiFlow, and IPL with gland expression. Primary outcome is tear breakup time at 6 and 15 months. Results pending.

Why some respected surgeons push back

A vocal group of physicians, including Dr. Steven Maskin and Dr. Rolando Toyos, argue that warm compresses are oversold for moderate and severe disease. There are no formal published position papers from either physician telling patients to stop doing compresses, but the scientific arguments behind their skepticism are legitimate and worth laying out one by one.

One. Heat cannot melt scar

Dr. Maskin invented intraductal meibomian gland probing. His central argument is that in many patients the true problem is periductal fibrosis, a fixed band of scar like tissue constricting the gland duct. No amount of external heat resolves scar. Probing physically enters the gland through its natural opening to release that fixed obstruction and restore flow. From this vantage point, a warm compress treats only the symptom, thick oil, while ignoring the structural cause. A 2020 review by Lam and colleagues echoed this, noting that refractory disease with features of periductal fibrosis may require gland probing because warm compresses alone are insufficient.

Two. Most compresses never reach therapeutic temperature

This is the Murakami finding described above, and it is the most damning practical criticism. The Cochrane review on thermal pulsation made the same observation, that conventional compresses struggle to maintain a temperature that can diffuse from the outer lid to the inner palpebral conjunctiva. Murphy and colleagues in 2020 found that a warm face cloth produced no significant improvement in meibomian gland dysfunction over eight weeks, while purpose built heated eye masks did.

Three. Heat and pressure reach the cornea

Blackie, McMonnies, and Korb showed in 2013 that even with minimal contact pressure, a compress at 45 degrees raised the corneal surface to a mean maximum of 39.4 degrees after eight minutes. They raised the concern of transient and possibly longer term corneal molding from the combination of heat and pressure during compress use and subsequent massage. In fairness, Riede Pult and colleagues in 2017 found no clinically relevant short term change in corneal topography after eyelid warming and massage, which suggests this particular worry may be more theoretical than practical.

Four. Pressure spikes in glaucoma

This one deserves real attention. The AAO Blepharitis guideline cautions about warm compress and massage routines in advanced glaucoma. Van den Bosch and colleagues in 2023 used telemetric pressure sensors in glaucoma patients and found that eyelid rubbing caused average peak pressure increases of 59.1 mmHg and eyelid squeezing caused increases of 42.2 mmHg. These are brief spikes, but the concern is that repeated daily lid massage after a warm compress could add up over time in an eye with an already vulnerable optic nerve.

Five. Compresses help less once disease is established

Park and colleagues in 2022 found that warm compression immediately increased tear film lipid layer thickness significantly more in normal eyes than in eyes with meibomian gland dysfunction. In the diseased group, only the minimum lipid layer thickness improved, whereas in normal eyes all parameters improved. The uncomfortable implication is that by the time a patient has established disease, the glands may be too obstructed or too damaged for external heat alone to restore function.

Six. Compliance and real world efficacy

Finally, there is human nature. Warm compresses demand an indefinite, twice daily commitment, and symptoms return as soon as patients stop. Multiple reviews note that many patients will not achieve meaningful improvement with compresses alone. The AAO thermal pulsation report acknowledged that in office treatment may fill a void when regimented lid hygiene and warm compress therapy are not possible or not desirable for a given patient.

The counterpoint

Here is the part the interventionists sometimes skip over. The mainstream literature has not abandoned warm compresses, and for good reason. The TFOS DEWS III report, the AAO Preferred Practice Pattern, and the NEJM review all continue to endorse them as first line therapy. The NEJM review specifically notes that warm compresses combined with mechanical cleansing decrease bacterial load and enhance gland function. Done correctly, compresses are nearly free, low risk in most patients, and backed by decades of clinical use.

So the honest synthesis is not that warm compresses are useless. It is that the interventionist camp represents a more aggressive philosophy that prioritizes in office procedures, probing, intense pulsed light, and thermal pulsation, for moderate to severe or refractory disease. The two views are less a contradiction than a disagreement about where on the disease spectrum a warm wet towel stops being enough.

How to actually do a warm compress

Use moist heat ideally but even a dry pack is better than nothing in my own personal experience. I use one--the Wizard 2x/day and it helps my eyes feel less dry. BUT--A bundled warm wet towel is the only method proven to heat the inner lid to the therapeutic threshold and may be even better. Though in my experience, I found it very few Patients have the time to do this-- thus a plug-in warm compress pack maybe better than nothing.

Start warm, around 45 degrees Celsius on the outer lid, warm but never scalding, so the inner lid can reach 40 to 41.5 degrees. Protect your skin and never chase a burn.

Keep it on for a full 10 minutes, rewarming the towel as it cools, since a towel loses its heat within a couple of minutes.

Do it once or twice a day, and understand this is long term maintenance, not a one time cure. Symptoms return when you stop.

Follow the heat with gentle lid massage or gland expression to push the softened oil out.

If you have glaucoma, talk to your eye doctor before adding vigorous lid massage, because squeezing and rubbing can spike eye pressure.

And here is the bottom line I give my own patients. If you are doing all of this --warm compresses, hard, blinking, gentle lid, massaging, over-the-counter, non-preserved, artificial tears, lifitegrast (xiidra), and/or cyclosporine (ie Restasis, Vevye, Cequa) faithfully and your eyes are still tired, gritty, red, and dry, that is not a personal failure and it does not mean you are lazy. It means your glands may need more than heat, whether that is in office thermal pulsation (ie Lipiflow, TearCare, etc), and/or a stronger anti-inflammatory procedure--intense pulsed light (IPL), and radiofrequency, and/or meibomian gland probing. That is the real reason surgeons who would rather be operating now spend so much of the day talking about a warm wet towel. The towel is where treatment starts. For many patients it is not where treatment ends.

References

Sabeti S, Kheirkhah A, Yin J, Dana R. Management of Meibomian Gland Dysfunction: A Review. Survey of Ophthalmology. 2020;65(2):205 to 217.

Clayton JA. Dry Eye. New England Journal of Medicine. 2018;378(23):2212 to 2223.

Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III Management and Therapy Report. American Journal of Ophthalmology. 2025.

American Academy of Ophthalmology. Blepharitis Preferred Practice Pattern. 2024.

Rocha KM, Farid M, Raju L, et al. Eyelid Margin Disease (Blepharitis and Meibomian Gland Dysfunction): Clinical Review of Evidence Based and Emerging Treatments. Journal of Cataract and Refractive Surgery. 2024;50(8):876 to 882.

Borchman D. The Optimum Temperature for the Heat Therapy for Meibomian Gland Dysfunction. The Ocular Surface. 2019;17(2):360 to 364.

Murakami DK, Blackie CA, Korb DR. All Warm Compresses Are Not Equally Efficacious. Optometry and Vision Science. 2015;92(9):e327 to e333.

Warren NA, Maskin SL. Review of Literature on Intraductal Meibomian Gland Probing With Insights From the Inventor and Developer. Clinical Ophthalmology. 2023;17:497 to 514.

Lam PY, Shih KC, Fong PY, et al. A Review on Evidence Based Treatments for Meibomian Gland Dysfunction. Eye and Contact Lens. 2020;46(1):3 to 16.

Pucker AD, Yim TW, Rueff E, et al. LipiFlow for the Treatment of Dry Eye Disease. Cochrane Database of Systematic Reviews. 2024;2:CD015448.

Murphy O, O'Dwyer V, Lloyd-Mckernan A. The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Blepharitis. Current Eye Research. 2020;45(5):563 to 575.

Blackie CA, McMonnies CW, Korb DR. Warm Compresses and the Risks of Elevated Corneal Temperature With Massage. Cornea. 2013;32(7):e146 to e149.

Riede-Pult BH, Evans K, Pult H. Investigating the Short Term Effect of Eyelid Massage on Corneal Topography. Optometry and Vision Science. 2017;94(6):700 to 706.

van den Bosch JJON, Pennisi V, Mansouri K, et al. Effect of Eyelid Muscle Action and Rubbing on Telemetrically Obtained Intraocular Pressure in Patients With Glaucoma With an IOP Sensor Implant. British Journal of Ophthalmology. 2023;107(10):1425 to 1431.

Park HM, Lee WJ, Lim HW, Kim YJ. Immediate and Quantitative Changes in Tear Film Parameters and Meibomian Gland Structures After Warm Compression and Meibomian Gland Squeezing. Journal of Clinical Medicine. 2022;11(15):4577.

Thode AR, Latkany RA. Current and Emerging Therapeutic Strategies for the Treatment of Meibomian Gland Dysfunction. Drugs. 2015;75(11):1177 to 1185.

Tao JP, Shen JF, Aakalu VK, et al. Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology. Ophthalmology. 2023;130(12):1336 to 1341.

Cote S, Zhang AC, Ahmadzai V, et al. Intense Pulsed Light Therapy for the Treatment of Meibomian Gland Dysfunction. Cochrane Database of Systematic Reviews. 2020;3:CD013559.

Upaphong P, Tangmonkongvoragul C, Phinyo P. Pulsed Oral Azithromycin Versus 6 Week Oral Doxycycline for Moderate to Severe Meibomian Gland Dysfunction. JAMA Ophthalmology. 2023;141(5):423 to 429.

Hu Z, Wong HYM, Chan EHY, et al. Safety and Efficacy of Vectored Thermal Pulsation, Intense Pulsed Light, and Eyelid Warm Compress Therapies (VIEW). PLoS One. 2026;21(4):e0342421.