Lid wiper epitheliopathy

Artificial intelligence models utilize lifestyle factors to predict dry eye related outcomes

The purpose of this study is to examine and interpret machine learning models that predict dry eye (DE)-related clinical signs, subjective symptoms, and clinician diagnoses by heavily weighting lifestyle factors in the predictions. Machine learning models were trained to take clinical assessments of the ocular surface, eyelids, and tear film, combined with symptom scores from validated questionnaire instruments for DE and clinician diagnoses of ocular surface diseases, and perform a classification into DE-related outcome categories. Outcomes are presented for which the data-driven algorithm identified subject characteristics, lifestyle, behaviors, or environmental exposures as heavily weighted predictors. Models were assessed by 5-fold cross-validation accuracy and class-wise statistics of the predictors. Age was a heavily weighted factor in predictions of eyelid notching, Line of Marx anterior displacement, and fluorescein tear breakup time (FTBUT), as well as visual analog scale symptom ratings and a clinician diagnosis of blepharitis. Comfortable contact lens wearing time was heavily weighted in predictions of DE symptom ratings. Time spent in near work, alcohol consumption, exercise, and time spent outdoors were heavily weighted predictors for several ocular signs and symptoms. Exposure to airplane cabin environments and driving a car were predictors of DE-related symptoms but not clinical signs. Prediction accuracies for DE-related symptoms ranged from 60.7 to 86.5%, for diagnoses from 73.7 to 80.1%, and for clinical signs from 66.9 to 98.7%. The results emphasize the importance of lifestyle, subject, and environmental characteristics in the etiology of ocular surface disease. Lifestyle factors should be taken into account in clinical research and care to a far greater extent than has been the case to date.

A pilot study of morphological features of the eyelid margin with conjunctival goblet cells and MUC5AC in tear film of dry eye

PURPOSE

This study aimed to investigate the morphological features of eyelid margin in dry eye patients and determine their correlations with conjunctival goblet cells, MUC5AC secretion, and clinical tests of tear film.

METHODS

Patients diagnosed with dry eye disease (DED) were asked to complete the evaluations of symptoms and signs of dry eye, including Ocular Surface Disease Index (OSDI) questionnaire, Lipid layer thickness (LLT), partial blinking (PB) rate, tear-film breakup time (TBUT), Schirmer's I test (SIt), and meiboscore. Marx line (ML), lid wiper epitheliopathy (LWE), and meibomian orifices (MOs) were used as indicators of morphological features of the eyelid margin. PAS staining of conjunctival goblet cells and MUC5AC measurement of the tear samples were also performed.

RESULTS

A total of 30 patients diagnosed with DED were included. The ML score was correlated with the SIt. The MOs showed a significant negative correlation with the TBUT and LLT. The LWE was corrected to TBUT and meiboscore, and also associated with decreased conjunctival goblet cell density and MUC5AC concentration in the tear film rather than ML and MOs in the eyelid margin of dry eye patients. The tear MUC5AC concentration had a significant positive correlation with conjunctival goblet cell density.

CONCLUSION

The eyelid margin is crucial for maintaining the integrity of tear film and ocular surface. Attracting more attention to the eyelid margin is beneficial to routine clinical practice, and lid wipers could be used to evaluate the secretion of MUC5AC in the tear film secreted by conjunctival goblet cells.

Investigating the Effect of Reducing the Signs and Symptoms of Lid Wiper Epitheliopathy in Patients With Dry Eye Disease With Perfluorohexyloctane

Background

Perfluorohexyloctane (PFHO) acts to prevent the evaporation of the tear film. It has the potential to limit friction related issues between the eye lid margin and the ocular surface. Prior to the present work, this had not yet been evaluated.

Objective

To examine the potential of using perfluorohexyloctane for reducing the signs and symptoms of lid wiper epitheliopathy (LWE).

Methods

Data were collected at 4 visits spanning 2 months. Patients who had symptomatic dry eye and a LWE score of ≥1.0 on the Korb LWE scale were recruited. Participants were randomized to PFHO 4 times a day or no treatment. Lid wiper epitheliopathy was graded at each visit with the Korb and photographic LWE (PLWE) scales. Symptoms were assessed using the Standard Patient Evaluation of Eye Dryness questionnaire and visual analog scales (0-100).

Results

A total of 52 participants were enrolled (mean ± SD age, 49.7 ± 15.7 years; 79% female). Right eyes in the treatment group were significantly more likely to show an improvement of ≥0.5-units in PLWE scores at 2 months than the no treatment group (P = 0.04), but no left eye differences were noted. Korb and PLWE scores were significantly better in the treatment group compared with the no treatment group starting at 2 weeks and remained so for the duration of the study (all P < 0.001). Standard Patient Evaluation of Eye Dryness scores and dry eye symptoms were significantly better in the treatment than in the no treatment group at the 2-month visit (all P ≤ 0.01).

Conclusions

Perfluorohexyloctane significantly reduced LWE and improved dry eye symptoms compared with no treatment, suggesting that PFHO may enhance ocular lubrication and reduce friction-related damage. Masked, randomized, trials are still needed to compare PFHO to other treatments in participants with LWE to support generalizability of results. ClinicalTrials.gov study NCT06671041.

Effect of lid-wiper epitheliopathy on the corneal epithelial thickness distribution: a novel semiautomatic quantitative method

BACKGROUND

To explore a novel semi-automatic quantitative method for detecting lid-wiper epitheliopathy (LWE) and analyze its impact on the distribution of corneal epithelial thickness (CET).

METHODS

A total of 37 eyes from 37 adults were included in this study. The lid wipers were stained with lissamine green strips, and the stained areas were recorded using a digital slit-lamp biomicroscopy and analyzed using ImageJ software. Factors such as age, sex, and refraction were included as variables that influenced LWE. The CET was divided into 25 regions and recorded using spectral-domain optical coherence tomography.

RESULTS

Methodological consistency and repeatability were verified through intra- and inter-operator intraclass correlation coefficients, with values of 0.889 and 0.922, respectively. After adjusting for age, sex, and spherical equivalent refraction, a negative correlation was observed between LWE and epithelial thickness. Specifically, negative correlations were observed in the nasal, subnasal, and inferior regions within the 2-5 mm range; subnasal and infratemporal regions within the 5-7 mm range; and the infratemporal region within the 7-9 mm range.

CONCLUSIONS

This study validated a novel method for assessing the severity of LWE by quantitatively analyzing the LWE area. Additionally, LWE is associated with thinning of the inferior corneal epithelium.

Prosthetic eye care - The current state of the art

After eye loss, a fast supply with a visually appealing prosthetic eye is not just a cosmetic solution, it is the key factor for a successful social, occupational, and psychological rehabilitation. For a long time, prosthetic eye care was based on acquired experiences, and there was a significant lack of systematic studies and peer-reviewed literature on this subject. However, in recent decades, research in the field of ocular prosthetics has been driven forward by ophthalmologists, ocularists, optometrists, ophthalmoplastic surgeons, and psychologists. Many essential findings have been made for improving the care of anophthalmic patients. In this extensive review, the current state of the art regarding prosthetic eye care based on the newest scientific findings is summarized. The broad focus includes important historical aspects in ocular prosthetics, in particular the historical development that led to ocularistic care with different prosthetic materials - cryolite glass and polymethyl methacrylate. Furthermore, epidemiology and etiology of eye loss, surgical techniques of eye removal as well as types and production of prosthetic eyes are set out. Important topics with new insights include psychological issues such as living with a prosthetic eye, treatment of children with anophthalmia and microphthalmia, as well as evidence-based prosthetic eye maintenance and handling. In addition, anophthalmic socket complications and associated treatment options with a focus on the common dry anophthalmic socket and post-enucleation socket syndromes were described in detail. Finally, we will speculate how the field of prosthetic eye care will develop in the future.

Quarter of a century of contact lens prescribing trends in Australia (2000-2024)

CLINICAL RELEVANCE

Knowledge of contact lens prescribing trends can (a) assist practitioners to benchmark their own prescribing habits, (b) help the contact lens industry understand preferred products, and (c) support academics in scholarly writings.

BACKGROUND

This work aims to document contact lens prescribing trends in Australia over the past quarter of a century.

METHODS

An annual survey of contact lens prescribing trends was conducted in Australia each year from 2000 to 2024, inclusive, by asking optometrists to provide information relating to 10 consecutive contact lens fits undertaken between January and March.

RESULTS

Over the 25-year survey period, a total of 20,281 contact lens fits were reported. Lens wearers were 34.4 ± 14.7 years of age and 65% were female. Over the survey period, rigid lenses increased from 13% to 21% of all lens fits. Of all soft lens fits, silicone hydrogel lenses increased from 22% to 96%; soft torics increased from 24% to 30%; daily disposables increased from 7% to 63%; soft extended wear decreased from 16% to 5%; multifocals increased from 5% to 26%; and myopia control (first fit in 2011) reached 3% by 2024. Rigid lens extended wear (primarily orthokeratology) increased from 0.3% to 17% of rigid lens fits, primarily for myopia control. Multi-purpose lens care solutions are ubiquitous, and peroxide systems are seldom prescribed. Rigid lenses and monthly replacement soft lenses are largely worn full time, whereas daily disposables are worn full time and part time in equal measure. Australian and global prescribing trends are broadly consistent.

CONCLUSIONS

Contact lens fitting trends this century can be characterised as: soft lenses - significant increase in silicone hydrogels, daily disposables, torics and multifocals; rigid lenses - dominance of high-Dk materials, and recent resurgence in scleral and orthokeratology fits. There is little extended wear fitting. Multi-purpose care systems are ubiquitous.

Lid wiper epitheliopathy: Topical review of current identification strategies and future perspectives

Lid Wiper Epitheliopathy (LWE) is a recognized ocular condition affecting visual quality and ocular comfort, characterized by the damage of the marginal conjunctiva of the upper eyelid. This review critically examines the current strategies for LWE identification and explores the multifactorial etiology of LWE and its association with various ocular surface diseases. A literature review conducted on PubMed identified 67 relevant studies, which were analyzed to enhance understanding of LWE's diagnostic criteria and its clinical implications, offering future perspectives on improving diagnostic accuracy and patient outcomes. The association between LWE and contact lens-related discomfort is examined, with studies reporting conflicting findings regarding its prevalence and severity among soft contact lens wearers. Moreover, LWE has been linked to tear film abnormalities, altered tear composition, and eyelid margin abnormalities in non-contact lens wearers, further complicating diagnosis and management. Current LWE grading systems, including subjective methods and semi-objective approaches, are reviewed, highlighting challenges such as subjectivity, complexity, and variability. Recent advances in LWE grading, including semi-automated methods and photographic scales, show promise but face implementation challenges in clinical settings. The review concludes by proposing areas for further research, including investigating factors contributing to LWE onset and development, developing more sensitive diagnostic tools, and exploring the impact of LWE on ocular surface health and visual function. Standardization, validation, and innovation in grading systems are emphasized to enhance diagnostic accuracy and improve clinical outcomes for patients with LWE. Ongoing research in LWE grading is essential for addressing diagnostic challenges and optimizing assessment methodologies in clinical practice.

2024 Charles F. Prentice Medal award lecture: Moments of inspiration

In this Prentice Medal Award lecture, I shall recount my career in vision science in the context of three types of inspiration-"being inspired," "personal inspiration," and "inspiring others." My research has derived inspiration from a variety of sources, such as contemporary and historical research doyens in the ophthalmic field and beyond, artists, Greek philosophers, and abstract constructs such as principles and adages. A given moment of inspiration can range from being a profound experience to a subtle realization during a quiet moment of reflection. Here I shall recount the primary research domains of vision science that have defined my academic career in the context of the three types of inspiration defined above. These research domains are ophthalmic markers of diabetic neuropathy, ocular response to contact lens wear, contact lens-induced parainflammation, contact lens-associated microbial keratitis, grading scales for contact lens complications, contact lens prescribing surveys, material properties of contact lenses, contact lens compliance, history of contact lenses, ocular thermography, and ophthalmic bibliometrics. The notions of "being inspired" and "personal inspiration" are necessarily subjective, although I have endeavored to present them here in a scientific context. Conversely, the notion of "inspiring others" can be objectively gauged, at least in part, by counting article citations or the number of times articles are read online or downloaded from a journal website. In conclusion, my research in the vision sciences has been inspired by others, derived from personal ideas, and perhaps in turn has inspired others.

Discriminative performance of ocular surface staining and lid wiper epitheliopathy in dry eye disease: An investigator-masked, prospective registry-based, diagnostic accuracy study

PURPOSE

To evaluate the diagnostic performance of corneal and conjunctival staining, and lid wiper epitheliopathy (LWE) in detecting dry eye disease, as defined by the global consensus Tear Film and Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) criteria.

METHODS

A total of 2066 community residents (1285 females; mean ± SD age, 40 ± 19 years) were recruited in an investigator-masked, prospective registry-based, diagnostic accuracy study. Dry eye symptomology and ocular surface parameters were assessed in a single clinical session. The Sjögren's International Collaborative Clinical Alliance (SICCA) corneal and conjunctival staining scoring and Korb lid wiper epitheliopathy (LWE) grading were evaluated by an independent masked assessor.

RESULTS

Overall, 807 (39 %) participants fulfilled the TFOS DEWS II criteria for dry eye disease, of which 178 (9 %) participants were classified as moderate-to-severe disease. The discriminative abilities of superior and inferior LWE (C-statistics, 0.724 and 0.712, respectively) were greater than corneal and conjunctival staining (C-statistics, 0.573 and 0.627, respectively). The Youden-optimal diagnostic cut-offs for the SICCA corneal and conjunctival staining scores were both ≥1, and the optimal thresholds for the Korb superior and inferior LWE grades were both ≥1. LWE was more commonly detected in both mild-to-moderate and moderate-to-severe dry eye disease, and demonstrated more consistent correlation with other ocular surface parameters across a broader range of disease severity.

CONCLUSIONS

LWE demonstrates superior diagnostic performance relative to corneal and conjunctival staining. These findings would support the routine incorporation of LWE evaluation as part of the diagnostic workup of dry eye disease.

Epidemiology and Risk Factors of Dry Eye Disease: Considerations for Clinical Management

Dry eye disease is a multifactorial condition characterised by tear film instability, hyperosmolarity and ocular surface inflammation. Understanding the epidemiology of dry eye disease and recognising both modifiable and non-modifiable risk factors can assist eye care practitioners in assessing, treating, and managing patients with the condition. This review considers current knowledge surrounding its incidence and prevalence, as well as associated demographic, systemic, ocular, and iatrogenic, and lifestyle-related modifiable risk factors. Population-based prevalence estimates vary according to the diagnostic criteria used to define dry eye disease, as well as severity and demographic characteristics of the population. Considering recent data and variable population demographics, conservative prevalence estimates suggest that 10-20% of the population over 40 years of age report moderate to severe symptoms and/or seek treatment for dry eye disease. Individuals with specific non-modifiable demographic risk factors may be at increased risk of developing dry eye disease. Advanced age, female sex and East Asian ethnicity have been identified as key non-modifiable demographic features predisposing individuals to dry eye disease. Systemic conditions that have been associated with an increased risk of dry eye disease include migraine, Sjögren syndrome, connective tissue disorders, mental health disorders, diabetes mellitus and androgen deficiency. Medications that may contribute to this risk include antidepressants, antihistamines, and hormone replacement therapy. Ocular and iatrogenic risk factors of dry eye disease include blepharitis, Demodex infestation, ocular surgery, blink completeness, contact lens wear, and topical ophthalmic medications. A range of modifiable lifestyle factors that can increase the risk of dry eye disease have also been identified, including low humidity environments, digital screen use, quality of sleep, diet, and eye cosmetic wear. Dry eye is a common disease affecting millions globally. Increasing knowledge regarding its associated risk factors can better prepare the eye care practitioner to successfully manage patients with this ocular surface disease.

Lubricating drops for contact lens discomfort in adults

BACKGROUND

Contact lens discomfort is a symptom-based clinical diagnosis that affects 13% to 75% of contact lens wearers. The Tear Film and Ocular Surface Society defines contact lens discomfort as "a condition characterized by episodic or persistent adverse ocular sensations related to lens wear either with or without visual disturbance, resulting from reduced compatibility between the lens and ocular environment, which can lead to decreased wearing time and discontinuation from lens wear." Signs of the condition include conjunctival hyperemia, corneal and conjunctival staining, altered blinking patterns, lid wiper epitheliopathy, and meibomian gland dysfunction. Eye care specialists often treat contact lens discomfort with lubricating drops, including saline, although there is no clear evidence showing this treatment is effective and safe.

OBJECTIVES

To evaluate the efficacy and safety of lubricating drops for ocular discomfort associated with contact lens wear in adults.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase.com, two other databases, and two trials registries to May 2024, without date or language restrictions.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs) that evaluated lubricating drops, including saline, versus no treatment, or that evaluated lubricating drops versus saline, in adult contact lens wearers. We included studies regardless of publication status, language, or year of publication.

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology. The critical outcome was contact lens discomfort. Important outcomes were corneal fluorescein staining and conjunctival redness. Adverse outcomes were incident microbial keratitis, inflammatory corneal infiltrates, and participant discontinuation. We assessed risk of bias for outcomes reported in the summary of findings table using the Cochrane risk of bias tool RoB 2, and we rated the certainty of the evidence using GRADE.

MAIN RESULTS

We included seven RCTs conducted in the USA, Canada, Italy, and France. They randomized a total of 463 participants to lubricating drops, saline, or no treatment. Four trials evaluated lubricating drops and saline versus no treatment, but one of them provided no usable outcome data. Three trials evaluated lubricating drops versus saline. Study characteristics All trial participants were adults, and the mean age ranged from 25.7 years to 36.7 years. The proportion of women varied from 15% to 82%. The trials lasted between one and four weeks. Of the five trials that reported contact lens discomfort, we judged three at high risk of bias, and considered the other two had some risk of bias concerns. Lubricating drops (including saline) versus no treatment Lubricating drops compared with no treatment may reduce contact lens discomfort, measured on a 37-point scale (lower is better), but the evidence is very uncertain (mean difference [MD] -5.9 points, 95% confidence interval [CI] -3.74 to -8.05; 2 RCTs; 119 participants). One trial found no difference between lubricating drops and no treatment in "end-of-day" comfort. The trial that compared saline with no treatment provided no results for the control group. Two studies measured corneal fluorescein staining on a scale of 0 to 20 (lower is better). We found low-certainty evidence of little to no difference between lubricating drops and no treatment in changes in the extent (MD -0.15 points, 95% CI -0.86 to 0.56; 2 RCTs; 119 participants), depth (MD -0.01 points, 95% CI -0.44 to 0.42; 2 RCTs; 119 participants), or type (MD 0.04 points, 95% CI -0.38 to 0.46; 2 RCTs; 119 participants) of corneal fluorescein staining scores. Regarding conjunctival redness, measured on a scale of 0 to 4 (lower is better), there was low-certainty evidence of little to no difference between lubricating drops and no treatment in nasal region scores (MD 0.10, 95% CI -0.29 to 0.49; 1 RCT; 73 participants) and temporal region scores (MD 0.00, 95% CI -0.39 to 0.39; 1 RCT; 73 participants). No studies reported microbial keratitis or inflammatory corneal infiltrates, and no trials reported vision-threatening adverse events up to four weeks of treatment. All trials reported the proportion of participants who discontinued participation. In two trials, no participants left any treatment group. Our meta-analysis of another two studies suggests little difference in the number of people who dropped out of the lubricating treatment group versus the no treatment group (risk ratio [RR] 1.42, 95% CI 0.19 to 10.94; 138 participants; low-certainty evidence). Lubricating drops versus saline Lubricating drops may have little to no effect compared with saline on contact lens discomfort measured on a visual analog scale of 0 to 100 (lower is better), but the evidence is very uncertain (MD 9.5 points, 95% CI -4.65 to 23.65; 1 RCT; 39 participants). No studies reported corneal fluorescein staining or conjunctival redness. No studies reported microbial keratitis or inflammatory corneal infiltrates, and no trials reported vision-threatening adverse events up to four weeks of treatment. Our meta-analysis of three studies suggests little difference in the number of people who dropped out of the lubricating treatment group versus the saline group (RR 1.56, 95% CI 0.47 to 5.12; 269 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that lubricating drops may improve contact lens discomfort compared with no treatment, but may have little or no effect on contact lens discomfort compared with saline. Low-certainty evidence also suggests that lubricating drops may have no unwanted effects that would lead to discontinuation over one to four weeks. Current evidence suggests that prescribing lubricating drops (including saline) to people with contact lens discomfort is a viable option. However, most studies did not assess patient-reported contact lens (dis)comfort using a validated instrument. Therefore, further well-designed trials are needed to generate high-certainty evidence on patient-reported outcomes as well as on longer-term safety outcomes.

Analysis of Factors Associated with Anterior Location of Marx's Line

PURPOSE

The study aimed to investigate the factors associated with anterior location of Marx's line in ocular surface and living habits, especially in tear film.

MATERIALS AND METHODS

This cross-sectional study enlisted 483 participants with meibomian gland dysfunction, who were divided into two groups: 160 participants with mild anterior location of Marx's line and 323 participants with moderate-to-severe anterior location. Participants completed a survey of demographic characteristics (sex, age, length of visual terminal use, sleep duration, skin property), and the Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness questionnaires. They also underwent slit-lamp examinations of the lids, and measurements of non-invasive tear break up time, tear meniscus height, fluorescein tear break up time, lipid layer thickness, partial blink rate, lid wiper epitheliopathy, and meibomian gland dropout.

RESULTS

The tear meniscus height (mild:0.21(0.18-0.25), moderate-to-severe:0.19(0.16-0.23), p = 0.004), fluorescein tear break up time(mild:3(2-4),moderate to severe:2(1-3), p = 0.000), max LLT(mild:87(62-100), moderate-to-severe:99(69-100), p = 0.04), average LLT(mild:64.5(47.5-96.75), moderate-to-severe:74(53-100), p = 0.012), min LLT(mild:52(38-75), moderate-to-severe:59(41-85), p = 0.029) differed significantly between mild and moderate-to-severe anterior location of Marx's line, and associated to the anterior location of Marx's line(r=-0.134, p = 0.03; r=-0.194, p = 0.000; r = 0.093, p = 0.041; r = 0.119, p = 0.009; r = 0.105, p = 0.022) However, no statistical significance was observed in the OSDI, SPEED, partial blink rate, non-invasive tear breakup time, lipid layer thickness, meibomian gland dropout and lid wiper epitheliopathy(p > 0.05). Meanwhile, in the demographic characteristics, statistically significant correlations were associated with skin property(r = 0.154, p = 0.001) and sleep duration(r=-0.124, p = 0.006), but not with age, sex, and the length of visual terminal use (p > 0.05).

CONCLUSIONS

Lower TMH and shorter TBUT positively correlated with anterior location of the Marx's line, and were risk factors. Meanwhile, participants with oily skin and shorter sleep duration were more likely to exhibit anterior location of Marx's line.

Conjunctival Chalasis Should Not be Overlooked: Investigation Into Postoperative Ocular Surface Changes in Involutional Blepharoptosis

BACKGROUND

Involutional blepharoptosis is common among elderly people. The tightening of eyelids postptosis surgery could potentially increase friction between the eyelid and the ocular surface, but this hypothesis has not yet been substantiated by research. The authors explored the relationship between involutional blepharoptosis surgery and friction-related diseases, namely conjunctivochalasis, lid wiper epitheliopathy, and superior limbic keratoconjunctivitis.

METHODS

We conducted a prospective study involving 31 patients who underwent levator advancement for involutional blepharoptosis. Both preoperatively and 6 weeks postoperatively, the authors assessed a range of outcome measures, including margin reflex distance-1, 2, tear film break-up time, superficial punctate keratopathy, inferior conjunctivochalasis, upper lid wiper epitheliopathy, and superior limbic keratoconjunctivitis.

RESULTS

Conjunctivochalasis was detected in 18 eyes preoperatively and 20 eyes postoperatively. Lid wiper epitheliopathy was detected in 2 eyes preoperatively and in no eyes postoperatively. Superior limbic keratoconjunctivitis was detected in 2 eyes preoperatively and 1 eye postoperatively. From preoperative to postoperative assessments, conjunctivochalasis worsened in 11 eyes (17.2%), and there were no eyes with worsening lid wiper epitheliopathy or superior limbic keratoconjunctivitis. There was a significant worsening of superficial punctate keratopathy in the group with exacerbated conjunctivochalasis compared with the unchanged group (0.72 vs. 0.12, P =0.0222). The superficial petechial keratopathy in the 6 cases in which there was worsening of both conjunctivochalasis and superficial petechial keratopathy were all located inferiorly in the cornea.

CONCLUSIONS

Conjunctivochalasis can worsen following ptosis surgery, potentially leading to an increase in inferior superficial punctate keratopathy. When performing involutional blepharoptosis surgery, surgeons should be mindful of the potential implications of friction-related diseases, particularly conjunctivochalasis.

Assessing neophyte response to daily disposable silicone hydrogel contact lenses: A randomised clinical trial investigation over one month

OBJECTIVE

This randomised clinical trial assessed the impact on symptoms, tear film dynamics and ocular surface integrity of daily disposable silicone-hydrogel contact lenses (CLs) over a month, paying special attention to lid wiper epitheliopathy (LWE) and its implications for CL discomfort.

METHODS

Neophyte CL wearers (n = 44, 21.09 ± 5.00 years old) were randomly assigned to either the experimental (n = 24) or control group (n = 20). Participants assigned to the experimental group were required to wear daily disposable CLs for 1 month for at least 8 h/day and 6 days/week. All participants were healthy subjects (no history of ocular surgery or active ocular disease) with spherical refractive errors between -8.00 and +5.00 D and cylindrical power <0.75 D. At the baseline and 1-month sessions, the Dry Eye Questionnaire 5 (DEQ-5) was completed, together with the measurement of tear film osmolarity with the TearLab osmometer, tear meniscus height (TMH) and lipid layer pattern (LLP) using a slit-lamp with Tearscope Plus attached, fluorescein break-up time (FBUT), maximum blink interval (MBI), corneal staining with fluorescein under cobalt blue light and LWE with lissamine green under slit lamp and halogen white light.

RESULTS

At the baseline session, LWE showed a negative correlation with DEQ-5 (r = -0.37, p = 0.02). Significant differences in FBUT and LWE (p = 0.04) and a positive correlation between LWE and DEQ-5 (r = 0.49, p = 0.007) were observed at 1 month. Intrasession analysis at 1 month showed significant differences between the experimental and control groups in DEQ-5, FBUT and LWE (all p ≤ 0.02). Intersession analysis in the experimental group showed variations in DEQ-5, FBUT and LWE (all p ≤ 0.02) but no significant variation in the control group (all p ≥ 0.11).

CONCLUSION

The presence of LWE was significantly correlated with higher symptom values in the DEQ-5. Also, participants in the experimental group presented higher values of LWE after 1 month of CL wear, in comparison with the control group.

End-of-day assessment of asymptomatic versus highly symptomatic soft contact lens wearers

PURPOSE

To investigate differences in key clinical parameters between asymptomatic and highly symptomatic soft contact lens (CL) wearers after 14 h of wear.

METHODS

In this pilot investigation, Phase 1 identified asymptomatic (CLDEQ-8 score ≤ 7) and highly symptomatic (CLDEQ-8 score ≥ 20) subjects after fitting with nelfilcon A CLs. Phase 2 investigated the following over a single nelfilcon A CL-wearing day (14 ± 2 h): blinking characteristics, tear meniscus height (TMH), non-invasive tear break-up time (NIBUT), tear film osmolarity and eyelid margin staining. Parameters for the two groups were compared using linear mixed models and post-hoc testing. The relationship between comfort scores and the clinical parameters was also investigated.

RESULTS

Overall, 161 and 42 subjects were enrolled into Phase 1 and 2, respectively. Twenty-five asymptomatic and 17 symptomatic subjects completed Phase 2. Lower eyelid TMH was decreased after 14 h in symptomatic compared with asymptomatic subjects (least square mean [LSM] difference -0.04 mm, 95% CI: -0.07, -0.01). Osmolarity was lower in symptomatic than in asymptomatic subjects at fitting (LSM difference -9.89, 95% CI: -18.91, -0.86). Upper eyelid margin staining was greater after 14 h in symptomatic than in asymptomatic subjects (LSM difference 0.53, 95% CI: 0.01, 1.05) and greater after 14 h than baseline in the symptomatic group (LSM difference 0.61, 95% CI: 0.16, 1.07). There was a significant relationship between comfort and upper eyelid margin staining (r = -0.40, 95% CI: -0.63, -0.11) and blink rate (r = -0.31, 95% CI: -0.57, -0.003).

CONCLUSION

The potential parameters most effective in differentiating asymptomatic from symptomatic wearers were upper eyelid margin staining and lower TMH. The parameter with the strongest relationship to comfort was upper eyelid margin staining, where higher comfort scores were associated with lower levels of staining.

Influential Signs of Dry Eye-Related Ocular Symptoms in Participants With Unstable Tear Film

PURPOSE

The aim of this study was to investigate the factors influencing dry eye disease (DED)-related ocular symptoms in participants with short fluorescein tear break-up time (FTBUT).

METHODS

This cross-sectional study included 82 participants with short FTBUT (<10 seconds). Examinations included Ocular Surface Disease Index (OSDI), FTBUT, average noninvasive tear break-up time (NIBUTave), lid wiper epitheliopathy, lipid layer thickness, blink rate, partial blink, tear meniscus height, and meibomian gland (MG) evaluation which included ratio of residual MG area (RMGA) and MG grade in tarsal plates. One-way analysis of variance was used to detect differences between symptomatic tear film instability group (FTBUT <5 s, OSDI ≥13), asymptomatic tear film instability group (FTBUT <5 s, OSDI <13), and control group (FTBUT ≥5 s, OSDI <13). A bivariate correlation, partial correlation, and multiple linear regression analyses were used to identify major factors. Only the right eye was included.

RESULTS

Among the participants with FTBUT <5 seconds, symptomatic group showed less upper RMGA ( P < 0.001) and NIBUTave ( P = 0.010). OSDI was negatively associated with upper RMGA ( r = -0.450, P < 0.001) and NIBUTave ( r = -0.414, P = 0.001), and positively associated with upper MG grade ( r = 0.277, P = 0.027). Linear regression analysis showed that the upper RMGA significantly affected OSDI (B = -41.895, P = 0.001), while not significantly correlated with age, upper MG grade, and NIBUTave.

CONCLUSIONS

The upper RMGA might be the main factor affecting DED-related discomfort in participants with unstable tear film, indicating an early ocular change in DED.

A Hue-Value method for semi-automated assessment of Lid Wiper Epitheliopathy

BACKGROUND

Lid wiper epitheliopathy (LWE) is a marker of an abnormal lid/cornea interaction. This study proposes an automated Hue-Value grading algorithm of LWE staining following manual selection of the region of interest.

METHODS

Images of LWE staining were processed using Hue and Value from HSV (Hue-Saturation-Value) color space with a custom MATLAB program. Thirty-one images were successfully analyzed. Examiners analyzed images in random order twice, separated by more than a week. Bland Altman and Intraclass Correlation Coefficients (ICC) were performed.

RESULTS

There was no difference (p > 0.05) between upper (UL) and lower (LL) eyelids for LWE height (UL: 0.12 ± 0.12 mm, LL: 0.12 ± 0.07 mm), width (UL: 10.70 ± 3.84 mm, LL: 10.26 ± 3.49 mm), or area (UL: 2.85 ± 2.67 mm2, LL: 2.63 ± 1.71 mm2). There was no between examiner difference for all eyelid LWE height or area (p > 0.05), but a difference in LWE width (0.16 mm; p = 0.031). ICC for LWE height, width and area were 0.996 (95% CI: 0.993 to 0.998), 0.997 (95% CI: 0.992 to 0.998) and 0.999 (95% CI: 0.998 to 0.999). There was no between examiner difference for height or area (p > 0.05) for UL, but a difference in LWE width (0.28 mm; p = 0.026). ICC for height, width and area were 0.999 (95% CI: 0.996 to 1.00), 0.995 (95% CI: 0.982 to 0.999) and 1.00 (95% CI: 0.999 to 1.00). There was no difference in LWE height, width or area for LL (all p > 0.05). ICC were 0.991 (95% CI: 0.973 to 0.997) for height, 0.998 (95% CI: 0.995 to 0.999) for width and 0.997 (95% CI: 0.990 to 0.999) for area.

CONCLUSIONS

This novel method results in highly repeatable interexaminer measures of LWE staining after general lid region delineation. Small differences in LWE width were observed between examiners.

Impact of the physical properties of contact lens materials on the discomfort: role of the coefficient of friction

Contact Lens Discomfort (CLD) is the main cause in contact lens (CLs) discontinuation, referred in literature as drop-out phenomenon. Despite such evidence was reported in several clinical studies, a relationship between physico-chemical properties of CLs and CLD is not still totally understood. In this regard, the friction of CLs surfaces seems to be related to discomfort feeling events, probably due to an alteration of the lubricate function of the tear film after the CL placement inside the ocular environment. In the last years, many studies have been finalized to the friction measurements of CLs surface, finding conflicting data due to a lack in standardized protocol. The aim of this review is primarily to show evident relationships between CLs surface properties (i.e. wettability, tear evaporation, tear film quality, etc.) and the coefficient of friction (CoF), resulting therefore the most relevant physical quantity in the CLs characterization. In addition, we reported the most recent studies in CLs tribology, which highlight that the introduction of a standard protocol in CoF measurements is necessary to obtain reproducible results, considering the aim to evaluate in a more precise way the relationship between this material surface property and comfort in CLs users.

TFOS Lifestyle: Impact of contact lenses on the ocular surface

Several lifestyle choices made by contact lens wearers can have adverse consequences on ocular health. These include being non-adherent to contact lens care, sleeping in lenses, ill-advised purchasing options, not seeing an eyecare professional for regular aftercare visits, wearing lenses when feeling unwell, wearing lenses too soon after various forms of ophthalmic surgery, and wearing lenses when engaged in risky behaviors (e.g., when using tobacco, alcohol or recreational drugs). Those with a pre-existing compromised ocular surface may find that contact lens wear exacerbates ocular disease morbidity. Conversely, contact lenses may have various therapeutic benefits. The coronavirus disease-2019 (COVID-19) pandemic impinged upon the lifestyle of contact lens wearers, introducing challenges such as mask-associated dry eye, contact lens discomfort with increased use of digital devices, inadvertent exposure to hand sanitizers, and reduced use of lenses. Wearing contact lenses in challenging environments, such as in the presence of dust and noxious chemicals, or where there is the possibility of ocular trauma (e.g., sport or working with tools) can be problematic, although in some instances lenses can be protective. Contact lenses can be worn for sport, theatre, at high altitude, driving at night, in the military and in space, and special considerations are required when prescribing in such situations to ensure successful outcomes. A systematic review and meta-analysis, incorporated within the review, identified that the influence of lifestyle factors on soft contact lens dropout remains poorly understood, and is an area in need of further research. Overall, this report investigated lifestyle-related choices made by clinicians and contact lens wearers and discovered that when appropriate lifestyle choices are made, contact lens wear can enhance the quality of life of wearers.

A review of diagnostic tests for qualitative and quantitative tear film deficiency in dogs

Dry eye disease (DED) is a complex multifactorial condition caused by loss of ocular surface homeostasis from quantitative and/or qualitative tear film deficiency. Schirmer tear test (STT) is often the only diagnostic test used to assess for DED in veterinary practice. STT is invaluable in the diagnosis and monitoring of quantitative tear film deficiency (i.e., keratoconjunctivitis sicca); however, it is not sufficient to optimize therapy and fully recognize other contributing factors for the disturbance in ocular surface homeostasis. The present work reviews diagnostic tests for assessing aqueous tear production in veterinary medicine, as well as the quality of tears, corneal epithelial barrier integrity, and the lacrimal functional unit.

Impact of meibomian gland dysfunction on quality of life and mental health in a clinical sample in Ghana: a cross-sectional study

OBJECTIVES

This study aimed to determine the impact of meibomian gland dysfunction (MGD) on quality of life and psychosomatic conditions.

DESIGN

This was a clinic-based cross-sectional study.

SETTING

This study was conducted at the eye clinic of the University of Cape Coast, Ghana.

PARTICIPANTS

215 clinical subjects visiting the clinic for a comprehensive eye examination.

PRIMARY AND SECONDARY OUTCOME MEASURES

Symptomatic MGD, asymptomatic MGD, quality of life scores, depression, anxiety and stress.

RESULTS

215 clinical subjects consented to participate in the study, but 212 were included in the analysis. The mean age was 21.9 (± 3.8) years, 54 had MGD and 158 did not have MGD served as controls. There was no statistically significant difference in the mean quality of life scores between subjects with MGD and subjects without MGD (t=1.57, p=0.12). The quality of life scores (DEQS) (p=0.022) were significantly higher in the symptomatic MGD group compared with the asymptomatic MGD group. There was no significant difference in quality of life scores (DEQS) (p=0.251) in the asymptomatic MGD group compared with healthy controls. Using Pillai's trace in the MANOVA, there was a significant effect of MGD on depression, anxiety and stress (V=0.05, F(3,208)=3.76, p=0.012). Furthermore, Pillai's trace in the MANOVA showed a significant difference between asymptomatic and symptomatic MGDs for depression, anxiety and stress scores stress (V=0.24, F(3, 51)=5.24, p=0.003).

CONCLUSION

The study revealed no difference in the quality of life scores between MGD and non-MGD groups. However, the symptomatic MGD group had worse quality of life and psychosomatic symptoms than the asymptomatic MGD group and non-MGD group.

Associations Between Lid Wiper Microvascular Responses, Lens Fit, and Comfort After One Day of Contact Lens Adaptation by Neophytes

PURPOSE

To determine associations between lid wiper microvascular responses, lens fit, and comfort after 1 day of contact lens adaptation by neophytes.

METHODS

Functional slitlamp biomicroscopy was used to image the microvascular network of the upper tarsal conjunctiva, lid wiper, and bulbar conjunctiva. Fractal dimension was obtained to represent vessel density. Ultra-high-resolution optical coherence tomography was used to image the lens edge and fitting characteristics, including lens movement and lens-induced conjunctival indentation. Ocular comfort was rated using a 50-point visual analogue scale (VAS). Forty-nine healthy subjects without a history of contact lens wear were recruited. A contact lens was then fitted in the right eye. Imaging was taken at baseline and 6 hr after lens wear.

RESULTS

The changes of VAS comfort score were negatively related to the changes of the vessel density in the lid-wiper (R 2 =0.18, P =0.002) and bulbar conjunctiva (R 2 =0.13, P =0.009). However, the changes of VAS were positively related to the changes in vessel density of the tarsal conjunctiva (R 2 =0.11, P =0.02). The changes of ocular microvasculature were not related to the objective metrics of the lens-fitting characteristics ( P >0.05). Similarly, the changes in the VAS comfort score were not related to the objective metrics of the lens-fitting characteristics ( P >0.05).

CONCLUSION

Contact lens discomfort seemed to relate to lid wiper microvascular responses rather than fitting characteristics after 1 day of contact lens adaptation by neophytes.

Lid wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm

OBJECTIVE

To evaluate the presence of wiper epitheliopathy in patients with blepharospasm and/or hemifacial spasm before and 4 weeks after routine treatment with botulinum toxin.

METHODS

Prospective study comprising 31 eyes of 20 patients with neurological diagnosis of hemifacial spasm (9 eyes of 9 patients) and essential blepharospasm (22 eyes of 11 patients). Various ocular surface parameters were assessed before and 4 weeks after infiltration with botulinum toxin using the OSDI questionnaire, Schirmer's test, tear break-up time (BUT), fluorescein and lissamine green staining assessed with the Oxford test and the degree of involvement of the palpebral wiper.

RESULTS

100% of the patients had palpebral wiper involvement before (30% mild and 70% moderate) and after toxin treatment (100% mild). 75% of patients had mild-normal OSDI before treatment, after treatment it was 80%. The BUT was 7.2 ± 0.2 sg before and 7.5 ± 0.7 sg after treatment. Schirmer's test was 11.4 ± 5.5 and 12.5 ± 5.5 mm before and after treatment. The Oxford test was initially pathological in 69.3% of patients, after 4 weeks it was pathological in only 54%.

CONCLUSION

Wiper epitheliopathy is present in 100% of patients with blepharospasm and/or hemifacial spasm. The main pathophysiological mechanism that triggers it in these patients is the increase in the coefficient of friction, as tear volume and stability are normal.

A Practical Approach to Severity Classification and Treatment of Dry Eye Disease: A Proposal from the Mexican Dry Eye Disease Expert Panel

Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.

Advances in Dry Eye Disease Examination Techniques

Dry eye-related ocular surface examination is very important in the diagnosis and treatment of dry eye disease. With the recent advances in science and technology, dry eye examination techniques have progressed rapidly, which has greatly improved dry eye diagnoses and treatment. However, clinically, confusion remains about which examination to choose, how to ensure the repeatability of the examination, and how to accurately interpret the examination results. In this review, we systematically evaluate previous examinations of dry eye, analyze the latest views and research hotspots, and provide a reference for the diagnosis and management of dry eye.

Video display terminal use and other risk factors for abnormal blinking in children: gender differences

OBJECTIVE

To explore the risk factors for abnormal blinking in children and compare these between boys and girls.

METHODS

Children attending the Children's Optometry Clinic between June 2019 and June 2020 were recruited for the study. The time they had spent viewing video displays (VDTt) over the past 6 months was recorded. Incomplete blinking (IB) and blinking rate were measured and all participants were allocated to groups based on their blink rate (<20 times/min = normal blinking group, NBG; ≥20 times/min = abnormal blinking group, ABG). Tear film (TF) stability was also evaluated. The corresponding statistical methods are used to analyze the data.

RESULTS

A total of 87 boys and 80 girls were enrolled in the study. No significant difference in age was found between the 2 groups. There was a significant difference in TF stability between the two groups (P<0.05). According to binary logistic analysis, VDTt and ocular protection index (OPI) are important risk factors for abnormal blinking, with cut-off values of 1.75 hours and 1.014 respectively in boys; and 1.25 hours and 1.770 respectively in girls. The average of lipid layer thickness was an important protective factor for children using VDT for long periods, with a cut-off value of 58.5 nm in boys and 53.5nm in girls.

CONCLUSION

Risk factors for abnormal blinking in both boys and girls include VDTt and OPI.

Filaggrin Expression in the Lid Margin During Contact Lens Wear

AIM

To investigate the expression of the keratinization-related protein, filaggrin, in the lid margin epithelium of contact lens (CL) wearers compared with nonwearers.

METHODS

This was a cross-sectional study of 100 individuals with different exposures to CL wear: short, moderate, and long experience; previous CL wearers; and nonwearers as controls. Impression cytology samples were collected from the lid wiper (LW) area of the central upper lid margin. After fixing, an equal, random sample was selected from each group (n=13) for immunocytochemistry analysis using antihuman primary anybody (mouse filaggrin), then stained with secondary antibody (fluorescein isothiocyanate-conjugated donkey anti-mouse immunoglobulin G horseradish peroxidase) to detect filaggrin. Imaging was performed with the 3i-Vivo 2-photon microscope equipped with a Zeiss 20×-objective and SlideBook-reader software.

RESULTS

Sixty-five samples from 65 participants (37 women; mean age±SD: 25.1±4.1 years) were collected. Filaggrin was detected in all 65 randomly selected immunostained marginal epithelium samples. All samples were similar in showing patchy areas of filaggrin immunostaining, regardless of CL wear, symptoms or epithelium morphology. Because the filaggrin immunostaining showed similar patterns across almost all the observed samples, comparison between subject groups was impractical. The presence of filaggrin in the healthy LW was additionally confirmed by an independent laboratory.

CONCLUSION

Filaggrin expression seems to be a normal part of epithelial cell differentiation in the lid margin and may not be a useful keratinization/stress biomarker in the marginal epithelium. Investigating other keratinization biomarkers that are not detected in the normal mucocutaneous junction/LW may help to understand the keratinization nature of LW epithelium changes in CL wearers.

Natural course of lid wiper epitheliopathy (LWE) in symptomatic contact lens wearers

PURPOSE

To establish the time course of lid wiper epitheliopathy (LWE) in established CL wearers after a single day (6-10 h) of daily disposable contact lens (CL) wear, the following day post-CL removal and 1-week after CL discontinuation.

METHODS

Twenty-one symptomatic (CLDEQ-8 score ≥ 12) habitual wearers of MyDay® silicone hydrogel daily disposable were included. LWE staining was assessed prior to CL wear (Visit 1, V1) using semi-automated analysis after instillation of two drops of 1 % lissamine green (10 μL) that were applied to the superior bulbar conjunctiva. LWE measurements were repeated after 6-10 h of continuous CL wear (Visit 2, V2), post-CL removal the following day (Visit 3, V3) and after 1-week CL discontinuation (Visit 4, V4). At each visit, ocular symptoms were evaluated using the SPEED-8 questionnaire and set of 0-100 visual analogue scales (VAS).

RESULTS

LWE showed no significant changes after 6-10 h of continuous CL wear (p = 0.536), post-CL removal the following day (p = 0.677) or following 1-week of CL discontinuation (p = 0.478). Analysis revealed a significant improvement in symptomatology between V1 and V2 (SPEED-8, p < 0.01) and also improvements in the 0-100 VAS scores between V2 and V4 for average daily dryness (p < 0.01), end-of-day dryness (p < 0.01) and frequency of end-of-day dryness (p < 0.05).

CONCLUSION

The present data suggest that the etiology of LWE is multifactorial and the sole intervention of temporarily discontinuing CL wear does not lead to resolution of these clinical signs.

Clinical Factors for Determining the Severity of Lid Wiper Epitheliopathy in Dry Eye

PURPOSE

Lid wiper epitheliopathy (LWE) is an epitheliopathy of the marginal conjunctival portion of the eyelids that wipes the ocular surface during blinking. Although LWE is often observed in patients with dry eye, the factors determining LWE severity in dry eye remain unknown. Therefore, we investigated the relationship between LWE, tear abnormalities, and blinks in dry eye.

METHODS

This study involved 76 eyes of 76 female patients with dry eye (mean age: 57.2 yrs). In all eyes, tear meniscus radius, spread grade (SG) of the tear film lipid layer (ie, SG 1-5, with 1 being the best), fluorescein breakup time (FBUT), fluorescein breakup pattern, corneal and bulbar conjunctival epithelial damage (CED: 15 points maximum; CjED: 6 points maximum, respectively), upper eyelid LWE grade (3 points maximum), and Schirmer 1 test were evaluated. Blink rate, palpebral aperture height, upper eyelid opening/closing-phase amplitude, upper eyelid opening/closing-phase duration, and upper eyelid opening/closing-phase maximum velocity were measured by the use of a custom-made high-speed blink analyzer. Finally, the factors that determine the LWE grade were investigated by multiple regression analysis, in which the parameters were chosen using the stepwise procedure.

RESULTS

Significant correlations were found between LWE grade and tear meniscus radius, SG, FBUT, CED, CjED, and Schirmer 1 test (P < 0.002). LWE grade was found to be described as -0.001 + (0.283 × SG) - (0.253 × FBUT) + (0.003 × upper eyelid closing-phase maximum velocity) (R2 = 0.57, P < 0.0001). The prevalence and grade of LWE were significantly higher in aqueous deficient dry eye.

CONCLUSIONS

Tear volume, tear film stability, and blink should be considered as factors for determining LWE severity.

Meibomian Gland Changes in Open-angle Glaucoma Users Treated with Topical Medication

SIGNIFICANCE

Glaucoma patients treated with topical hypotensive eye drops often experience changes in the ocular surface, including the lid margin and the meibomian glands. In this study, the clinical parameters of the ocular surface have been analyzed to detect the presence of meibomian gland dysfunction-related dry eye disease.

PURPOSE

This study aimed to evaluate the meibomian gland dysfunction in glaucoma patients secondary to topical antiglaucomatous treatment.

METHODS

A total of 131 eyes from different patients with open-angle glaucoma treated with topical medication and 92 eyes from different patients with untreated ocular hypertension were consecutively and prospectively enrolled. The structure of the meibomian glands was assessed using noncontact meibography (Keratograph 5M; Oculus, Wetzlar, Germany), and their function was evaluated by measurement of meibomian glands expressibility, the duct appearance, and the Marx line location. Moreover, tear osmolarity measurement, corneal staining score (Oxford scale), and ocular symptom assessment (Ocular Surface Disease Index questionnaire) were performed. We also compared these variables in the glaucoma group according to the presence (or not) of preservative in topical treatment.

RESULTS

Meibomian gland depletion was higher in glaucoma patients with topical medication (P < .001). Furthermore, the quantity of meibomian glands and expressibility of meibum in these patients were altered compared with the control group (P < .001 in both cases). In addition, the glaucoma group presented a higher degree of corneal staining as measured with the Oxford scale (P < .001). The Marx line location score was higher (P < .001 in central Marx line and P < .003 in temporal Marx line) in patients using drugs containing preservative than in those having preservative-free treatment. Logistical regression found that Marx line central, Marx line temporal, quantity of meibum expression, and quality of meibum expression have predictive ability to detect meibomian gland dysfunction-related dry eye disease.

CONCLUSIONS

Glaucoma topical treatments produce meibomian gland dysfunction altering their structure and function, and this condition can be worsened using topical treatments containing preservative.

Ocular surface microvascular response and its relation to contact lens fitting and ocular comfort: an update of recent research

This review examines vascular responses in the ocular surface to contact lens wear and its relation to lens fitting characteristics and contact lens-related discomfort. A search of PubMed was performed to find original research in English, within the past 10 years, that studied the ocular surface, including lid-wiper vascular responses to the lens. The interaction between the lens and ocular surface triggers vascular responses, impacting the lens fitting and contact lens-related discomfort. Contact lens-related discomfort is a multifactorial event, which is affected by lens characteristics. Overall, contact lenses with low modulus and a relatively tight fit produce significant ocular comfort. If an appropriate lens fit is achieved, lens fitting characteristics may not play a critical role in contact lens-related discomfort. On the other hand, the pathogenic and vascular changes of lid-wiper vascular responses appear to play an essential role in developing contact lens-related discomfort, in concert with reactions of the cornea (compression and staining) and conjunctiva (indentation and staining). Robust evaluation of lid-wiper changes at the cellular and microvascular level may hold the key to better understanding the mechanism of contact lens-related discomfort and reveal strategies for eliminating lid wiper epitheliopathy and improving ocular comfort in contact lens wearers.

Impression cytology and meibomian glands in conjunctivochalasis

PURPOSE

To evaluate the tear parameters, meibomian glands and lid margin and tarsal conjunctival impression cytology in patients with conjunctivochalasis (CCH).

METHODS

The study included 57 patients diagnosed with CCH and 35 healthy volunteers. Tear break-up time (TBUT) was measured and Schirmer test was performed. Meibomian gland morphologies, dropout rates, and meiboscores were evaluated using meibography. Finally, impression cytology samples were taken by pressing the impression filters on the lower lid margin and lower tarsal conjunctiva. The samples were evaluated according to the Nelson grading system.

RESULTS

Schirmer test was longer and TBUT was shorter in the study group (p = 0.035 and p < 0.001, respectively). The median of meibomian gland dropout rate was 33.45% (Interquartile range [IQR]; 23.17%-49.75%) and 18.80% (IQR; 12.35%-26.50%) in the study and control groups, respectively (p < 0.001). There was no significant difference in terms of lid-margin cytology between the two groups (p = 0.481). In tarsal conjunctiva cytology, the median value of Nelson grade of the study group was 2 (IQR; 1-2) and that of the control group was 1 (IQR; 1-2) (p = 0.040). When Nelson grade-2 and above was accepted as the pathological limit, it was found that 27.5% of the study group and 15.2% of the control group showed pathological findings (p = 0.204).

CONCLUSIONS

In patients with CCH, damage occurs in the tarsal conjunctiva with the effects of redundant conjunctival folds. In these patients, atrophy occurs in the meibomian glands and tear stability is impaired. Therefore, CCH should not be overlooked in clinical practice.

CLEAR - Evidence-based contact lens practice

Evidence-based contact lens -->practice involves finding, appraising and applying research findings as the basis for patient management decisions. These decisions should be informed by the strength of the research study designs that address the question, as well as by the experience of the practitioner and the preferences and environment of the patient. This reports reviews and summarises the published research evidence that is available to inform soft and rigid contact lens history and symptoms taking, anterior eye health examination (including the optimised use of ophthalmic dyes, grading scales, imaging techniques and lid eversion), considerations for contact lens selection (including the ocular surface measurements required to select the most appropriate lens parameter, lens modality and material selection), evaluation of lens fit, prescribing (teaching self-application and removal, adaptation, care regimen and cleaning instructions, as well as -->minimising risks of lens wear through encouraging compliance) and an aftercare routine.

CLEAR - Effect of contact lens materials and designs on the anatomy and physiology of the eye

This paper outlines changes to the ocular surface caused by contact lenses and their degree of clinical significance. Substantial research and development to improve oxygen permeability of rigid and soft contact lenses has meant that in many countries the issues caused by hypoxia to the ocular surface have largely been negated. The ability of contact lenses to change the axial growth characteristics of the globe is being utilised to help reduce the myopia pandemic and several studies and meta-analyses have shown that wearing orthokeratology lenses or soft multifocal contact lenses can reduce axial length growth (and hence myopia). However, effects on blinking, ptosis, the function of Meibomian glands, fluorescein and lissamine green staining of the conjunctiva and cornea, production of lid-parallel conjunctival folds and lid wiper epitheliopathy have received less research attention. Contact lens wear produces a subclinical inflammatory response manifested by increases in the number of dendritiform cells in the conjunctiva, cornea and limbus. Papillary conjunctivitis is also a complication of all types of contact lenses. Changes to wear schedule (daily disposable from overnight wear) or lens materials (hydrogel from SiHy) can reduce papillary conjunctivitis, but the effect of such changes on dendritic cell migration needs further study. These changes may be associated with decreased comfort but confirmatory studies are needed. Contact lenses can affect the sensitivity of the ocular surface to mechanical stimulation, but whether these changes affect comfort requires further investigation. In conclusion, there have been changes to lens materials, design and wear schedules over the past 20+ years that have improved their safety and seen the development of lenses that can reduce the myopia development. However, several changes to the ocular surface still occur and warrant further research effort in order to optimise the lens wearing experience.

A beginner's guide to mucous membrane grafting for lid margin keratinization: Review of indications, surgical technique and clinical outcomes

The posterior lid margin, where the mucocutaneous junction (MCJ) between the eyelid skin and tarsal conjunctiva is located, plays a critical role in maintaining the homeostasis of the ocular surface. Posterior migration of the MCJ leads to lid-margin keratinization (LMK), which has a domino effect on the delicate balance of the ocular surface microenvironment. This occurs most commonly following Stevens-Johnson syndrome/toxic epidermal necrolysis and is not known to regress spontaneously or with medical therapy. Over time, LMK causes blink-related chronic inflammatory damage to the corneal surface which may have blinding consequences. Lid-margin mucous membrane grafting (MMG) is the only definitive therapy for LMK. Timely MMG can significantly alter the natural course of the disease and not only preserve but even improve vision in affected eyes. Literature searches were conducted on PubMed, using the keywords "mucous membrane grafts," "lid margin keratinization," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "lid related keratopathy," and "lid wiper epitheliopathy". This review, which is a blend of evidence and experience, attempts to describe the indications, timing, surgical technique, postoperative regimen, and clinical outcomes of MMG for LMK. The review also covers the possible complications and pearls on how they can be effectively managed, including how suboptimal cosmetic outcomes can be avoided. The authors hope that this review will aid ophthalmologists, including cornea and oculoplasty specialists, to learn and perform this vision-saving surgery better, with the aim of helping their patients with chronic ocular surface disorders, relieving their suffering, and improving their quality of life.

Trends in Dry Eye Disease Management Worldwide

Dry eye disease (DED) is a condition frequently encountered in ophthalmology practice worldwide. The purpose of this literature review is to highlight the worldwide trends in DED diagnosis and therapy amongst practitioners and determine if a more uniform approach to manage this multifactorial condition has developed over the past two decades. A manual literature search utilizing PubMed was conducted to obtain papers with survey results relating to ophthalmology and optometry diagnosis and treatment of dry eye from January 2000 to January 2020. This did not include data from clinical trials as we were only interested in community clinical practice trends. The terms “dry eye” and “survey” were searched in combination with one or more of the following words or phrases: prevalence, diagnosis, treatment, therapy, etiology, risk factors, therapy, and quality of life. Papers were selected based on their direct applicability to the subject and were only included if they contained relevant survey data from community practitioners. The available literature suggests common trends worldwide in the diagnosis and treatment of DED. These trends have not modified substantially over the past two decades. Practitioner education on the benefits of measuring tear film homeostasis could increase its use as a diagnostic tool to complement current tools. Of the results found, 75% of the papers were published after 2006 and only one paper after 2017. More recent survey results are required to determine if research into DED pathophysiology is altering the current trend in DED management.

Anatomical and physiological considerations in scleral lens wear: Eyelids and tear film

Scleral lenses can affect a range of anterior segment structures including the eyelids and the tears. The eyelids, consisting of the outer skin layer, the middle tarsal plate, and the posterior palpebral conjunctiva, provide physical protection and house the meibomian glands and cilia which have important and unique functions. Tears consist of a mix of aqueous, mucus, and lipidomic components that serve vital functions of lubricity, protection, and nourishment to the ocular surface. Both the eyelids and the tear film interact directly with scleral lenses on the eye and can affect but also be impacted by scleral lens wear. The purpose of this paper is to review the anatomy and physiology of the eyelids and tear film, discuss the effects and impacts of the scleral lenses on these structures, and identify areas that require further research.

Punctate fluorescein staining scores in dogs with or without aqueous tear deficiency

OBJECTIVE

To compare the superficial punctate fluorescein staining in dogs with and without aqueous tear deficiency.

PROCEDURES

An eye from each client-owned dogs presented to Triangle Animal Eye Clinic between January and December 2018 underwent tear and ocular surface tests, which included the Schirmer tear test (STT), phenol red thread test (PRT), and strip meniscometry tube tear test (SMT). Punctate fluorescein staining of the cornea (PFS-C) and the upper palpebral conjunctiva (PFS-UPC) were also performed. Fifty-seven dogs with STT results of <15 mm/min had aqueous tear deficiency (AD); 31 dogs had <10 mm/min and 26 dogs had ≥10 mm/min. The 162 dogs with STT results of ≥15 mm/min did not have AD. The test results of the groups were compared using Kruskal-Wallis and Steel-Dwass multiple comparison tests.

RESULTS

Two hundred and nineteen eyes from 219 dogs were enrolled in this study. The PRT and SMT results, presented as mean ± SD, were significantly lower in the AD group than in the non-AD group (PRT: 29.5 ± 8.1 vs 36.9 ± 5.6 mm/15 s; SMT: 6.2 ± 3.8 vs 10.8 ± 2.8 mm/5 s). The PFS scores were significantly higher in the AD group than in the non-AD group (PFS-C: 4.4 ± 0.7 and 3.7 ± 0.8; PFS-UPC: 2.3 ± 0.5 and 1.7 ± 0.5).

CONCLUSIONS

These results suggest that aqueous tear deficiency is not only reflected by PRT and SMT but also PFS-C and PFS-UPC.

Assessment of mucin-related gene alterations following treatment with rebamipide ophthalmic suspension in Sjögren's syndrome-associated dry eyes

Ocular surface mucins are thought to play vital roles in maintaining the homeostasis of the pre-ocular surface tear film. We performed ocular surface tests with impression cytology to assess the expression levels of mucin-related genes on the ocular surface in healthy eyes. In addition, we investigated alterations in mucin-related gene expression secondary to treatment with rebamipide ophthalmic suspension in patients with Sjögren’s syndrome-associated dry eyes (SS-DE). Thirty-three healthy individuals (control group) and 13 patients from our hospital with SS-DE were enrolled. Impression cytology was performed using Schirmer’s test paper for RNA sampling. The mRNA levels of SAM-pointed domain-containing ETS-like factor (SPDEF), mucin 5AC (MUC5AC), and mucin 16 (MUC16) were determined using a real-time reverse transcription-polymerase chain reaction. The ocular surface test was performed once for the control group, and at baseline as well as 2, 4, 8, and 12 weeks after treatment in the Sjögren’s syndrome-associated dry eyes group. mRNA levels of SPDEF, MUC5AC, and MUC16 were not significantly different between the control and SS-DE groups before rebamipide ophthalmic suspension treatment. SPDEF mRNA levels in control subjects were significantly correlated with levels of MUC5AC. Among SS-DE patients, SPDEF mRNA levels were significantly increased at 2, 4, and 8 weeks after treatment compared with baseline levels. MUC16 mRNA levels were significantly decreased from baseline levels at 4 and 8 weeks post-treatment. Ocular surface test using impression cytology is a clinically useful tool for assessing mucous conditions on the ocular surface and can be used to determine the effects of instillation treatment with eye drops that affect mucin production at the ocular surface.

Relationships between the material properties of silicone hydrogels: Desiccation, wettability and lubricity

Silicone hydrogels (SiHy), represent composite matrices composed of hydrophobic gas permeable silicone (Si) rich core and a surface enriched with hydrophilic polymer moieties. Their utilization in contact lens design requires number of SiHy properties (hydration, wettability, lubricity) to be optimized for the challenging conditions at the ocular surface. Typical limitations in literature are that (i) these properties are studied in isolation, monitoring only one parameter but not the rest of them, and (ii) measurements are performed with hydrated samples immediately after removal from storage solutions. Here we study the simultaneous evolution of critical material properties (evaporative loss of water, water contact angle, coefficient of friction) of different SiHy subjected to continuous blink-like desiccation/rehydration cycling. SiHy with wetting agents incorporated in their core (narafilcon A, senofilcon A) were particularly susceptible to extended desiccation. Stenfilcon A, a material with only 3% bulk Si content maintained its performance for 4 h of cycling, and delefilcon A (80% surface water content) resisted extended 8 h of desiccation/rehydration runs. Strong correlation exists between the evolution of SiHy wettability and lubricity at ≥4 h of blink-like cycling. Understanding the interplay between SiHy properties bears insights for knowledge based design of novel ophthalmic materials.

Impact of Improper Approach to Identify Lid Wiper Epitheliopathy (LWE)

Purpose

Variability in the use of ophthalmic dyes to diagnose lid wiper epitheliopathy (LWE) has led to division in the literature and clinical practice. The principal aim of this study was to evaluate whether the use of a non-optimal methodology to identify LWE had a potential for false negatives; in which LWE was overlooked.

Patients and Methods

A total of 20 participants were initially categorized to not have LWE and were enrolled in this study. The protocol examined whether or not LWE would later be revealed through the use of optimized methodology. Semi-automated analysis was performed of images taken after two different drop instillations with varying post-dye viewing times for both lissamine green (LG) and sodium fluorescein (NaFl).

Results

There was a significant increase in area of staining revealed when an optimal methodology for LWE identification was used. Comparisons for every non-optimal condition were statistically significantly different against the optimal condition (all p<0.01). The use of a non-optimal methodology resulted in a 70% false-negative rate when using LG and a 95% false-negative rate when using NaFl.

Conclusion

The study demonstrated that using a double instillation of dye was statistically different from a single-dose, even with extended wait time for clinical observation. A single instillation did not offer adequate volume of dye for adequate lid margin uptake. A careful adherence to volume as well as a repeat administration is key to revealing the full area of LWE. A non-optimal approach to diagnose LWE can lead to false negatives.