Ocular Rosacea

Investigation of Thiol/Disulfide Homeostasis and Clinical Parameters in Rosacea Patients According to Skin Subtypes

Background/Objective: The aim of this study was to compare thiol/disulfide homeostasis and clinical parameters of rosacea patients across skin subtypes of the disease and healthy controls. Methods: This prospective study included 90 rosacea patients with different skin subtypes (phymatous, erythematotelangiectatic and papulopustular) and ocular involvement and 30 healthy controls. Plasma native thiol (NT), total thiol (TT) and disulfide levels of the patients and controls were measured using an automated spectrophotometric method, and disulfide/native thiol ratio (DNTR), disulfide/total thiol ratio (DTTR) and native thiol/total thiol ratio (NTTR) were calculated. Tear breakup time (TBUT), meiboscore, Schirmer, ocular surface disease index (OSDI) and rosacea-specific quality of life scale (RosaQoL) were measured clinically. Results: Disulfide, DNTR and DTTR were significantly higher, and NT, TT and NTTR were significantly lower in the rosacea patients compared to the controls (p < 0.001). TBUT and Schirmer were significantly lower, and meiboscore and OSDI were significantly higher in the patients compared to the controls (p < 0.01). According to the skin subtypes, disulfide, DNTR and DTTR were significantly higher, and NTTR was significantly lower in the erythematotelangiectatic subtype compared to the other subtypes (p < 0.002). TBUT was significantly lower, and RosaQol was significantly higher in the erythematotelangiectatic subtype (p < 0.0083). Strong correlations were found between DNTR and TBUT and between DNTR and Meiboscore in all subtypes (p < 0.005), while there were strong correlations between DNTR and OSDI and between DNTR and RosaQol only in the erythematotelangiectatic and papulopustular subtypes (p < 0.05). Conclusions: The thiol/disulfide homeostasis shifted towards disulfides, an indicator of oxidative stress in rosacea, and this was more pronounced in the erythematotelangiectatic subtype. The impairment in TBUT and RosaQol was also more prominent in the erythematotelangiectatic subtype and strongly associated with the DNTR.

Current application of intense pulsed light for the management of dry eye disease: A systematic review and meta-analysis

This review explored intense pulsed light (IPL) as an alternative treatment for dry eye disease (DED) symptom relief by correcting tear-film homeostasis. A systematic search was performed in March 2022 on five databases (Medline, Embase, SCOPUS, ProQuest, and EBSCO). Studies were extracted for the following outcomes of interest: standard patient evaluation of eye dryness questionnaire (SPEED), ocular surface disease index (OSDI), tear break-up time (TBUT), and corneal fluorescein staining (CFS). All studies published up to March 2022 were reviewed. Cochrane risk of bias tool (RoB 2) was used to screen studies for risk of bias where appropriate. A meta-analysis was done to quantify any reported quantitative data. Thirteen studies were included in this study. A total of 931 individuals and 1454 numbers of eyes were reviewed in this meta-analysis. Among studies that explored and reported the effect of IPL in individuals with DED, TBUT and OSDI improved significantly post intervention, with a standardized mean difference (SMD) of 1.02 [95% CI 0.41-1.64] and 0.28 [95% CI 0.04-0.52], respectively. CFS and SPEED scores, however, showed no statistically significant difference, with an SMD of 0.22 [95% CI -0.19 to 0.64] and 0.28 [95% CI -0.11 to 0.66], respectively. In conclusion, current evidence indicates IPL as a possible adjunctive treatment in individuals with DED in an otherwise limited treatment option. Further studies through more extensive trials are needed to validate this finding and elucidate its mechanism.

Diagnostic Challenges of Ocular Rosacea

OBJECTIVE

This study aims to address the issues surrounding the diagnosis of ocular rosacea and to evaluate the development of the patients’ condition after treatment, as well as to distinguish between healthy and diseased patients using a glycomic analysis of tears.

METHODOLOGY

A prospective study was conducted to assess a total of 68 eyes in 34 patients over a six-week period. These patients were diagnosed with ocular rosacea based on subjective symptoms and clinical examination. The study monitored the development of objective and subjective values. The difference between patients with the pathology and healthy controls was established by means of analysis of glycans in tears.

RESULTS

Skin lesions were diagnosed in 94% of patients with ocular rosacea, with the most commonly observed phenotype being erythematotelangiectatic (68.8%). The mean duration of symptoms was 29.3 months (range 0.5–126 months) with a median of 12 months. Throughout the study, an improvement in all monitored parameters was observed, including Meibomian gland dysfunction, bulbar conjunctival hyperemia, telangiectasia of the eyelid margin, anterior blepharitis, uneven and reddened eyelid margins, and corneal neovascularization. The study also observed improvements in subjective manifestations of the disease, such as foreign body sensation, burning, dryness, lachrymation, itching eyes, photophobia, and morning discomfort. The analysis of glycans in tears partially separated tear samples based on their origin, which allowed for the differentiation of patients with rosacea from healthy controls. In the first sample, the pathology was determined in a total of 63 eyes (98.4%) of 32 patients, with further samples showing a change in the glycomic profile of patients’ tears during treatment.

CONCLUSION

The study demonstrated objective and subjective improvements in all the patients. Tear sampling and analysis could provide a means of timely diagnosis of ocular rosacea.

Is Demodex Blepharitis Connected With Cataract Surgery?

PURPOSE

To determine whether there is an increased incidence of Demodex of the eyelashes among patients after cataract extraction surgery.

DESIGN

Prospective, noncomparative clinical study.

METHODS

A cohort of patients who underwent cataract extraction surgery had several eyelashes removed preoperatively that were examined independently by the hospital laboratory for the presence of the Demodex mite. This was repeated 3 weeks after surgery. During several postoperative weeks, patients received the standard treatment of steroid drops alone for a period as individually required.

RESULTS

A total of 62 patients were included in the study (31 men and 31 women), with a mean age of 71.04 years (range, 47-87). In the group positive for Demodex, the male-to-female ratio was 2:3 (P = .2772). Demodex colonization was observed in 22.58% of samples before cataract surgery and in 32.26% after cataract surgery and topical postoperative steroid therapy (P = .0143).

CONCLUSIONS

There is a statistically significant increase in Demodex colonization of eyelashes after cataract surgery and postoperative topical steroid treatment. Although Demodex colonization does not necessarily cause blepharitis, our findings of increased colonization should raise the possibility of Demodex blepharitis being considered by ophthalmologists in patients with chronic postoperative eye discomfort after cataract surgery. This study was carried out at the Emek Medical Center.

Rosacea: The eyes have it

Rosacea is a chronic inflammatory dermatosis typically affecting the facial skin but also the eyes. With its chronic course with fluctuating episodes of flashing, redness, papulopustules, and nodules it poses a severe psychologic burden to the affected individuals. In addition to the facial changes, more than half of the patients have ocular involvement ranging from blepharitis and conjunctival hyperemia to more severe ophthalmic damage, and even blindness. Clinically, the ocular involvement in rosacea includes meibomian gland dysfunction with relapsing hordeola and chalazia, diffuse hyperemic conjunctivitis, photophobia, episcleritis, or kerato-conjunctivitis, and in rare cases, corneal ulcers. These are mainly observed in adult patients but can also occur in children. Depending on the degree of cutaneous or ocular findings, patients with rosacea may present first to the dermatologist or to the ophthalmologist. Both specialists should be aware of the potential oculocutaneous involvement. Any ocular complaints expressed by the patient in the setting of a dermatologist's office should be referred promptly for an ophthalmologic examination. Conversely, signs suggestive of rosacea in the eye should lead the ophthalmologist to consider underlying skin disease. A timely interdisciplinary collaboration is paramount for the earlier diagnosis and treatment, thus preventing permanent eye impairment in this chronic dermatosis.

Chitosan-Coated SLN: A Potential System for Ocular Delivery of Metronidazole

Ophthalmic drops for ocular delivery exhibit inadequate residence time, which often requires multiple daily dosing that may result in patient non-adherence. In this study, the development of a once-daily-dosed chitosan-coated metronidazole (MTZ)-loaded solid lipid nanoparticles (SLNs) for ocular delivery was undertaken. Melt emulsification and ultrasonication were used to manufacture MTZ-loaded SLN, which were subsequently coated with chitosan (CS) by mechanical stirring using a 0.1% w/v solution. Gelucire^® 48/16 and Transcutol^® HP were used as the solid lipid and synthetic solvent, respectively, with Tween^® 20 included as a stabilizing agent. The critical quality attributes (CQA) of the optimized CS-coated SLN that was monitored included particle size, polydispersity index, Zeta potential, % entrapment efficiency, % MTZ loading, pH, and osmolarity. The optimized coated nanocarriers were evaluated using laser Doppler anemometry (LDA) and were determined to be stable, with particle sizes in the nanometre range. In vitro mucoadhesion, MTZ release and short-term stability, in addition to the determination of the shape of the optimized CS-coated SLN, were undertaken. The mucoadhesive properties of the optimized CS-coated MTZ-loaded SLN demonstrated increased ocular availability, which may allow dose reduction or longer intervals between doses by improving precorneal retention and ocular availability. Overall, our findings suggest that CS-coated MTZ-loaded SLNs have the potential for clinical application, to enhance ocular delivery through the release of MTZ.

Ocular Symptoms and Rosacea: A Population-Based Study

<b><i>Background:</i></b> The symptoms of ocular rosacea are often non-specific and there is no dependable diagnostic test for the disease, which may cause difficulties in diagnostics. The aim of this study was to examine the association between clinical findings of rosacea and self-reported ocular symptoms in a general population of middle-aged subjects. <b><i>Methods:</i></b> A clinical whole-body examination by a dermatologist was performed for 1,932 subjects belonging to the Northern Finland Birth Cohort 1966 Study. The presence of ocular symptoms was self-reported. The difference between rosacea and ocular symptoms was tested. Logistic regression analysis was used to identify associations between rosacea and ocular symptoms. <b><i>Results:</i></b> The prevalence of rosacea was 15.1% (<i>n</i> = 292); in the subjects with rosacea, erythematoteleangiectatic rosacea was found in 83.2% (<i>n</i> = 242), papulopustular in 15.4% (<i>n</i> = 45), ocular in 0.03% (<i>n</i> = 1), and phymatic in 0.1% (<i>n</i> = 3). Ocular symptoms in rosacea subjects were common, with dryness (32.3%), tearing (29.4%), foreign-body sensation (21.8%), and photophobia (20.5%) being the most common ones. Foreign-body sensation was reported significantly more often in those with rosacea compared to those without (<i>p</i> &#x3c; 0.04). In logistic regression analyses, after adjusting, the subjects with rosacea had a 1.5-fold increased risk for decreased visual acuity in the dark (OR 1.48, 95% CI 1.01–2.14) compared to those without rosacea. <b><i>Conclusion:</i></b> Eye symptoms are common in subjects with rosacea. All patients with rosacea should be asked about ocular symptoms and both skin and eyelids should be examined even if the cutaneous findings are mild.

Ocular manifestations of rosacea: A clinical review

Ocular rosacea is a chronic inflammatory condition that can occur in the absence of cutaneous features. The most common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring and, rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. It can also be associated with systemic disorders such as cardiovascular disease. Management ranges from local therapy to systemic treatment, depending on the severity of the disease. In this review, we describe the epidemiology, pathophysiology, clinical features and treatment of rosacea and ocular rosacea.

The Role of Meibography in the Diagnosis of Meibomian Gland Dysfunction in Ocular Surface Diseases

Purpose

To evaluate dysfunction in various ocular surface diseases (OSDs) including primary meibomian gland disease (MGD), perennial allergic conjunctivitis, and primary and secondary Sjögren syndromes.

Methods

A retrospective analysis of 146 patients (111 women and 35 men) with symptomatic OSDs was performed. Patients were divided into two groups: the non-MGD group (55 patients) and the MGD group (91 patients). All patients had an evaluation of ocular surface symptoms and clinical tests, including tear film breakup time (BUT), the first and the mean noninvasive breakup time (NIKBUTf and NIKBUTavg, respectively). The meibomian gland loss of the lower eyelid was quantified using meibography and the meiboscale.

Results

There was no significant difference regarding age or sex ratio between the two groups. The meiboscale in the MGD group was significantly higher than that in the non-MGD group (P = 0.003). The non-MGD patients were more symptomatic than those in the MGD group (P = 0.043). There were no significant differences between MGD and non-MGD groups regarding a Schirmer test (P = 0.195), BUT (P = 0.719), NIKBUTf (P = 0.96), or NIKBUTavg (P = 0.70). In the whole population, there was a negative correlation between meiboscale and NIKBUT (r = -0.21, P = 0.02), but no other correlations were found.

Conclusions

Meibomian gland dysfunction was observed among different OSDs. Meibomian gland loss evaluated by meibography might help identify MGD in patients suffering from OSD.

Translation Relevance

Meibography provides a better understanding of MGD in several OSD. It may be useful to integrate this objective analysis to improve treatments of OSD associated to MGD.

Nuclear Factor Kappa-B Is Enriched in Eyelid Specimens of Rosacea: Implications for Pathogenesis and Therapy

PURPOSE

To assess the role of nuclear factor kappa-B (NFKB) in cutaneous specimens of rosacea and unaffected tissue.

METHODS

Immunohistochemical staining was performed for the activated, phosphorylated variant of NFKB (pNFKB) in eyelid specimens of rosacea (n = 12) and normal, healthy tissue (n = 12). The numbers of positively staining cells/40× microscopic field were counted across 5 consecutive fields. Additionally, quantitative Western blotting was carried out for pNFKB and NFKB in specimens of rosacea (n = 15) and normal controls (n = 14). Statistical comparisons were performed via a dedicated software package.

RESULTS

The mean number of cells/40× microscopic field that stained positively for pNFKB was 18.4 (standard deviation = 15.3) for control patients and 39.3 (standard deviation = 16.9) for rosacea patients, and the difference between the 2 groups was statistically significant (P = .0024). On Western blotting, the mean ratios of pNFKB:NFKB for control and rosacea patients measured 0.58 (standard deviation = 0.81) and 3.11 (standard deviation = 3.53), respectively. The 2 groups were statistically significantly different (P = .0002).

CONCLUSIONS

The activated form of NFKB is enriched in rosacea, indicating a role for this pathway in the pathogenesis of this disease. Interference with NFKB signaling may represent a novel therapy for rosacea as clinical agents become available. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

[Ophthalmic Rosacea: etiopathogenesis and modern treatment methods]

Rosacea is a multifactorial chronic inflammatory disease with various clinical manifestations. Primarily it is seen as a dermatological condition, but it's not uncommon for it to develop ophthalmological implications affecting eyelids, cornea and conjunctiva. The article describes main aspects of its etiopathogenesis, variations in its clinical course and treatment approaches. There is currently no universal treatment strategy for the disease due to its varying clinical manifestation, particularly of its ophthalmological form, differing severity of the pathological process, lack of knowledge about its etiology and pathogenesis. Leading role in its pathological process belongs to disturbance of regulatory mechanisms of the vascular, immune and nervous systems. Additionally, higher levels of metalloproteinases and vascular endothelial growth factor (VEGF) can be observed. Possible influence of a range of micro-organisms also hasn't been excluded. Basic therapy involves both systemic and topical drugs. The first include tetracycline antibiotics. A new direction in Rosacea treatment that aims at structural and functional restoration of vascular endothelium, improvement of microcirculation and recovery of rheological properties of blood is angioprotector therapy, in particular with Calcium Dobesilate (Doxi-Hem). Aside from systemic drugs, the ophthalmological forms of Rosacea are treated topically with anti-inflammatory preparations, immunosuppressants and artificial tears that are chosen depending on the symptoms' severity. In cases with heavy corneal damage, various types of keratoplasty can be performed. Collaboration between ophthalmology and dermatology specialists is necessary in order to choose adequate strategy for Rosacea treatment.

Long-term effects of intense pulsed light treatment on the ocular surface in patients with rosacea-associated meibomian gland dysfunction

PURPOSE

We aimed to determine the long-term effects of intense pulsed light (IPL) treatment in rosacea-associated meibomian gland dysfunction (MGD).

METHODS

We enrolled 17 rosacea subjects with moderate and severe MGD who underwent four IPL sessions at 3-week intervals and were followed up for 12 months. The subjects underwent clinical examinations at baseline (first IPL) and at 3 (second), 6 (third), 9 (fourth), and 12 weeks, as well as 6 and 12 months, after baseline. Ocular surface parameters, including the Ocular Surface Disease Index (OSDI), tear break-up time (TBUT), staining score, and noninvasive Keratograph tear break-up time (NIKBUT), as well as meibomian gland parameters, including the lid margin vascularity and meibum expressibility and quality, were evaluated.

RESULTS

All ocular surface and meibomian gland parameters for all subjects exhibited significant changes from baseline to the final examination (Friedman, P < 0.050 for all). In particular, improvements in the lower lid margin vascularity, meibum expressibility and quality, and ocular symptoms persisted up to the final examination (Wilcoxon, P < 0.050 for all). However, the improvements of TBUT, staining score, and NIKBUT after IPL were not maintained at 6 and 12 months after baseline.

CONCLUSIONS

In rosacea-associated MGD, four IPL treatments at 3-week intervals can improve long-term lid parameters and ocular symptoms without adverse effects.

The function and morphology of Meibomian glands in patients with thyroid eye disease: a preliminary study

BACKGROUND

To investigate function and morphology of the meibomian gland (MG) in patients with thyroid eye disease (TED).

METHODS

In this prospective case series study, patients with unilateral or bilateral TED were consecutively enrolled. The diagnosis of TED was based on the typical orbital findings and/or radiographic evidence. The disease activity of TED was classified according to the clinical activity score (CAS). Degrees of lagophthalmos and exophthalmos, blinking rates, and results of the Schirmer test 1 were also recorded. All patients completed the SPEED questionnaire and underwent MG assessment, including lipid layer thickness (LLT), MG dropout (MGd), and MG expression.

RESULTS

In total 31 eyes from 17 patients with unilateral or bilateral TED were included. Patients were divided into inactive TED (CAS 0-1; 20 eyes from 11 patients) and active TED (CAS 2-3, 11 eyes from 6 patients) groups. MGd was significantly more severe in the active TED than the inactive TED group [Median (Inter-quartile region): 3.0 (2.0-3.0) vs. 2.0 (1.0-2.0) degree, P = 0.04]. However, patients with active TED had thicker LLT than those with inactive TED (90.0 [80.0-100.0] vs. 65.0 [47.8-82.5] nm, P = 0.02), and LLT was positively correlated with lagophthalmos (r = 0.37, P = 0.04).

CONCLUSIONS

Patients with active TED had more severe MGd, but thicker LLT. Active TED may cause periglandular inflammation of MGs, leading to MGd, but compensatory secretion from residual MGs and lagophthalmos-induced forceful blinking might temporarily release more lipids over the tear film.

Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting

Meibomian gland dysfunction (MGD) is a common and chronic disorder that has a significant adverse impact on patients' quality of life. It is a leading cause of evaporative dry eye disease (DED), as meibomian glands play an important role in providing lipids to the tear film, which helps to retard the evaporation of tears from the ocular surface. MGD is also often present in conjunction with primary aqueous-deficient DED. Obstructive MGD, the most commonly observed type of MGD, is the main focus of this article. MGD is probably caused by a combination of separate conditions: primary obstructive hyperkeratinization of the meibomian gland, abnormal meibomian gland secretion, eyelid inflammation, corneal inflammation and damage, microbiological changes, and DED. Furthermore, skin diseases such as rosacea may play a part in its pathology. Accurate diagnosis is challenging, as it is difficult to differentiate between ocular surface diseases, but is crucial when choosing treatment options. Ocular imaging has advanced in recent years, providing ophthalmologists with a better understanding of ocular diseases. This review presents a literature update on the 2011 MGD workshop and an optimized approach to accurate diagnosis of MGD using currently available methods and tests. It also outlines the emerging technologies of interferometry, non-contact meibography, keratography and in vivo confocal laser microscopy, which offer exciting possibilities for the future. Selected treatment options for MGD are also discussed.

The 2016 Bowman Lecture Conjunctival curses: scarring conjunctivitis 30 years on

This review is in two sections. The first section summarises 35 conditions, both common and infrequent, causing cicatrising conjunctivitis. Guidelines for making a diagnosis are given together with the use of diagnostic tests, including direct and indirect immunofluorescence, and their interpretation. The second section evaluates our knowledge of ocular mucous membrane pemphigoid, which is the commonest cause of cicatrizing conjunctivitis in most developed countries. The clinical characteristics, demographics, and clinical signs of the disease are described. This is followed by a review and re-evaluation of the pathogenesis of conjunctival inflammation in mucous membrane pemphigoid (MMP), resulting in a revised hypothesis of the autoimmune mechanisms causing inflammation in ocular MMP. The relationship between inflammation and scarring in MMP conjunctiva is described. Recent research, describing the role of aldehyde dehydrogenase (ALDH) and retinoic acid (RA) in both the initiation and perpetuation of profibrotic activity in MMP conjunctival fibroblasts is summarised and the potential for antifibrotic therapy, using ALDH inhibition, is discussed. The importance of the management of the ocular surface in MMP is briefly summarised. This is followed with the rationale for the use of systemic immunomodulatory therapy, currently the standard of care for patients with active ocular MMP. The evidence for the use of these drugs is summarised and guidelines given for their use. Finally, the areas for research and innovation in the next decade are reviewed including the need for better diagnostics, markers of disease activity, and the potential for biological and topical therapies for both inflammation and scarring.

Risk Factors and Symptoms of Meibomian Gland Loss in a Healthy Population

Purpose. The aim of this study was to investigate the relationships between MGL and ocular symptoms, several systemic conditions, and key markers of ocular surface health. Methods. We included into the study 91 healthy volunteers between the ages of 20 and 77 years. We analyzed meibomian gland morphology, function, and lid margin alterations. We correlated our findings with self-reported ocular symptoms, systemic medical history, lifestyle factors, and tear film abnormalities. Results. We observed that a high ocular surface disease index, a history of either chalazion or hordeolum, experience of puffy eyelids upon waking, and foreign body sensation all appeared to be predictors of an abnormal meiboscore after adjusting for age and sex (p = 0.0007; p = 0.001; p = 0.02; p = 0.001, resp.). Multivariate logistic regression model including age and sex showed that there were three independent predictors of abnormal meiboscore: older age (OR = 1.03, 95% CI = 1.01–1.04 per year, p = 0.006), postmenopausal hormone therapy (OR = 4.98, 95% CI = 1.52–16.30, p = 0.007), and the use of antiallergy drugs (OR = 5.85, 95% CI = 2.18–15.72, p = 0.0004). Conclusion. Our findings extend current knowledge on the pathophysiology of MGL.

Ocular response analyser measurements and central corneal thickness in ocular rosacea patients

Rosacea is a chronic cutaneous disorder which is known to cause inflammation and increased proteolytic activity on the ocular surface that might lead to corneal biomechanical alterations. The aim of this study is to evaluate the corneal biomechanical properties of ocular rosacea patients and compare the measurements with healthy individuals as measured with Reichert ocular response analyser (ORA). Besides full eye examination [best corrected visual acuity (BCVA), intraocular pressure (IOP) measured with Goldmann applanation tonometry (IOP-G)], central corneal thickness (CCT), and ORA [corneal hysteresis (CH), corneal resistance factor (CRF), corneal compensated IOP (IOPcc), Goldmann correlated IOP (IOPg)] measurements of 30 eyes of 15 ocular rosacea patients (study group) and 30 eyes of 15 healthy individuals (control group) were performed. For comparisons paired t test was used. Mean age of study group was 45.26 ± 11.65 (range 25 and 63) and control group was 45.00 ± 8.91 (range 26 and 58) years (p = 0.865). No significant difference in BCVA, CCT, IOP-G, IOPcc was detected among groups. However, IOPg, CH, and CRF in the study group were significantly lower than in the control group (p = 0.013, p = 0.013, p = 0.009, respectively). IOPg, CH, and CRF parameters of ocular rosacea patients were significantly lower than normal individuals. These differences and their probable clinical reflections that might effect making decisions in conditions such as glaucoma should be investigated in larger number of patients.

Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction

Meibomian gland dysfunction (MGD) is the most frequent cause of dry eye disease (DED). Eyelid inflammation, microbial growth, associated skin disorders as well as potentially severe corneal complications culminate to make MGD a complex multifactorial disorder. It is probable that MGD is a heterogeneous condition arising from any combination of the following five separate pathophysiological mechanisms: eyelid inflammation, conjunctival inflammation, corneal damage, microbiological changes and DED resulting from tear film instability. The pathogenesis of both MGD and DED can be described in terms of a 'vicious circle': the underlying pathophysiological mechanisms of DED and MGD interact, resulting in a double vicious circle. The MGD vicious circle is self-stimulated by microbiological changes, which results in increased melting temperature of meibum and subsequent meibomian gland blockage, reinforcing the vicious circle of MGD. Meibomian gland blockage, dropout and inflammation directly link the two vicious circles. MGD-associated tear film instability provides an entry point into the vicious circle of DED and leads to hyperosmolarity and inflammation, which are both a cause and consequence of DED. Here we propose a new pathophysiological scheme for MGD in order to better identify the pathological mechanisms involved and to allow more efficient targeting of therapeutics. Through better understanding of this scheme, MGD may gain true disease status rather than being viewed as a mere dysfunction.

Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A Report by the American Academy of Ophthalmology

OBJECTIVE

To review the existing medical literature on the role of oral antibiotics in the management of ocular surface disease (OSD) that arises from disorders of the meibomian glands and to assess the efficacy of oral antibiotics in the management of this common ocular disease.

METHODS

A literature search was last conducted on August 12, 2015, in the PubMed and Cochrane databases for English-language original research investigations that evaluated the role of doxycycline, minocycline, and azithromycin in OSD among adult patients. The searches identified 87 articles, and 8 studies ultimately met the criteria outlined for this assessment.

RESULTS

The 8 studies identified in the search documented an improvement in meibomian gland-related OSD after treatment with these agents, although side effects were common. This search identified only 1 randomized, controlled trial to assess the efficacy of these medications.

CONCLUSIONS

Although oral antibiotics are used commonly in the management of OSD, there is no level I evidence to support their use. There are only a few studies that have assessed the efficacy of oral antibiotics in clinically meaningful ways in the management of OSD that arises from disorders of the meibomian glands. The current level of evidence is insufficient to conclude that antibiotics are useful in managing OSD arising from disorders of the meibomian glands. The few existing studies on the topic indicate that oral antibiotics may be an effective treatment for OSD that results from meibomian gland disease.

Cataract surgery in patients with ocular surface disease: An update in clinical diagnosis and treatment

In this article we review essentials of diagnosis and management of ocular surface disease in patients who undergo cataract surgery. It is clearly shown that dry eye disease worsens following the cataract surgery in patients with prior history of ocular surface disease, Also new cases of dry eye might appear. Current strategies for the timely diagnosis and proper management of dry eye syndrome in the face of cataract surgery patients are mainly emphasized. To achieve the best outcome in cataract surgery, a healthy ocular surface is crucial. While ocular surface preparation is indispensable in patients with established ocular surface disease, it is also helpful in those with minimal signs or symptoms of surface disease. The current approach begins with early diagnosis and drastic management of ocular surface disease before cataract surgery using a stepwise regimen customized to each patient and disease severity. These measures are continued throughout and after the surgery.

Ocular rosacea: a dermatologic perspective

As many as 50% of patients given the diagnosis of cutaneous rosacea also have ocular rosacea. Conservative figures indicate that approximately 10 million patients are affected by ocular rosacea in the United States alone. Despite this prevalence, ocular symptoms of rosacea are often improperly diagnosed, particularly when they occur in the absence of skin involvement.

Glycomic analysis of tear and saliva in ocular rosacea patients: the search for a biomarker

The purpose of this study was to study changes in glycosylation in tear and saliva obtained from control and ocular rosacea patients in order to identify potential biomarkers for rosacea. Tear fluid was collected from 51 subjects (28 healthy controls and 23 patients with ocular rosacea). Saliva was collected from 42 of the same subjects (25 controls and 17 patients). Pooled and individual samples were examined to determine overall glycan profiles and individual variations in glycosylation. O-and N- glycans were released from both patients and control subjects. Released glycans were purified and enriched by solid-phase extraction (SPE) with graphitized carbon. Glycans were eluted based on glycan size and polarity. SPE fractions were then analyzed by high-resolution mass spectrometry. Glycan compositions were assigned by accurate masses. Their structures were further elucidated by tandem mass spectrometric using collision-induced dissociation (CID), and specific linkage information was obtained by exoglycosidase digestion. N- and O-glycans were released from 20-μL samples without protein identification, separation, and purification. Approximately 50 N-glycans and 70 O-glycans were globally profiled by mass spectrometry. Most N-glycans were highly fucosylated, while O-glycans were sulfated. Normal tear fluid and saliva contain highly fucosylated glycans. The numbers of sulfated glycans were dramatically increased in tear and saliva of rosacea patients compared to controls. Glycans found in tear and saliva from roseatic patients present highly quantitative similarity. The abundance of highly fucosylated N-glycans in the control samples and sulfated O-glycans in ocular rosacea patient samples may lead to the discovery of an objective diagnostic marker for the disease.

Inter-examiner reliability in meibomian gland dysfunction assessment

PURPOSE

We evaluated inter-examiner reliability in grading of clinical variables associated with meibomian gland dysfunction (MGD) in real-time examination versus a graded digital image.

METHODS

Meibography grading of meibomian gland atrophy and acini appearance, and slit-lamp grading of lid debris and telangiectasias were conducted on 410 post-menopausal women. Meibography and slit-lamp photos were captured digitally and saved for analysis by a masked examiner. Gland atrophy was graded as a proportion of partial glands in the lower lid, and acini appearance by the presence/absence of grape-like clusters. Lid debris and telangiectasias were graded based on severity and quantity from the same image, respectively. Observed agreement and weighted kappas (κ(w)) with 95% confidence intervals (CI) determined the degree of inter-examiner reliability between grading of these clinical variables in real-time examination and digital photographs using a multiple-point categorical scale.

RESULTS

Observed agreement was determined for telangiectasias (40.6%), lid debris (50.9%), gland dropout (42.8%), and acini appearance (54.5%). Inter-examiner reliability for the four clinical outcomes ranged from fair agreement for acini appearance (κ(w) = 0.23, 95% CI = 0.14-0.32) and lid debris (κ(w) = 0.24, 0.16-0.32) to moderate agreement for gland dropout (κ(w) = 0.50, 0.40-0.59) and telangiectasias (κ(w) = 0.47, 0.39-0.55). Conclusions. Gland dropout and potentially lid telangiectasia grading from a photograph are more representative of grading in a real-time examination compared to acini appearance and lid debris. Alternative grading scales and/or clinical variables associated with MGD should be addressed in future studies.

Cataract surgery in the face of ocular surface disease

PURPOSE OF REVIEW

This article reviews the importance of ocular surface management in patients undergoing cataract surgery. The current strategies for the diagnosis and management of ocular surface disease in cataract surgery patients are discussed.

RECENT FINDINGS

The current trend is to diagnose and treat ocular surface disease before cataract surgery using a stepwise regimen tailored to the individual patient and disease severity.

SUMMARY

Maintaining a healthy ocular surface is essential for achieving the best visual outcome in cataract patients. Ocular surface preparation is beneficial not only in patients with established ocular surface disease, but also in those with minimal signs or symptoms of surface disease.

Nocturnal Lagophthalmos: An Overview and Classification

Nocturnal lagophthalmos is the inability to close the eyelids during sleep. Lagophthalmos is associated with exposure keratopathy, poor sleep, and persistent exposure-related symptoms. There are a variety of causes of lagophthalmos, grouped as proptosis/eye exposure etiologies and palpebral insufficiency etiologies. Although obvious lagophthalmos is usually detected, it is sometimes difficult to recognize obscure lagophthalmos, due either to eyelash obstruction or overhang of the upper lid anterior and inferior to the most superior portion of the lower lid in a closed position. We present a novel classification system and illustrations of obvious and obscure lagophthalmos. A diagnosis can usually be made with a focused history and slit lamp examination. Treatment is multipronged and may include minor procedures or ocular surgery to correct the lid malposition; natural, topical or oral agents; and punctal plugs to manage ocular surface effects. Correct and timely diagnosis allows greater opportunity for relief of patient suffering and prevention of severe ocular surface pathology, as well as educated planning for future ocular surgical procedures.