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Aim: To compare differences in clinical dry eye features and meibomian gland health status between dry eye patients from rural and urban populations in Ghana. Methods: We examined 211 (rural=109, urban=102) participants with subjective dry eye symptoms. Tear film break -up time (TBUT), Schirmer's test and ocular surface staining (OSS) were assessed. Symptoms were evaluated using the SPEED II questionnaire. Meibomian glands (MG) in the right eye upper (UL) and lower lids (LL) were imaged using a custom meibographer. MG area was determined by intensity threshold segmentation using Image J software. MG loss (MGL) was also graded based on Pult's grading scheme. Mann–Whitney, Spearman correlation, chi-square and odds analyses were performed; p< 0.05 was considered significant. Results: Rural participants showed greater SPEED scores, reduced TBUT, and lower Schirmer scores, p < 0.05. The proportion of rural participants with MGL were significantly more (82.3%) than urban participants (63.3%), p < 0.05. They also showed greater MGL than urban participants, p < 0.05. Chi-square test revealed significantly different meiboscale distributions (UL: χ2=13.58, LL: χ2=15.29) between the groups, p < 0.05. Overall significant relationships were observed between MGL and age [rs= 0.61], OSS [rs= 0.35], TBUT [rs= − 0.52], and Schirmer scores [rs= − 0.40], p < 0.05. Conclusion: The data suggest that the participants from the rural population have worse dry eye and meibomian gland health status than those from the urban population. The significant relationships between the various clinical variables suggest important links between MGD and DED. Subtle differences in the everyday working and living environment could likely account for the differences in the severity of DED and MGD between the two groups. And considering the increased pattern of urbanization, industrialization and modernization and the related environmental effects in Africa, future longitudinal studies on specific environmental risk factors or mediators of DED and MGD are necessary to ascertain the MGD and DED situation in Ghana and Africa at large. [ABSTRACT FROM AUTHOR]