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Kaštelan S, Hat K, Tomić Z, Matejić T, Gotovac N. Sex Differences in the Lacrimal Gland: Implications for Dry Eye Disease. Int J Mol Sci 2025; 26:3833. [PMID: 40332492 PMCID: PMC12028224 DOI: 10.3390/ijms26083833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2025] [Revised: 04/10/2025] [Accepted: 04/16/2025] [Indexed: 05/08/2025] Open
Abstract
Sexual dimorphism significantly impacts the lacrimal gland's structure, function, and ageing processes, playing an important role in dry eye disease (DED) pathophysiology. This multifactorial disorder, characterised by tear film instability, inflammation, and visual impairment, disproportionately affects women, especially after menopause. It highlights the interplay between sex steroid hormones, lacrimal gland function, and environmental factors. Systemic and local androgens are vital for maintaining lacrimal gland health and tear production, while the role of oestrogens remains less clear. Evidence suggests dose and context-dependent effects on inflammation and glandular function. Histopathological and molecular studies reveal significant sex differences in the lacrimal gland, with women exhibiting more pronounced age-related degenerative changes, including fibrosis and acinar atrophy, contributing to their increased susceptibility to DED. Despite these findings, the underlying mechanisms connecting sex steroid hormones, receptor expression, and local tissue regulation to these disparities remain poorly understood, highlighting the need for further research. This review synthesises the current knowledge of sex-specific differences in the lacrimal gland, emphasising the importance of integrating systemic and local biomarkers, histological data, and molecular insights into personalised therapeutic strategies. By tailoring treatments to patients' unique hormonal and molecular profiles, personalised medicine has the potential to transform DED management, addressing unmet clinical needs and improving outcomes.
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Affiliation(s)
- Snježana Kaštelan
- Department of Ophthalmology, Clinical Hospital Dubrava, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Koraljka Hat
- Department of Maxillofacial Surgery, Clinical Hospital Dubrava, University of Zagreb School of Dental Medicine, 10000 Zagreb, Croatia
| | - Zora Tomić
- Health Centre of the Croatian Department of Internal Affairs, 10000 Zagreb, Croatia
| | - Tomislav Matejić
- Surgery Clinic, Clinical Hospital Sveti Duh, 10000 Zagreb, Croatia
| | - Nikola Gotovac
- Department of Clinical Radiology, General Hospital Požega, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, 31000 Osijek, Croatia
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Jüngert K, Paulsen F, Jacobi C, Horwath-Winter J, Garreis F. Prolactin Inducible Protein, but Not Prolactin, Is Present in Human Tears, Is Involved in Tear Film Quality, and Influences Evaporative Dry Eye Disease. Front Med (Lausanne) 2022; 9:892831. [PMID: 35847789 PMCID: PMC9279896 DOI: 10.3389/fmed.2022.892831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Decreased production of the aqueous component of the tear film is an important cause of the development of dry eye disease (DED). Tear production is influenced by hormones and hormone-like factors. Prolactin (PLR), a multifunctional pituitary gland hormone, is regularly present in the lacrimal gland of rats and rabbits. In humans, serum PLR concentration correlates with tear quality. To gain deeper insights of possible effects of PRL, prolactin receptor (PRLR) and prolactin inducible protein (PIP), we analyzed the three proteins in the human lacrimal apparatus and in reflex tears of healthy volunteers as well as patients suffering from DED. Methods Gene expression of PRLR and PIP was analyzed by RT-PCR in cadaveric human lacrimal gland and ocular surface tissues, immortalized human corneal epithelial cells (HCE and hTEPI) and human Meibomian gland epithelial cells (HMGECs). At the protein level, the expression and localization of PRL, PRLR and PIP in formalin-fixed paraffin sections of the lacrimal apparatus were studied by immunohistochemistry. In addition, tear fluid from DED patients and healthy volunteers was analyzed by ELISA to determine the concentration of PRL and PIP. Results RT-PCR analyses revealed gene expression of PRLR and PIP in human tissue samples of cornea, lacrimal glands, and eyelids, whereas only PIP, but not PRLR, was detectable in immortalized corneal epithelial cells. Immunohistochemistry revealed for the first time the expression and localization of PRL, PRLR, and PIP in human tissues of the lacrimal apparatus and at the ocular surface. PRL and PRLR were detectable in corneal epithelium, lacrimal glands, and Meibomian glands. Reflex tears from DED patients revealed significantly increased PIP concentrations, whereas PRL was undetectable in tears of DED patients and healthy volunteers. Conclusion PRL, PRLR, and PIP are found in the lacrimal apparatus and on the ocular surface. PIP, but not PRL, is present in human tears and appears to be involved in the physiology of tear film quality. Our clinical data revealed that PIP may affect tear quality, but further functional analyses are needed to fully elucidate the effects of PRL and PIP-associated factors in tear secretion as well as in the connection of DED.
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Affiliation(s)
- Katharina Jüngert
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Friedrich Paulsen
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christina Jacobi
- Eyes and Skin Practice Dr. Jacobi, Nürnberg, Germany
- Department of Ophthalmology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | | | - Fabian Garreis
- Department of Functional and Clinical Anatomy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- *Correspondence: Fabian Garreis
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Yücekul B, Gürlek B. Non-invasive evaluation of meibomian gland morphology and tear film and anterior segment parameters in women with polycystic ovarian syndrome. Photodiagnosis Photodyn Ther 2021; 37:102654. [PMID: 34844002 DOI: 10.1016/j.pdpdt.2021.102654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/16/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the meibomian glands (MG), non-invasive tear film break-up time (NITBUT), and corneal and anterior segment measurements in patients with polycystic ovary syndrome and healthy women. METHODS The study included 66 polycystic ovarian syndrome (PCOS) patients and 42 healthy volunteers aged 18-35 years. The first and average NITBUT, MG loss, mean keratometry (Km), central (CCT) and thinnest (TCT) corneal thicknesses, anterior chamber depth (ACD), anterior chamber volume (ACV), irido-corneal angle (ICA), corneal volume (CV) and Ocular Surface Disease Index (OSDI) results were analyzed. RESULTS The mean MG loss values were 29.9 ± 11.9 and 20.8 ± 11.0 in the PCOS and control groups, respectively (p < 0.001). MG loss (meiboscale ≥ 1) was determined in 64 (96.9%) eyes in the PCOS group and in 36 (85.7%) eyes in the control group. There was no significant difference between the groups in respect of NITBUT, OSDI, Km, CCT, TCT, ACD, ACV, ICA and CV values (p > 0.05, for all). CONCLUSION MG loss is a physiological process which is distinct in PCOS patients, but does not cause tear film alterations. Further studies are needed to show the contributing factors of MGD in PCOS patients.
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Affiliation(s)
- Burcu Yücekul
- Department of Ophthalmology, Haseki Training and Research Hospital, Sultangazi, Istanbul 34265, Turkey.
| | - Beril Gürlek
- Department of Obstetrics and Gynecology, Recep Tayyip Erdogan University Faculty of Medicine, Rize, Turkey
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Grasso A, Di Zazzo A, Giannaccare G, Sung J, Inomata T, Shih KC, Micera A, Gaudenzi D, Spelta S, Romeo MA, Orsaria P, Coassin M, Altomare V. Sex Hormones Related Ocular Dryness in Breast Cancer Women. J Clin Med 2021; 10:jcm10122620. [PMID: 34198684 PMCID: PMC8232194 DOI: 10.3390/jcm10122620] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Dry eye syndrome (DES) is strictly connected to systemic and topical sex hormones. Breast cancer treatment, the subsequent hormonal therapy, the subsequent hyperandrogenism and the early sudden menopause, may be responsible for ocular surface system failure and its clinical manifestation as dry eye disease. This local dryness is part of the breast cancer iatrogenic dryness, which affects overall mucosal tissue in the fragile population of those with breast cancer. Methods: A literature review regarding the role of sex hormone changes and systemic hormonal replacement treatments (SHRT) in DES available on PubMed and Web of Science was made without any restriction of language. Results: Androgens exert their role on the ocular surface supporting meibomian gland function and exerting a pro-sebaceous effect. Estrogen seems to show a pro/inflammatory role on the ocular surface, while SHRT effects on dry eye are still not well defined, determining apparently contradictory consequences on the ocular surface homeostasis. The role of sex hormones on dry eye pathogenesis is most likely the result of a strict crosstalk between the protective androgens effects and the androgen-modulating effects of estrogens on the meibomian glands. Conclusions: Patients with a pathological or iatrogenic hormonal imbalance, such as in the case of breast cancer, should be assessed for dry eye disease, as well as systemic dryness, in order to restore their social and personal quality of life.
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Affiliation(s)
- Antonella Grasso
- Breast Unit, University Campus Bio-Medico, 00128 Rome, Italy; (A.G.); (P.O.); (V.A.)
| | - Antonio Di Zazzo
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, 00128 Rome, Italy; (D.G.); (S.S.); (M.C.)
- Correspondence: ; Tel.: +39-06225418893; Fax: +39-9622541456
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy;
| | - Jaemyoung Sung
- Department of Ophthalmology, School of Medicine, Juntendo University, 1130033 Tokyo, Japan; (J.S.); (T.I.)
| | - Takenori Inomata
- Department of Ophthalmology, School of Medicine, Juntendo University, 1130033 Tokyo, Japan; (J.S.); (T.I.)
| | - Kendrick Co Shih
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong;
| | - Alessandra Micera
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Sciences, IRCCS–Fondazione Bietti, 00198 Rome, Italy;
| | - Daniele Gaudenzi
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, 00128 Rome, Italy; (D.G.); (S.S.); (M.C.)
| | - Sara Spelta
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, 00128 Rome, Italy; (D.G.); (S.S.); (M.C.)
| | | | - Paolo Orsaria
- Breast Unit, University Campus Bio-Medico, 00128 Rome, Italy; (A.G.); (P.O.); (V.A.)
| | - Marco Coassin
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, 00128 Rome, Italy; (D.G.); (S.S.); (M.C.)
| | - Vittorio Altomare
- Breast Unit, University Campus Bio-Medico, 00128 Rome, Italy; (A.G.); (P.O.); (V.A.)
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Lacrimal gland excision in male and female mice causes ocular pain and anxiety-like behaviors. Sci Rep 2020; 10:17225. [PMID: 33057056 PMCID: PMC7560880 DOI: 10.1038/s41598-020-73945-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022] Open
Abstract
Lacrimal gland excision (LGE) induced dry eye produces more severe corneal damage in female mice, yet signs of LGE-induced ocular pain and anxiety in male and female mice have not been characterized. Excision of either the extraorbital gland (single LGE), or both the extraorbital and intraorbital glands (double LGE) was performed in male and female C57BL/6J mice to induce moderate and severe dry eye. Ongoing pain was assessed by quantifying palpebral opening and evoked nociceptive responses after corneal application of capsaicin and menthol. The open-field and plus maze were used to assess anxiety. Single LGE caused a reduction in palpebral opening and an increase in capsaicin and menthol-evoked responses only in female mice. Furthermore, single LGE produced signs of increased anxiety in female but not male mice. Overall, female mice appear more susceptible to signs of ocular pain, irritation, and anxiety in response to aqueous tear deficiency.
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Ye X, She X, Shen L. Association of sex with the global burden of glaucoma: an analysis from the global burden of disease study 2017. Acta Ophthalmol 2020; 98:e593-e598. [PMID: 31912656 DOI: 10.1111/aos.14330] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/18/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To investigate the association of sex with the global burden of glaucoma by year, age and socio-economic status using disability-adjusted life years (DALYs). METHOD The global, regional and national sex-specific DALY numbers, crude DALY rates and age-standardized DALY rates caused by glaucoma, by year and age, were obtained from the Global Burden of Disease Study 2017. Human development index (HDI) in 2017 as a national socio-economic indicator was obtained from the Human Development Report. t-Test and linear regression were performed to explore the association between sex difference in age-standardized DALY rates and HDI. RESULTS Globally, changes in glaucoma DALY number and crude rates were similar of both sexes between 1990 and 2017. After controlling for population size and age structure, age-standardized DALY rates decreased consistently from 10.7 in 1990 to 9.4 in 2017 among men and from 8.8 in 1990 to 8.0 in 2017 among women. In 2017, the global average age-standardized DALY rates were 11.6 ± 8.6 (mean ± standard deviation) in women and 14.9 ± 12.1 in men. The sex difference in age-standardized DALY of 195 countries was significant (t = 3.109; p < .01) in 2017. Men had higher rates than women of the same age, and sexual differences increased with age. t-Test revealed that age-standardized DALY rates among men were higher than those among women for low-HDI countries (t = 3.102; p < .01) and high-HDI countries (t = 2.110; p < .05). The difference (male minus female) in age-standardized DALY rates (standardized β = -0.434, p < .001) and the female-to-male age-standardized DALY rate ratios (standardized β = -0.315, p < .001) were inversely correlated with HDI. CONCLUSION Although global glaucoma health care is progressing, sexual differences in glaucoma burden showed little improvement in the past few decades. Worldwide, men have higher glaucoma burden than women. Older age and lower socio-economic status are associated with greater sex differences in glaucoma burden. Our findings may enhance public awareness of sexual differences in global glaucoma burden and emphasize the importance of making sex-sensitive health policy to manage global vision loss caused by glaucoma.
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Affiliation(s)
- Xin Ye
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xiangjun She
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Lijun Shen
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, China
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Wang DH, Li ZY, Liu XQ. Measurement of the Lower Lid Margin Thickness by Anterior Segment Optical Coherence Tomography. Ophthalmic Res 2020; 64:22-27. [PMID: 32172252 DOI: 10.1159/000507221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To verify the feasibility of using anterior segment optical coherence tomography (AS-OCT) to measure the lower lid margin thickness (LLMT) from posterior lash line to the mucocutaneous junction. METHODS This was a prospective, single-center, observational study. Fifty-six volunteers between 20 and 79 years old with normal healthy eyes were included in this study. Using AS-OCT to measure the LLMT at the middle position was separately performed by two operators under the same conditions. RESULTS The mean age of 56 subjects (24 males and 32 females) was 45.4 ± 15.7 years. The LLMT measured by AS-OCT between two operators was 0.86 ± 0.23 mm and 0.85 ± 0.22 mm, respectively. The reliability and repeatability between two operators were evaluated by intraclass correlation coefficient (ICC = 0.97). Based on one operator's measurements, the LLMT was 0.70 ± 0.10 mm at ages 20-29, 0.68 ± 0.09 mm at ages 30-39, 0.94 ± 0.12 mm at ages 40-49, 0.93 ± 0.20 mm at ages 50-59, 1.03 ± 0.15 mm at ages 60-69, and 1.24 ± 0.19 mm at ages 70-79, which indicated a significant positive correlation with age (rs = 0.74, p < 0.001). In addition, there was a significant difference in the LLMT between genders (0.94 ± 0.26 vs. 0.80 ± 0.19 mm, p = 0.03). CONCLUSIONS A good agreement between two operators indicated that it seemed to be feasible to use AS-OCT to measure the LLMT. Additionally, we found that the LLMT appeared to be closely related to age and gender.
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Affiliation(s)
- Da-Hu Wang
- Department of Ophthalmology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhao-Yan Li
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xin-Quan Liu
- Department of Ophthalmology, LongHua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China,
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Chen X, Sullivan BD, Darabad RR, Liu S, Kam WR, Sullivan DA. Are BALB/c Mice Relevant Models for Understanding Sex-Related Differences in Gene Expression in the Human Meibomian Gland? Cornea 2019; 38:1554-1562. [PMID: 31169606 PMCID: PMC6832805 DOI: 10.1097/ico.0000000000002017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A compelling feature of dry eye disease is that it occurs predominantly in women. We hypothesize that this female prevalence is linked to sex-related differences in the meibomian gland (MG). This gland plays a critical role in maintaining the tear film, and its dysfunction is a major cause of dry eye disease. To understand the factors that underlie MG sexual dimorphism and promote dry eye in women, we seek to identify an optimal model for the human MG. Our goal was to determine whether a murine MG is such a model. Toward that end, we examined whether sex differences in MG gene expression are the same in BALB/c mice and humans. METHODS Eyelid tissues were collected from humans (n = 5-7/sex) and BALB/c mice (n = 9/sex). MGs were isolated and processed for the evaluation of gene expression by using microarrays and bioinformatics software. RESULTS Our analysis of the 500 most highly expressed genes from human and mouse MGs showed that only 24.4% were the same. Our comparison of 100 genes with the greatest sex-associated differences in human and mouse MGs demonstrated that none were the same. Sex also exerted a significant impact on numerous ontologies, Kyoto Encyclopedia of Genes and Genomes pathways, and chromosomes, but these effects were primarily species-specific. CONCLUSIONS Our results indicate that BALB/c mice are not optimal models for understanding sex-related differences in gene expression of the human MG.
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Affiliation(s)
- Xiaomin Chen
- Schepens Eye Research Institute, Massachusetts Eye and Ear,
and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Zhongnan Hospital, Wuhan University, Wuhan,
China
| | | | - Raheleh Rahimi Darabad
- Schepens Eye Research Institute, Massachusetts Eye and Ear,
and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Shaohui Liu
- Schepens Eye Research Institute, Massachusetts Eye and Ear,
and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Wendy R. Kam
- Schepens Eye Research Institute, Massachusetts Eye and Ear,
and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - David A. Sullivan
- Schepens Eye Research Institute, Massachusetts Eye and Ear,
and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Suzuki T, Fujiwara S, Kinoshita S, Butovich IA. Cyclic Change of Fatty Acid Composition in Meibum During the Menstrual Cycle. Invest Ophthalmol Vis Sci 2019; 60:1724-1733. [PMID: 31013345 PMCID: PMC6736406 DOI: 10.1167/iovs.18-26390] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Purpose To evaluate the fatty acid (FA) composition in the meibum of pre- and postmenopausal women and age-matched men. Methods This prospective study involved 24 healthy subjects; six premenopausal women in their 30s with a regular menstrual cycle (young-female [yF] group), six postmenopausal women in their 60s (elderly-female [eF] group), and 12 age-matched men (i.e., young-male [yM] and elderly-male [eM] groups, respectively). The menstrual cycle was divided into six phases (phase I–VI). Meibum was obtained from the meibomian gland orifices via a Daviel spoon, and its FA composition was then analyzed via gas chromatography mass spectrometry (GC-MS). Principal component analysis (PCA) was performed on the GC-MS results. Results The mean FA composition of all subjects was 40% saturated FAs (SFA) and 60% unsaturated FAs (UFAs). The PCA results of all groups indicated two categories (PC1 [77.5%] and PC2 [12.4%]); one consisting of yF-group samples of mainly phase II and III and the other consisting of the yF-group samples of the rest of the cycle, as well as from eF-group, yM-group, and eM-group samples. Each group had a distinctive nature. The FAs that most contributed to PC1 were C14:0, C16:0, and C18:0 in a positive correlation, and C18:1n9 in a negative correlation. Conclusions FA composition noticeably changes during the menstrual cycle and is somewhat affected by sex and age. The ratio of SFAs (C16:0, C18:0) to mono-UFAs (C18:1n9) in the FA composition might have an impact on the lipid quality of meibum, thus suggesting alteration of its melting temperature and viscosity.
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Affiliation(s)
- Tomo Suzuki
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Ophthalmology, Kyoto City Hospital Organization, Kyoto, Japan
| | | | - Shigeru Kinoshita
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Igor A Butovich
- Department of Ophthalmology, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
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Sullivan DA, Rocha EM, Aragona P, Clayton JA, Ding J, Golebiowski B, Hampel U, McDermott AM, Schaumberg DA, Srinivasan S, Versura P, Willcox MDP. TFOS DEWS II Sex, Gender, and Hormones Report. Ocul Surf 2017; 15:284-333. [PMID: 28736336 DOI: 10.1016/j.jtos.2017.04.001] [Citation(s) in RCA: 262] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 12/21/2022]
Abstract
One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.
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Affiliation(s)
- David A Sullivan
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
| | - Eduardo M Rocha
- Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Pasquale Aragona
- Department of Biomedical Sciences, Ocular Surface Diseases Unit, University of Messina, Messina, Sicily, Italy
| | - Janine A Clayton
- National Institutes of Health Office of Research on Women's Health, Bethesda, MD, USA
| | - Juan Ding
- Schepens Eye Research Institute, Massachusetts Eye & Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Blanka Golebiowski
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Ulrike Hampel
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alison M McDermott
- The Ocular Surface Institute, College of Optometry, University of Houston, Houston, TX, USA
| | - Debra A Schaumberg
- Harvard School of Public Health, Boston, MA, USA; University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sruthi Srinivasan
- Centre for Contact Lens Research, School of Optometry, University of Waterloo, Ontario, Canada
| | - Piera Versura
- Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Schröder A, Abrar DB, Hampel U, Schicht M, Paulsen F, Garreis F. In vitro effects of sex hormones in human meibomian gland epithelial cells. Exp Eye Res 2016; 151:190-202. [DOI: 10.1016/j.exer.2016.08.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/15/2016] [Accepted: 08/23/2016] [Indexed: 12/31/2022]
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Growth Hormone Influence on the Morphology and Size of the Mouse Meibomian Gland. J Ophthalmol 2016; 2016:5728071. [PMID: 26981277 PMCID: PMC4769763 DOI: 10.1155/2016/5728071] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/11/2016] [Accepted: 01/19/2016] [Indexed: 12/20/2022] Open
Abstract
Purpose. We hypothesize that growth hormone (GH) plays a significant role in the regulation of the meibomian gland. To test our hypothesis, we examined the influence of GH on mouse meibomian gland structure. Methods. We studied four groups of mice, including (1) bovine (b) GH transgenic mice with excess GH; (2) GH receptor (R) antagonist (A) transgenic mice with decreased GH; (3) GHR knockout (−/−) mice with no GH activity; and (4) wild type (WT) control mice. After mouse sacrifice, eyelids were processed for morphological and image analyses. Results. Our results show striking structural changes in the GH-deficient animals. Many of the GHR−/− and GHA meibomian glands featured hyperkeratinized and thickened ducts, acini inserting into duct walls, and poorly differentiated acini. In contrast, the morphology of WT and bGH meibomian glands appeared similar. The sizes of meibomian glands of bGH mice were significantly larger and those of GHA and GHR−/− mice were significantly smaller than glands of WT mice. Conclusions. Our findings support our hypothesis that the GH/IGF-1 axis plays a significant role in the control of the meibomian gland. In addition, our data show that GH modulates the morphology and size of this tissue.
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Truong S, Cole N, Stapleton F, Golebiowski B. Sex hormones and the dry eye. Clin Exp Optom 2014; 97:324-36. [PMID: 24689906 DOI: 10.1111/cxo.12147] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 11/26/2013] [Accepted: 01/19/2014] [Indexed: 01/15/2023] Open
Abstract
The greater prevalence of dry eye in women compared to men suggests that sex hormones may have a role in this condition. This review aims to present evidence for how sex hormones may affect the ocular structures involved in the production, regulation and maintenance of the normal tear film. It is hypothesised that hormone changes alter the homeostasis of the ocular surface and contribute to dry eye. Androgens impact on the structure and function of the meibomian and lacrimal glands and therefore androgen deficiency is, at least in part, associated with the aetiology of dry eye. In contrast, reports of the effects of oestrogen and progesterone on these ocular structures and on the conjunctiva are contradictory and the mechanisms of action of these female-specific sex hormones in the eye are not well understood. The uncertainty of the effects of oestrogen and progesterone on dry eye symptoms is reflected in the controversial relationship between hormone replacement therapy and the signs and symptoms of dry eye. Current understanding of sex hormone influences on the immune system suggests that oestrogen may modulate a cascade of inflammatory events, which underlie dry eye.
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Affiliation(s)
- Susan Truong
- The University of New South Wales, Kensington, New South Wales, Australia
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Darabad RR, Suzuki T, Richards SM, Jensen RV, Jakobiec FA, Zakka FR, Liu S, Sullivan DA. Influence of aromatase absence on the gene expression and histology of the mouse meibomian gland. Invest Ophthalmol Vis Sci 2013; 54:987-98. [PMID: 23233261 DOI: 10.1167/iovs.12-10992] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE We hypothesize that aromatase, an enzyme that controls estrogen biosynthesis, plays a major role in the sex-related differences of the meibomian gland. To begin to test this hypothesis, we examined the influence of aromatase absence, which completely eliminates estrogen production, on glandular gene expression and histology in male and female mice. METHODS Meibomian glands were obtained from adult, age-matched wild-type (WT) and aromatase knockout (ArKO) mice. Tissues were processed for histology or the isolation of total RNA, which was analyzed for differentially expressed mRNAs by using microarrays. RESULTS Our results show that aromatase significantly influences the expression of more than a thousand genes in the meibomian gland. The nature of this effect is primarily sex-dependent. In addition, the influence of aromatase on sex-related differences in gene expression is predominantly genotype-specific. However, many of the sex-related variations in biological process, molecular function, and cellular component ontologies, as well as in KEGG (Kyoto Encyclopedia of Genes and Genomes) pathways, are remarkably similar between WT and ArKO mice. The loss of aromatase activity has no obvious effect on the histology of meibomian glands in male or female mice. CONCLUSIONS Our findings demonstrate that aromatase has a significant impact on gene expression in the meibomian gland. The nature of this influence is sex-dependent and genotype-specific; however, many of the sex-related variations in gene ontologies and KEGG pathways are similar between WT and ArKO mice. Consequently, it appears that aromatase, and by extension estrogen, do not play a major role in the sex-related differences of the mouse meibomian gland.
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Affiliation(s)
- Raheleh Rahimi Darabad
- Schepens Eye Research Institute, Department of Ophthalmology, Boston, Massachusetts 02114, USA
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15
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Liu S, Richards SM, Lo K, Hatton M, Fay A, Sullivan DA. Changes in gene expression in human meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2011; 52:2727-40. [PMID: 21372006 PMCID: PMC3088560 DOI: 10.1167/iovs.10-6482] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 12/15/2010] [Accepted: 03/01/2011] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Meibomian gland dysfunction (MGD) may be the leading cause of dry eye syndrome throughout the world. However, the precise mechanism(s) underlying the pathogenesis of this disease is unclear. This study was conducted to identify meibomian gland genes that may promote the development and/or progression of human MGD. METHODS Lid tissues were obtained from male and female MGD patients and age-matched controls after eyelid surgeries (e.g., to correct entropion or ectropion). Meibomian glands were isolated and processed for RNA extraction and the analysis of gene expression. RESULTS The results show that MGD is associated with significant alterations in the expression of almost 400 genes in the human meibomian gland. The levels of 197 transcripts, including those encoding various small proline-rich proteins and S100 calcium-binding proteins, are significantly increased, whereas the expression of 194 genes, such as claudin 3 and cell adhesion molecule 1, is significantly decreased. These changes, which cannot be accounted for by sex differences, are accompanied by alterations in many gene ontologies (e.g., keratinization, cell cycle, and DNA repair). The findings also show that the human meibomian gland contains several highly expressed genes that are distinct from those in an adjacent tissue (i.e., conjunctival epithelium). CONCLUSIONS The results demonstrate that MGD is accompanied by multiple changes in gene expression in the meibomian gland. The nature of these alterations, including the upregulation of genes encoding small proline-rich proteins and S100 calcium-binding proteins, suggest that keratinization plays an important role in the pathogenesis of MGD.
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Affiliation(s)
- Shaohui Liu
- From the Schepens Eye Research Institute
- the Department of Ophthalmology, and
| | - Stephen M. Richards
- From the Schepens Eye Research Institute
- the Department of Ophthalmology, and
| | - Kristine Lo
- the Department of Ophthalmology, and
- the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts; and
| | - Mark Hatton
- From the Schepens Eye Research Institute
- the Department of Ophthalmology, and
- Ophthalmic Consultants of Boston, Boston, Massachusetts
| | - Aaron Fay
- the Department of Ophthalmology, and
- the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts; and
| | - David A. Sullivan
- From the Schepens Eye Research Institute
- the Department of Ophthalmology, and
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16
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Knop E, Knop N, Millar T, Obata H, Sullivan DA. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci 2011; 52:1938-78. [PMID: 21450915 PMCID: PMC3072159 DOI: 10.1167/iovs.10-6997c] [Citation(s) in RCA: 747] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 03/23/2011] [Indexed: 12/15/2022] Open
Affiliation(s)
- Erich Knop
- Ocular Surface Center Berlin, Department for Cell and Neurobiology, Center for Anatomy, Charité-Universitätsmedizin Berlin, Berlin, Germany
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17
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Abstract
Among ophthalmic diseases dry eye in its various forms, represents an entity with one of the highest prevalences and at the same time the lowest chance for causal therapy. Since some years there is growing evidence that sex hormones play a key role in the formation and course of the disease and thus provide potentially promising approaches for therapy. The objective of this article is to briefly outline current scientific knowledge on the relationship between androgens, estrogens,and progesterones on the one hand and the lacrimal gland and Meibomian glands respectively.
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Affiliation(s)
- F Schirra
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes, UKS, Kirrberger Str. 1, 66421, Homburg/Saar, Deutschland.
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18
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Nien CJ, Paugh JR, Massei S, Wahlert AJ, Kao WW, Jester JV. Age-related changes in the meibomian gland. Exp Eye Res 2009; 89:1021-7. [PMID: 19733559 DOI: 10.1016/j.exer.2009.08.013] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 08/21/2009] [Accepted: 08/27/2009] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to characterize the age-related changes of the mouse meibomian gland. Eyelids from adult C57Bl/6 mice at 2, 6, 12 and 24 months of age were stained with specific antibodies against peroxisome proliferator activated receptor gamma (PPARgamma) to identify differentiating meibocytes, Oil Red O (ORO) to identify lipid, Ki67 nuclear antigen to identify cycling cells, B-lymphocyte-induced maturation protein-1 (Blimp1) to identify potential stem cells and CD45 to identify immune cells. Meibomian glands from younger mice (2 and 6 months) showed cytoplasmic and perinuclear staining with anti-PPARgamma antibodies with abundant ORO staining of small, intracellular lipid droplets. Meibomian glands from older mice (12 and 24 months) showed only nuclear PPARgamma localization with less ORO staining and significantly reduced acinar tissue (p < 0.04). Acini of older mice also showed significantly reduced (p < 0.004) numbers of Ki67 stained nuclei. While Blimp1 appeared to diffusely stain the superficial ductal epithelium, isolated cells were occasionally stained within the meibomian gland duct and acini of older mice that also stained with CD45 antibodies, suggesting the presence of infiltrating plasmacytoid cells. These findings suggest that there is altered PPARgamma receptor signaling in older mice that may underlie changes in cell cycle entry/proliferation, lipid synthesis and gland atrophy during aging. These results are consistent with the hypothesis that mouse meibomian glands undergo age-related changes similar to those identified in humans and may be used as a model for age-related meibomian gland dysfunction.
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Affiliation(s)
- Chyong Jy Nien
- The Gavin Herbert Eye Institute, University of California Irvine Medical Center, 101 The City Drive, Orange, CA 92868, USA
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19
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Sullivan DA. Tearful relationships? Sex, hormones, the lacrimal gland, and aqueous-deficient dry eye. Ocul Surf 2007; 2:92-123. [PMID: 17216082 DOI: 10.1016/s1542-0124(12)70147-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Sex and the endocrine system exert a significant influence on the physiology and pathophysiology of the lacrimal gland. The purpose of this article is to briefly review the nature and magnitude of these interactions between sex, hormones and lacrimal tissue, and to address how they may relate to the pathogenesis of aqueous-deficient dry eye. Towards this end, this article has a 3-fold approach: first, to summarize the influence of androgens, estrogens, glucocorticoids, mineralocorticoids, retinoic acid, prolactin, alpha-melanocyte stimulating hormone, adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone, growth hormone, thyroid-stimulating hormone, arginine vasopressin, oxytocin, thyroxine, parathyroid hormone, insulin, glucagon, melatonin, human chorionic gonadotropin and cholecystokinin on the structure and function of the lacrimal gland; second, to discuss the mechanism of action of each hormone on lacrimal tissue; and third, to discuss the clinical relevance of the endocrine-lacrimal gland interrelationship, with a particular focus on each hormone's role (i.e. if relevant) in the development of aqueous-tear deficiency.
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Affiliation(s)
- David A Sullivan
- Schepens Eye Research Institute and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 02114, USA.
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20
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Abstract
The meibomian glands of the lid produce a lipid material whose synthesis is dependent on neuronal, hormonal, and vascular factors. This lipid material is fluid, spreads easily, is a surfactant as well as an aqueous barrier and must remain functional after a blink. To satisfy these requirements, the meibomian lipids have a specific composition. Even after delivery it may be modified by lipases produced by ocular bacteria, and modifications in the lipid components can lead to unique disease states. For example, bacteria may degrade lipids, producing an unstable tear film and irritating free fatty acids; and hormonal imbalances may alter lipid profiles to destabilize the tear film and produce evaporative dry eye.
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Affiliation(s)
- James P McCulley
- Department of Ophthalmology, University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas 75390, USA.
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21
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Den S, Shimizu K, Ikeda T, Tsubota K, Shimmura S, Shimazaki J. Association between meibomian gland changes and aging, sex, or tear function. Cornea 2007; 25:651-5. [PMID: 17077655 DOI: 10.1097/01.ico.0000227889.11500.6f] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To study changes in the lid margin and meibomian glands and their association with aging, sex, and tear function. METHODS We examined 354 eyes in 177 subjects (76 men and 101 women; 21-93 years; mean age, 63.0 +/- 14.3 years) with no ocular symptoms or ocular surface disorders. Anatomic changes in the lid margin were studied using slit-lamp biomicroscopy. Meibomian gland function and morphology were evaluated on the basis of meibum expression and meibography, respectively. Tear function and ocular surface epithelium were assessed with the Schirmer test, by tear film break-up time, and with a fluorescein staining test. RESULTS Eyes with abnormal lid margin anatomy, hyposecretion of meibum, and meibomian gland dropout were seen in 26 (7.3%), 46 (12.4%), and 68 eyes (18.6%), respectively, with a significant association between each finding and aging (P = <0.0001, 0.0498, and <0.0001, respectively). In patients < or =69 years of age, no significant association was found between meibomian gland-related findings and sex. However, a high incidence of abnormal lid margin and gland dropout was noted in men > or =70 years of age compared with women. No significant association was found between changes in the lid margin and meibomian glands and tear function in patients > or =40 years of age. CONCLUSION Among symptom-free subjects, we found that changes in the lid margin and meibomian glands were closely related to aging. Among elderly subjects, changes in the anatomic lid margin and meibomian gland morphology were observed more frequently in men than in women. Tear function showed no association with either changes in the lid margin or function of the meibomian glands.
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Affiliation(s)
- Seika Den
- Department of Ophthalmology, Tokyo Dental College, Chiba, Japan.
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Richards SM, Yamagami H, Schirra F, Suzuki T, Jensen RV, Sullivan DA. Sex-related effect on gene expression in the mouse meibomian gland. Curr Eye Res 2006; 31:119-28. [PMID: 16500762 DOI: 10.1080/02713680500514644] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Sex-related differences have been identified in the anatomy and physiology of the meibomian gland. We hypothesize that these differences are due, at least in part, to variations in gene expression. This study's objective was to determine whether sex-related differences do exist in meibomian gland gene expression. We also sought to elucidate whether such differences, if any, might be (a) analogous to those known to occur in the lacrimal gland and (b) due to the effect of sex steroids. METHODS Meibomian glands were obtained from young adult male and female BALB/c mice (n=7 to 15 mice per sex per experiment), pooled according to sex and processed for the isolation of RNA. Samples were evaluated for differentially expressed mRNAs by using CodeLink Bioarrays and GEM 1 and 2 gene chips. Bioarray data were analyzed with GeneSifter. Net software and also compared with microarray data in GEO and GeneSifter databases. RESULTS Our results demonstrate that sex has a significant influence on the expression of 164 genes in the mouse meibomian gland. These genes are involved in a broad spectrum of biological processes, molecular functions, and cellular components, including such activities as metabolism, catalysis, cell growth and maintenance, membrane architecture, nucleic acid binding, transcription, and signal transduction. In addition, the nature of the sex-related variations in meibomian gland gene expression is quite different from those in the lacrimal gland and appear to be mediated in part by the action of androgens, but not estrogens or progestins. CONCLUSIONS These findings support our hypothesis that sex-related differences exist in gene expression of the meibomian gland.
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Affiliation(s)
- Stephen M Richards
- Schepens Eye Research Institute and Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 02114, USA
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23
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Sullivan DA, Yamagami H, Liu M, Steagall RJ, Schirra F, Suzuki T, Krenzer KL, Cermak JM, Sullivan RM, Richards SM, Schaumberg DA, Dana MR, Sullivan BD. Sex steroids, the meibomian gland and evaporative dry eye. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2003; 506:389-99. [PMID: 12613938 DOI: 10.1007/978-1-4615-0717-8_56] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- D A Sullivan
- Schepens Eye Research Institute, and Harvard Medical School, Boston, Massachusetts, USA
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