Meibomian gland dysfunction in patients with Sjögren syndrome

Corneal Epithelial Thickness in Sjogren's Disease: A Pilot Study

Purpose

This study was to assess corneal epithelial thickness (CET) in patients with Sjogren's disease (SjD).

Methods

A retrospective chart review was conducted of SjD patients from September 2021 to January 2022. Patient demographics, unanesthetized Schirmer's test, serologic markers, and symptoms as measured by the Ocular Surface Disease Index (OSDI) were reviewed. Epithelial thickness from both eyes was measured using anterior segment OCT at the central 3mm and concentric 5mm, 7mm, and 9mm zones for the superior, temporal, inferior, and nasal corneal quadrants. Associations between corneal epithelial thickness with patient demographics, clinical characteristics, and symptoms were evaluated using regression models.

Results

Fifteen SjD patients (100% female) were included with a mean age of 58.4 years. Patients with Sjogren's disease had a significantly thinner superior corneal epithelium compared to the inferior epithelium (mean 47.7mm vs 53.1mm, p = 0.001). The epithelial thickness mean standard deviation (MSD) was significantly inversely correlated with the unanesthetized Schirmer test (r=-0.39, p = 0.005), suggesting that an overall variability of CET correlates with decreased aqueous tear production. SS-A, SS-B, ANA, and RF positivity were not associated with any measures of CET.

Conclusion

This pilot study suggests that there is significant superior versus inferior thinning of corneal epithelium in Sjogren's patients. There was a significant correlation between variability of corneal epithelial thickness and decreased tear production in Sjogren's patients. Further larger studies are needed to understand the relationship of CET with objective and subjective measurements of ocular surface disease.

Advances in artificial intelligence for meibomian gland evaluation: A comprehensive review

Meibomian gland dysfunction (MGD) is increasingly recognized as a critical contributor to evaporative dry eye, significantly impacting visual quality. With a global prevalence estimated at 35.8 %, it presents substantial challenges for clinicians. Conventional manual evaluation techniques for MGD face limitations characterized by inefficiencies, high subjectivity, limited big data processing capabilities, and a dearth of quantitative analytical tools. With rapidly advancing artificial intelligence (AI) techniques revolutionizing ophthalmology, studies are now leveraging sophisticated AI methodologies--including computer vision, unsupervised learning, and supervised learning--to facilitate comprehensive analyses of meibomian gland (MG) evaluations. These evaluations employ various techniques, including slit lamp examination, infrared imaging, confocal microscopy, and optical coherence tomography. This paradigm shift promises enhanced accuracy and consistency in disease evaluation and severity classification. While AI has achieved preliminary strides in meibomian gland evaluation, ongoing advancements in system development and clinical validation are imperative. We review the evolution of MG evaluation, juxtapose AI-driven methods with traditional approaches, elucidate the specific roles of diverse AI technologies, and explore their practical applications using various evaluation techniques. Moreover, we delve into critical considerations for the clinical deployment of AI technologies and envisages future prospects, providing novel insights into MG evaluation and fostering technological and clinical progress in this arena.

Efficacy and safety of topical azithromycin therapy in patients with blepharitis and meibomian gland dysfunction

PURPOSE

To assess the effects of 1% azithromycin ophthalmic solution (AZM) in patients with bacterial blepharitis accompanied by meibomian gland dysfunction (MGD).

STUDY DESIGN

A multicenter, single arm, prospective interventional study.

METHODS

AZM was administered to the affected eyes twice daily for the first 2 days and once daily for the subsequent 12 days. Lid margin hyperaemia/redness, collarette at the root of the eyelashes, conjunctival hyperaemia, foreign body sensation, and epiphora were assessed on Days 1, 14, and 28. The Dry Eye-related Quality of Life Score (DEQS) and objectives related to MGD, including lid vascularity, lid margin irregularity, foaming, lid plugging, keratoconjunctival disorders, Marx line, meibum grade, and tear breakup time, were also assessed. Bacterial culture of the conjunctival sac and meibum was performed on Days 1 and 14.

RESULTS

Twenty-four eyes of 24 patients (10 men/14 women, mean age 72.3 ± 13.2) were included. On Days 14 and 28, the total score, lid vascularity, lid plugging, and meibum grade showed significant improvement (p < 0.05). On Day 1, 71 strains were isolated from 22 of the 24 eyes (91.7%). Cutibacterium acnes, Corynebacterium spp., and Staphylococci were detected at high frequencies. The overall disappearance rates of the bacteria in the conjunctival sac and meibum at the end of treatment were 65.7% and 58.3%, respectively. No serious ocular or systemic adverse events were observed.

CONCLUSION

Fourteen-day treatment with AZM was effective in patients with blepharitis accompanied by MGD, and the efficacy of AZM persisted for a period after the treatment.

Exploring Sjögren's syndrome through interdisciplinary perspectives: a concise review

Dr. Henrik Sjögren after whom Sjögren's Syndrome is named, was a Swedish ophthalmologist who identified the syndrome which had three main symptoms namely, dry eyes, dry mouth, and arthritis. His contributions also highlighted the systemic complications of the syndrome which made our understanding of this disease better. Since then, there have been several studies on Sjögren's Syndrome (SS) of which two of them have changed the perception of the disease's prevalence. The first was a British study in the late 1990s which indicated this syndrome was no more a rare condition. The second is a 2008 study in the US which placed the syndrome as the second most prevalent autoimmune disease after rheumatoid arthritis (RA). Being one of the most prevalent autoimmune disease, there is a pressing need for a more profound and comprehensive understanding of the syndrome. This review endeavors to offer a comprehensive overview of the disease, encompassing its prevalence, manifestations, mechanisms, genetic factors, diagnostic methods, and treatment options. This review additionally offers the āyurvedic viewpoint on SS and its symptoms. This supplementary insight has the potential to contribute to the development of an integrated and holistic approach to managing the condition.

LipiFlow for the treatment of dry eye disease

BACKGROUND

Meibomian gland dysfunction (MGD) is the most common underlying cause of dry eye disease (DED). MGD leads to pathological alteration of the composition or quantity of meibum, or both, which subsequently results in tear evaporation and the typical signs and symptoms associated with DED. The LipiFlow Thermal Pulsation System (LipiFlow) is a medical device used to treat MGD in office; however, it is unclear if LipiFlow can outperform other DED treatments.

OBJECTIVES

To evaluate the effectiveness of LipiFlow for treating DED signs and symptoms and the safety of LipiFlow compared with sham or other available treatments for MGD in adults.

SEARCH METHODS

The Cochrane Eyes and Vision Information Specialist searched the electronic databases for randomized controlled trials. There were no restrictions on language or date of publication. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, including the Cochrane Eyes and Vision Trials Register; 2022, Issue 6), MEDLINE Ovid, Embase.com, PubMed, LILACS (Latin American and Caribbean Health Science Information database), ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) electronic databases. We also examined the reference lists of identified trials, review articles, and guidelines for information about relevant trials that may not have been identified by our search strategy. We contacted investigators regarding ongoing trials. The last database search was performed on 24 October 2022.

SELECTION CRITERIA

We included studies conducted in adults (over 18 years of age) with DED or MGD as defined by the primary trial investigators. We imposed no restrictions on race, ethnicity, or sex. We considered trials involving contact lens wearers if they were equally represented between groups.

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology.

MAIN RESULTS

We included 13 trials that randomized a total of 1155 participants (28 to 236 participants randomized per study). Six trials were conducted in the USA, three in China, two in Thailand, one in France, and one in Italy. Eight trials were of single-center design, while four trials were of multicenter design; one trial did not report the number of participating centers. Study characteristics The study population of the included trials was 66% female (range 48% to 80%), with an age range of 19 to 86 years. LipiFlow, used as a stand-alone intervention, was compared with basic warm compresses in five studies, thermostatic device in five studies, oral intervention in one trial, and topical dry eye medications in one trial. LipiFlow was also evaluated together with eyelid hygiene product versus eyelid hygiene products alone in one trial. Findings Five trials compared LipiFlow with a basic warm compress applied for varying durations and frequencies during the trial period; only one of these trials combined a warm compress with eyelid massage. Analyzing symptom scores by different questionnaires (Ocular Surface Disease Index [OSDI] and Standard Patient Evaluation of Eye Dryness [SPEED]) yielded conflicting evidence of a difference in symptoms between LipiFlow and basic warm compresses after four weeks. There was no evidence of a difference in meibomian gland expression, meibum quality, or tear breakup time when comparing LipiFlow with basic warm compresses. Another five trials compared LipiFlow with thermostatic devices. Analysis of symptom scores at four weeks showed that thermostatic devices had reduced OSDI scores by a mean difference (MD) of 4.59 (95% confidence interval [CI] 1.23 to 7.95; I2 = 0, P = 0.007; 553 participants; very low certainty evidence) as compared with LipiFlow. When we compared LipiFlow plus eyelid hygiene with eyelid hygiene alone, there was no evidence of difference in signs or symptoms at any time point evaluated. Only one trial compared LipiFlow with a topical DED medication (lifitegrast 5%). The single-trial estimate suggested that 5% lifitegrast may increase meibomian gland expression scores compared with LipiFlow at day 42 (MD -1.21, 95% CI -2.37 to -0.05; 50 participants; low certainty evidence) by using a meibomian gland expression scale of 0 to 8. One trial compared LipiFlow with an oral intervention (doxycycline), finding that LipiFlow may result in significantly better SPEED scores than doxycycline at three months (MD -4.00, 95% CI -7.33 to -0.67; 24 participants; very low certainty evidence). No other significant differences in signs or symptoms were found between LipiFlow and doxycycline at three months. We did not find any other statistically significant differences in symptoms or signs for any other analysis performed in this review at the one- to four-week time point. Adverse events No trial reported any intervention-related, vision-threatening adverse events.

AUTHORS' CONCLUSIONS

LipiFlow performs similarly to other commonly used DED treatments with regard to DED signs and symptoms. The best available evidence was deemed to have a high level of bias, leading to low or very low certainty evidence. Additional research with adequate masking, a standardized testing methodology, and a sample representative of the MGD population is therefore needed before any firm conclusions can be drawn regarding comparative benefits and harms.

Leger AJ, Galor A. Living with your biome: how the bacterial microbiome impacts ocular surface health and disease

Introduction

Microbiome research has grown exponentially but the ocular surface microbiome (OSM) remains an area in need of further study. This review aims to explore its complexity, disease-related microbial changes, and immune interactions, and highlights the potential for its manipulation as a therapeutic for ocular surface diseases.

Areas Covered

We introduce the OSM by location and describe what constitutes a normal OSM. Second, we highlight aspects of the ocular immune system and discuss potential immune microbiome interactions in health and disease. Finally, we highlight how microbiome manipulation may have therapeutic potential for ocular surface diseases.

Expert Opinion

The ocular surface microbiome varies across its different regions, with a core phyla identified, but with genus variability. A few studies have linked microbiome composition to diseases like dry eye but more research is needed, including examining microbiome interactions with the host. Studies have noted that manipulating the microbiome may impact disease presentation. As such, microbiome manipulation via diet, oral and topical pre and probiotics, and hygienic measures may provide new therapeutic algorithms in ocular surface diseases.

Clinical Features of Sjögren Syndrome-Related Dry Eye Disease in Anterior Segment Photographs

PURPOSE

Dry eye disease (DED) is a major complication of autoimmune disorders, including Sjögren syndrome (SS), ocular graft-versus-host disease, and other rheumatic diseases. DED often affects patients' quality of life, necessitating early detection and treatment. However, no simple screening method for DED has yet been established in ophthalmologic practice. This retrospective study aimed to identify the characteristic features of SS-related DED from anterior segment images.

METHODS

Five hundred two cases (SS, 68 cases; ocular graft-versus-host disease, 50 cases; other conditions, 27 cases; simple DED, 72 cases; and no DED, 97 cases) were enrolled.

RESULTS

The inferior corneal fluorescein staining score (CFS_I) was significantly higher in the SS group ( P < 0.001). Moreover, the nasal lissamine green staining score (LG_N) was high in the SS group ( P < 0.001). The sensitivity, specificity, and area under the curve of the receiver operating characteristic curve were calculated for the CFS_I plus LG_N in relation to the SS-positive and SS-negative statuses; the sensitivity and specificity were 80.6% and 91.1%, respectively, with an area under the curve of 0.926.

CONCLUSIONS

A positive CFS_I combined with a positive LG_N correlates with a high risk for SS. A positive CFS_I and a positive LG_N are important signs for an immune-related DED, especially SS, and may be useful in the early detection of SS-related DED.

Ocular Surface Evaluation in Immunoglobulin G4-Related Ophthalmic Disease

PURPOSE

To evaluate the functional and structural changes of the meibomian glands and ocular surface in immunoglobulin G4-related ophthalmic disease (IgG4-ROD) patients.

DESIGN

Cross-sectional, matched case-control comparison study.

METHODS

This study included 64 patients with biopsy-proven IgG4-ROD (aged 63.4 ± 12.2 years, 39 male) and 64 sex- and age-matched healthy controls. Patients were managed by hospitals covering the publicly funded ophthalmology service in Hong Kong. Outcome measures included anterior segment examination and keratographic and meibographic imagings.

RESULTS

A total of 64 worst-affected eyes of the 64 IgG4-ROD patients were analyzed. Corneal fluorescein staining (P = .0187), lid margin telangiectasia (P = .0360), lid-parallel conjunctival folds (P = .0112), papillae (P = .0393), meibomian gland plugging (P = .0001), meibomian gland expressibility (P = .0001), and meibum quality (P = .0001) were more significant in IgG4-ROD patients compared with healthy controls. Both upper and lower meibomian gland dropouts (P = .001 and .0003), and tear meniscus height (P = .0001) were higher in IgG4-ROD patients. Non-invasive tear break-up time (NITBUT) (P = .0166) and Schirmer test results (P = .0243) were lower in IgG4-ROD patients. Upper (r = 0.336, P = .0140) meibomian gland dropouts and NITBUT (r = -0.293, P = .0497) were positively and negatively correlated with the IgG4-ROD onset age, respectively. The number of extraocular organ involvement was negatively correlated with the Schirmer test(r = -0.341, P = .0167). Lower NITBUT was found in IgG4-ROD eyes with lacrimal gland enlargement than in IgG4-ROD eyes without lacrimal gland enlargement radiologically (P < .0001).

CONCLUSIONS

IgG4-ROD patients showed features of both aqueous tear deficiency and evaporative dry eye disease. We recommend ocular surface evaluation to all patients newly diagnosed with IgG4-ROD. Further studies are warranted to clarify the mechanism of IgG4-related dry eye disease.

Meibography and tear function alterations in premature ovarian failure

PURPOSE

Premature ovarian failure (POF) is the deterioration of normal ovarian function before the age of 40. In the presence of chemotherapy, radiation, genetic factors, autoimmune conditions, hypoandrogenemia, hypoestrogenemia and increased gonadotropin hormones, dry eye with early menopause findings may be encountered. The goal of our study is to compare the tear film alterations and meibomian gland status of patients diagnosed with POF at the time of diagnosis with healthy volunteers.

METHODS

In our study, 90 patients with POF and 60 control patients were evaluated. Complete ophthalmologic examinations of the patients, ocular surface disease index (OSDI) score, Oxford score for corneal and conjunctival involvement, Schirmer 1 and 2 tests, noninvasive tear break-up time (BUT), lower lid meibomian drop out grades with noncontact meibography, and meibomian gland distortion and shortening scores were compared between the two groups.

RESULTS

The mean age was 29.49±2.92 years in the patient group and 29.37±2.85 years in the control group (P=0.830). OSDI scores were statistically significant higher in the patient group (32.11±18.88) compared to the control group (12.93±14.92) (P<0.001). On Oxford scoring, there was a significant increase in the patient group (P<0.001). There was no significant difference between the groups in terms of Schirmer 1 and 2 tests (P=0.195, P=0.117). NIBUT was significantly lower in the patient group (11.93±4.59) compared to the control group (18.72±5.38) (P<0.001). While there was no difference between the groups in terms of lower lid meiboscores or meibomian gland length (P>0.005), there was a significant deterioration in the patient group in the distortion grading showing the morphological evaluation of the meibomian glands (p=0.037). In the ROC analysis, OSDI score (AUC=0.816, P<0.0001) and NIBUT (AUC=0.820, P<0.0001) parameters showed high specifity and sensitivity for the disease.

DISCUSSION

Ocular surface damage and dry eye symptoms are observed more frequently in patients with POF. We believe that hormonal insufficiency may cause deterioration in tear film composition, ocular surface damage with changes in tear homeostasis, and a change in the structure of the meibomian glands, starting with distortion at an early age.

Autoimmune Disease-Related Dry Eye Diseases and Their Placement Under the Revised Classification Systems: An Update

Dry eye disease (DED) is a chronic and progressive disorder involving the ocular surface, characterized by disturbances in tear film composition, instability of the tear film, and inflammation of the ocular surface. There are two forms of DED: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). Autoimmune diseases are systemic disorders involving multiple organs, including the eyes, and have a significant impact on DED. There have been multiple studies demonstrating the relation between autoimmune diseases and DED. This article reviews the current knowledge regarding the epidemiological characteristics, pathogenesis, and treatments of autoimmune disease-related DED.

Investigation of Inter- and Intra-Day Variability of Tear Fluid Regarding Flow Rate, Protein Concentration as well as Protein Composition

Purpose

The purpose of this study was to present the determination of inter- and intra-day variations in tear flow rate, and tear fluid protein concentration, as well as protein composition regarding their impact for future biomarker studies.

Methods

Tear fluid was collected noninvasively from 18 healthy subjects by performing Schirmer tests at 4 different time points repetitive in a period of 2 days. The tear flow rate on the Schirmer test strips was measured. Proteins were extracted from strips and quantified using amino acid analysis. Protein composition was analyzed by the strips data-independent (DIA) based mass spectrometry. To exclude any impairments to health, volunteers underwent a detailed neurological as well as an ophthalmological examination.

Results

Whether tear fluid was collected from oculus sinister or oculus dexter did not affect the tear flow rate (P ≈ 0.63) or protein concentration (P ≈ 0.97) of individual subjects. Moreover, protein concentration was independent from the tear volume, so that a change in volume may only influence the total protein amount. When the examination days were compared, investigation of tear flow rate (P ≈ 0.001) and protein concentration (P ≈ 0.0003) indicated significant differences. Further, mass spectrometric analysis of tear fluid revealed 11 differentially regulated proteins when comparing both examination days.

Conclusions

Our findings provide evidence of inter-day variation in tear flow rate, tear proteome concentration, and composition in healthy subjects, suggesting that inter-day variation needs to be taken into consideration in biomarker research of tear fluid. Identified proteins were assigned to functions in the immune response, oxidative and reducing processes, as well as mannose metabolism.

Impacts of gender and age on meibomian gland in aged people using artificial intelligence

Purpose: To evaluate the effects of age and gender on meibomian gland (MG) parameters and the associations among MG parameters in aged people using a deep-learning based artificial intelligence (AI). Methods: A total of 119 subjects aged ≥60 were enrolled. Subjects completed an ocular surface disease index (OSDI) questionnaire, received ocular surface examinations including Meibography images captured by Keratograph 5M, diagnosis of meibomian gland dysfunction (MGD) and assessment of lid margin and meibum. Images were analyzed using an AI system to evaluate the MG area, density, number, height, width and tortuosity. Results: The mean age of the subjects was 71.61 ± 7.36 years. The prevalence of severe MGD and meibomian gland loss (MGL) increased with age, as well as the lid margin abnormities. Gender differences of MG morphological parameters were most significant in subjects less than 70 years old. The MG morphological parameters detected by AI system had strong relationship with the traditional manual evaluation of MGL and lid margin parameters. Lid margin abnormities were significantly correlated with MG height and MGL. OSDI was related to MGL, MG area, MG height, plugging and lipid extrusion test (LET). Male subjects, especially the ones who smoke or drink, had severe lid margin abnormities, and significantly decreased MG number, height, and area than the females. Conclusion: The AI system is a reliable and high-efficient method for evaluating MG morphology and function. MG morphological abnormities developed with age and were worse in the aging males, and smoking and drinking were risk factors.

Evaluating the Differences Between Fluorescein Tear Break-up Time and Noninvasive Measurement Techniques

OBJECTIVES

To compare fluorescein tear break-up time (BUT) and noninvasive BUT measured using interferometry and corneal topography.

METHODS

We investigated 34 eyes of 34 patients with dry eye (mean age 39.2±8.3 years) and 16 eyes of 16 non-dry eye subjects (33.5±6.5 years). Tear film stability was measured using fluorescein BUT, noninvasive BUT (NIBUT)-DR1 with an interferometer, and noninvasive keratographic BUT (NIKBUT)-first and average using corneal topography. Correlations between fluorescein BUT and noninvasive BUT parameters were determined statistically. The noninvasive BUTs were compared between the dry eye and non-dry eye groups. The agreement between fluorescein and noninvasive BUTs was described using Bland-Altman analysis.

RESULTS

Fluorescein BUT was significantly correlated with NIBUT-DR1, NIKBUT-first, and NIKBUT-average. The Bland-Altman analysis revealed bias and 95% limits of agreement between fluorescein BUT and noninvasive BUTs as follows: NIBUT-DR1: 2.07 s, -5.33 to 9.46 s; NIKBUT-first: 3.39 s, -5.46 to 12.24 s; NIKBUT-average: 6.61 s, -1.58 to 14.79 s. The noninvasive BUTs were significantly different between the two groups. When NIBUT-DR1, NIKBUT-first, and NIKBUT-average with Bland-Altman correction were used as an index for dry eye, the cut-off values were 7.1, 8.4, and 11.6 s, respectively. The sensitivities were 0.735, 0.818, and 0.727 and specificities were 0.500, 0.437, and 0.562, respectively.

CONCLUSION

Fluorescein BUT and noninvasive BUTs were significantly correlated, and noninvasive BUTs had higher values than fluorescein BUT. Considering the differences between fluorescein BUT and noninvasive BUTs, noninvasive methods can be used as effective tool for diagnosing dry eye.

Is Corneal Subbasal Nerve Loss Associated With Meibomian Gland Loss in Inactive Mild and Moderate-to-Severe Graves' Ophthalmopathy?

PURPOSE

To evaluate meibomian gland and subbasal nerve plexus parameters in Graves' Ophthalmopathy (GO) and association of meibomian gland loss with corneal subbasal nerve plexus loss.

METHODS

Fifty-two eyes of 52 mild and moderate-to-severe GO patients and 32 eyes of 32 healthy controls were enrolled. The meibomian gland dropout area (MGDA) and meibography scores were evaluated using noncontact meibography. In vivo confocal microscopy of corneal subbasal nerve plexus were conducted. ACCMetrics was used to obtain corneal parameters.

RESULTS

Compared with healthy subjects, GO patients had worse upper and lower eyelid MGDA ( p < 0.001, for all) and upper, lower and total meibography scores ( p < 0.001, p = 0.001, and p < 0.001, respectively). Eyelid margin scores were worse in the GO group ( p < 0.001) and showed correlation with all noncontact meibography parameters ( p < 0.001 for all). All corneal subbasal nerve parameters were significantly lower in the GO group compared with the controls ( p < 0.05 for all). Subbasal nerve parameters of GO patients did not reveal a correlation with MGDA and meibography scores but showed correlations with ocular surface disease index score and Schirmer I test (r = -0.304; p = 0.042 and r = 0.336; p = 0.021, respectively).

CONCLUSION

Meibomian gland and corneal nerve loss could be observed even in the inactive phase and mild GO. The lack of a correlation between meibomian gland loss and subbasal nerve loss suggests that meibomian gland loss is not a significant additional component in the pathogenesis of subbasal nerve damage in GO. Furthermore, our study revealed new evidence regarding the use of eyelid margin score to represent meibomian gland loss in GO.

Meibomian Gland Assessment in Routine Ophthalmology Practice

This cross-sectional study aimed to investigate the connection between meibomian gland (MG) excreta quantity and quality after MG expression (MGX), dry eye disease (DED) symptoms, and objective DED signs and to clarify the relationship between dry eye and MG function in DED pathophysiology. The study included 200 subjects, 100 with and 100 without dry eye symptoms. Schein questionnaire was used to determine the severity of dry eye symptoms and self-reported skin type for facial skin dryness self-evaluation. Objective dry eye signs were assessed by monitoring conjunctival hyperemia, lid parallel conjunctival folds (LIPCOF), tear break-up time (TBUT), fluorescein surface staining and digital MGX. Subjects with DED symptoms had significantly lower MG quantity scores than healthy controls (p < 0.001). Meibum quality and quantity scores significantly correlated with female gender (p = 0.002), Schein questionnaire score (p < 0.001), fluorescein corneal staining score (p = 0.019), self-reported skin type (p < 0.001), TBUT (p < 0.001) and LIPCOF (p = 0.041). After adjustment for age and gender in a logistic regression analysis, dry eye was independently and significantly associated with self-reported skin type (OR 0.73, p < 0.001), LIPCOF (OR 1.04, p < 0.001), fluorescein corneal staining (OR 1.05, p = 0.019), TBUT (OR 0.77, p < 0.001) and meibum quantity score (OR 0.59, p < 0.001). Dry eye symptoms and objective signs correlated well in this study. MGX discriminated between the subjects with and without DED symptoms and was associated with other objective DED signs. Results showed a significant association between meibum quality and quantity, MG function, DED and facial skin dryness self-perception. This paper established a correlation between dry eye symptoms caused by MG dysfunction and dry skin, which can help general health practitioners consider dry eye as a cause of chronic eye complaints with patients who report dry skin.

Analysis of Meibomian Glands in Juvenile Systemic Lupus Erythematosus Patients without Dry Eye Symptoms and Signs

PURPOSE

To evaluate meibomian gland loss and its possible association with disease duration and activity in Juvenile Systemic Lupus Erythematosus (JSLE) patients' without dry eye symptoms or signs.

STUDY DESIGN

Prospective clinical study.

METHODS

Ten eyes of 10 JSLE patients were evaluated using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and 14 eyes of 14 healthy controls were also enrolled. Ocular Surface Disease Index (OSDI) questionnaire and Schirmer I test were performed. Lid margin score, meibum quality and expressibility scores were evaluated. Noninvasive first breakup time (NIF-BUT) and noninvasive average breakup time (NIAvg-BUT), meibomian gland dropout area (MGDA) and meibography scores were evaluated using non-contact meibography (Sirius; CSO).

RESULTS

There was no significant difference between the JSLE patients and the healthy controls in the OSDI, NIF-BUT, NIAvg-BUT and Schirmer I tests. Also lid margin score, meibum quality and expressibility scores were not significantly different between the groups. However, JSLE patients had increased upper and lower lid MGDA and increased upper lid, lower lid and total meibography scores compared to the healthy subjects. Furthermore, the duration of JSLE showed a high positive correlation with upper and lower lid MGDA and meibography scores.

CONCLUSION

Meibomian gland loss could be observed in JSLE patients with no clinical signs and symptoms of dry eye. Considering the longer life expectancy of children, the positive correlation of disease duration with the meibomian gland reveals the importance of routine eye examinations from the diagnosis of the disease.

Intense Pulse Light Combined With Low-Level Light Therapy in Dry Eye Disease: A Systematic Review

OBJECTIVES

To evaluate the improvement in symptoms and signs associated with intense pulse light (IPL) combined with low-level light therapy (LLLT) in the treatment of dry eye disease (DED).

METHODS

A systematic review of full-length original studies reporting the effects of IPL combined with LLLT for DED in two databases, PubMed and Scopus, was performed according to the PRISMA statement. The quality assessment tool for case series studies from the National Heart, Lung, and Blood Institute was used to analyze the quality of the studies selected.

RESULTS

The search provided a total of 393 articles, of which six were included. Significant decreases in the Ocular Surface Disease Index (OSDI) score, meibomian gland dysfunction (MGD) score, MGD grade, and meiboscore and increases in tear film stability, lipid layer thickness, and loss area of the meibomian gland have been reported. Concerning tear volume, tear meniscus height, and Schirmer test remained unchanged. In relation to tear osmolarity and corneal fluorescein staining, contradictory outcomes were found.

CONCLUSIONS

Intense pulse light combined with LLLT for the treatment of dry eye improves OSDI, tear film stability, and meibomian gland function; thus, this treatment may be recommended for DED patients due to MGD.

LipiFlow for the treatment of dry eye disease

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To evaluate the effectiveness of the LipiFlow Thermal Pulsation System on dry eye signs and symptoms compared to placebo or other commercially available treatments for meibomian gland dysfunction in adults.

Unilateral Herpetik Keratitli Hastalarda Kuru Göz Parametrelerinin Değerlendirilmesi

Amaç: Çalışmamızın amacı tek taraflı herpes simpleks virüs (HSV) keratiti olan hastalarda etkilenen ve etkilenmeyen gözler arasındaki gözyaşı parametrelerinin özellikle meibomian bezlerinin durumunun değerlendirilmesidir. Yöntem: Kliniğimizde tek taraflı HSV endoteliti ve HSV stromal keratiti tanılarıyla tedavi uygulanmış ve 3 aydan uzun süredir sakin dönemde seyreden hastaların muayeneleri ve gözyaşı filmi menisküsü yüksekliği (GFMY), alanı (GFMA), non-invazif gözyaşı kırılma zamanı (NIGKZ), schirmer testi, meibomian bezleri ekspressibilite gradeleri, drop-out dereceleri ve mikroyapısının değerlendirilmesini içeren gözyaşı parametreleri retrospektif olarak değerlendirildi. Bulgular: Hastalarımızın yaş ortalaması 58,0 (55,25-72,25) yıldı. Medyan NIGKZ etkilenen gözde 6,85 (4,62-17,0) sn. ve etkilenmemiş gözde 15,85 (10,47-17,15) sn. idi. Gruplar arasındaki değişim istatistiksel olarak anlamlı olmasa da, etkilenen gözde NIGKZ değerlerinin belirgin şekilde daha düşük olduğu gözlendi. Schirmer test değerleri, GFMY ve GFMA, etkilenen ve etkilenmeyen gözler arasında benzerdi. Etkilenen ve etkilenmeyen gözlerin meibomian bezi değerlendirmeleri, meibomian ekspresyonu ve bırakma dereceleri benzer dağılım gösterdi. Sonuç: Her iki gözde meibom bezlerinin hem morfolojik hem de mikroyapısal özelliklerinde benzer etkiler gözlemledik. Bu durum bize her iki gözde gelişen kuru göz hastalığının sadece nörosensoriyel anomalilerden değil meibomian bezlerdeki değişikliklerden de kaynaklanabileceğini düşündürmektedir.

Is contact lens discomfort related to meibomian gland morphology?

PURPOSE

To examine the relationship between contact lens (CL) discomfort and meibomian gland (MG) morphology assessed by a semi-objective software in subjects without an alteration of MG function (meibum quality and expressibility).

METHODS

Nineteen symptomatic (CLDEQ-8 ≥ 12) CL wearers, 19 asymptomatic (CLDEQ-8 < 12) wearers, and 22 non-wearers were recruited. Upper and lower eyelid meibography images were taken and the following parameters were analysed using a semi-objective software in the central 2/3 of each eyelid: number of MG, number of partial MG, percentage of MG loss and percentage of tortuosity. One-way ANOVA or Kruskal-Wallis H test were used for comparisons among groups. The relationships between CLDEQ-8 and MG morphology parameters were analysed using the Spearman correlation coefficient and multivariable linear regression models.

RESULTS

No significant differences were found among groups in the MG morphology of the upper or lower eyelids. In all CL wearers, a significant correlation with CLDEQ-8 was found in the upper eyelid for the number of MG (rho = 0.47, p = 0.003). In symptomatic wearers, significant correlations with CLDEQ-8 were found in the lower eyelid for the number of partial MG (rho = 0.49, p = 0.03) and the percentage of partial MG (rho = 0.61, p = 0.005). In all CL wearers, multivariable models were fitted to explain CLDEQ-8 score including the number of MG, the number of partial MG and the percentage of MG loss from the lower eyelid (R² = 0.19; p = 0.007), and the number of MG from the upper eyelid (R² = 0.19; p = 0.001). In symptomatic wearers, a model was fitted including the percentage of MG loss from the lower eyelid (R² = 0.30; p = 0.016).

CONCLUSIONS

Alterations of MG morphology, without clinically apparent alteration of MG function, can be involved in causing CL discomfort and influence the degree of symptoms. The differences in findings between eyelids indicate the need to monitor both eyelids, especially the lower one, in CL wearers.

Association of Meibomian Gland Dysfunction with Oral Statin Use

This retrospective cross-sectional study aimed to determine the association of oral statin use, dry eye disease (DED), and meibomian gland dysfunction (MGD). A total of 93 subjects were included and divided into two groups: statin users (n = 45) and nonstatin users (n = 47). Significant differences were observed in the total cholesterol (p = 0.013), low-density lipoprotein (LDL) (p = 0.005), and meiboscore (p = 0.000) levels between the two groups. For stratified analysis, the statin group was divided into subgroups according to the type or dose of statin and total duration of statin use. However, there were no differences in clinical features between the subgroups. In multiple regression analysis, meiboscore was significantly associated with age (slope = 0.05, p = 0.00) and statin use (slope = −1.19, p = 0.00), with an R² of 0.44. Thus, older adults and participants who do not use statin appeared to have higher scores. In conclusion, although the mechanism is unclear, statins may exert a protective effect on the meibomian gland. Further lipidomic studies are required to determine the pharmacological effects of statins on the meibomian gland and other meibum components.

Ocular Surface Inflammatory Disorders (OSID): A Collective of Systemic Etiologies Which Cause or Amplify Dry Eye Syndrome

The ocular surface inflammatory disorders (OSID) are caused by systemic disorders that conduct a persistent inflammatory reaction in the ocular adnexal connective tissues, such as the conjunctiva, lacrimal gland (LG) and meibomian glands (MGs), which cause an inflammatory dry eye. The etiologies of OSID are a subset of systemic pathologies such as graft versus host disease, Sjögren’s syndrome, allergies, cicatrizing conjunctivitis, and more. These cause a purely inflammatory dry eye syndrome as a consequence of the persistent surrounding inflammation in the adnexal tissues, which is distinct from the age-related dry eye disease. A limitation toward management of these conditions is the lack of available biomarkers that can detect presence of inflammation and quantify damage on the conjunctiva and LG, even though these are considered to be drivers of the inflammatory milieu. The OSID and dry eye syndrome are caused by different immune cells which are not exclusively limited to T cell lymphocytes, but rather derive from an orchestrated multicellular immunologic response. Recognition of this syndrome is crucial to direct research in a direction that clarifies the potential role of inflammation and its associated immune phenotype on the conjunctiva and adnexal ocular tissues in OSID and dry eye syndrome. On this paper, we review the basic and clinical research evidence for the existence of OSID with focus on the different immune cells involved, the target tissues and potential consequences and OSIDs diagnostic and therapeutic implications.

Impact of Air Pollution on the Ocular Surface and Tear Cytokine Levels: A Multicenter Prospective Cohort Study

Purpose

To assess air pollution-induced changes on ocular surface and tear cytokine levels.

Methods

As a prospective multicenter cohort study, 387 dry eye disease (DED) participants were recruited from five provinces in China and underwent measurements of ocular surface disease index (OSDI), Schirmer’s I test (ST), tear meniscus height (TMH), tear film break-up time (TBUT), corneal fluorescein staining (CFS), meibomian gland (MG) function, and tear cytokines. The associations between ocular surface parameters and exposure to particulate matter (PM), ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂) for 1 day, 1 week, and 1 month before the examination were analyzed in single- and multi-pollutant models adjusted for confounding factors.

Results

In the multi-pollutant model, the OSDI score was positively correlated with PM with diameter ≤2.5 μm (PM_2.5), O₃, and SO₂ exposure [PM_2.5: β (1 week/month) = 0.229 (95% confidence interval (CI): 0.035–0.424)/0.211 (95% CI: 0.160–0.583); O₃: β (1 day/week/month) = 0.403 (95% CI: 0.229–0.523)/0.471 (95% CI: 0.252–0.693)/0.468 (95% CI: 0.215–0.732); SO₂: β (1 day/week) = 0.437 (95% CI: 0.193–0.680)/0.470 (95% CI: 0.040–0.901)]. Tear secretion was negatively correlated with O₃ and NO₂ exposures but positively correlated with PM_2.5 levels. Air pollutants were negatively correlated with TBUT and positively related with CFS score. Besides SO₂, all other pollutants were associated with aggravated MG dysfunction (MG expression, secretion, and loss) and tear cytokines increasement, such as PM_2.5 and interleukin-8 (IL-8) [β (1 day) = 0.016 (95% CI: 0.003–0.029)], PM with diameter ≤10 μm (PM₁₀) and IL-6 [β (1 day) = 0.019 (95% CI: 0.006–0.033)], NO₂ and IL-6 [β (1 month) = 0.045 (95% CI: 0.018–0.072)], among others. The effects of air pollutants on DED symptoms/signs, MG functions and tear cytokines peaked within 1 week, 1 month, and 1 day, respectively.

Conclusion

Increased PM_2.5, O₃, and SO₂ exposures caused ocular discomfort and damage with tear film instability. PM₁₀ exposure led to tear film instability and ocular injury. PM, O₃, and NO₂ exposures aggravated MG dysfunction and upregulated tear cytokine levels. Therefore, each air pollutant may influence DED via different mechanisms within different time windows.

Relationship between meibomian gland loss in infrared meibography and meibum quality in dry eye patients

Background

In the present study, we evaluated the correlation between meibomian gland dropout and meibum quality in the same central 8 meibomian glands of the eyelid.

Methods

Ninety-nine eyes of 91 patients with dry eye were included in the study. Dropout of the 8 central meibomian glands of the eyelids was graded as 0, 1, 2, or 3, according to the dropout area. The meibum quality was graded as follows: grade 0, no secretion; 1, inspissated/toothpaste consistency; 2, cloudy liquid secretion; and 3, clear liquid secretion. For 68 eyes of 68 patients, correlation analysis between dropout and meibum quality was performed. To precisely analyze the direct correlation between meibomian gland dropout in meibography and meibum quality, we evaluated 31 eyes of 23 patients with focal dropout in meibography.

Results

The median (interquartile range) meiboscore was 1.0 (2.0) in the upper eyelids and 0.0 (1.0) in the lower eyelids. The median (interquartile range) meibum quality grade was 3.0 (1.0) in the upper eyelids and 1.0 (1.0) in the lower eyelids. No significant correlation between the meiboscore and meibum quality grade was detected in the upper (p =0.746) or lower (p =0.551) eyelids. Analysis of the direct correlation between meibomian gland dropout in meibography and meibum quality in patients with focal dropout (loss of 1 or 2 adjacent meibomian glands), however, indicated that meibomian glands with dropout secreted little to no meibum.

Conclusions

Overall analysis revealed no relationship between meibomian gland dropout and meibum quality, but more detailed investigation of each meibomian gland alone revealed that meibomian glands with dropout secrete little to no meibum.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02509-5.

The effects of short-term and long-term air pollution exposure on meibomian gland dysfunction

We aim to assess the effects of different air pollutants on meibomian gland dysfunction (MGD). As a prospective multicenter study, 864 patients were recruited from four different regions (i.e., coal, oil, steel, and living). The oil region had a significantly lower temperature and higher O₃ and SO₂ concentrations than other regions. Notably, participants in oil region presented with more frequent and serious MGD signs and higher cytokine levels (median interleukin 6 [IL-6] in oil: 2.66, steel: 0.96, coal: 0.38, living: 0.56; IL-8 in oil: 117.52, steel: 46.94, coal: 26.89, living: 33; vascular endothelial growth factor [VEGF] in oil: 25.09, steel: 14.02, coal: 14.02, living: 28.47). The short-term fluctuations of cytokine levels were associated with the changes in gas levels (PM_2.5 and IL-8: β = 0.016 [0.004–0.029]; O₃ and IL-6: β = 0.576 [0.386–0.702]; O₃ and IL-8: β = 0.479 [0.369–0.890]; SO₂ and VEGF: β = 0.021 [0.001–0.047]). After long-term exposure, lid margin neovascularization (r = 0.402), meibomian gland (MG) expression (r = 0.377), MG secretion (r = 0.303), MG loss (r = 0.404), and tear meniscus height (r = − 0.345) were moderately correlated with air quality index (AQI). Individuals in oil region had more serious MGD signs and higher cytokine levels. MGD is susceptible to long-term exposure to high AQI.

Evaluation of Tear Evaporation Rate in Subjects with a High Body Mass Index

Aim This study evaluated the tear evaporation rate (TER) in subjects with a high body mass index (BMI) and tested the correlation between BMI and dry eye.

Methods Thirty male subjects aged 18 – 38 years (26.4 ± 4.0 years) with a high BMI (26.4 – 47.0 kg/m2) were enrolled in the study. In addition, a control group of 30 males aged 20 – 36 years (24.0 ± 3.6 years) with a normal BMI (< 25 kg/m2) participated in the study for comparison. Each subject completed the ocular surface disease index (OSDI), followed by the TER measurement using a handheld VapoMeter.

Results Significant differences (Wilcoxon test; p = 0.002 and 0.001) were found between the median scores of the OSDI (10.3 [3.7] vs. 5.9 [7.2]) and TER (35.5 [13.1] vs. 15.5 [12.8] g/m2 h) in the study and control groups, respectively. The OSDI indicated dry eye in 60.0% of subjects in the study group (n = 18). The TER measurements showed that 76.7% of subjects in the study group (n = 23) had dry eyes. A medium correlation (r = 0.569; p = 0.001) was found between the OSDI scores and TER measurements.

Conclusions The means of the tear evaporation rate and the ocular surface disease index scores are significantly higher in subjects with a high BMI compared with the control group. Therefore, a high BMI is considered a risk factor for dry eye. The measurement of the tear evaporation rate using a handheld VapoMeter is a simple and rapid method to detect dry eyes in combination with other tools.

Exploratory Search for Characteristic Symptoms to Distinguish Meibomian Gland Dysfunction from Dry Eye in a Population-Based Study in Japan

Symptom overlap between meibomian gland dysfunction (MGD) and dry eye (DE) makes it difficult to distinguish between these two conditions on the basis of symptoms alone. We searched for characteristic symptoms that might help to distinguish MGD from DE on the basis of a population-based study. Subjects comprised 311 residents of Takushima island (18 to 96 years), including 117 individuals with MGD and 114 with DE. Responses to a symptom-related questionnaire (19 items) were subjected to factor analysis, and univariate regression analysis was performed to identify ocular surface parameters associated with characteristic symptoms of MGD. Factor analysis revealed aggregation of symptoms according to three factors: Factor 1 related to Symptom Score, Factor 2 to DE, and Factor 3 to MGD. Symptoms associated with DE included 11 items, whereas the only item related to MGD was tearing sensation. Pearson’s correlation analysis revealed that tearing sensation was associated with tear meniscus height (TMH), noninvasive tear-film breakup time, fluorescein staining score, meiboscore, meibum grade, and Schirmer value. Subjects with MGD experienced significantly more tearing and had a larger TMH than did those without MGD (p = 0.0334). Tearing sensation may thus be a characteristic symptom of MGD. Physicians should suspect MGD who complain of tearing sensation.

Meibomian gland alteration in patients with systemic lupus erythematosus

PURPOSE

To investigate meibomian gland (MG) alteration in patients with systemic lupus erythematosus (SLE).

METHODS

This study included 23 SLE patients evaluated with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and 21 healthy controls (HCs). All the subjects were evaluated with Ocular Surface Disease Index (OSDI) questionnaire, and the eyes were performed examinations of tear meniscus height (TMH), non-invasive keratographic tear film break-up time (NIKBUT), Schirmer I Test, MG eyelid score, meibography score, and in vivo confocal microscopy (IVCM) on the meibomian gland.

RESULTS

There was no significant difference between the SLE patients and the HCs in the TMH, NIKBUT, and Schirmer I Test. However, the SLE patients had higher MG eyelid scores and meibography scores on both upper eyelid and lower eyelid than the HCs. Through meibography observation, 34.8% of the SLE patients presented MG deficiency in Grade 3, whereas that of all the HCs were less than Grade 3. The SLE patients were found to have significant MG atrophy and vascular enrichment around the meibomian glands (MGs). The SLE patients were also found to have excessive inflammatory cell infiltration around the MGs, especially the typical lymph node-like foci of inflammatory cell infiltration.

CONCLUSIONS

MG alteration can be found in the SLE patients. Examinations of the MGs can help diagnose or infer ocular diseases at an early stage of SLE.

[Modern possibilities of studying the composition of meibomian glands secretion]

As the main source of various lipids, the meibomian glands are involved in the formation of lipid layer of the tear film and the maintenance of homeostasis of the ocular surface. This process is directly dependent on the chemical composition and thickness of the lipid layer. In addition to lipid components, the meibum also contains various proteins that affect the properties of the tear film. The introduction of various modifications of mass spectrometry into clinical practice is a new diagnostic approach that allows obtaining information about the composition of meibomian glands secretion and tears.

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.

Is dry eye disease the same in young and old patients? A narrative review of the literature

Advanced age is one of the most evident risk factors for dry eye disease (DED), with male/female sex, chronic drug consumption, and prolonged device use. This article aims to review the literature about the changes of the ocular surface associated with DED in the elderly and patients < 40 years. The pathophysiologic changes of the ocular surface responsible for eye dryness are linked with inflammation and neurosensory abnormalities and may occur with a different feature in young patients compared with elders. Peculiar treatment strategies may be needed for young and older subjects with DED.

Meibomian gland dysfunction and primary Sjögren's syndrome dry eye: a protocol for systematic review and meta-analysis

INTRODUCTION

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disorder that primarily affects the exocrine glands such as the lacrimal and the salivary glands. Dry eye disease (DED) is one of the most prevalent manifestations of pSS and is usually classified into aqueous-deficient dry eye and evaporative dry eye. Sjögren's syndrome dry eye (SSDE) is generally described as aqueous-deficient dry eye. However, as the leading pathophysiological mechanism of evaporative dry eye, meibomian gland dysfunction (MGD) also has influence on SSDE, which has been shown in recent studies. We speculate that SSDE is more than just an aqueous-deficient dry eye. While no related systematic review and meta-analysis has been published, the present study is designed to derive a better understanding of the association between MGD and SSDE.

METHODS AND ANALYSIS

The Preferred Reporting items for Systematic Reviews and Meta-Analysis for Protocols 2015 statement was used to prepare this protocol. PubMed, Embase, Web of Science, Cochrane Database, China National Knowledge Infrastructure and Wan Fang Database will be searched from their inception to 31 October 2021, with restrictions to publications in English or Chinese. Two reviewers will independently carry out data extraction and quality assessment. The diagnosis of pSS will meet the standard diagnostic criteria, such as American College of Rheumatology/European League against Rheumatism Classification Criteria (ACR/EULAR) or American-European Consensus Group Classification criteria (AECG), and the definition of MGD and DED will differ between studies. The quality of included studies will be judged using the Newcastle-Ottawa Quality Scale. We will carry out this meta-analysis using RevMan V.5.4.1. The incidence of MGD in patients with SSDE will be indicated as OR with 95% CI.

ETHICS AND DISSEMINATION

Ethical approval is not required as this meta-analysis is performed based on published studies and does not involve human participants. The results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021226017.

Efficacy of Intense Pulsed Light Treatment in Patients with Sjögren’s Syndrome Associated with Meibomian Gland Dysfunction

Purpose: To investigate the efficacy of intense pulsed light (IPL) treatment in patients with meibomian gland dysfunction (MGD) associated with Sjögren’s syndrome.Methods: This study included 43 patients with MGD and Sjögren’s syndrome. Patients received either IPL with meibomian gland expression (IPL/MGX) (n = 22) or MGX only (n = 21). Treatments were administered three times at a 3-week interval. Patients were followed up 6 weeks after the end of the treatment. Ocular Surface Disease Index (OSDI), tear film breakup time with fluorescein dye (FBUT), non-invasive tear breakup time, tear meniscus height (TMH), Schirmer test, SICCA ocular surface staining score, meibum quality score (MQS), and meibum expression score (MES) were evaluated at each visit. Meibomian gland dropouts (meiboscore) and tear film lipid layer grade were measured using keratography.Results: OSDI, FBUT, corneal surface staining score, MQS, meiboscore, and tear film lipid layer grade improved after IPL/MGX treatment (p < 0.05). In both treatment groups, MES significantly improved (p < 0.01 and p < 0.05 for IPL/MGX and MGX groups, respectively). The Schirmer test score, conjunctival surface staining score, and TMH after treatment were not significantly different between the groups. After treatment, the IPL/MGX group had significantly lower OSDI, FBUT, corneal staining score, MQS, and MES, but higher FBUT, compared with the MGX group (p < 0.05).Conclusions: IPL treatment effectively improved tear film, ocular surface parameters, meibomian gland function, and lipid layer grade in patients with Sjögren’s syndrome and MGD.

Autoimmune Epithelitis and Chronic Inflammation in Sjögren's Syndrome-Related Dry Eye Disease

Autoimmune epithelitis and chronic inflammation are one of the characteristic features of the immune pathogenesis of Sjögren’s syndrome (SS)-related dry eye disease. Autoimmune epithelitis can cause the dysfunction of the excretion of tear fluid and mucin from the lacrimal glands and conjunctival epithelia and meibum from the meibomian glands. The lacrimal gland and conjunctival epithelia express major histocompatibility complex class II or human leukocyte antigen-DR and costimulatory molecules, acting as nonprofessional antigen-presenting cells for T cell and B cell activation in SS. Ocular surface epithelium dysfunction can lead to dry eye disease in SS. Considering the mechanisms underlying SS-related dry eye disease, this review highlights autoimmune epithelitis of the ocular surface, chronic inflammation, and several other molecules in the tear film, cornea, conjunctiva, lacrimal glands, and meibomian glands that represent potential targets in the treatment of SS-related dry eye disease.

Effects of Aging on Human Meibum

Purpose

The purpose of this study was to determine if aging affects meibum lipid composition in non-meibomian gland dysfunction (MGD)/non-dry eye (DE) population. Aging has been repeatedly linked to pathological changes in various tissues and organs, including the onset of MGD and DE, in a number of clinical and population-wide surveys. Both conditions have been associated with abnormal meibum secretion and composition, among other factors. However, the chemical basis for such a connection has not been established yet.

Methods

To identify and characterize possible changes in the meibum and meibogenesis with aging, lipidomic analyses of meibum samples collected from human subjects of two age groups - young (29 ± 5 years, n = 21) and elderly (68 ± 7 years, n = 29) - with similar male to female ratios in each group were conducted. Intact lipid species from major lipid groups of meibum (such as wax esters, cholesteryl esters, free cholesterol, triacylglycerols, etc.) were compared using lipidome-wide untargeted (such as Principal Component Analysis) and targeted (such as Orthogonal Projections to Latent Structures Discriminant Analysis) approaches, along with focused analyses of specific lipid species in liquid-chromatography mass spectrometry (LC-MS) and tandem mass spectrometry (MS-MS) experiments.

Results

Extremely high similarities of meibum lipids in the two age groups were observed, with only minor changes in the individual lipid species. The magnitude of the intergroup variability for tested lipid species was comparable to the intragroup variability for the same meibum components. No statistically significant differences in the lipid esterification, elongation, and unsaturation patterns were observed.

Conclusions

Chronological aging itself seems to have only minor effect on meibogenesis in healthy, non-MGD/non-DE subjects.

A spectroscopic approach to measuring meibum lipid composition and conformation in donors with Sjӧgren's syndrome

Patients with Sjӧgren's syndrome (SS) have dry eye associated with meibomian gland dysfunction (MGD). The meibum from donors with dry eye due to MGD but without SS (MMGD) presents with lower levels of cholesteryl ester, less straight chains, and more ordered hydrocarbon chains compared with meibum from donors without MGD (Mn). The aim of the current study was to compare the composition and hydrocarbon chain conformation of meibum from donors with Sjögren's syndrome (Mss) to Mn and MMGD. Meibum was expressed from patients with SS using an ILUX instrument (Alcon Inc., Fort Worth TX). All of the nine meibum donors with SS were female. Meibum composition was characterized using 1H-NMR and meibum hydrocarbon chain conformation was measured using fourier transform infrared spectroscopy. Meibum from every donor with SS measured contained a significantly (P < 0.01) higher cholesteryl ester/wax ester ratio and more straight chains compared with donors without SS or dry eye. None of the nine phase transitional parameters were significantly different, P > 0.05, for Mss compared with Mn. Nor was the CH3/CH2 band height ratio used to estimate the number of hydrocarbon CH3 and CH2 moieties different, P = 0.22, for Mss compared with Mn. In conclusion, the compositional differences between Mss compared with Mn did not result in differences in any of the nine meibum lipid phase transitional parameters measured. The compositional differences observed between Mss and Mn could be markers for or contribute to SS as the differences could lead to tear film lipid packing differences other than conformational differences.

Meibomian gland atrophy with duration of Sjogren's syndrome in adult females

BACKGROUND

To investigate the correlation between the duration of Sjögren syndrome (SS) and ocular surface parameters in patients with SS-related dry eye.

METHODS

We analyzed 108 eyes of 108 female patients with primary SS-related dry eye. All patients underwent rheumatoid serologic tests and ocular surface assessments. The ocular surface assessment included the Standard Patient Evaluation of Eye Dryness (SPEED) score, meibomian gland (MG) atrophy, lipid layer thickness (LLT), partial and total blinking, partial blinking rate, Schirmer's I test, non-invasive tear break-up time, and ocular surface staining score. Correlations between the duration of SS and ocular surface assessments were calculated.

RESULTS

The average age and SS duration of the participants were 56.7 ± 10.2 (range 21-78) years and 54.15 ± 41.10 (range 1-134) months, respectively. There was a strong positive correlation between SS duration and MG atrophy (r = 0.766, p < 0.001). The correlation between SS duration and MG atrophy rate remained significant after controlling for age (r = 0.559, p < 0.001). Average, maximum, and minimum LLTs showed weak negative correlations with SS duration (r = - 0.310, - 0.211, and-0.304, respectively, p = 0.014, 0.028, and 0.022, respectively) and MG atrophy (r = - 0.191, - 0.326, and - 0.299, respectively, p = 0.049, 0.002, and 0.009, respectively). SPEED score showed a weak positive correlation to SS duration (r = 0.303, p = 0.042) and a moderate positive correlation to MG atrophy (r = 0.450, p = 0.029).

CONCLUSIONS

Longer duration of primary SS was related to more severe MG atrophy. Therefore, it is necessary to perform meibography in SS patients to verify MG atrophy status. A comparative study with non-SS dry eye patients is required to validate this study.

Relationship between serum lipid level and meibomian gland dysfunction subtype in Korea using propensity score matching

To analyze the relationship between systemic lipid profile levels and meibomian gland dysfunction (MGD) subtype in Korea. The ophthalmic data of 95 eyes and the serum lipid profiles of 95 patients were reviewed. These factors were compared with those of the general population using data from the Korean National Health and Nutrition Examination Survey (KNHANES), which evaluated 2,917 subjects. Of these, the comparison group (1:5 ratio; n = 475) was selected using propensity score matching according to age and sex. In addition, we analyzed the relationship between serum lipid profile levels and MGD subtypes in MGD patients. The mean high-density lipoprotein (HDL) value of the MGD patients was significantly higher than that of the general population (P < 0.0001). Moreover, the mean low-density lipoprotein (LDL) levels of the MGD patients was significantly lower than that of the general population (P = 0.0002). However, the mean total cholesterol (TC), and triglyceride (TG) levels of the MGD patients were not significantly different from those of the general population (TC: P = 0.4282, TG: P = 0.5613). In addition, no serum lipid levels statistically differed among the MGD subtypes (TC: P = 0.7650, HDL: P = 0.2480, LDL: P = 0.3430, TG: P = 0.7030). A statistically significant increase in HDL and decrease in LDL concentration were observed in the MGD group, although there was no difference in any serum lipid level among the MGD subtypes.

In vivo confocal microscopy assessment of meibomian glands microstructure in patients with Graves' orbitopathy

BACKGROUND

To evaluate microstructural changes in the meibomian glands (MGs) in patients with active and inactive Graves' orbitopathy (GO), using in vivo confocal microscopy (IVCM), and to investigate the correlations between clinical and confocal findings.

METHODS

Forty patients (80 eyes) with GO (34 eyes with active GO, 46 eyes with inactive GO), and 31 age- and sex-matched control participants (62 eyes) were enrolled consecutively. A researcher recorded the clinical activity score (CAS) for each patient. A complete ophthalmic examination was then performed, including external eye, ocular surface and MGs. IVCM of the MGs was performed to determine the MG acinar density (MAD), MG longest and shortest diameters (MALD and MASD), MG orifice area (MOA), MG acinar irregularity (MAI), meibum secretion reflectivity (MSR), acinar wall inhomogeneity (AWI), acinar periglandular interstices inhomogeneity (API), and severity of MG fibrosis (MF).

RESULTS

All confocal microscopy assessments of MGs significantly differed among groups (all P = 0.000). Compared to controls, GO groups showed lower MOA (1985.82 ± 1325.30 μm2 in active GO and 2021.59 ± 1367.45 μm2 in inactive GO vs. 3896.63 ± 891.90 μm2 in controls, all P = 0.000) and MAD (87.21 ± 32.69 /mm2 in active GO and 80.72 ± 35.54 /mm2 in inactive GO vs. 114.69 ± 34.90 /mm2 in controls, P = 0.001 and 0.000, respectively); greater MALD (118.11 ± 30.23 μm in active GO and 120.58 ± 27.64 μm in inactive GO vs. 58.68 ± 20.28 μm in controls, all P = 0.000) and MASD (44.77 ± 19.16 μm in active GO and 46.02 ± 20.70 μm in inactive GO vs. 27.80 ± 9.90 μm in controls, all P = 0.000); and higher degrees of MAI, MSR, and MF (all P<0.05). Eyes with active GO had higher degrees of MAI (P = 0.015), AWI (P = 0.000), and API (P = 0.000), while eyes with inactive GO had higher degrees of MSR (P = 0.000) and MF (P = 0.017). In GO groups, AWI and API were positively correlated with CAS (r = 0.640, P = 0.000; r = 0.683, P = 0.000, respectively), and MF was negatively correlated with CAS (r = - 0.228, P = 0.042).

CONCLUSIONS

IVCM effectively revealed microstructural changes of MGs in eyes with GO and provided strong in vivo evidence for the roles of obstruction and inflammation in the ocular surface disease process. Furthermore, it revealed discernible patterns of MG abnormalities in eyes with active GO and inactive GO, which are not easily distinguishable by typical clinical examinations.

Combined Low-Level Light Therapy and Intense Pulsed Light Therapy for the Treatment of Dry Eye in Patients with Sjögren's Syndrome

PURPOSE

To evaluate the effects of combined intense pulsed light therapy (IPL) and low-level light therapy (LLLT) in dry eye disease (DED) in patients affected by Sjögren's syndrome. Patients and Methods. This is a monocentric, prospective, interventional study. At baseline, all the study patients (n = 20) were on tear substitute therapy and underwent Schirmer type-1 test and breakup time (BUT) test. After baseline measurements, tear substitute therapy was suspended, and patients underwent IPL and LLLT. The same investigations were carried out at one (T1) and at three (T3) months after treatment. The Ocular Surface Disease Index (OSDI) survey was used to measure the severity of DED.

RESULTS

BUT test showed an increase in tear film breakup time in patients with DED 1 month after the beginning of the treatment (T0 vs T1: p=0,01). This increase was even more statistically significant after 3 months of the IPL and LLLT treatment (T0 vs T3: p < 0.0001). Schirmer test values increased too, but there was not statistically significance between values at T0 and T1 or T3. The patients perceived an improvement in their condition, which resulted in a lower score on the OSDI survey. The OSDI score was lower at T1 than T0 (T0 vs T1: p=0.0003), while it tended to increase again after 3 months although it was still lower than baseline (T0 vs T3: p=0.02). No facial or ocular side effects were reported.

CONCLUSIONS

The use of combined IPL/LLLT for the treatment of DED in patients affected by Sjögren's syndrome appears to be beneficial.

Does Sjogren's syndrome affect only the lacrimal gland in the eye? Time to replace the missing stones

Purpose:

This study aimed to reveal the cause of meibomian gland disease and meibomian gland loss in patients with Sjögren's syndrome (SS) as the leading factor for dry eyes.

Methods:

The study included a total of 30 patients with SS and dry eye symptoms and a control group of 50 age- and gender-matched healthy subjects. The dryness parameters of all the participants were evaluated. At first, meibography was performed to measure meibomian gland loss using noninvasive methods. Later, meibomian gland expression and secretion quality were evaluated using silt-lamp biomicroscopy. Correlations between the measurements were analyzed statistically.

Results:

In patients with SS, MG loss was significantly greater than in the control group (19.7 ± 71%, 12.7 ± 9.6%, P < 0.001). All dry eye parameters (tear film breakup time, Schirmer's test score, OSDI, stain score, dry eye disease) were statistically significant in the SS group. There was an extremely negative correlation between upper MB loss and BUT (P = 0.08, r: 0.781). There was an extremely positive correlation between upper MB loss and staining (P = 0.015, r: 0.739). An extremely negative correlation was determined between sub-MB loss and BUT (P = 0.18, r:-0.781), and a moderately positive significant correlation was found between sub-MB loss and staining (P = 0.031, r: 0.659).

Conclusion:

The results of this study demonstrated that patients with SS were at a higher risk of being exposed to meibomian gland loss, which directly leads to the severe dry eye symptoms associated with SS.

Corneal nerve structure in patients with primary Sjögren's syndrome in China

Background

The aim of this study was to evaluate the in vivo confocal microscopic morphology of corneal subbasal nerves and its relationship with clinical parameters in patients with primary Sjögren’s syndrome in China.

Methods

This was a case control study of 22 dry eye disease (DED) patients with primary Sjögren’s syndrome (pSS) and 20 control subjects with non-Sjögren dry eye disease (NSDE). Each patient underwent an evaluation of ocular surface disease using the tear film break-up time (TBUT), noninvasive tear film break-up time (NIKBUT), noninvasive tear meniscus height (NIKTMH), corneal staining (National Eye Institute scale, NEI), Schirmer I test, meibography, and corneal subbasal nerve analysis with in vivo confocal microscopy (IVCM). The right eye of each subject was included in this study.

Results

SS patients showed a shorter TBUT (P = 0.009) and Schirmer I test results (P = 0.028) than the NSDE group. However, there was no significant difference in NIKBUT between the two groups (P = 0.393). The nerve density of subbasal nerves, number of nerves and tortuosity of the SS group were significantly lower than those of the NSDE group (P = 0.001, P < 0.001 and P = 0.039, respectively). In the SS group, the mean nerve length was correlated with age and the Schirmer I test (r = − 0.519, P = 0.013 and r = 0.463, P = 0.035, respectively). Corneal staining was correlated with nerve density and the number of nerves (r = − 0.534, P = 0.013 and r = − 0.487, P = 0.025, respectively).

Conclusions

Sjögren syndrome dry eye (SSDE) patients have more severe clinical dry eye parameters than non-Sjögren dry eye disease (NSDE) patients. Compared with NSDE patients, we found that SSDE patients showed decreased corneal subbasal nerve density and numbers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01967-7.

Ocular Surface Biomarkers

ABSTRACT

Sjögren syndrome (SS) is a chronic inflammatory autoimmune disease of the lacrimal and salivary glands. Salivary gland biopsy is still one of the most valuable and acceptable diagnostic tests for SS, which however, is an invasive test. Therefore, noninvasive diagnostic biomarkers with high specificity and sensitivity are required for the diagnosis and assessment of SS. Because ophthalmological testing constitutes to an important part for the diagnosis of SS. Tears harbor biomarkers with a high potential to be used for differential diagnosis and assessment of treatment in many systemic disorders, including SS. This review aims to summarize recent advances in the identification of tear biomarkers of SS, trying to identify reliable, sensitive, and specific biomarkers that can be used to guide treatment decisions.

Atypical Granulomatosis with Polyangiitis Presenting with Meibomitis, Scleritis, Uveitis and Papillary Bladder Tumor: A Case Report and Literature Review

Granulomatosis with polyangiitis (GPA) presents with a variety of systemic findings, sometimes with ocular findings initially, but is often difficult to diagnose at an early stage. An 85-year-old male had complaints of ocular dryness and redness and was diagnosed with meibomian gland dysfunction with meibomitis. Despite an initial treatment with topical steroid and antibiotics, the meibomitis did not improve and the left eye developed scleritis and iridocyclitis. The patient was administered topical mydriatics and oral steroids. During follow-up, the patient developed left hearing difficulty and reported a darker urine. Urinalysis revealed microscopic hematuria. A blood test showed an elevated erythrocyte sedimentation rate, positivity for perinuclear anti-neutorophil cytoplasmic antibody, and elevations in blood urea nitrogen and serum creatinine. Nasal mucosal biopsy showed a non-necrotizing granulomatous inflammation. Renal biopsy revealed focal glomerulosclerosis. Cystoscopy and bladder wash followed by a planned transurethral resection revealed atypical cells and apical papillary tumors which were resected. Iridocyclitis and scleritis responded well to oral prednisolone with 0.1% topical betamethasone and prednisolone ointment. The patient is tumor free with no recurrences 24 months after resection. GPA may present atypically with meibomian gland dysfunction without showing representative clinical findings. Early detection and treatment are essential for visual recovery.

Ocular Pathophysiology of Sjögren's Syndrome

The purpose of this review is to delve into the clinical and research understanding of the pathophysiology and presentation of Sjögren's-related keratoconjunctivitis sicca in order address the diagnostic and management challenge that it represents, as well as to provide a basis for appreciating the pharmacotherapies designed to treat the ophthalmic symptoms of Sjögren's disease.

Experimental Pharmacotherapy for Dry Eye Disease: A Review

Dry eye disease (DED) is a complex multifactorial disease showing heterogenous symptoms, including dryness, photophobia, ocular discomfort, irritation and burning but also pain. These symptoms can affect visual function leading to restrictions in daily life activities and reduction in work productivity with a consequently high impact on quality of life. Several pathological mechanisms contribute to the disease: evaporative water loss leads to impairment and loss of tear homeostasis inducing either directly or indirectly to inflammation, in a self-perpetuating vicious cycle. Dysregulated ocular immune responses result in ocular surface damage, which further contributes to DED pathogenesis. Currently, DED treatment is based on a flexible stepwise approach to identify the most beneficial intervention. Although most of the available treatments may control to a certain extent some signs and symptoms of DED, they show significant limitations and do not completely address the needs of patients suffering from DED. This review provides an overview of the emerging experimental therapies for DED. Several promising therapeutic strategies are under development with the aim of dampening inflammation and restoring the homeostasis of the ocular surface microenvironment. Results from early phase clinical trials, testing the effects of EnaC blockers, TRPM8 agonist or mesenchymal stem cells in DED patients, are especially awaited to demonstrate their therapeutic value for the treatment of DED. Moreover, the most advanced experimental strategies in the pipeline for DED, tivanisiran, IL-1R antagonist EBI-005 and SkQ1, are being tested in Phase III clinical trials, still ongoing. Nevertheless, although promising results, further studies are still needed to confirm efficacy and safety of the new emerging therapies for DED.

Evaluation of dry eye disease in children with blepharokeratoconjunctivitis

OBJECTIVE

To evaluate the symptoms and signs of dry eye disease (DED) in children diagnosed with blepharokeratoconjunctivitis (BKC).

DESIGN

Prospective case-controlled study PARTICIPANTS: Consecutive patients with BKC and normal controls.

METHODS

All participants underwent a comprehensive dry eye assessment including the Canadian Dry Eye Assessment (CDEA) questionnaire, tear film osmolarity test, Schirmer's test without anesthesia, slit lamp examination, tear film break-up time, corneal fluorescein staining (CFS), and lissamine green conjunctival staining (LGCS), according to the Sjögren's International Collaborative Clinical Alliance ocular staining score. For each test the result of the more severe eye was included in the statistical analysis.

RESULTS

Twenty-five patients were recruited-11 with BKC and 14 healthy controls. No difference in symptoms was found between children with BKC (CDEA score 6.1 ± 5.5) and normal controls (CDEA score 3.6 ± 3.2; p = 0.16). Children with BKC had significantly higher mean CFS (1.1 ± 1.6 vs 0.1 ± 0.4; p = 0.04) but similar mean LGCS (1.4 ± 1.8 vs 1.5 ± 2.1; p = 0.81) than normal controls. No statistically significant differences were observed in other tests between the 2 groups. CDEA scores were significantly correlated to CFS in normal controls (r = 0.59, p = 0.03), and approached significance in children with BKC (r = 0.56, p = 0.07).

CONCLUSIONS

The only test that can distinguish DED in patients with BKC from children without BKC is the CFS score. This should guide management and monitoring of this unique patient population with DED symptoms and signs.

Factors associated with ocular surface epithelial damage in patients with primary Sjögren's syndrome

BACKGROUND

The aim of this study was to evaluate the effects of systemic parameters, laboratory findings, oral parameters, and other ocular surface parameters on ocular surface epithelial damage in patients with primary Sjögren's syndrome (pSS).

METHODS

A total of 82 dry eye disease (DED) patients with pSS were enrolled in this study. Ocular surface epithelial damage was measured by ocular staining score (OSS). Systemic parameters, laboratory findings including serologic markers, oral parameters, and other ocular surface parameters were collected. Other ocular surface parameter assessments such as the Schirmer's test, fluorescein tear breakup time, meibomian gland examinations, noninvasive keratographic tear film break-up time measurements using the Keratograph® 5 M were performed, and the Ocular Surface Disease Index was determined.

RESULTS

In a multivariate analysis, decreased age and increased duration of pSS were significantly related to increased logarithm-transformed OSS (β = -0.011, P = 0.043 and β = 0.003, P = 0.008). Among the ocular surface parameters, decreased fluorescein tear breakup time and increased MGD grade were significantly associated with increased logarithm-transformed OSS (β = -0.183, P < 0.001 and β = 0.192, P = 0.049).

CONCLUSIONS

Ocular surface epithelial damage in patients with pSS was associated with young age, long duration of disease, unstable tear film, and decreased meibomian gland function.