How red is a white eye? Clinical grading of normal conjunctival hyperaemia

Diamond Bur Microblepharoexfoliation Combined with Intense Pulse Light and Meibomian Gland Expression for Evaporative Dry Eye: A Short-term Controlled Clinical Trial

INTRODUCTION

To assess the efficacy and safety of the combination of microblepharoexfoliation (MBE), intense pulse light (IPL) and meibomian gland expression (MGX) for treatment of meibomian gland dysfunction (MGD).

METHODS

This was a prospective, parallel-control trial conducted from April 2022 to January 2023. Participants were assigned to receive either three sessions of MBE-IPL-MGX treatment and home-based therapy (treatment group) or home-based therapy alone (control group). Outcome measures were assessed at baseline and after 2-month follow-up.

RESULTS

Seventy eyes of 70 patients were enrolled. MBE-IPL-MGX treatment achieved better improvements than home-based therapy in ocular surface disease index (OSDI) and symptom assessment in dry eye (SANDE) scores, noninvasive tear film break-up time (NIBUT), lipid layer grade (LLG), loss area meibomian gland (LAMG) and meibomian gland yielding secretion score (MGYSS). The mean differences between the two groups were as follows: OSDI (- 11.23 ± 4.68 points, P < 0.001), SANDE (- 24.63 ± 13.41 points, P < 0.001), NIBUT (1.3 ± 1.57 s, P = 0.033), LLG (0.4 ± 0.04 points, P = 0.003), LAMG (- 2.85 ± 1.69%, P = 0.023) and MGYSS (7.5 ± 2.32 points, P < 0.001). In addition, the increment (Δ) of MGYSS after MBE-IPL-MGX treatment was significantly higher in MGD grades 2 and 3 (all P < 0.001).

CONCLUSIONS

MBE-IPL-MGX treatment is an effective and well-tolerated procedure that improves dry eye symptoms and signs as well as meibomian gland secretions in patients with MGD. In addition, this treatment is recommended for MGD grades 2 and 3.

The influence of large-diameter multifocal contact lens on ocular surface, visual quality, and visual function for presbyopic adults with dry eye syndromes

This study investigated the influence of large-diameter multifocal contact lenses on the ocular surface, visual quality, and visual function for presbyopic adults with dry eye syndromes. The study enrolled 40-55-year-old adults with presbyopia and dry eye syndromes (DES). The subjects were randomly assigned to three groups wearing different designs of contact lenses (Proclear, SMR, and Optimum) for 6-8 h a day for two weeks. Ocular surface health, tear quality, visual quality, and visual function were measured before and after lens wear. No significant difference was observed across all three groups for the amount of conjunctival redness, blink frequency (lens on), and stereopsis vision before and after wearing. Although there seemed to be a significant declining trend for corneal staining and limbal redness, non-invasive tear break-up time (TBUT), and lipid layer thickness while lens wear, the measured values were all within the normal range. Vice-versa after lens removal, results also showed significant improvement on lipid layer thickness, blink frequency (lens off), and contact TBUT. A significant improvement was observed in the modulation transfer function (MTF) of the total area ratio after wearing contact lenses. In contrast, the MTF of the high-order aberration area ratio resulting from lens wear was lower than that of the baseline measurement. There are also significant improvements observed for SMR and Optimum regarding near visual acuity, near point of accommodation, and the subjective questionnaire (OSDI and VBP) scores. Although it is difficult to avoid a specific negative impact on the ocular surface and tear film, visual function and visual quality can still be positively improved, especially shown on larger diameter and distance-center designed multifocal contact lenses.

Machine Learning System for Lung Neoplasms Distinguished Based on Scleral Data

Lung cancer remains the most commonly diagnosed cancer and the leading cause of death from cancer. Recent research shows that the human eye can provide useful information about one's health status, but few studies have revealed that the eye's features are associated with the risk of cancer. The aims of this paper are to explore the association between scleral features and lung neoplasms and develop a non-invasive artificial intelligence (AI) method for detecting lung neoplasms based on scleral images. A novel instrument was specially developed to take the reflection-free scleral images. Then, various algorithms and different strategies were applied to find the most effective deep learning algorithm. Ultimately, the detection method based on scleral images and the multi-instance learning (MIL) model was developed to predict benign or malignant lung neoplasms. From March 2017 to January 2019, 3923 subjects were recruited for the experiment. Using the pathological diagnosis of bronchoscopy as the gold standard, 95 participants were enrolled to take scleral image screens, and 950 scleral images were fed to AI analysis. Our non-invasive AI method had an AUC of 0.897 ± 0.041(95% CI), a sensitivity of 0.836 ± 0.048 (95% CI), and a specificity of 0.828 ± 0.095 (95% CI) for distinguishing between benign and malignant lung nodules. This study suggested that scleral features such as blood vessels may be associated with lung cancer, and the non-invasive AI method based on scleral images can assist in lung neoplasm detection. This technique may hold promise for evaluating the risk of lung cancer in an asymptomatic population in areas with a shortage of medical resources and as a cost-effective adjunctive tool for LDCT screening at hospitals.

Developing a Deep Learning Model to Evaluate Bulbar Conjunctival Injection with Color Anterior Segment Photographs

The present research aims to evaluate the feasibility of a deep-learning model in identifying bulbar conjunctival injection grading. Methods: We collected 1401 color anterior segment photographs demonstrating the cornea and bulbar conjunctival. The ground truth was bulbar conjunctival injection scores labeled by human ophthalmologists. Two convolutional neural network-based models were constructed and trained. Accuracy, precision, recall, F1-score, Kappa, and the area under the curve (AUC) were calculated to evaluate the efficiency of the deep learning models. The micro-average and macro-average AUC values for model grading bulbar conjunctival injection were 0.98 and 0.98, respectively. The deep learning model achieved a high accuracy of 87.12%, a precision of 87.13%, a recall of 87.12%, an F1-score of 87.07%, and Cohen's Kappa of 0.8153. The deep learning model demonstrated excellent performance in evaluating the severity of bulbar conjunctival injection, and it has the potential to help evaluate ocular surface diseases and determine disease progression and recovery.

A Novel Human Sex Difference: Male Sclera Are Redder and Yellower than Female Sclera

In a seminal study, Kobayashi and Kohshima (1997) found that the human sclera-the white of the eye-is unique among primates for its whitish color, and subsequent work has supported the notion that this coloration underlies the human ability to gaze follow. Kobayashi and Kohshima also claimed that there is no significant sex difference in sclera color, though no data were presented to support the claim. We investigated sclera color in a standardized sample of faces varying in age and sex, presenting the first data comparing male and female sclera color. Our data support the claim that indeed there is a sex difference in sclera color, with male sclera being yellower and redder than female sclera. We also replicated earlier findings that female sclera vary in color across the adult lifespan, with older sclera appearing yellower, redder, and slightly darker than younger sclera, and we extended these findings to male sclera. Finally, in two experiments we found evidence that people use sclera color as a cue for making judgements of facial femininity or masculinity. When sclera were manipulated to appear redder and yellower, faces were perceived as more masculine, but were perceived as more feminine when sclera were manipulated to appear less red and yellow. Though people are typically unaware of the sex difference in sclera color, these findings suggest that people nevertheless use the difference as a visual cue when perceiving sex-related traits from the face.

Bevacizumab Eye Drops Vs. Intra-meibomian Gland Injection of Bevacizumab for Meibomian Gland Dysfunction-Associated Posterior Blepharitis

Aims

This study aimed to evaluate the efficacy and safety of bevacizumab eye drops compared with those of an intra-meibomian gland (MG) injection of bevacizumab when performed in conjunction with standard lid hygiene in patients with meibomian gland dysfunction (MGD)-associated posterior blepharitis.

Methods

This prospective, open-label, observer-blinded randomized controlled trial included 60 eyes of 30 patients with MGD-associated posterior blepharitis who exhibited lid margin telangiectasia, treated at the Chula Refractive Surgery Center of King Chulalongkorn Memorial Hospital. Patients were randomized to receive lid hygiene plus 0.05% bevacizumab eye drops or a single intra-MG injection of 2.5% bevacizumab. All patients were instructed to perform routine lid hygiene care as demonstrated in an instructional video. Primary outcomes included telangiectasia grading and the lid margin neovascularized area (LMNA). Secondary outcomes included the Ocular Surface Disease Index (OSDI) score, corneal staining, meibum quality, meiboscore, conjunctival redness, fluorescein break-up time (FBUT), lipid layer thickness, treatment compliance, and adverse events. All parameters were evaluated before and 3 months after treatment.

Results

After treatment, there were no significant differences in telangiectasia grade and LMNA between groups (mean difference, −0.14, 95% CI −0.42 to 0.15, p = 0.338, −0.1, 95% CI −1.1 to 0.8, p = 0.761, respectively); however, the injection group exhibited significant improvements in both telangiectasia grade and LMNA, while, in the eye drop group, only telangiectasia grade showed a significant improvement relative to baseline. The injection group also exhibited significant improvements in corneal staining (mean difference, −0.78, 95% CI −1.29 to −0.27, p = 0.003), meiboscores (mean difference, −0.37, 95% CI −0.52 to −0.21, p <0.001), and FBUT (mean difference, 1.25, 95% CI 0.21–2.29, p = 0.019) compared to the eye drop group. OSDI scores, corneal staining, meibum quality, meiboscores, and conjunctival redness significantly improved relative to baseline in both groups. No local and systemic adverse event was observed at month 3 in both groups.

Conclusion

When performed with regular lid hygiene, intra-MG injection and topical application of bevacizumab are safe and effective for improving lid margin telangiectasia and the signs and symptoms of MGD-associated posterior blepharitis. This therapy may represent an alternative or adjunctive treatment for patients with MGD-associated posterior blepharitis.

Results from a Prospective, Open-Label, Phase 4 Pilot Study of Repository Corticotropin Injection for Moderate and Severe Dry Eye Disease

INTRODUCTION

There is a substantial unmet need for effective therapies to treat patients with refractory dry eye disease (DED). The goal of this open-label pilot study was to investigate the efficacy and safety of repository corticotropin injection (RCI; Acthar® Gel; Mallinckrodt Pharmaceuticals) in subjects with DED, most of whom did not experience adequate response to standard-of-care therapies.

METHODS

Adults with moderate or severe-acute DED received 80 U of subcutaneous RCI twice weekly for 12 weeks. Primary efficacy outcomes were improvements in corneal fluorescein staining of superficial punctate keratitis (SPK) lesions and Symptom Assessment in Dry Eye (SANDE) scores. Secondary outcomes included changes in Schirmer's test scores, conjunctival lissamine green staining, erythema, intraocular pressure (IOP), and best corrected visual acuity (BCVA). Adverse events (AEs) were assessed continuously throughout the study.

RESULTS

Fifteen subjects received at least 1 dose of RCI, and 12 subjects completed the study. Compared to baseline (day 1), significantly fewer fluorescein-stained SPK lesions were detected at day 14 (p = 0.0250) and day 84 (p = 0.0240) after RCI treatment. Mean SANDE scores progressively declined from 62.0 at baseline to 46.9 at day 84. Erythema (p = 0.0046), conjunctival lissamine green staining of SPK lesions (p = 0.0317), and IOP (p = 0.0052) were all significantly improved after 12 weeks of RCI therapy. Schirmer's test scores and BCVA showed no significant changes throughout the study. No ocular AEs or deaths occurred, and no new safety signals were identified for RCI.

CONCLUSIONS

These results suggest that RCI may be a safe and effective treatment for moderate and severe DED.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03287635.

Inter-Eye Comparison of the Ocular Surface of Glaucoma Patients Receiving Surgical and Medical Treatments

Background: Ocular surface frequently affects glaucoma patients. In this paper we aimed at evaluating the impact of glaucoma surgery on the ocular surface of patients who received unilateral trabeculectomy. Methods: 26 consecutive patients successfully treated with trabeculectomy on one eye (Trab Eye) and under control with topical treatments on the fellow eye (Med Eye) were included in this observational study. They received IDEEL and OSDI questionnaires, Tear Film Osmolarity (TFO), grading of conjunctival hyperemia, fluorescein tear break-up time (tBUT), grading of corneal staining and Schirmer test. Results: IDEEL and OSDI scores were 48 ± 38 and 11 ± 12, respectively, with moderate correlation (r = 0.50, p = 0.03). Compared with Med eyes, Trab Eyes had higher tBUT (6.5 ± 3.5 vs. 5.1 ± 2.7 s, p = 0.004), lower conjunctival hyperemia (0.8 ± 0.9 and 1.7 ± 1.1 respectively, p < 0.001) and lower corneal staining (0.3 ± 0.5 and 0.6 ± 0.5, respectively, p = 0.03). Correlation between corneal staining and conjunctival hyperemia was 0.55 in Trab Eyes (p = 0.01) and 0.44 in Med Eyes (p > 0.05). Patients with bilateral corneal staining had had threefold worse questionnaire scores (p < 0.05). The duration of treatment and the daily exposure to preservatives did not directly affect OS parameters in this cohort of patients. Conclusions: Patients receiving successful trabeculectomy showed better OS homeostasis (higher TBUT, lower grading of conjunctival hyperemia and corneal staining) than fellow medically treated eyes. Presence of corneal epithelial damage in both eyes is the factor more consistently affecting questionnaire scores.

Transscleral cyclophotocoagulation with MicroPulse® laser versus cyclophotocoagulation with continuous diode laser in patients with open-angle glaucoma

PURPOSE

To present the efficacy and safety of surgical treatment of moderate to advanced stage of open-angle glaucoma using the surgical method of transscleral cyclophotocoagulation with MicroPulse® laser (Iridex, Silicon Valley, California, USA) and to compare these results with those of continuous transscleral cyclophotocoagulation with diode laser.

METHODS

In a prospective observational clinical study 22 patients (30 eyes) with moderate and advanced open-angle glaucoma underwent transscleral cyclophotocoagulation. 15 eyes were treated with transscleral cyclophotocoagulation with MicroPulse® laser with 2500 mW (group A) and 15 eyes with continuous diode laser 810 nm and power between 2000 and 2300 mW (group B). The follow-up period of the study was 12 months.

RESULTS

A reduction of the intraocular pressure > 30% was achieved in 53.3% of the group A and in 60% of the group B during the follow-up period of 12 months. A statistically significant decrease of the number of antiglaucoma agents was observed in group A. One eye (6.6%) of group A underwent additional antiglaucoma procedures to achieve target intraocular pressure. The corresponding percentage is 40% in group B. The postoperative inflammatory response was significantly more limited in group A compared to group B.

CONCLUSIONS

The transscleral cyclophotocoagulation with MicroPulse® diode laser with 2500 mW achieves a similar decrease of the intraocular pressure as cyclophotocoagulation with continuous diode laser for the first postoperative months, but more satisfactory reduction of the number of eye drops as well as more limited postoperative inflammatory response.

CLEAR - Contact lens technologies of the future

Contact lenses in the future will likely have functions other than correction of refractive error. Lenses designed to control the development of myopia are already commercially available. Contact lenses as drug delivery devices and powered through advancements in nanotechnology will open up further opportunities for unique uses of contact lenses. This review examines the use, or potential use, of contact lenses aside from their role to correct refractive error. Contact lenses can be used to detect systemic and ocular surface diseases, treat and manage various ocular conditions and as devices that can correct presbyopia, control the development of myopia or be used for augmented vision. There is also discussion of new developments in contact lens packaging and storage cases. The use of contact lenses as devices to detect systemic disease has mostly focussed on detecting changes to glucose levels in tears for monitoring diabetic control. Glucose can be detected using changes in colour, fluorescence or generation of electric signals by embedded sensors such as boronic acid, concanavalin A or glucose oxidase. Contact lenses that have gained regulatory approval can measure changes in intraocular pressure to monitor glaucoma by measuring small changes in corneal shape. Challenges include integrating sensors into contact lenses and detecting the signals generated. Various techniques are used to optimise uptake and release of the drugs to the ocular surface to treat diseases such as dry eye, glaucoma, infection and allergy. Contact lenses that either mechanically or electronically change their shape are being investigated for the management of presbyopia. Contact lenses that slow the development of myopia are based upon incorporating concentric rings of plus power, peripheral optical zone(s) with add power or non-monotonic variations in power. Various forms of these lenses have shown a reduction in myopia in clinical trials and are available in various markets.

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.

Bulbar Redness and Dry Eye Disease: Comparison of a Validated Subjective Grading Scale and an Objective Automated Method

SIGNIFICANCE

In this study, assessments of conjunctival redness were performed to evaluate whether patients with or without dry eye disease (DED) could be discriminated based on this measure. Our findings suggest that subjectively grading redness by quadrant, as opposed to automated en face measurements, may be more suitable for this purpose.

PURPOSE

This study aimed to quantify bulbar redness using the validated bulbar redness (VBR) grading scale and an automated objective method (Oculus Keratograph 5M; K5M) in participants with DED and non-DED controls.

METHODS

Participants with DED (Ocular Surface Disease Index score ≥20 and Oxford scale corneal staining ≥2) and controls (Ocular Surface Disease Index score ≤10 and corneal staining ≤1) attended two study visits. In part 1A of visit 1, baseline bulbar redness was graded with the VBR scale in each conjunctival quadrant of both eyes, followed by automated measurements of temporal and nasal redness with the K5M. This was immediately followed by part 1B, during which a topical vasoconstrictor was instilled into both eyes. Redness assessments were repeated 5 and 30 minutes after instillation with both instruments. Participants returned 14 days later for visit 2, where the same assessments as for visit 1A were repeated.

RESULTS

Seventy-four participants (50 DED and 24 controls) completed the study. There were statistically significant differences in redness between the DED and control groups when assessed with the VBR scale (14/16 comparisons; all, P < .05), whereas no significant differences in K5M-derived redness between the DED and non-DED groups were found at any location or time point. Both subjective and objective instruments detected statistically significant reductions in redness 5 and 30 minutes after instillation of the vasoconstrictor (all, P < .01).

CONCLUSIONS

Although both subjective and objective instruments were sensitive to detecting changes in redness induced by vasoconstriction, statistically significant differences in redness between DED and control groups were only found using the VBR scale.

Deep Learning Algorithm for Automated Detection of Polycystic Ovary Syndrome Using Scleral Images

The high prevalence of polycystic ovary syndrome (PCOS) among reproductive-aged women has attracted more and more attention. As a common disorder that is likely to threaten women's health physically and mentally, the detection of PCOS is a growing public health concern worldwide. In this paper, we proposed an automated deep learning algorithm for the auxiliary detection of PCOS, which explores the potential of scleral changes in PCOS detection. The algorithm was applied to the dataset that contains the full-eye images of 721 Chinese women, among which 388 are PCOS patients. Inputs of the proposed algorithm are scleral images segmented from full-eye images using an improved U-Net, and then a Resnet model was applied to extract deep features from scleral images. Finally, a multi-instance model was developed to achieve classification. Various performance indices such as AUC, classification accuracy, precision, recall, precision, and F1-score were adopted to assess the performance of our algorithm. Results show that our method achieves an average AUC of 0.979 and a classification accuracy of 0.929, which indicates the great potential of deep learning in the detection of PCOS.

Comparative analysis of ocular redness score evaluated automatically in glaucoma patients under different topical medications

PURPOSE

To compare ocular redness score calculated automatically between glaucoma patients and healthy controls, and to assess the associations between this score and both demographical and clinical characteristics.

METHODS

Glaucoma patients under different topical medications and matched controls were enrolled in this observational cross-sectional study. The Keratograph 5M (Oculus Optikgeräte GmbH) was used to automatically measure 5 redness scores: global; nasal bulbar; temporal bulbar; nasal limbal; temporal limbal. The Student t and ANOVA tests were used to compare continuous variables between groups. A multiple linear regression analysis was performed to evaluate the associations between redness scores and the use of different active principles.

RESULTS

One hundred two glaucoma patients and 32 controls were included. Ocular redness scores were significantly higher in glaucoma patients compared to controls (always p < 0.001). The number of active principles was significantly associated with all the redness scores (always p < 0.05). The use of carbonic anhydrase inhibitors (CAIs) was the strongest predictor of overall redness, followed by prostaglandin analogs (PAs) and alpha-adrenergic agonists (AAAs) (respectively, β = 0.400, p = 0.002; β = 0.330, p = 0.013; β = 0.311, p = 0.044). The post hoc analysis measuring the effect of different PAs on redness scores showed that overall redness and bulbar nasal redness scores were significantly lower in patients using tafluprost and latanoprost compared to those using travoprost and bimatoprost 0.01% (respectively, p = 0.025 and p = 0.024).

CONCLUSION

Ocular redness was significantly higher in patients with glaucoma compared to control subjects. The number of active principles and the use of PAs, CAIs and AAAs were associated with higher redness scores.

Impact of pterygium on the ocular surface and meibomian glands

PURPOSE

To analyze how ocular surface parameters correlate to presence of pterygium and investigate the possible impact of pterygia on tear film findings and meibomian glands findings.

METHODS

We investigated objective parameters of the ocular surface such as conjunctival hyperemia, tear film stability and volume, meibomian gland dysfunction, dry eye disease, corneal topography comparing healthy individuals and correlating with the pterygium clinical presentation.

RESULTS

A total of 83 patients were included. Corneal astigmatism induction was 2.65 ± 2.52 D (0.4-11.8). The impact of pterygium on the ocular surface parameters compared to matched controls was seen in: conjunctival hyperemia (control 1.55±0.39/pterygium 2.14±0.69; p = 0.0001), tear meniscus height (control 0.24±0.05 mm/pterygium 0.36±0.14mm; p 0.0002), meiboscore lower eyelid (control 0.29±0.64/pterygium 1.38±0.95; p 0.0001) and meiboscore upper eyelid (control 0.53±0.62/pterygium 0.98±0.75; p = 0.0083). We found a high number of pterygium patients (88%) presented meibomian gland alterations. Interestingly, meibomian gland loss was coincident to the localization of the pterygium in 54% of the upper and 77% lower lids.

CONCLUSION

Pterygium greatly impacts on ocular surface by inducing direct alterations in the pattern of meibomian glands besides corneal irregularities, conjunctival hyperemia and lacrimal film alterations, inducing significant symptoms and potential signs of dysfunction.

The short-term physiological impact of switching reusable silicone hydrogel wearers into a hydrogel daily disposable multifocal

Purpose: To evaluate ocular physiological responses to etafilcon A multifocal (etMF) daily disposable (DD) lenses after 4 weeks of wear, when switching from habitual silicone hydrogel (SiHy) daily wear.

Method: A single-arm, open-label, bilateral dispensing study was conducted in 39 habitual spherical SiHy wearers (14 hyperopes; 25 myopes). Clinical visits occurred with habitual SiHy (control) at baseline and after 4 weeks of etMF DD open-eye lens wear at exit. Objective limbal/bulbar hyperemia using the Oculus K5M (0–4) and subjective grading of lid wiper epitheliopathy (LWE) (0–4) were tested for non-inferiority (NI), using a margin of 1 grade. Corneal thickness along a 10 mm cord was measured using the Visante OCT and tested for NI using a 30 μm margin. Corneal staining area was graded (0–100%).

Results: The least-square mean differences (LSMD) and 95% confidence interval (95% CI) between etMF DD and habitual SiHy in central and peripheral corneal thickness (μm) were 3.64 (−2.0, 9.29) and 3.0 (−7.72, 13.72) in hyperopic, and 3.56 (−0.66, 7.78) and 6.40 (−1.62, 14.42) in myopic subjects. The LSMD (95% CI) for bulbar and limbal hyperemia were −0.08 (−0.19, 0.02) and −0.01 (−0.12, 0.09) in hyperopes, and 0.04 (−0.03, 0.12) and 0.04 (−0.04, 0.11) in myopes. The LSMD (95% CI) for LWE were 0.11 (−0.39, 0.60) and 0.30 (−0.07, 0.67) for hyperopes and myopes, respectively.

Conclusions: No clinically significant differences in a variety of physiological responses were found when habitual reusable SiHy daily wear subjects were refitted into hydrogel etMF, when the subjects were followed for 4 weeks.

Inter-visit measurement variability of conjunctival vasculature and circulation in habitual contact lens wearers and non-lens wearers

Background

The inter-visit variation of measuring bulbar conjunctival microvasculature and microcirculation needs to be considered when the results from multiple visits are interpreted. This study examined the inter-visit variability of measuring conjunctival microvasculature and microcirculation in habitual contact lens (HCL) wearers and non-contact lens (NCL) wearers.

Methods

Twenty-eight subjects were recruited including 13 HCL wearers (10 females and 3 males; mean age ± standard deviation, 25.8 ± 4.6 years) who had worn contact lenses on a daily basis for at least 3 years and 15 NCL wearers (10 females and 5 males, age 25.5 ± 4.0 years) were recruited. The temporal bulbar conjunctiva was imaged using a functional slit-lamp bio-microscope (FSLB) imaging system. FSLB imaging was performed in the morning when the HCL wearers did not wear their lenses. The measurements included conjunctival vessel diameter, vessel density, blood flow velocity and flow volume. In addition, conjunctival microvasculature was analyzed using monofractal (Dbox, representing vessel density) and multifractal (D0 representing vessel complexity) analyses. The repeated measurement was conducted at least one week after the first visit and both eyes of each participant were imaged. The coefficient of variation (CV) was calculated as the standard deviation of the differences between test and re-test then divided by the mean of the measurements. The intra-class correlation coefficient (ICC) was also calculated.

Results

No significant differences of all vascular measurements in both the right and left eyes were found between two groups (P > 0.05). Between two measurements on two different visits, the CV was from 2.4% (vessel density D0) to 63.5% (blood flow volume Q) in HCL wearers and from 3.4% (D0) to 40.6% (blood flow volume) in NCL wearers. The ICC was from 0.60 (vessel diameter) to 0.81 (axial blood flow velocity VA) in HCL wearers and from 0.44 (Q) to 0.68 (cross-sectional blood flow velocity VS) in NCL wearers.

Conclusions

The measurement variability of the vessel density of the bulbar conjunctiva appeared to have the smallest inter-visit variation. The measurement variability of the vasculature and circulation in HCL wearers were similar to that in NCL wearers.

Comparison of different smartphone cameras to evaluate conjunctival hyperaemia in normal subjects

Despite the significant advantages that smartphones’ cameras can provide in teleophthalmology and artificial intelligence applications, their use as black-box systems for clinical data acquisition, without adequate information of the quality of photographs can compromise data accuracy. The aim of this study is to compare the objective and subjective quantification of conjunctival redness in images obtained with calibrated and non-calibrated cameras, in different lighting conditions and optical magnifications. One hundred ninety-two pictures of the eye were taken in 4 subjects using 3 smartphone cameras{Bq, Iphone, Nexus}, 2 lighting levels{high 815 lx, low 122 lx} and 2 magnification levels{high 10x, low 6x}. Images were duplicated: one set was white balanced and color corrected (calibrated) and the other was left as it was. Each image was subjective and objectively evaluated. There were no significant differences in subjective evaluation in any of the conditions whereas many statistically significant main effects and interaction effects were shown for all the objective metrics. The clinician’s evaluation was not affected by different cameras, lighting conditions or optical magnifications, demonstrating the effectiveness of the human eye’s color constancy properties. However, calibration of a smartphone’s camera is essential when extracting objective data from images.

Evaluated Conjunctival Blood Flow Velocity in Daily Contact Lens Wearers

OBJECTIVE

This study examined conjunctival microvasculature development in long-term habitual contact lens (HCL) wearers after a night of sleep.

METHODS

Twenty HCL wearers (15 women and 5 men, aged 28.6±6.9 years, mean age±standard deviation) who had worn contact lenses on a daily basis for at least 3 years and 40 noncontact lens (NCL) wearers (23 women and 17 men, aged 36.5±6.6 years, mean age±standard deviation) participated in the study. A functional slitlamp biomicroscopy imaging system was used to image the temporal bulbar conjunctiva. Imaging was performed in the morning while the contact lens wearers were not wearing their lenses after a night of sleep. The conjunctival vessel diameters, blood flow velocities, and flow rates were measured. In addition, fractal analyses were performed to obtain the vessel network density (Dbox) and complexity (D0).

RESULTS

The average blood flow velocity in HCL wearers after a night of sleep was 0.59±0.19 mm/s, which was significantly higher than that in NCL wearers (0.48±0.17 mm/s, P<0.05). The microvessel network density and complexity levels (Dbox=1.64±0.05 and D0=1.71±0.05, respectively) in the HCL wearers were significantly higher than those in NCL wearers (Dbox=1.61±0.05 and D0=1.69±0.04, both P<0.05). The blood flow velocity was positively correlated with the duration of contact lens wear (r=0.46, P<0.05) and with the daily number of lens-wearing hours (r=0.49, P<0.05) in HCL wearers.

CONCLUSIONS

This study identified microvascular alterations in the conjunctiva in response to daily contact lens wear after a night of sleep in long-term daily contact lens wearers. The unrecovered changes may indicate that para-inflammation occurs on ocular surfaces because of contact lens wear and that overnight sleeping with no lenses may not sufficiently restore the ocular surface to an intact state.

An Amplifying Cascade of Contact Lens-Related End-of-Day Hyperaemia and Dryness Symptoms

End-of-day (EOD) symptoms of dryness are too often the cause of poor soft contact lens (SCL) tolerance and abandonment of wear. This review examines an amplifying cascade model for these symptoms, which involve thin tear layers on contact lens (CL) front surfaces being susceptible to evaporation-related short tear breakup (TBU) times. Susceptibility to faster tear loss by evaporation may be exacerbated by other forms of tear instability, such as lipid and mucin deficiencies as well as lens surface soiling. Bulbar and palpebral conjunctival hyperaemia and associated faster evaporation of warmer pre-conjunctival tears could also contribute to evaporative dry eye EOD symptoms. In CL wearers, a cascade of increasing hyperaemia toward the end of day, associated increasing tear temperature and evaporative loss, shortened TBU times (TBUTs) and increased osmolarity, all elevate the risk of higher symptom levels according to progressive amplification of this cascade. Chronic wound healing responses to SCL wear, perhaps related to limbal conjunctival trauma, stem cell deficiency and persistent epitheliopathy, as well as one or more immune responses, may contribute directly or indirectly to inflammation and the amplifying evaporative dryness cascade. A diurnal cycle that culminates in EOD symptoms appears to involve a process of recovery from causal mechanisms after lens removal, which allows lenses to be worn comfortably, at least initially the next day. Possible recovery processes are discussed in this review as are procedures that may help de-amplify an inflammatory, evaporative dryness cascade and alleviate EOD symptoms. Evidence of an accrual of adverse responses over long periods of more or less successful lens wear indicate an incremental failure to recover from EOD hyperaemia. Such incremental failure could help explain how SCL wear too often needs to be abandoned after many years of comfortable wear.

Ocular Impression-Taking-Which Material Is Best?

OBJECTIVES

To assess the efficacy and effect on clinical signs of a polyvinylsiloxane (Tresident; Shütz Dental Group GmbH, Germany) compared with an irreversible hydrocolloid (Orthoprint; Zhermack SpA, Badia Polesine, Italy) for ocular impression-taking.

METHODS

Twenty subjects were recruited (13 female and 7 male), with mean age 31.1±4.6 years (SD) (range 25.8-39.7). Subjects attended for 2 sessions, each of 1-hr duration, on 2 separate days. Each session was scheduled at the same time on each day. At each visit, the subject underwent an ocular impression procedure, using either Tresident or Orthoprint, in random order and to one eye only. Investigator 2 was blind to this assignment. Two experienced practitioners conducted the study, investigator 1 performed the ocular impression procedures and investigator 2 observed and assessed the clinical signs: logMAR visual acuity, ocular surface staining, tear break-up time (TBUT), and ocular hyperemia.

RESULTS

Visual acuity was unaffected by either material; TBUT was marginally disrupted by both materials, but was not clinically significant according to published criteria; ocular redness increased with both materials; and corneal staining was significantly greater after Orthoprint impression. Less redness and clinically insignificant staining after impression-taking, with fewer clinical complications, was found after use of Tresident.

CONCLUSIONS

Tresident offers a quicker, more effective, and clinically viable method of obtaining ocular impression topography compared with the traditional Orthoprint, and Orthoprint causes significantly more superficial punctuate staining of the corneal epithelium than Tresident.

Put a (Limbal) Ring on It: Women Perceive Men's Limbal Rings as a Health Cue in Short-Term Mating Domains

Limbal rings are dark annuli encircling the iris that fluctuate in visibility based on health and age. Research also indicates their presence augments facial attractiveness. Given individuals' prioritization of health cues in short-term mates, those with limbal rings may be implicated as ideal short-term mates. Three studies tested whether limbal rings serve as veridical health cues, specifically the extent to which this cue enhances a person's value as a short-term mating partner. In Study 1, targets with limbal rings were rated as healthier, an effect that was stronger for female participants and male targets. In Study 2, temporally activated short-term mating motives led women to report a heightened preference for targets with limbal rings. In Study 3, women rated targets with limbal rings as more desirable short-term mates. Results provide evidence for limbal rings as veridical cues to health, particularly in relevant mating domains.

Corneal Swelling with Cosmetic etafilcon A Lenses versus No Lens Wear

Purpose

To determine if the use of pigments or adding polyvinyl pyrrolidone during the fabrication of 1-DAY ACUVUE DEFINE (AD) brand contact lenses impacts open-eye corneal swelling compared with no lens wear (NLW).

Methods

A partial double-masked, randomized, bilateral crossover study was conducted in 24 Asian subjects using AD, 1-DAY ACUVUE DEFINE with Lacreon (ADL), NLW, and a control lens with no tint (1-DAY ACUVUE MOIST [AM]). Central corneal thickness was measured before insertion and immediately after removal after 8 ± 1 h of open-eye wear using an optical pachymeter in one eye. Corneal thickness along a 10-mm cord was measured in the contralateral eye using the Visante optical coherence tomographer (OCT). Corneal swelling was tested for noninferiority using a 5% margin. The endothelial bleb response was measured at baseline and 20 min after lens insertion using specular microscopy. Subjective grading of corneal staining and limbal/bulbar hyperemia were also monitored.

Results

After 8 ± 1 h of open-eye wear, central corneal swelling across the study lenses with either optical pachymeter or OCT methods was negligible. Peripheral corneal swelling least-square mean differences with OCT were −0.03% (95% confidence interval [95% CI], −0.65 to 0.58%) and −0.26% (95% CI, −0.87 to 0.36%) between AD and ADL and the control lens (AM), respectively, and 1.67% (95% CI, 1.06 to 2.29%) and 1.45% (95% CI, 0.84 to 2.06%) between AD and ADL and NLW, respectively. No endothelial blebs were observed. No clinically significant differences were distinguished between the lenses and NLW for corneal staining and limbal/bulbar hyperemia.

Conclusions

After 8 ± 1 h of open-eye wear, central and peripheral corneal swelling along the horizontal meridian with AD, ADL, AM, and NLW were equivalent. These results confirm that the addition of polyvinyl pyrrolidone or pigments to etafilcon A to obtain a limbal ring design have no impact on corneal swelling or limbal/bulbar hyperemia during normal open-eye wear.

Prediction of Changes in Visual Acuity and Contrast Sensitivity Function by Tissue Redness after Pterygium Surgery

PURPOSE

The goal of this study was to predict visual acuity (VA) and contrast sensitivity function (CSF) with tissue redness grading after pterygium surgery.

MATERIALS AND METHODS

A total of 67 primary pterygium participants were selected from patients who visited an ophthalmology clinic. We developed a semi-automated computer program to measure the pterygium fibrovascular redness from digital pterygium images. The final outcome of this software is a continuous scale grading of 1 (minimum redness) to 3 (maximum redness). The region of interest (ROI) was selected manually using the software. Reliability was determined by repeat grading of all 67 images, and its association with CSF and VA was examined.

RESULTS

The mean and standard deviation of redness of the pterygium fibrovascular images was 1.88 ± 0.55. Intra-grader and inter-grader reliability estimates were high with intraclass correlation ranging from 0.97 to 0.98. The new grading was positively associated with CSF (p < 0.01) and VA (p < 0.01). The redness grading was able to predict 25% and 23% of the variance in the CSF and the VA, respectively.

CONCLUSIONS

The new grading of pterygium fibrovascular redness can be reliably measured from digital images and showed a good correlation with CSF and VA. The redness grading can be used in addition to the existing pterygium grading.

Lid Wiper Microvascular Responses as an Indicator of Contact Lens Discomfort

PURPOSE

To analyze quantitatively the alterations in the microvascular network of the upper tarsal conjunctiva, lid wiper, and bulbar conjunctiva relative to ocular discomfort after contact lens wear.

DESIGN

A prospective, crossover clinical study.

METHODS

Functional slit-lamp biomicroscopy was used to image the microvascular network of the upper tarsal conjunctiva, lid wiper, and bulbar conjunctiva. The microvascular network was automatically segmented, and fractal analyses were performed to yield the fractal dimension (D_box) that represented vessel density. Sixteen healthy subjects (9 female and 7 male) with an average age of 35.5 ± 6.7 years (mean ± standard deviation) were recruited. The right eye was imaged at 9 AM and 3 PM at the first visit (day 1) when the subject was not wearing contact lenses. During the second visit (day 2), the right eye was fitted with a contact lens for 6 hours. Microvascular imaging was performed before (at 9 AM) and after lens wear (at 3 PM). Ocular comfort was rated using a 50-point visual analog scale before and after 6 hours of lens wear, and its relationships with microvascular parameters were analyzed.

RESULTS

There were no significant differences in D_box among the upper tarsal conjunctiva, lid wiper, and bulbar conjunctiva among the measurements at 9 AM (day 1 and day 2) and 3 PM (day 1) when the subjects were not wearing the lenses (P > .05), whereas after 6 hours of lens wear, the microvascular network densities were increased in all 3 of these locations. D_box of the lid wiper increased from 1.411 ± 0.116 to 1.548 ± 0.079 after 6 hours of contact lens wear (P < .01). D_box of the tarsal conjunctiva was 1.731 ± 0.026 at baseline and increased to 1.740 ± 0.030 (P < .05). D_box of the bulbar conjunctiva increased from 1.587 ± 0.059 to 1.632 ± 0.060 (P < .001). The decrease in ocular discomfort was strongly related to the D_box change in the lid wiper (r = 0.61, P < .05). There were no correlations between the changes of ocular comfort and the microvascular network densities of either the tarsal or bulbar conjunctivas (P > .05).

CONCLUSIONS

This study is the first to show that the microvascular network of the lid wiper can be quantitatively analyzed in contact lens wearers. The microvascular responses of the lid wiper were significantly correlated with contact lens discomfort.

Dry Eye Signs and Symptoms Persist During Systemic Neutralization of IL-1β by Canakinumab or IL-17A by Secukinumab

To evaluate whether inhibition of the proinflammatory cytokines IL-1β or IL-17A by canakinumab or secukinumab, respectively, influence the signs and symptoms of dry eye.

Assessing ocular bulbar redness: a comparison of methods

PURPOSE

We consider whether quantification of ocular bulbar redness, using image processing of relative Red-channel activity (Red-value), can be applied to a clinical sample and how this approach compares to an automated bulbar redness grading technique (Oculus Keratograph 5M, R-scan).

METHODS

Red-values from dry eye patients (n = 25) were determined using image processing of digital photographs over the nasal bulbar conjunctiva. Red-values were compared with subjective grades from six clinicians who graded the images using the IER scale. We considered the level of agreement between the Red-value and automated bulbar redness scores from the commercial instrument (R-scan). Scoring variability for each technique was assessed using the geometric coefficient of variation (gCoV, %). Agreement between techniques was considered with Bland-Altman analyses.

RESULTS

Red-values showed a strong linear relationship (R(2) = 0.99) to the R-scan. The Red-value had least variability (gCoV = 0.97%, 95% CI: 0.76-1.35%). The IER grade showed a linear relationship with Red-value (R(2) = 0.99), bound by a floor effect; it did not discriminate changes in redness below a threshold of 1.75 units (Red-value = 33.0%), after which it paralleled the redness returned by the R-scan. Intra-method variability for the redness returned by the R-scan (gCoV = 9.84%, 95% CI: 7.60-13.94%) and IER grades (gCoV = 7.30%, 95% CI: 1.73-10.31%) was similar (p > 0.05). Bland-Altman analysis showed the R-scan was consistently biased towards lower absolute redness scores than the IER.

CONCLUSIONS

Digital imaging processing, using relative Red-channel activity, was the least variable of the three techniques. The R-scan and IER showed similar intra-observer variability. The linear relationship between R-scan and Red-value suggests that the R-scan could be derived using similar methods.

Assessment of Bulbar Redness with a Newly Developed Keratograph

PURPOSE

To determine the validity and reliability of the clinical assessment of bulbar redness (BR) using a newly developed corneal topographer.

METHODS

This is a cross-sectional diagnostic evaluation study. The BR scores [Oculus Index (OI)] from 30 eyes of 26 patients with different degrees of conjunctival hyperemia were assessed and scored automatically using a new method: a keratograph equipped with scanning and scoring software. The values obtained via this system were correlated with three image-based comparative subjective scales: the Institute for Eye Research (IER), the Efron, and the Validated Bulbar Redness (VBR) grading scales. The IER and Efron scores were interpolated to 0.1 unit, and the VBR scores were interpolated to 1 unit. We also evaluated the repeatability of each method and the level of agreement between the OI score and the scores achieved using the three other image-based methods.

RESULTS

There was a significant correlation between the OI score and the scores obtained with the IER (r = 0.921, p < 0.001), Efron (r = 0.958, p < 0.001), and VBR (r = 0.965, p < 0.001) scales. The intraobserver intraclass correlation coefficients were 0.947, 0.874, 0.810, and 0.920 for the OI, IER, Efron, and VBR, respectively, and the intraobserver coefficients of repeatability were 13.924, 16.111, 17.684, and 16.900, respectively. Furthermore, the interobserver intraclass correlation coefficients were 0.889, 0.880, 0.884, and 0.881 for the OI, IER, Efron, and VBR, respectively, and the interobserver coefficients of repeatability were 15.934, 16.366, 22.059, and 21.373, respectively.

CONCLUSIONS

The OI is an objective and reliable method for scoring BR. Its reproducibility was the highest of all the four modalities. The keratograph is recommended, therefore, as a suitable alternative for BR assessment.

Comparison between live and photographed slit lamp grading of corneal staining

PURPOSE

To compare live and photographic (still) grades of corneal staining of the same eyes and the repeatability of grading between two investigators.

METHODS

Thirty patients were recruited to participate in a contact lens study, and their level of corneal staining was graded by two investigators in situ (live images), using slit lamp biomicroscopy. Digital still images of the corneal staining were also captured during the study visits. An independent observer selected 105 of the still images graded by investigator 1 and another 105 images graded by investigator 2 and presented them to the original investigator in a random order, on three separate occasions. Grading was performed at the time of the live grading and the three still image sessions, using the Centre for Contact Lens Research corneal staining scale that combines grades of both extent and type to provide an overall "global staining score" from 0 to 10,000 for corneal staining. A comparison was made between live and still grades as well as the intrainvestigator repeatability for the multiple grading of the still images.

RESULTS

The mean (±SD) of corneal staining grades recorded for the same eyes examined live and then later on three occasions was 1795 (±1083) and 714 (±974), respectively, for participants examined by investigator 1 (p < 0.001) and 1854 (±1075) and 461 (±411) for those examined by investigator 2 (p < 0.001). There was a significant difference over the three repeated still grading sessions for each investigator (p < 0.001), although there was a high degree of consistency among the three still grading sessions for each of the investigators: the intraclass correlation for investigator 1 was 0.91 (confidence interval, 0.87 to 0.93) and that for investigator 2 was 0.82 (confidence interval, 0.77 to 0.87).

DISCUSSION

Digital still image grading of corneal staining significantly underrepresented the amount of corneal staining observed through a slit lamp. Clinical investigators graded corneal staining with a high degree of consistency.

Efficacy of a preservative-free formulation of fixed-combination bimatoprost and timolol (Ganfort PF) in treatment-naïve patients vs previously treated patients

PURPOSE

To evaluate, using subgroup analysis, the effect of treatment status on the intraocular pressure (IOP)-lowering efficacy of a preservative-free formulation of fixed-combination bimatoprost 0.03%/timolol 0.5% (FCBT PF).

METHODS

A primary, multicenter, randomized, double-masked, 12-week study compared the efficacy and safety of FCBT PF with preserved FCBT (Ganfort(®)) in 561 patients diagnosed with glaucoma or ocular hypertension. For this analysis, eligible patients were treatment-naïve or had inadequate IOP lowering and underwent a washout of previous treatment. IOP (8 am, 10 am, and 4 pm) was measured at baseline and weeks 2, 6, and 12. Subgroup analysis of the FCBT PF arm assessed changes in average eye IOP from baseline in treatment-naïve vs previously treated patients. To evaluate the effect of treatment status at baseline (treatment-naïve vs previously treated) on IOP reduction in the FCBT PF treatment group, an analysis of covariance model was used with treatment status and investigator as fixed effects, and baseline average eye IOP, age, glaucoma diagnosis, and baseline average eye corneal thickness as covariates. P-values and the 95% confidence intervals were determined using the model.

RESULTS

In the FCBT PF arm, IOP mean changes from baseline ranged from -8.7 mmHg to -9.8 mmHg in treatment-naïve patients (N=50), compared with -7.3 mmHg to -8.5 mmHg in previously treated patients (N=228). Baseline IOP, age, glaucoma diagnosis, and corneal thickness significantly affected IOP reduction in the FCBT PF group. Adjusting for these covariates, FCBT PF had a greater IOP-lowering effect (0.8-1.7 mmHg) in treatment-naïve patients than previously treated patients, which was statistically significant (P≤0.05) at seven of nine time points.

CONCLUSION

In this subgroup analysis, FCBT PF reduced IOP more effectively in treatment-naïve than in previously treated patients possibly due, in part, to altered responsiveness or tachyphylaxis that has been associated with prior ocular hypotensive agent treatment.

Comparison of corneal safety and intraocular pressure-lowering effect of tafluprost ophthalmic solution with other prostaglandin ophthalmic solutions

PURPOSE

The benzalkonium chloride (BAK) content of tafluprost ophthalmic solution (Tapros(®): tafluprost) has been reduced to balance corneal safety and preservative effectiveness (old formulation: 0.01%; new formulation: 0.001%). However, no reports have been published on its clinical effect. Therefore, we conducted a clinical research study to compare the safety of BAK-reduced tafluprost on the ocular surface with other prostaglandin ophthalmic solutions.

METHODS

This clinical study included 28 glaucoma patients (28 eyes) with a treatment history of latanoprost ophthalmic solution (Xalatan(®)) or travoprost ophthalmic solution (Travatan Z(®)), who presented with corneal epithelial disorders. The subjects were switched to BAK-reduced tafluprost, and its effect on the ocular surface was examined after 1 and 2 months of treatment [using fluorescein staining score, hyperemia, tear film breakup time, and intraocular pressure (IOP) lowering].

RESULTS

In all analyzed subjects (N=27), the fluorescein staining score was significantly improved after switching to BAK-reduced tafluprost (P<0.0001). Conversely, the IOP-lowering effect was not notably changed. The subjects switched from latanoprost (n=10) showed significant improvement in fluorescein staining score (P<0.05) as well as in IOP lowering (P<0.01). The subjects switched from travoprost (n=17) also showed significant improvement in fluorescein staining score (P<0.001), but without a significant change in IOP lowering.

CONCLUSIONS

Tafluprost with reduced BAK has potential as a superior antiglaucoma drug, not only for its IOP-lowering effect, but also for its good corneal safety profile.

Task shifting in primary eye care: how sensitive and specific are common signs and symptoms to predict conditions requiring referral to specialist eye personnel?

BACKGROUND

The inclusion of primary eye care (PEC) in the scope of services provided by general primary health care (PHC) workers is a 'task shifting' strategy to help increase access to eye care in Africa. PEC training, in theory, teaches PHC workers to recognize specific symptoms and signs and to treat or refer according to these. We tested the sensitivity of these symptoms and signs at identifying significant eye pathology.

METHODS

Specialized eye care personnel in three African countries evaluated specific symptoms and signs, using a torch alone, in patients who presented to eye clinics. Following this, they conducted a more thorough examination necessary to make a definite diagnosis and manage the patient. The sensitivities and specificities of the symptoms and signs for identifying eyes with conditions requiring referral or threatening sight were calculated.

RESULTS

Sensitivities of individual symptoms and signs to detect sight threatening pathology ranged from 6.0% to 55.1%; specificities ranged from 8.6 to 98.9. Using a combination of symptoms or signs increased the sensitivity to 80.8 but specificity was 53.2.

CONCLUSIONS

In this study, the sensitivity and specificity of commonly used symptoms and signs were too low to be useful in guiding PHC workers to accurately identify and refer patients with eye complaints. This raises the question of whether this task shifting strategy is likely to contribute to reducing visual loss or to providing an acceptable quality service.

Automated grading system for evaluation of ocular redness associated with dry eye

Background

We have observed that dry eye redness is characterized by a prominence of fine horizontal conjunctival vessels in the exposed ocular surface of the interpalpebral fissure, and have incorporated this feature into the grading of redness in clinical studies of dry eye.

Aim

To develop an automated method of grading dry eye-associated ocular redness in order to expand on the clinical grading system currently used.

Methods

Ninety nine images from 26 dry eye subjects were evaluated by five graders using a 0–4 (in 0.5 increments) dry eye redness (Ora Calibra™ Dry Eye Redness Scale [OCDER]) scale. For the automated method, the Opencv computer vision library was used to develop software for calculating redness and horizontal conjunctival vessels (noted as “horizontality”). From original photograph, the region of interest (ROI) was selected manually using the open source ImageJ software. Total average redness intensity (Com-Red) was calculated as a single channel 8-bit image as R – 0.83G – 0.17B, where R, G and B were the respective intensities of the red, green and blue channels. The location of vessels was detected by normalizing the blue channel and selecting pixels with an intensity of less than 97% of the mean. The horizontal component (Com-Hor) was calculated by the first order Sobel derivative in the vertical direction and the score was calculated as the average blue channel image intensity of this vertical derivative. Pearson correlation coefficients, accuracy and concordance correlation coefficients (CCC) were calculated after regression and standardized regression of the dataset.

Results

The agreement (both Pearson’s and CCC) among investigators using the OCDER scale was 0.67, while the agreement of investigator to computer was 0.76. A multiple regression using both redness and horizontality improved the agreement CCC from 0.66 and 0.69 to 0.76, demonstrating the contribution of vessel geometry to the overall grade. Computer analysis of a given image has 100% repeatability and zero variability from session to session.

Conclusion

This objective means of grading ocular redness in a unified fashion has potential significance as a new clinical endpoint. In comparisons between computer and investigator, computer grading proved to be more reliable than another investigator using the OCDER scale. The best fitting model based on the present sample, and usable for future studies, was C4=−12.24+2.12C2HOR+0.88C2RED:C4 is the predicted investigator grade, and C2HOR and C2RED are logarithmic transformations of the computer calculated parameters COM-Hor and COM-Red. Considering the superior repeatability, computer automated grading might be preferable to investigator grading in multicentered dry eye studies in which the subtle differences in redness incurred by treatment have been historically difficult to define.

Evaluation of the ocular tolerance of a novel eyelid-warming device used for meibomian gland dysfunction

PURPOSE

Obstructive meibomian gland dysfunction (MGD) frequently induces a chronic complaint with various symptoms related to dry eye and discomfort. Previous research indicates a pivotal role for heat therapy for melting the meibum as part of any successful management plan, but delivery of constant temperature during treatment is vital. This study evaluated the performance of a novel device designed to deliver controlled, latent, moist heat to the eyelids and surrounding area.

METHODS

The signs, symptoms and ocular temperature of 25 normal subjects (M8, F17; age 29.2±5.7 years) were recorded before and after a 10min application of the Blephasteam(®) device. Ocular temperature (non-invasive ocular thermography; A40 Flir, UK), tear film stability (NIBUT), intra-ocular pressure (IOP), and ocular surface staining and hyperaemia were recorded. Results were checked for normality and compared using paired t-tests.

RESULTS

Temperatures in both eyelids were significantly greater after device application (upper +1.7±0.9°C; lower +2.1±0.7°C, p<0.0005). Bulbar conjunctival hyperaemia significantly decreased after treatment (p<0.005), but limbal and palpebral hyperaemia remained similar (p=0.33 and p=0.11, respectively). Ocular surface staining (p=0.74) and tear film stability (p=0.12) were unchanged in this normal cohort, and there was no significant change in IOP (13.8±2.0mmHg vs 12.9±2.2mmHg; p=0.092).

CONCLUSIONS

The Blephasteam(®) device provides effective levels of warming that would be sufficient to melt meibum, and no adverse ocular responses were recorded in this cohort, indicating that this is a safe device. Interestingly, even in this normal cohort, ocular surface redness appears less after treatment.

Grading of tarsal conjunctiva of young adults in Malaysia

BACKGROUND

The monitoring and assessment of the upper tarsal conjunctiva can be enhanced by the use of a grading scale. The aim of this study was to categorise the appearance of normal tarsal conjunctiva among young adults in Malaysia using the Institute for Eye Research grading scale and to investigate inter- and intra-observer agreement.

METHODS

The appearance of the upper tarsal conjunctiva of 416 non-contact lens wearing subjects aged between 19 to 24 years was assessed by two separate observers for roughness and redness in three separate zones using the Institute for Eye Research grading scale. The average grade for each zone and overall grade for roughness and redness were calculated. Inter- and intra-observer agreements were analysed.

RESULTS

Subjects were categorised for ethnicity and the roughness and redness were calculated. No significant differences were found between Malay and Chinese eyes (p > 0.05). The average grades for the upper tarsal conjunctiva redness and roughness were 0.90 ± 0.25 and 0.86 ± 0.43, respectively. Significantly higher roughness scores were found in zone 1 compared to the other two zones (p = 0.03). Significant association was also found between tarsal conjunctiva redness and roughness (Spearman ρ= 0.45, p < 0.001). Correlation between redness and roughness with age (p = 0.48, p = 0.65) and gender (p = 0.30, p = 0.79) were not significant. Only 2.2 per cent of subjects had scores higher than 2.0 for roughness or redness. Inter- and intra-observer analysis showed good agreement between two observers during the study.

CONCLUSION

The roughness and redness of normal tarsal conjunctiva among young adults in Malaysia were found to be less than two units. Results of this study might be beneficial in clinical trials using contact lenses where changes in the tarsal conjunctiva are commonly used as an outcome measure.

The relationship between clinical signs and dry eye symptoms

PURPOSE

To evaluate (i) the relationship between traditional and new clinical tests (lid-wiper epitheliopathy (LWE), lid-parallel conjunctival folds (LIPCOF)) and dry eye symptoms in non-contact lens wearers, and (ii) that a combination of these tests can improve predictive ability for the development of dry eye symptoms.

METHODS

Tear meniscus height (TMH), non-invasive break-up time (NIBUT), ocular hyperaemia, LIPCOF, phenol red thread test (PRTT), corneal and conjunctival staining, and LWE grades were observed in a cohort of 47 healthy, non-lens wearers (male=17, female=30, median age=35 years, range=19-70). Symptoms were assessed using the Ocular Surface Disease Index (OSDI).

RESULTS

LWE was significantly correlated to both temporal and nasal LIPCOF (0.537 -0.248, P < 0.001). Significant correlations were found between NIBUT and TMH (r=0.461, P=0.001) and PRTT (r = 0.640, P < 0.001). OSDI scores were significant correlated to NIBUT, TMH, PRTT, LIPCOF, and LWE (r>∣0.31∣; P<0.05). Significant discriminators of OSDI+/- were NIBUT (area under the receiver operative characteristic curve (AUC)=0.895), TMH (0.715), PRTT (0.781), LIPCOF (temporal/nasal/Sum 0.748/0.828/0.816), and LWE (0.749). Best predictive ability was achieved by combining NIBUT with nasal LIPCOF (AUC=0.944).

CONCLUSIONS

The individual tests NIBUT, TMH, PRTT, LIPCOF, and LWE were significantly, but moderately, related to OSDI scores. The strongest relationship appeared by combining NIBUT with nasal LIPCOF.

Influence of the blink interval on tear meniscus height in soft contact lens and nonlens wearers

PURPOSE

Tear meniscus height (TMH) is an indirect measurement of tear film volume. This study investigated the temporal changes in the TMH during the blink interval in the morning (8-9 am) and at the end of the day (5-6 pm) in both soft contact lens (CL) and nonlens wearers (NLW).

METHODS

Fifty participants (25 CL; 25 NLW) were evaluated for their subjective symptoms, TMH, noninvasive break up time, and bulbar hyperemia at the am and pm visits on the same day. The TMH was measured at set intervals between 2 and 15 sec during the blink interval, using an optical coherence tomographer.

RESULTS

The NLW group revealed no changes in a variety of symptoms during the day, whereas the CL group reported an increase in dryness (P=0.03) and grittiness (P=0.02) over the day. For both groups, the TMH and calculated tear meniscus volume revealed lower values immediately after the blink and increased progressively afterwards, mainly due to reflex tearing. The am tear meniscus volume values tended to be higher than the pm values for both groups, but this was not significant (NLW P=0.13; CL P=0.82). Noninvasive break up time deteriorated during the day for both groups but was only significant for the CL group (P=0.002), whereas bulbar hyperemia revealed no statistically significant change for either group.

CONCLUSIONS

Reflex tearing may play a substantial role in the TMH differences observed over the blink interval. Standardization of the time when a TMH measurement is performed will be valuable in comparing tear film clinical studies.