Tear film osmolarity in patients with thyroid ophthalmopathy

Systematic review of ocular surface treatments in the setting of thyroid eye disease

Introduction

Approximately 85% of patients with thyroid eye disease experience ocular surface symptoms. Although corneal exposure plays a role in inducing inflammatory changes to the ocular surface, multiple studies reveal more complexity to the abnormal tear film composition and parameters in thyroid eye disease patients including those who do not have proptosis or increased corneal exposure. Currently, a majority of cases of thyroid associated dry eye symptoms are given treatments intended for ocular surface disease arising from different etiologies.

Methods

Medline via Ovid, Cochrane CENTRAL, PubMed, and Google Scholar were systematically searched for articles evaluating the efficacy of treatments for dry eye symptoms in patients with thyroid eye disease. Articles were from all geographic regions and dates ranged from inception until October 2023.

Results

Seven papers ultimately met inclusion criteria and were included in this review. These papers revealed that multiple topical and non-topical treatment modalities address dry eye symptoms in thyroid eye disease and improve subjective and objective ocular surface parameters. However, due to the few studies that exist and due to disparities in sample size and study design, no overwhelming best practices were identified that could influence clinical practice.

Conclusion

This systematic review identifies the current treatments that exist and highlights the clear unmet need for a large population suffering with dry eye symptoms. Ideally, further well-designed investigations into this area would target topical, non-invasive modalities to develop first line options for thyroid eye disease patients.

Dry Eye Disease: An Update on Changing Perspectives on Causes, Diagnosis, and Management

Dry eye disease is a common clinical problem encountered by ophthalmologists worldwide. Interest in this entity has increased in recent years due to the consequences it has on the ocular surface after any surface procedure. With changing times, several new factors have come to light that can influence this disease. The effect of the COVID-19 pandemic has also been greatly felt, with a range of causes, starting from increased screen work to inflammatory processes, exacerbating the condition in many. With changes in the concepts of the etiopathogenesis of the disease, a paradigm shift has taken place in the approaches to treatment. More researchers are in favor of a new tear film-oriented approach that tries to localize the disease to a single component in the tear film. Innovation of newer techniques for the treatment of meibomian gland disease has also made its foray into clinical ophthalmology. Newer drug formulations and molecules are underway to better treat the inflammatory component of the disease. Many other receptors and targets for the treatment of dry eyes are being researched. This review hopes to provide a succinct, narrative summary of the relevant research on dry eye disease to date to increase awareness about the nature and future course of this disease and its management.

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

Ocular Surface Disease Related to the Inflammatory and Non-Inflammatory Phases of Thyroid Eye Disease

Purpose

This study evaluated the ocular surface disease (OSD), especially dry eye disease (DED) parameters by combining qualitative and quantitative tools, including tear matrix metalloproteinase 9 (MMP-9), in patients with Graves' disease (GD) with and without Thyroid eye disease (TED).

Patients and Methods

A total of 17 active TED, 16 inactive TED, 16 GD without ophthalmopathy, and 16 healthy controls were included. All patients were assessed with CAS, ophthalmometry, qualitative tear MMP-9, Ocular Surface Disease Index (OSDI), ocular surface staining, Schirmer test, meibography, tear meniscus height, conjunctival hyperemia, and non-invasive tear film break-up time. Patients were classified into three subtypes of DED: aqueous tear deficiency, meibomian gland dysfunction (MGD) and mixed dry eye.

Results

Inactive TED was shown to be an associated factor with DED (odds ratio 14, confidence interval 2.24-87.24, p=0.0047), and presented more DED than healthy controls (87.5% versus 33.3%, p=0.0113). MGD was also more prevalent among these subjects than in healthy control (62.5% versus 6.7%; p=0.0273). No significant differences were found in other ophthalmological parameters, except for more intense conjunctival redness among active TED than GD without ophthalmopathy (p=0.0214). Qualitative MMP-9 test was more frequently positive in both eyes among active TED than in other groups (p < 0.0001).

Conclusion

Patients with GD were symptomatic and presented a high prevalence of ocular surface changes and DED, particularly the subgroup with inactive TED. Tear MMP-9 detection was associated with active TED suggesting a relationship between ocular surface changes and the initial inflammatory phase of ophthalmopathy.

Investigation of Conjunctival Goblet Cell and Tear MUC5AC Protein in Patients With Graves' Ophthalmopathy

Purpose

The aim of this study was to investigate conjunctival goblet cell density (GCD) and tear mucin-5AC (MUC5AC) protein levels in patients with Graves' ophthalmopathy (GO) and their association with dry eye indicators.

Methods

A total of 99 patients with GO (54 active, 45 inactive) and 40 healthy controls were recruited. Comprehensive ophthalmic examinations, including the external eye, ocular surface, GCD, and tear MUC5AC ELISA, were performed. The GCD examination was performed in temporal bulbar conjunctiva, including IVCM GCD by in vivo confocal microscopy (IVCM) and filled GCD of cytokeratin-7 and MUC5AC-positive co-immunomarkers by impression cytology. Tear MUC5AC protein was detected using samples extracted from Schirmer strips.

Results

The GO group showed a significant decrease in IVCM GCD, filled GCD, and normalized tear MUC5AC protein compared to controls, with the active GO group showing the greatest decrease (all P < 0.05). Tear MUC5AC protein levels in GO correlated with those of IVCM GCD (r = 0.40, P < 0.001) and filled GCD (r = 0.54, P < 0.001, respectively). Higher ocular surface disease index (r = -0.22, P < 0.05; r = -0.20, P < 0.05; r = -0.21, P < 0.05) and lisamine green staining (r = -0.23, P < 0.05; r = -0.38, P < 0.001; r = -0.42, P < 0.001) were associated with lower tear MUC5AC protein levels, IVCM GCD, and filled GCD, respectively, which decreased with increasing clinical activity score (r = -0.24, P < 0.05; r = -0.28, P < 0.01; r = -0.27, P < 0.01) and conjunctival congestion score (r = -0.27, P < 0.01; r = -0.33, P < 0.001; r = -0.42, P < 0.001).

Conclusions

The goblet cell count and tear MUC5AC protein in GO eyes were decreased, possibly due to ocular surface inflammation.

Translational Relevance

This study observed the change of tear film mucin in GO patients.

The Changes in Ocular Biomechanical Response Parameters and Intraocular Pressure After Surgical Treatment for Thyroid Eye Disease

Purpose

To investigate changes in ocular biomechanical response parameters and intraocular pressure (IOP) in patients with thyroid eye disease (TED) undergoing orbital decompression or anterior blepharotomy.

Methods

Eighty-three eyes from 46 patients receiving orbital decompression (the orbital decompression group) and 45 eyes from 28 patients receiving anterior blepharotomy (the anterior blepharotomy group) were retrospectively enrolled from a tertiary center. Corvis ST tonometry was used to assess ocular biomechanical response and biomechanically corrected IOP (bIOP) pre- and postoperatively. Non-contact tonometry (IOP-NCT) was also performed.

Results

In the anterior blepharotomy group, the margin reflex distance decreased (P < 0001). The highest concavity radius (P = 0.026) and whole eye movement (P = 0.003) increased. Neither IOP-NCT nor bIOP had a significant change. In the orbital decompression group, the extent of exophthalmos decreased (P < 0.001). The A2 length (P = 0.009) decreased. The bIOP did not show a significant change (16.4 ± 2.7 vs. 16.7 ± 4.5; P = 0.415), but the IOP-NCT decreased significantly (17.5 ± 3.3 vs. 16.0 ± 3.3; P < 0.001). Higher baseline IOP-NCT (β = -0.40, P < 0.001) and greater reduction in stiffness parameter A1 (SP-A1; β = 0.05, P = 0.002) were associated with more significant IOP-NCT reduction after the orbital decompression.

Conclusions

Ocular biomechanical response parameters may change after TED surgery, potentially affecting IOP measurements, particularly in patients receiving orbital decompression.

Analysis of diagnostic tests in patients with dry eye and hypothyroidism: an observational study

PURPOSE

Colombia is a country with a high prevalence of hypothyroidism, approximately 18.5% compared to the rest of Latin American countries, which is estimated at 10%. That is why in the ophthalmology consultation we find a large proportion of patients with this disease and who also present symptoms of dry eye. When conducting a search in the medical literature, most publications refer to the clinical presentation of dry eye in hyperthyroidism, which is why the main objective of this study is to evaluate tear function tests in the diagnosis of dry eye in patients with hypothyroidism.

METHODS

This is an observational, cross-sectional study carried out in the period between May and December 2019 in the ocular surface unit of the Ophthalmic Technology Center (CTO) in Bogotá. The tests of: OSDI test (Ocular Surface Disease Index), Schirmer type I, tear meniscus height, NiBUT, Osmolarity, Ferning test, Lisamine Green test of 59 patients with Dry Eye Disease (DED) and history of hypothyroidism.

RESULTS

Schirmer type I and NiBUT tests were the parameters that presented the highest percentage of severity, while lissamine green staining and meniscometry showed a tendency to normality.

CONCLUSIONS

The population of this study presents a mixed type dry eye without epithelial cell damage.

Tears as a Source of Biomarkers in the Diagnosis of Graves' Orbitopathy

Thyroid eye disease (TED) is a poorly understood autoimmune manifestation of thyroid diseases most commonly associated with Graves' disease. Due to a lack of specific biomarkers and uncertain signs and symptoms, Graves' orbitopathy (GO) is challenging to diagnose early and treat effectively. Nowadays, there is great interest in searching for precise molecular biomarkers for early detection, disease monitoring, and clinical management. Researchers are keen to identify novel methods to predict and diagnose diseases and to monitor patient therapeutic response. Tears, due to their direct contact with the eye and the fact that lacrimal glands can also be affected by the disease, could give new insights into the mechanisms taking place in thyroid-associated orbitopathy (TAO) and reveal potential promising biomarkers. Tear fluid offers the possibility of the non-invasive acquisition of a sample with a high protein content, thereby attracting continuously growing interest in the discovery of novel biomarkers. This article provides an up-to-date overview of the various putative tear-fluid biomarkers that have been identified. In this review, we present the potential use of tears as a diagnostic fluid and tool to investigate the mechanism of ocular diseases and discuss the future research directions in this area.

Ocular surface and the upper eyelid contour after surgical treatment of upper eyelid retraction in thyroid eye disease

BACKGROUND: Most of the thyroid eye disease (TED) patients have dry eye syndrome. Upper eyelid retraction (UER) is the most common TED symptom and one of dry eye causes. There are two groups of UER surgical treatment methods: transconjunctival and transcutaneous, which can influence on upper eyelid contour, tear film and ocular surface. AIM: To evaluate the influence of different methods of UER surgery on upper eyelid contour and ocular surface. MATERIALS AND METHODS: 12 patients (19 eyes) were included in the study. Visual acuity test, measurements of UER and palpebral fissure height, Shirmer 1 test, LIPCOF-test and tear break-up time test, Meibomian gland dysfunction staging, corneal and conjunctival fluorescein staining and determination of the ocular surface disease index (OSDI) were performed before surgery and 1 week, 1 and 3 months after. Patients were divided into two groups. Patients of group 1 had UER less than 4 mm and they underwent an upper tarsal muscle extirpation. Patients of group 2 had UER 4 mm and more and they underwent a recession of the levator palpebrae superioris muscle apouneurosis. RESULTS: In all patients UER and the height of the palpebral fissure decreased 7 days after surgery and increased again after 3 months, and the dynamics of this change was more pronounced in group 2. There was one patient (both sides) with poor upper eyelid contour after surgery in both groups. BCVA and OSDI improved, while other parameters had a large scatter of data. CONCLUSIONS: We have found that surgical treatment of UER caused by TED improves the contour of the eyelid, increases visual acuity and leads to a subjective improvement in the condition of the ocular surface.

Dry eye syndrome: comprehensive etiologies and recent clinical trials

Dry eye syndrome (DES) is multifactorial and likely to be a cause of concern more so than ever given the rapid pace of modernization, which is directly associated with many of the extrinsic causative factors. Additionally, recent studies have also postulated novel etiologies that may provide the basis for alternative treatment methods clinically. Such insights are especially important given that current approaches to tackle DES remains suboptimal. This review will primarily cover a comprehensive list of causes that lead to DES, summarize all the upcoming and ongoing clinical trials that focuses on treating this disease as well as discuss future potential treatments that can improve inclusivity.

Improvement of Ocular Surface Disease by Lateral Tarsoconjunctival Flap in Thyroid-Associated Orbitopathy Patients with Lid Retraction

There is a high incidence of ocular surface disease (OSD) in thyroid-associated orbitopathy (TAO) patients as a result of incomplete eyelid closure and chronic inflammatory eyelid status. This study was performed to evaluate the efficacy of a lateral tarsoconjunctival flap (LTF) in improving OSD in TAO patients from the perspective of correcting eyelid closures. As a study design, TAO patients were enrolled in this study to evaluate OSD perioperatively before they were scheduled for LTF surgery. Additional lid surgery was also recorded. The outcome was evaluated with perioperative OSD measurements and tear inflammatory mediators at baseline and one month and three months postoperatively. As a result, 42 patients (5 male, 37 female) underwent LTF surgery, and 13 patients received medial pretarsal support with collagen grafts. Eleven patients underwent blepharotomy, and 6 patients received Botox injections for upper lid retraction. The mean age of the participants was 46.4 years old, and the mean follow-up period was 10.6 months. Their clinical activity score (CAS) at the time of the operation was 2.1. Dry eye parameters, such as ocular surface disease index, tear breakup time, Schirmer’s I test score, and meibomian gland dropout were all significantly improved 3 months postoperatively. Tear osmolarity and inflammatory mediators in tear fluid, such as IL-6, IL-8, IL-18 and MCP-1, were also significantly improved after the procedures. After the surgery, all complications were mild and temporary. As a conclusion, LTF could provide TAO patients with both lid retraction correction and improvement of ocular surface disorders. Dry eye parameters significantly improved 3 months postoperatively. This method can serve as an alternative treatment option for lid correction in TAO patients.

Comparative Clinicopathological Evaluation of the Ocular Surface in Newly Diagnosed Patients of Hyperthyroidism and Hypothyroidism Compared to Healthy Subjects

Introduction Thyroid eye disease is a multifactorial disorder affecting the tear film and ocular surface, which leads to dry eye. The aim of the study is to evaluate the tear function test and ocular surface changes clinically and to correlate pathologically using impression cytology in recently diagnosed cases of thyroid dysfunction, including both hyperthyroid and hypothyroid patients, and to compare the results with healthy subjects. Methods This was a cross-sectional analytical study. Thirty diagnosed patients with hyperthyroidism and hypothyroidism, each within three months, and 30 healthy age-matched controls were included. All patients and controls underwent an assessment of proptosis, palpebral fissure height (PFH), tear function test, Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's test, tear break-up time (TBUT), and impression cytology for ocular surface assessment. These parameters were compared between cases and controls. Standard statistical analysis was used. Results Mean proptosis and PFH showed no significant difference among groups (P-value = .071). The mean value of OSDI was 42.33+22.67, 41.15+16.03, and 29.33+6.84 in the hyperthyroid, hypothyroid, and controls groups, respectively; the difference being statistically significant (p=0.001). Mean TBUT was 7.13+3.28 sec, 6.38+2.46 sec, and 11.15+2.39 sec in hyperthyroidism, hypothyroidism, and controls, respectively (p=0.001). The mean value of the Schirmer tear test was 12.93+5.81 mm, 13.30+4.44 mm, and 17.55+7.35 mm in hyperthyroidism, hypothyroidism, and controls, respectively (p=0.001). Eighty percent (80%) of patients in the hyperthyroidism group had grade 2-3 squamous metaplasia as compared to 70% in hypothyroidism patients and 24.4% in controls, signifying ocular surface damage (p<0.05). Conclusions The mean PFH and proptosis did not differ between the three groups. However, increased OSDI score, decreased Schirmer's test value, decreased TBUT, and grades 2-3 squamous metaplasia in patients with thyroid dysfunction suggest the presence of dry eyes. Despite no clinically visible signs of thyroid ophthalmopathy, there is ocular surface damage right from the early stages of thyroid dysfunction, possibly attributable to the evaporative mechanism as well as ocular surface inflammation and instability of the tear film.

Beyond dry eye: how co-morbidities influence disease phenotype in dry eye disease

Dry Eye Disease (DED) is a complex and multifactorial disorder of tear homoeostasis that results in pain, visual disturbance, and ocular surface damage. It is highly prevalent around the world and is associated with many co-morbidities that may contribute to or exacerbate symptoms and signs of disease and affect disease phenotype. However, DED is not one disease and can manifest with a variety of symptoms and/or signs. In this review, we discuss relationships between various co-morbidities and DED phenotypes. For example, individuals with immune mediated diseases, like Sjögren's Syndrome and Graft versus Host Disease, often present with aqueous tear deficiency (ADDE) in the setting of lacrimal gland dysfunction. Individuals with disorders that affect the periocular skin, like rosacea and seborrhoeic dermatitis, often present with evaporative dry eye (EDE) in the setting of eyelid and/or meibomian gland abnormalities. Individuals with pain related disorders, such as chronic pain syndrome and migraine, often present with ocular pain out of proportion to tear film abnormalities, often with accompanying corneal nerve hypersensitivity. Individuals with diabetes mellitus often present with an epitheliopathy in the setting of decreased sensation (neurotrophic keratitis). While not absolute, understanding relationships between co-morbidities and DED phenotypes can help tailor a therapeutic plan to the individual patient.

Corneal Endothelium: A Promising Quantitative Index for Graves Ophthalmopathy Activity Evaluation

PURPOSE

To investigate the corneal endothelium damage in Graves ophthalmopathy (GO) and its role as a promising quantitative index to evaluate GO activity.

DESIGN

Cross-sectional study.

METHODS

This study included 128 eyes of 64 patients with GO. All subjects underwent ophthalmologic examinations, including proptosis, tear break-up time (BUT), corneal fluorescein staining, and Schirmer test. Corneal endothelium was measured by noncontact specular microscope and ocular biometric parameters were measured by IOLMaster 700. Each eye was assigned a specific clinical activity score (CAS), then grouped as active (CAS ≥3 points) or inactive (CAS <3 points). Ocular parameters between the 2 groups were compared using generalized estimating equations accounting for inter-eye correlation, and receiver operating characteristic (ROC) curves were also obtained. Main outcome measures were parameters of corneal endothelium.

RESULTS

Among the included eyes, 81 eyes had inactive GO and 47 eyes had active GO. Corneal endothelial cell morphology was altered in active GO compared with inactive GO. The coefficient variation of cell area (CV) was significantly higher in active GO compared with inactive GO (37.0 [34.4-41.2]% vs 33.9 [30.9-36.8]%, P = .001), and positively correlated with CAS (r = 0.322, P < .001). Moreover, CV showed a diagnostic capacity to differentiate the active eyes from inactive eyes. The area under the ROC curve was 0.705.

CONCLUSIONS

Active GO had morphologic changes in corneal endothelium compared with inactive GO. CV is a sensitive indicator to reflect corneal endothelial function, and has the potential to be adopted as a noninvasive, objective, and quantitative index for evaluating the activity status of GO patients.

Prevalence of Tear Film Hyperosmolarity in 1150 patients presenting for refractive surgery assessment

PURPOSE

To present an analysis of tear film hyperosmolarity in a large, consecutive population and evaluate the correlation of ocular and systemic conditions with tear film osmolarity.

SETTING

Private practice Sydney, Australia.

DESIGN

Single-centre, retrospective, consecutive cohort.

METHOD

1404 patients (n=1357 standard, n=47 post-refractive) undergoing screening for laser refractive surgery from October 2017 to October 2020 were reviewed. Routine examination included tear film osmolarity (TFO) and Ocular Surface Disease Index questionnaire). TFO was conducted prior to further tests and patients refrained from topical eye drops minimum two hours before the appointment.

RESULTS

Mean highest TFO in the standard population was 299.12±11.94mOsm/L with 82.3% of eyes <308mOsm/L indicating normal tear film homeostasis. The mean inter-eye TFO difference was 8.17±8.60mOsm/L with 65.2% of eyes <=8mOsm/L. Mean highest TFO in the post-refractive subgroup was 299.72±11.00mOsm/L with a mean inter-eye difference of 9.02±6.92mOsm/L. Post-refractive surgery patients indicated higher mean OSDI values of 15.28±14.46 compared to the remainder of the population 9.69±10.56 (p=0.012). Significant correlation was demonstrated between TFO scores and OSDI normal classification in the standard population only (p=0.005, r=0.077). The use of contact lens correlated inversely with TFO and OSDI scores (p=0.000, r=-0.136 and p=0.000, r=-0.152 respectively).

CONCLUSION

Our study represents the largest available cohort of TFO scores in a standard population presenting for refractive surgery. We found that although the majority of patients can be expected to fall within normal ranges, a reasonable percentage will be diagnosed with tear hyperosmolarity and therefore at risk of dry eye disease.

Evaluation of Meibomian Gland Loss and Ocular Surface Changes in Patients with Mild and Moderate-to-Severe Graves' Ophthalmopathy

OBJECTIVES

To evaluate the association of Graves' Ophthalmopathy (GO) with the meibomian glands and investigate the relation of ocular surface changes with meibomian gland parameters in patients with GO.

METHODS

This prospective study included 44 eyes of 44 mild and moderate-to-severe GO patients and 38 eyes of 38 control subjects. After a complete ophthalmologic examination, patients were assessed according to the Clinical Activity Score (CAS). The area of meibomian gland loss and meibography score was evaluated using meibography (Sirius; CSO, Florence, Italy). Schirmer test, tear break-up time (TBUT) and Ocular Surface Disease Index (OSDI) scores were evaluated.

RESULTS

Mean meibomian gland dropout area was 26.29 ± 1.58% in the GO group and 14.46 ± 1.52% in the healthy controls (p < .001). Mean meibography score in the GO group was 2.61 ± 0.15 while it was 1.32 ± 0.25 in the healthy controls (p < .001). Meibomian gland dropout area was positively correlated with CAS and OSDI questionnaire results (p = .015, r = 0.391; p < .001, r = 0.662, respectively) and negatively correlated with TBUT and Schirmer test scores (p < .001, r = -0.635; p = .003, r = -0.474, respectively). Meibography score was positively correlated with CAS and OSDI questionnaire results (p = .012, r = 0.383; p = .007, r = 0.419, respectively) and negatively correlated with TBUT and Schirmer test scores (p = .002, r = -0.467; p = .023, r = -0.359, respectively).

CONCLUSION

Meibomian glands are quantitatively decreased in patients with GO. The decrease of meibomian glands is correlated with objective and subjective dry eye findings. Dry eye treatment in GO patients should include meibomian gland deficiency as well.

Ocular surface changes in Graves' ophthalmopathy

Many patients with Graves' ophthalmopathy (GO) suffer from dry eye syndrome (DES), and this is one of the most common reasons of eye discomfort in patients with GO. The prevalence of DES in patients with GO is significantly higher than normal subjects. The ocular surface changes involving changes in tears, cornea, conjunctiva and glands occur in GO patients. However, the mechanism of how DES occurs in GO still remains unclear. In this review, the ocular surface changes were illustrated and analyzed the reasons for high prevalence of DES in GO patients.

Investigation of Meibomian Gland Function and Dry Eye Disease in Patients with Graves' Ophthalmopathy

We prospectively evaluated the relationship between meibomian gland dysfunction (MGD) and Graves’ ophthalmopathy (GO) in 19 patients (38 eyes) with subjective dry eye symptoms, compared to 14 age-matched normal participants (14 eyes). Extraocular muscle and lacrimal gland enlargement were evaluated by magnetic resonance imaging (MRI). Ocular surface examinations included fluorescein staining for keratoconjunctival epithelial damage, tear breakup time (TBUT) evaluation, and Schirmer’s test. Dry eye symptoms were evaluated with the Dry Eye-related Quality-of-Life Score (DEQS) questionnaire. Lid-margin abnormalities, meibum grade, and meiboscores were assessed using meibography. Clinical activity scores and T2 signal intensity ratios were used to define GO activity. All GO patients had obstructive MGD and 79% exhibited levator muscle enlargement. Ocular surface parameters of TBUT (p = 0.000), meibum score (p = 0.000), eyelid vasculitis (p = 0.000), meiboscore of the upper lid (p = 0.002), total meiboscores (p = 0.001), and DEQS (p = 0.000) significantly differed between GO patients and normal subjects. In addition, GO patients had significantly more abnormalities of the central region of the upper eyelid than normal subjects (p = 0.000). Thus, MGD might be related to eye discomfort and deterioration of the ocular surface in GO patients. Inflammation and morphological meibomian gland changes might be characteristic of GO.

Tear inflammatory cytokines and ocular surface changes in patients with active thyroid eye disease treated with high-dose intravenous glucocorticoids

PURPOSE

To evaluate high-dose intravenous glucocorticoid treatment on tear inflammatory cytokines and ocular surface parameters in patients with active TED. Correlations between tear inflammatory cytokines and clinical parameters were also investigated.

METHODS

This prospective pilot study included 15 moderate-to-severe and active TED patients. Control group consist of 15 sex and age-matched healthy subjects. All TED patients were treated with high-dose intravenous methylprednisolone with cumulative dose of 4.5 g during the therapy subdivided into 12 weekly infusions. Tear concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-17A, tumor necrosis factor (TNF)-α, and vascular endothelial growth factor (VEGF) were measured by multiplex bead analysis in TED patients at baseline and 12 weeks after treatment. Ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescent staining, and Schirmer's test were obtained from TED and controls.

RESULTS

All baseline cytokine levels except for IL-17A were significantly elevated in active TED patients compared with controls. Concentrations of IL-1β, IL-6, IL-8, TNF-α, and VEGF were significantly decreased at 12 weeks compared with baseline. OSDI and TBUT showed significant improvement at 6 and 12 weeks. There were significant positive correlations between IL-6, IL-8, and CAS, and negative correlation was found between IL-6 level and TED duration before methylprednisolone treatment. The reduction of IL-6, IL-8, and VEGF were positive correlated with the reduction in CAS at 12 weeks.

CONCLUSIONS

High-dose glucocorticoids treatment improved ocular surface symptom, increased the tear film stability, and decreased tear inflammatory cytokines in active TED. The reduction of the inflammatory cytokines is consistent with the improvement of clinical parameters.

In Vivo Confocal Microscopy Morphometric Analysis of Meibomian Glands in Patients With Graves Ophthalmopathy

PURPOSE

To characterize meibomian glands (MGs) features in patients with Graves ophthalmopathy (GO) by in vivo confocal microscopy (IVCM) and to further investigate possible correlations with ocular surface characteristics.

METHODS

Consecutive patients with GO and controls were enrolled. The following ocular surface parameters were measured: tear break-up time, Schirmer test, and corneal fluorescein staining (Oxford score) were performed on each subject. IVCM of MGs was performed, and the scans were analyzed with ImageJ software for the calculation of the following: acinar unit density, total gland area, total lumen area (TLA), acinar longest diameter, and acinar shortest diameter. A nonparametric Mann-Whitney U test was used to compare variables between patients with GO and controls. The Spearman correlation analysis was used to evaluate the correlations between ocular surface and IVCM parameters.

RESULTS

Twenty-one patients with GO and 24 sex- and age-matched healthy controls were included. Acinar unit density was significantly lower in patients with GO compared with controls (24.5 ± 8.1 vs. 34.2 ± 7.5 U/mm; P < 0.001). In addition, patients with GO showed significantly higher values of TLA, acinar longest diameter, and acinar shortest diameter compared with controls (respectively, 3104.7 ± 1713.3 vs. 1393.8 ± 448.0 μm, 94.4 ± 21.2 vs. 64.3 ± 10.1 µm and 56.6 ± 15.3 vs. 42.2 ± 12.3 μm; always P < 0.05). In patients with GO, TLA showed a significant inverse correlation with Schirmer test (Rs = -0.467; P = 0.038).

CONCLUSIONS

IVCM allowed to detect distinctive features of MGs in patients with GO and could represent a surrogate tool for the assessment of MG status in these patients.

Local Ocular Surface Alterations in Children with Hashimoto's Thyroiditis

PURPOSE

To evaluate the ocular surface characteristics based on Schirmer's test, tear break-up time (TBUT), and conjunctival impression cytology (CIC) in children with Hashimoto's thyroiditis (HT).

METHODS

This study included 51 children with HT and 53 control subjects. The ocular surface characteristics of participants were assessed via Schirmer's test, TBUT, and CIC. Conjunctival samples were examined cytologically according to the Nelson grading system.

RESULTS

Schirmer's and TBUT results were significantly lower in HT group (p < .05). All samples in both the study and control groups were evaluated as grade 0 according to the Nelson classification (p = .841), however, goblet cell density (GCD) was significantly lower in HT group (p = .001). Schirmer test results were significantly associated with the duration of HT (p = .025, r = -0.311).

CONCLUSION

Hashimoto's thyroiditis without any ocular complaints may cause ocular surface changes with TBUT and Schirmer's. Although CIC analysis showed similar grading results, GCD was significantly decreased in HT group.

Dry eye syndrome in thyroid eye disease patients: The role of increased incomplete blinking and Meibomian gland loss

PURPOSE

To compare the structure and function of the Meibomian gland and eyelid blinking patterns between thyroid eye disease (TED) patients with dry eye and nonthyroidal dry eye (DE) patients.

METHODS

This was a prospective, cross-sectional and observational study. Clinical measurements were performed as follows: (1) external examination, (2) Lipiview^® Interferometer (lipid layer thickness, incomplete blinking rate and meibography) and (3) slit-lamp biomicroscopy (corneal staining, tear break-up time (TBUT), meibum expression).

RESULTS

The TED and DE groups included 98 and 62 patients, respectively. The meiboscores of the upper eyelid in TED and DE groups were significantly different (1.21 ± 0.76 and 0.94 ± 0.71, respectively, p = 0.046). The rate of incomplete blinking was 53.3 ± 34.5 and 34.6 ± 36.3%, respectively, and was significantly higher in the TED group (p = 0.006). In the TED group, CAS was the only variable affecting the meiboscore of the upper and lower eyelids (p = 0.031, 0.039, respectively). Significantly, active TED patients had more decreased basal tear secretion than inactive TED patients (7.4 ± 2.1 mm versus 8.5 ± 1.5 mm, p = 0.024). Moreover, active TED patients had decreased meibum expression in both upper and lower eyelids compared with inactive TED patients (2.20 ± 0.88 versus 1.08 ± 0.84, p = 0.002 in upper eyelid, 2.10 ± 0.88 versus 1.18 ± 0.88, p = 0.007 in lower eyelid, respectively).

CONCLUSION

In TED patients, incomplete blinking and loss of Meibomian gland structure in the upper eyelid were more prominent than in DE patients. CAS was a factor affecting the structural loss of Meibomian glands in TED individuals.

Air Pollutants are associated with Dry Eye Disease in Urban Ophthalmic Outpatients: a Prevalence Study in China

BACKGROUND

Although previous prevalence studies of DED were reported from some countries worldwide, national data are unavailable in China. We aimed to conduct an up-to-date national survey on the prevalence of DED in China and find out the potential risk factors including air pollutant.

METHODS

23,922 eligible outpatients were recruited from ophthalmic clinics of 32 cities in China in 2013 by registration orders. The patients' demographic characteristics, history of keratorefractive surgery, diseases and medication history were collected and the daily air pollutant data in 2013. Multivariate logistic analysis was performed to identify the potential risk factors associated with DED. The association between related factors and dry eye diseases subtypes evaluated as p value and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Among 23,922 outpatients, the prevalence of DED was 61.57%, and that of the male patients was 57.64% and of the female was 65.32% (P < 0.0001). Multivariate logistic regression suggested that the possible risk factors for DED included: female, older age, history of keratorefractive surgery, presence of arthritis, thyroid diseases, and antihistamine, diuretic, duodenal ulcer drugs, diazepam. Air pollutants including O3, PM2.5, and SO2 were also identified as the risk factors.

CONCLUSION

The prevalence of DED among ophthalmic outpatients in China was considerably high. Age, gender, history of keratorefractive surgery, diseases, medication history, and air pollutants were associated with DED prevalence.

Altered Corneal Nerves in Chinese Thyroid-Associated Ophthalmopathy Patients Observed by In Vivo Confocal Microscopy

BACKGROUND Thyroid-associated ophthalmopathy (TAO) is a common endocrine autoimmune disease. The present study explored corneal nerve changes in TAO patients. MATERIAL AND METHODS Thirty-eight Chinese TAO patients and 20 healthy individuals were included in the study. Central corneal subbasal nerve density and morphology were evaluated with in vivo laser scanning confocal microscopy and quantified using automated CCmetrics software. RESULTS The values of the central corneal subbasal nerve plexus parameters of both active and inactive TAO patients were significantly decreased compared with those of controls, including corneal nerve fiber density (CNFD) (P<0.001 for both), corneal nerve branch density (CNBD) (P<0.001 for both), corneal nerve fiber length (CNFL) (P<0.001 for both), corneal nerve fiber total branch density (CTBD) (P<0.001 for both), corneal nerve fiber area (CNFA) (P<0.001 for both), corneal nerve fiber width (CNFW) (P=0.046, P=0.027, respectively), and corneal nerve fiber fractal dimension (ACNFrD) (P<0.001 for both). In addition, CNFD and ACNFrD values were significantly lower in the active TAO patients compared with those in the inactive TAO patients (P=0.020, P=0.002, respectively). There were significant correlations between CNFD, CNBD, CNFL, CTBD, CNFA, and ACNFrD and the ocular surface parameters and activity assessment items. CONCLUSIONS Abnormal corneal subbasal nerves were observed in both active and inactive Chinese TAO patients, suggesting that nerve degeneration is associated with the disease. However, the exact underlying mechanisms remain to be elucidated.

Tear Film Osmolarity in Subjects with Acute Allergic Rhinoconjunctivitis

BACKGROUND/AIM

Acute allergic rhinoconjuctivitis is the most common form of ocular allergies. The pathogenetic mechanisms are based on an immunoglobulin E (IgE)-mediated hypersensitivity reaction. On the other hand, tear osmolarity has been suggested to be an index of ocular surface damage and inflammation. These data were the motive to investigate the levels of tear osmolarity in subjects with acute allergic rhinoconjuctivitis, before and after administration of artificial tears.

PATIENTS AND METHODS

Forty-five subjects with acute allergic rhinoconjuctivitis were randomly divided into three groups, based on the type of artificial tears that they received: Group A (Thera tears), Group B (Wet therapy) and Group C (Tears Naturale free). The eye drops were administered six times a day for 60 days and all subjects underwent grading of subjective symptoms and clinical examination at baseline and at the end of the treatment.

RESULTS

The diagnosis of severe eye disease, which was based on ocular surface disease index (OSDI; Allergan, Inc, Irvine, CA, USA) and tear osmolarity values, concerned all patients at baseline. Although the administration of artificial tears significantly ameliorated the symptoms and the ocular variables in all groups, the results were better in the first group. Tear osmolarity was strongly and negatively correlated with tear film breakup time (BUT) and Schirmer I test at 2 months. Contrariwise, symptoms were eliminated, when tear osmolarity was decreased.

CONCLUSION

Acute allergic rhinoconjuctivitis is characterized by tear hyperosmolarity, which can be rehabilitated with the administration of hypotonic artificial tears.

The levels of 12 cytokines and growth factors in tears: hyperthyreosis vs euthyreosis

PURPOSE

Simultaneous analyses of the contents and ratios of 12 cytokines and growth factors in single samples of human tears were performed, and the results were compared between a group of healthy subjects and a group of patients with Graves' hyperthyreosis (GH) without thyroid-associated orbitopathy (TAO).

METHODS

Determinations and concentration measurements of interleukins (IL-2, IL4, IL-6, IL-8, IL-10, IL-1α, and IL-1β) interferon (IFN-γ), tumor necrosis factor (TNF-α), monocyte chemoattractant protein (MCP-1), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF) were performed with single tear samples from 21 patients with hyperthyreosis and 22 healthy subjects. The analyses were performed using a Randox microchip with an Evidence Biochip Array Analyzer.

RESULTS

We found significant differences between the healthy donor group and the hyperthyreosis group in the levels of IL-6, IL-10, VEGF, IL-1α, and MCP-1. The concentration of IL-6 was considerably higher in the hyperthyreosis group, IL-10 was higher in the healthy donor group, and VEGF and MPC-1 were higher in the hyperthyreosis group. The IL-8 and IFN-γ levels were higher in the hyperthyreosis group. The ratios of all of the cytokines to anti-inflammatory IL-10 were significantly elevated in the hyperthyreosis group.

CONCLUSION

There are clear differences in the levels of cytokines and growth factors in the tears of healthy subjects and patients with GH without TAO. Tear cytokine changes and related dysfunctional tear syndrome (DTS) could be an early sign of occult TAO in Graves' hyperthyreosis patients.

TFOS DEWS II Tear Film Report

The members of the Tear Film Subcommittee reviewed the role of the tear film in dry eye disease (DED). The Subcommittee reviewed biophysical and biochemical aspects of tears and how these change in DED. Clinically, DED is characterized by loss of tear volume, more rapid breakup of the tear film and increased evaporation of tears from the ocular surface. The tear film is composed of many substances including lipids, proteins, mucins and electrolytes. All of these contribute to the integrity of the tear film but exactly how they interact is still an area of active research. Tear film osmolarity increases in DED. Changes to other components such as proteins and mucins can be used as biomarkers for DED. The Subcommittee recommended areas for future research to advance our understanding of the tear film and how this changes with DED. The final report was written after review by all Subcommittee members and the entire TFOS DEWS II membership.

Prevalence of dry eye disease in autoimmune thyroid disease and the association of dry eye with clinical signs of thyroid associated ophthalmopathy: observational, noncomparative, cross-sectional study

Background

Autoimmune thyroid disease (AITD) is a risk factor for dry eye disease. The prevalence of dry eye in AITD is not definitely known.

Objectives

To determine the prevalence of dry eye in AITD and its association with clinical signs of thyroid associated ophthalmopathy (TAO).

Methods

We enrolled a cross-section of 92 patients with AITD between May 1 and August 31, 2013. All were examined to establish thyroid eye signs, and severity was classified as none, mild, and moderate-severe according to the European Group on Graves’ orbitopathy. Dry eye disease was verified using an Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), Schirmer test, and ocular surface fluorescein staining. Features of meibomian glands were inspected. This observational study was registered at www.clinicaltrials.in.th, No. TCTR20130713001.

Results

The prevalence of dry eye in AITD was 27% by OSDI questionnaire (95% confidence interval (CI), 16%-34%); 96% (95% CI, 93%-99%) by TBUT; 69% (95% CI, 62%-75%) by ocular surface staining; and 18% (95% CI, 12%-23%) using a Schirmer test, which associated dry eye and proptosis with an odds ratio (OR) of 9.3 (95% CI, 1.2-70.6, P = 0.031), and lagophthalmos by ocular surface staining with an OR of 5.8 (95% CI, 1.2-27.7, P = 0.026). Dry eye in patients with or without clinical signs of TAO was not significantly different.

Conclusions

The prevalence of dry eye varied by criteria, but was not different in AITD patients with or without TAO. Proptosis and lagophthalmos were associated more strongly with dry eye disease in AITD with TAO, than without.

Evaluation of Corneal Biomechanical Properties in Patients With Thyroid Eye Disease Using Ocular Response Analyzer

PURPOSE

To assess variations in the corneal biomechanical properties in thyroid eye disease (TED) patients using ocular response analyzer (ORA).

PATIENTS AND METHODS

In this observational cross-sectional study, 75 patients with TED and 57 healthy subjects were enrolled. The mean age of the patients and healthy subjects were 47.50±1.55 and 43.6±1.23 years, respectively (P=0.06). All study participants underwent comprehensive ophthalmologic examination, Goldmann applanation tonometry (GAT), corneal pachymetry, and corneal biomechanical analysis using ORA. Corneal hysteresis (CH), corneal resistance factor (CRF), cornea-compensated IOP value (IOPcc), and Goldmann-corrected IOP value (IOPg) were measured with ORA.

RESULTS

Central corneal thickness (CCT) in patients group (536.18±36.20 μm) and control group (539.22±28.83 μm) were not significantly different (P=0.1). In TED group, the IOPcc (20.23±0.54 mm Hg) was significantly higher than both IOP-GAT (17.54±0.49 mm Hg, P<0.001) and IOPg (18.35±0.52, P<0.001). CH in TED patients (9.01±0.20) was significantly lower compared with CH in healthy subjects (10.45±0.21) (P<0.001). Although CRF was lower in TED patients (10.06±0.16) in comparison with normal subjects (10.42±0.29), this difference was not statistically significant (P=0.25). Both CH and CRF were positively correlated with CCT (r=0.52, P<0.001 and r=0.62, P<0.001, respectively) in TED group.

CONCLUSIONS

In TED patients, CH seems to be lower than in normal subjects. GAT might underestimate the IOP due to differences in corneal properties of cornea in TED patients.

Meibomian gland dysfunction in Graves' orbitopathy

OBJECTIVE

To examine morphologic changes in the meibomian glands associated with patients with Graves' orbitopathy (GO) using a novel meibography imaging system, and to evaluate its correlation with GO clinical manifestations.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Fifty-one GO patients and 31 normal control participants.

METHODS

This retrospective study examined 51 GO patients and 31 normal control participants. The structure of the meibomian gland was assessed using the meibography imaging system. All of the participants completed the Ocular Surface Disease Index (OSDI) questionnaire. The tear film break-up time (BUT) was measured. The palpebral fissure height, exophthalmos, and eyelid retraction were also assessed.

RESULTS

The meibography score, tear film BUT, and OSDI indicated statistically significant differences between the GO and normal groups: The tear film BUT was shorter and the OSDI and meibography score were higher in the GO patient group. There was a significant negative correlation between the meibography score and the tear film BUT in GO patients (r = -.503 and p < .001). In the multivariable linear regression analysis, the meibography score of the GO patients had a positive association with exophthalmos and palpebral fissure height.

CONCLUSIONS

Compared with the normal control participants, GO patients had more unstable tear films and severe symptoms of dry eye. Using the meibography system, the authors found that GO patients had a higher prevalence of obstructive type meibomian gland dysfunction and changes in meibomian glands increased, with proptosis and lid fissure widening.

The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.

Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease

Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.

Tear film osmolarity and dry eye disease: a review of the literature

Objective

To evaluate the evidence in the peer-reviewed literature regarding the use of tear osmolarity as a physiological marker to diagnose, grade severity, and track therapeutic response in dry eye disease (DED). In addition, to review the evidence for the role of tear osmolarity in the pathophysiology of DED and ocular surface disease.

Methods

A literature review of all publications after the year 2000, which included the keywords “tear osmolarity”, was conducted. Relevant articles were graded according to quality of evidence and research, using the University of Michigan Practice Guideline and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) rating systems. Articles were further categorized by the nature of any reported financial support and by the overall impression they provided related to tear osmolarity.

Results

A total of 164 articles were identified as relevant to the search criteria, although some were editorials, and some were written in a foreign language. Of the total, it was possible to grade 159, and an overall impression was generated for 163. A positive impression of tear osmolarity in DED diagnosis was evident in 72% (117/163) of all articles, with a neutral impression in a further 21% (35/163); 7% had a negative impression. The percentage of positive impressions appeared independent of the quality of research; 73% (38/52) of articles graded high/moderate quality supported the use of tear film osmolarity measurement in DED diagnosis. Impressions were also independent of the source of financial support, with 72% (75/104) of independent studies positive.

Conclusion

The literature broadly supports the use of tear film osmolarity as an objective numerical measure for diagnosing, grading severity, and managing treatment of DED.

Tear osmolarity in ocular graft-versus-host disease

PURPOSE

The aim of this study was to evaluate tear osmolarity in patients with chronic graft-versus-host disease (cGVHD) with ocular involvement.

METHODS

In this observational cross-sectional study of 56 patients with ocular cGVHD referred to the tertiary-care Ocular Immunology and Uveitis Service at the San Raffaele Scientific Institute, Milan, from May 2010 to November 2013, we evaluated the following clinical parameters: Ocular Surface Disease Index (OSDI) symptoms questionnaire, tear osmolarity, Schirmer test, tear film break-up time (TBUT), corneal and conjunctival staining.

RESULTS

All patients developed systemic GVHD after undergoing allogeneic hematologic stem cell transplantation. Mean osmolarity was 314.0 ± 22.1 mOsm/L, mean OSDI score was 26.4 ± 21.2, mean TBUT was 6.50 ± 4.75 seconds, and mean Schirmer test value was 3.8 ± 3.3 mm. Tear osmolarity significantly inversely correlated with TBUT (r = 0.681; P < 0.001). Statistically significant inverse correlation was present with the Schirmer test (r = 0.203; P < 0.001), and positive correlation with the OSDI score (r = 0.188; P < 0.001), but both with low correlation strength. Osmolarity was statistically different in the subgroups according to the Oxford corneal staining scale (P = 0.0006) and to the van Bijsterveld conjunctival staining score (P = 0.006).

CONCLUSIONS

Tear osmolarity increased in patients with ocular cGVHD, significantly correlated with TBUT and, to a lesser extent, with the Schirmer test value and OSDI. These results emphasize the role of aqueous-deficient and evaporative dry eye disease in patients with cGVHD after undergoing allogeneic hematologic stem cell transplantation. Tear osmolarity may be considered a useful test in diagnostic assessment of dry eye disease associated with cGVHD.

Unraveling the molecular repertoire of tears as a source of biomarkers: beyond ocular diseases

Proteomics and metabolomics investigations of body fluids present several challenges for biomarker discovery of several diseases. The search for biomarkers is actually conducted in different body fluids, even if the ideal biomarker can be found in an easily accessible biological fluid, because, if validated, the biomarker could be sought in the healthy population. In this regard, tears could be considered an optimum material obtained by noninvasive procedures. In the past years, the scientific community has become more interested in the study of tears for the research of new biomarkers not only for ocular diseases. In this review, we provide a discussion on the current state of biomarkers research in tears and their relevance for clinical practice, and report the main results of clinical proteomics studies on systemic and eye diseases. We summarize the main methods for tear samples analyses and report recent advances in "omics" platforms for tears investigations. Moreover, we want to take stock of the emerging field of metabolomics and lipidomics as a new and integrated approach to study protein-metabolites interplay for biomarkers research, where tears represent a still unexplored and attractive field.

The relationship between Graves' ophthalmopathy and dry eye syndrome

Background

A complex relationship between Graves’ ophthalmopathy (GO) and dry eye syndrome exists. New research brings more insight into the association between these two diseases.

Methods

A review of the literature was conducted using the query terms “Graves’ Ophthalmopathy”, “Thyroid Eye Disease”, and “Dry Eye” in MedLine (PubMed) and Scopus. A total of 55 papers were reviewed. Case reports were excluded.

Conclusion

This review paper shows the close relationship between dry eye syndrome and GO. The underlying mechanisms behind their association suggest mechanical impairment of orbital muscles and immune-mediated lacrimal gland dysfunction as the causes of dry eye in GO patients. However, there are a variety of treatment options available for patients with GO with signs of dry eye, which help combat this issue.

Presence of Dry Eye in Patients with Hashimoto's Thyroiditis

Purpose. To evaluate the tear function tests in patients with Hashimoto's thyroiditis and to compare the results with healthy subjects. Methods. A hundred and ten patients with Hashimoto's thyroiditis and 100 healthy subjects were included in this study. The presence of thyroid-associated ophthalmopathy and tear function tests were evaluated clinically. The results were first compared between the patients and the control groups and then compared between patients with NOSPECS and patients without NOSPECS. Logistic regression analyses of the risk factors for dry eye including sex, gender, free plasma thyroxine, proptosis, upper eyelid margin-reflex distance, and duration of the disease were also evaluated. Results. The mean ocular surface disease index score was significantly higher and mean Schirmer and mean tear break-up time scores were significantly lower in patients compared to control subjects. Mean Schirmer and tear break-up time scores were found to be significantly lower in patients with NOSPECS when compared to the patients without NOSPECS. Both proptosis and free plasma thyroxine levels were significantly associated with dry eye. Conclusions. Patients with Hashimoto's thyroiditis tend to develop dry eye more common than healthy subjects. Proptosis and lower free plasma thyroxine levels were found to be risk factors for the presence of dry eye.

The effect of antihypertensive therapy on dry eye disease

CONTEXT

There is a generalization that "antihypertensive (antiHT) therapy causes Dry Eye Syndrome", which has been claimed for years however most of the publications are epidemiological studies. We performed a clinical study to investigate the effects of antiHT agents on tear function.

OBJECTIVE

The aim of this article is to evaluate the effects of different classes of antiHT medications on tear osmolarity, ocular surface problems and dry eye symptoms.

MATERIALS AND METHODS

Prospective, non-randomized a clinical study. A total of 71 patients who would be initiated antiHT medication due to elevated systemic blood pressure were included in the study. Thirty of these patients were given antiHT drugs containing diuretic (diuretic +), and 41 of them were given diuretic-free drugs (diuretic -). While the number of the patients medicated in the group that received Angiotensin Converting Enzyme inhibitors (ACE inh)/Angiotensin receptor blockers (ARB) (ACE/ARB +) was 29, the number of those medicated in the ACE/ARB-free group (ACE/ARB -) was 42. Ocular surface disease index scores, tear osmolarity, Schirmer I test, tear film break-up time (TBUT), fluorescein (FL) and rose bengal corneal staining patterns of the patients were analyzed. The patients were examined through the repetition of all the tests in the 1st and the 3rd month.

RESULTS

The participants (n = 71) comprised 38 males and 33 females with a mean age of 51.8 ± 10.4. When the first (0-1st month) and the third month (0-3rd months) control measurements between diuretics (+) and diuretics (-) groups before and after antiHT therapies were compared, a statistically significant difference was not found in any of the tests applied. When the 0-1st month measurements of ACE/ARB (+) and ACE/ARB (-) groups were compared, it was observed that staining with FL in ACE/ARB (+) group decreased in a statistically significant manner (p = 0.035) and there was a significant increase in TBUT values (p = 0.022).

DISCUSSION AND CONCLUSION

The use of antiHT drugs containing diuretic had no adverse effect on the tear function tests, but using drugs that contain ACE/ARB could have a positive impact.

Topical rebamipide treatment for superior limbic keratoconjunctivitis in patients with thyroid eye disease

PURPOSE

To evaluate efficacy of topical rebamipide for superior limbic keratoconjunctivitis (SLK) in patients with thyroid eye disease.

DESIGN

Retrospective, observational case series.

METHODS

Thirty-three eyes from 20 thyroid eye disease patients with SLK who received topical rebamipide (Mucosta ophthalmic suspension unit dose 2%; Otsuka Pharmaceutical Co, Ltd; chemical name, (2RS)-2-(4-chlorobenzoylamino)-3-(2-oxo-1, 2-dihydroquinolin-4-yl) propanoic acid) were included. The following items were evaluated before and 4 weeks after the start of treatments: presence or absence of SLK, rose bengal staining score, area and density classification of fluorescein staining, Schirmer test I results (without topical anesthesia), tear film break-up time, Hertel exophthalmometry values, and margin reflex distances 1 and 2.

RESULTS

Twenty-eight eyes showed complete disappearance of SLK after treatment (84.8%; P < .001). The other 5 eyes (15.2%) demonstrated significant improvement, but had residual punctate rose bengal staining and fluorescein staining near the superior corneal limbus. All 5 eyes exhibited at least 1 of the following findings: proptosis of more than 17.7 mm and upper or lower eyelid retractions or both. Incidence of upper eyelid retraction was significantly higher in eyes with SLK than in those without SLK at the 4-week follow-up (P = .021). The severity of rose bengal staining and fluorescein staining improved significantly after treatment (P < .001). Although the Schirmer test results remained constant before and after the treatment (P = .212), tear film break-up time increased significantly in the posttherapeutic state (P = .009). No serious adverse events were reported.

CONCLUSIONS

Topical rebamipide improved SLK in patients with thyroid eye disease, suggesting a first-line treatment in such patients.

Rethinking dry eye disease: a perspective on clinical implications

Publication of the DEWS report in 2007 established the state of the science of dry eye disease (DED). Since that time, new evidence suggests that a rethinking of traditional concepts of dry eye disease is in order. Specifically, new evidence on the epidemiology of the disease, as well as strategies for diagnosis, have changed the understanding of DED, which is a heterogeneous disease associated with considerable variability in presentation. These advances, along with implications for clinical care, are summarized herein. The most widely used signs of DED are poorly correlated with each other and with symptoms. While symptoms are thought to be characteristic of DED, recent studies have shown that less than 60% of subjects with other objective evidence of DED are symptomatic. Thus the use of symptoms alone in diagnosis will likely result in missing a significant percentage of DED patients, particularly with early/mild disease. This could have considerable impact in patients undergoing cataract or refractive surgery as patients with DED have less than optimal visual results. The most widely used objective signs for diagnosing DED all show greater variability between eyes and in the same eye over time compared with normal subjects. This variability is thought to be a manifestation of tear film instability which results in rapid breakup of the tearfilm between blinks and is an identifier of patients with DED. This feature emphasizes the bilateral nature of the disease in most subjects not suffering from unilateral lid or other unilateral destabilizing surface disorders. Instability of the composition of the tears also occurs in dry eye disease and shows the same variance between eyes. Finally, elevated tear osmolarity has been reported to be a global marker (present in both subtypes of the disease- aqueous-deficient dry eye and evaporative dry eye). Clinically, osmolarity has been shown to be the best single metric for diagnosis of DED and is directly related to increasing severity of disease. Clinical examination and other assessments differentiate which subtype of disease is present. With effective treatment, the tear osmolarity returns to normal, and its variability between eyes and with time disappears. Other promising markers include objective measures of visual deficits, proinflammatory molecular markers and other molecular markers, specific to each disease subtype, and panels of tear proteins. As yet, however, no single protein or panel of markers has been shown to discriminate between the major forms of DED. With the advent of new tests and technology, improved endpoints for clinical trials may be established, which in turn may allow new therapeutic agents to emerge in the foreseeable future. Accurate recognition of disease is now possible and successful management of DED appears to be within our grasp, for a majority of our patients.

Dry Eye Syndrome in Non-Exophthalmic Graves' Disease

BACKGROUND

The present study aims to assess qualitative and quantitative characteristics of tear film and corneal related impairment and to evaluate the quality of life in a cohort of non-exophthalmic Graves' disease (GD) patients.

METHODS

The series comprised 50 eyes from 25 newly diagnosed GD patients with no proptosis. As control group, 56 eyes of 28 thyroid disease-free subjects were enrolled.

RESULTS

The results of Schirmer I and II, break-up time, and Oxford scheme showed a significant difference between GD and controls. By ocular surface disease index (OSDI) questionnaire, eleven (44%) GD patients had normal ocular surface, while two (8%) had mild, four (16%) had moderate, and eight (32%) had severe dry eye. The mean score of the OSDI in the GD group was significantly (p < 0.001) higher with respect to the control group.

CONCLUSIONS

This study shows that the tear film and cornea are damaged in newly non-exophthalmic GD subjects.

Assessment of tear meniscus with optical coherence tomography in thyroid-associated ophtalmopathy

PURPOSE

To evaluate the tear-film meniscus with optical coherence tomography (OCT) in patients with Graves' disease (GD).

MATERIALS AND METHODS

Patients with GD without clinical features of thyroid-associated ophthalmopathy (TAO) (Group 1, n=35), patients with signs of TAO (Group 2, n=31) and healthy participants (Group 3, n=31) were enrolled. Palpebral fissure width, Schirmer test, tear break-up time (TBUT) test and tear-film meniscus height and area obtained with Fourier-domain-OCT were analyzed.

RESULTS

TBUT test scores were 8 s (2-25) in Group 1, 8 s (2-15) in Group 2 (p=0.380); and 10 s (5-17) in Group 3 (p=0.000 Group 1 versus 3, and 0.000 for Group 2 versus 3). Tear-film meniscus height did not significantly differ between Groups 1 and 2 (257.5 µm (86-962) and 258 µm (99-1340), respectively, p=0.980). In Group 3, tear-film meniscus height was 316 µm (122-720) (p=0.005 Group 1 versus 3 and 0.004 for Group 2 versus 3). Tear-film meniscus area did not significantly differ between Groups 1 and 2 (0.025 mm(2) (0.004-0.250) and 0.024 mm(2) (0.003-0.316), respectively, p=0.850). In Group 3, tear-film meniscus area was 0.048 mm(2) (0.006-0.75) (p=0.000 Group 1 versus 3 and 0.000 for Group 2 versus 3).

CONCLUSION

Tear function is significantly disturbed in GD. OCT is an effective way to assess the tearing function also in patients with GD.

Interleukin-7 expression in tears and orbital tissues of patients with Graves' ophthalmopathy

The aim of this study was to explore whether IL-7 participates in the pathogenesis of Graves' ophthalmopathy (GO). This was a prospective study. 20 GO patients (40 eyes) and 20 healthy volunteers (40 eyes) were recruited. The tear concentration of IL-7 was measured using ELISA assay. IL-7 expression in orbital tissues was evaluated by immunohistochemistry. Patients with inactive GO had the highest IL-7 concentrations in the tears, followed by healthy controls and patients with active GO per ELISA. Immunohistochemistry analysis showed that IL-7 expression in orbital tissues of the inactive GO samples was higher than that of the volunteers. Changes of IL-7 expression in different phases of GO suggested that IL-7 may play an important role in the pathogenesis of GO.