Meibomian Gland Dysfunction and Contact Lens Discomfort

Prevalence of meibomian gland dysfunction at a tertiary centre in Taiwan

CLINICAL RELEVANCE

Meibomian gland dysfunction and dry eye disease are closely related conditions that often coexist and can contribute to the development of each other. Understanding the similarities and differences between these diseases can assist clinicians in implementing effective treatments for both conditions in a clinical setting.

BACKGROUND

Dry eye disease is a multifactorial disease of the tears and ocular surface. This study aimed to evaluate the demographic characteristics of patients with meibomian gland dysfunction in Taiwan, investigate the association between meibomian gland dysfunction and dry eye parameters, and estimate the prevalence of meibomian gland dysfunction among patients with dry eye symptoms at a tertiary referral centre.

METHODS

This cross-sectional study enrolled patients aged ≥20 years who complained of dry eye symptoms and visited a tertiary centre between September 2019 and March 2020. The patients completed the Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness questionnaires before undergoing ocular examination. The lipid layer thickness and meiboscale scores were recorded. In addition, the study measured tear film break-up time, examined corneal staining, and evaluated the number of meibomian glands yielding liquid secretions using a slit lamp.

RESULTS

The study evaluated 202 eyes of 202 patients with a mean age of 58.05 ± 13.34 years. The prevalence of meibomian gland dysfunction was 93%. Mean meiboscale score and age were negatively associated, and tear film break-up time was positively associated with the mean number of meibomian glands yielding liquid secretions. Hyperlipidaemia and smoking were the main risk factors for Meibomian gland dysfunction.

CONCLUSIONS

The prevalence of meibomian gland dysfunction among patients with dry eye symptoms was extremely high at the tertiary centre, highlighting the strong relationship between Meibomian gland dysfunction and dry eye disease. Clinicians should consider meibomian gland dysfunction as a possible cause of dry eye.

Association of ocular surface and meibomian gland alterations with silicone hydrogel contact lens wear

PURPOSE

To evaluate silicone hydrogel contact lens (SH-CL) effects on the meibomian glands, corneal structure, and ocular surface parameters.

METHODS

Fifty SH-CL wearers for at least 6 months, and 50 sex and age-matched control subjects were recruited for this cross-sectional study. Visual display terminal (VDT) work and CL wear duration were questioned, ocular surface and tear functions were evaluated using OSDI questionnaire, tear break-up time (TBUT), corneal fluorescein staining, and Schirmer test. Corneal sensitivity was measured with Cochet-Bonnet aesthesiometry. Meibography and in vivo confocal microscopy (IVCM) were performed to evaluate meibomian glands and corneal structure. Intergroup comparisons were made using the Chi-square test, Wilcoxon test, or Kruskal-Wallis test.

RESULTS

In the CL group, TBUT was shorter (P = 0.01), corneal fluorescein staining (P = 0.04), OSDI scores (P < 0.001), and meiboscores (P < 0.001) were higher than the control group. The biomicroscopic evaluation revealed meibomian gland dysfunction (MGD) in 34 % of the CL group and 20 % of the control group, which was not statistically significant (P > 0.05). IVCM showed that endothelial cell density was lower (P = 0.01) and polymegethism was higher (P < 0.001) in the CL group. Subbasal nerve density and corneal sensitivity measurements were similar in the two groups (P > 0.05). The longer VDT work duration was associated with increased CFS in the CL group (P = 0.05).

CONCLUSION

The results showed that SH-CL wear increased dry eye symptoms and ocular discomfort, especially in longer VDT work duration. Meibography revealed significantly worse results in SH-CL wearers. SH-CL-related ocular discomfort seems to be more associated with MGD rather than neurosensorial alterations.

Risk Factors for Meibomian Gland Disease Assessed by Meibography

Purpose

To elucidate risk factors for meibomian gland disease (MGD) and understand associated changes in meibography and in relation to ocular surface disease.

Patients and Methods

As part of the standard workup for ocular surface disease at a tertiary academic center, 203 patients received an ocular history and lifestyle questionnaire. The questionnaire included detailed inquiries about ocular health and lifestyle, including makeup use, cosmetic eyelid procedures, screen time, and contact lens habits. Subjects also took the standardized patient evaluation of eye dryness (SPEED) II questionnaire. Meibomian gland (MG) dropout and structural changes were evaluated on meibography and scored by three independent graders using meiboscores. Statistical analysis was conducted to identify significant risk factors associated with MG loss.

Results

This retrospective, cross-sectional study included 189 patients (378 eyes) with high-quality images for grading, and the average age was 67 years (77% female). Patients older than 45 years had significantly more dropout than younger patients (p < 0.01). Self-reported eye makeup use did not significantly impact MG loss. Patients with a history of blepharoplasty trended toward higher meiboscores, but the difference was not statistically significant. Self-reported screen time did not affect meiboscores. Contact lens use over 20 years was associated with significant MG loss (p < 0.05). SPEED II scores had no relationship to meiboscores (p = 0.75).

Conclusion

Older age is a significant risk factor for MG loss. Any contact lens use over 20 years also impacted MG dropout. Highlighting the incongruence of symptoms to signs, SPEED II scores showed no relationship to the structural integrity of MGs.

Assessment of meibomian gland drop-out and visibility through a new quantitative method in scleral lens wearers: A one-year follow-up study

OBJECTIVES

To validate a previously developed algorithm based on the visibility of meibomian gland images obtained with Cobra fundus camera and to assess the changes in meibomian glands in scleral lens wearers over one year of lens wear.

METHODS

Infrared meibography was obtained from the upper eyelid using the Cobra fundus camera in forty-three volunteers (34.2 ± 10.1 years). Meibographies were classified into 3 groups: Group 1 = good subjective gland visibility and gland drop-out < 1/3 of the total area; Group 2 = low visibility and gland drop-out < 1/3; and Group 3 = low visibility and gland drop-out > 1/3. Meibomian gland visibility metrics were then calculated using the developed algorithm from the pixel intensity values of meibographies. Repeatability of new metrics and their correlations with gland drop-out were assessed. Meibographies and ocular symptoms were also assessed after 1 year of scleral lens wear in 29 subjects.

RESULTS

Gland drop-out percentage was not statistically different between groups 1 and 2 (p = 0.464). Nevertheless, group 1 showed higher grey pixel intensity values than the other groups. Statistically significant correlations were found between gland visibility metrics and gland drop-out percentage. Repeatability was acceptable for all metrics, coefficient of variation achieving values between 0.52 and 3.18. While ocular symptoms decreased with scleral lens wear (p < 0.001), no statistically significant differences were found in gland drop-out percentage (p = 0.157) and gland visibility metrics (p > 0.217).

CONCLUSIONS

The proposed method can assess meibomian gland visibility in an objective and repeatable way. Scleral lens wear appears to not adversely affect meibomian gland drop-out and visibility while might improve dry eye symptoms after one year of lens wear. These preliminary results should be confirmed with a control group.

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.

The Effects of Soft Contact Lens Wear on The Tear Film and Meibomian Gland Drop-Out and Visibility

As contact lens (CL) wear affects the ocular surface, this cross-sectional study aims to assess the effects of soft CL wear and its duration on the tear film and meibomian gland (MG) drop-out and visibility. Thirty non-CL wearers (22.5 ± 2.3 years) and twenty-four soft CL wearers (23.8 ± 2.2 years) participated in this study. The Keratograph 5M was used to assess the ocular surface. CL users were surveyed on years of CL wear and hours per week. MG visibility was assessed using a previously developed method based on analysing pixel intensity of meibographies. The CL group showed higher gland drop-out (p < 0.001) and lower gland visibility (p < 0.022). Gland drop-out was independently associated with CL wear (p = 0.006). When gland drop-out was excluded, the relative energy of pixel intensity values showed an independent association with CL wear (p = 0.005). Prolonged hours of CL wear were associated with higher dry eye symptoms and entropy of MGs (p < 0.029). A reduction in non-invasive keratograph break-up time was associated with using CLs for ≥8 years (p = 0.030). Overall, gland drop-out was higher and gland visibility lower in soft CL wearers. New gland visibility metrics might help to assess MGs in soft CL wearers quickly and objectively.

Dry Eye and Meibomian Gland Dysfunction in Neovascular Age-Related Macular Degeneration Patients Treated with Intravitreal Injections

Objectives:

To determine if patients treated with multiple intravitreal injections for neovascular age-related macular degeneration are more likely to suffer from dry eye and meibomian gland dysfunction.

Materials and Methods:

Sixty eyes of 30 patients were enrolled. One eye of each patient was treated with multiple monthly intravitreal injections for neovascular AMD (Group 1) and the fellow healthy eye received no treatment (Group 2). The presence of dry eye was evaluated using tear film break-up time, Schirmer 1 test, the Oxford scale, and Ocular Surface Disease Index (OSDI). The loss rate of meibomian glands was evaluated by meibography and was graded and scored (meiboscore) from grade 0 (no loss of glands) to grade 3 (loss of >2/3 of total meibomian glands) for each eyelid.

Results:

Group 1 had lower mean Schirmer 1 and tear film break up-time measurements and higher mean OSDI score than Group 2, but the differences were not statistically significant (p=0.257, p=0.113, and p=0.212, respectively). Mean Oxford scale scores and meiboscore of the upper eyelids showed no statistically significant difference between the groups (p=0.594, p=0.663, respectively). The meiboscore of the lower eyelids was significantly higher in Group 1 (p=0.048).

Conclusion:

Multiple factors such as povidone-iodine and the preservatives in topical eye drops may cause inflammation leading to ocular surface damage in patients treated with multiple intravitreal injections. As the treatment requires repeated injections, exposure to these factors might worsen the ocular surface inflammation. The possibility of dry eye and meibomian gland dysfunction should be considered in these patients.

Orthokeratology Lens Wear for 2 Years in Children Did Not Alter Tear Film Lipid Thickness by Non-Invasive Interferometry

Purpose

Previous studies suggest that overnight orthokeratology (OOK) may be detrimental to tear function. We aimed to investigate the effect of OOK on lipid layer thickness (LLT), blink pattern, and meibomian gland and elucidate the relationship of these variables.

Methods

Thirty-seven participants who wore OOK lenses every night for at least 2 years and twenty-four healthy non-contact lens wearers (controls) were enrolled in this retrospective study. LipiView interferometry, blink pattern analysis, the ocular surface status, and morphology and function of the meibomian gland were determined.

Results

The OOK group and healthy controls had similar LLT, blink patterns, ocular surface status, and the function of the meibomian gland. OOK participants demonstrated higher meiboscore in the lower eyelids (p < 0.05) but not in the upper eyelids. Within the OOK group, LLT was significantly impacted by the partial blink rate (p < 0.05) and the total score of the upper meibomian gland (p = 0.10).

Conclusions

Wearing OOK for 2 or more years increased lower eyelid meibomian gland dropout but did not have a reduction of LLT.

Preferred practice patterns for photorefractive keratectomy surgery

Over the past two decades, excimer laser-based refractive surgery procedures have been successfully established for their safety and satisfactory visual outcomes. Surface ablation procedures or photorefractive keratectomy (PRK) are practised commonly for the correction of refractive errors including myopia, astigmatism and hyperopia. Satisfactory visual outcomes are achieved in majority of cases, although a very small percentage have issues related to corneal haze, regression, and its associated visual disturbances. To ensure optimal outcomes and to minimize complications, certain keys to success have been designed on the basis of the current review of literature on surface ablation procedures.

Contact Lens Discomfort Management: Outcomes of Common Interventions

PURPOSE

To assess the consecutive implementation of habitual contact lens discomfort (CLD) management strategies: lid hygiene, daily disposable CL (DDCL) fitting, and artificial tear (AT) supplementation.

METHODS

Contact lens (CL) wearers with CLD symptoms (CLDEQ-8 ≥12 points) were included in the study. Subjects with Meibomian gland dysfunction (MGD) were instructed to perform lid hygiene. All participants were fitted with a DDCL (delefilcon A) and evaluated 1 month later. After, half of them were randomly assigned to use AT (Povidone-2%) at least three times/day, and all participants were evaluated 1 month later. Tests performed were: lower tear meniscus area (LTMA), bulbar, limbal, and tarsal hyperemia, noninvasive tear break-up time (NITBUT), and corneal and conjunctival staining. Weighted combined clinical scores (CS) were created to analyze signs. Changes in symptoms (CLDEQ-8) and CS were analyzed using linear mixed models.

RESULTS

Forty-two subjects (mean age: 23.2±4.9 years) completed the study. Two CS were created, CS 1 was composed of bulbar, limbal, and tarsal hyperemia and corneal staining, and CS 2 by NITBUT, LTMA, and conjunctival staining. CLDEQ-8 was reduced after lid hygiene (mean: -2.73±2.13; P=0.012) and DDCL use (mean: -10.1±3.54; P<0.01), but not after AT use (P=0.62). CS 1 did not change after any intervention. CS-2 was higher (P=0.04) in DGM subjects after lid hygiene, it decreased (P=0.04) after DDCL use.

CONCLUSIONS

Lid hygiene is effective for reducing CLD symptoms in MGD patients. Refitting subjects with delefilcon A is an effective intervention for CLD to reduce symptoms and achieve a healthier ocular surface. Simultaneous administration of AT did not further improve CLD.

Could contact lens dryness discomfort symptoms sometimes have a neuropathic basis?

Symptoms of dryness discomfort in soft contact lens wearers frequently lead to discontinuation from wear. The negative influence of pre-fitting tear dysfunctions appears likely to be exacerbated by the challenges to tear homeostasis caused by contact lenses. The corneal mechanisms for symptoms in contact lens wearers are different to those for dry eye disease because the cornea is insulated by the lens from ambient conditions as well as from lid wiper friction during blinking. Symptoms of dryness discomfort might be the consequence of increased lid wiper friction during blinking when the lens front surface becomes soiled and dry and exhibits very rapid tear break up. It is possible that some cases of contact lens intolerance and discontinuation could be a function of lid wiper neuropathy. In relation to the possibility of corneal neuropathy, a stagnant post-lens tear pool with the possibility of increased concentrations of metabolic by-products, cellular debris, and bacterial exotoxins, might have the potential to disturb the corneal epithelial and sub-basal nerves. Contributions by contact lens-induced inflammation to any neuropathic changes may partly depend on the degree to which inflammatory mediators are concentrated in a stagnant post-lens tear pool. It does not appear to be known if corneal neuropathic changes could develop under these conditions. The chances of neuropathic involvement may be greater if discomfort develops after a significant period of successful wear and there is a history of comorbid pain conditions. Esthesiometry and in vivo confocal microscopy in discontinued contact lens wearers may support a diagnosis of contact lens-related corneal neuralgia.

CLEAR - Evidence-based contact lens practice

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

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

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

Associations with meibomian gland loss in soft and rigid contact lens wearers

PURPOSE

This study aimed to evaluate the structural changes in meibomian glands (MGs) and meibomian gland dysfunction (MGD)-associated ocular surface alterations in contact lens (CL) wearers.

METHODS

This prospective, multi-center, cross-sectional study included 44 soft CL wearers, 21 rigid CL wearers, and 26 healthy non-wearers. After completing the Ocular Surface Disease Index (OSDI) questionnaire, the participants were examined for lid margin abnormalities, tear breakup times, ocular surface staining, meibum quality and expressibility. Afterwards upper and lower eyelid meibography and Schirmer I test were performed.

RESULTS

A total of 91 participants (64 females and 27 males) (91 eyes) were classified into three groups. The mean percentage of meibomian gland loss (PMGL) was 25.3 ± 12.5 % in soft CL wearers, 34 ± 13.4 % in rigid CL wearers, and 18.4 ± 9.2 % in the control group. Mean OSDI score was higher in soft CL wearers (15.5 ± 18) than in the control group (3.5 ± 2.6) (p < 0.001) and the OSDI scores were correlated with mean PMGL in CL wearers (r = 0.411, p = 0.002, r = 0.588, p = 0.005, respectively). In soft CL wearers, the duration of CL use was the only predictive variable for mean PMGL in multivariate analysis. In a regression model including both CL groups, age and rigid CL material were predictive variables for mean PMGL.

CONCLUSIONS

CL use may cause MGD and this effect may be more pronounced in rigid CL wearers. In soft CL wearers, the duration of CL use is an important variable associated with MG loss, and subjective symptoms may guide the prediction of MG loss in these cases.

Meibomian Gland Morphology: The Influence of Structural Variations on Gland Function and Ocular Surface Parameters

PURPOSE

To objectively and quantitatively characterize meibomian gland morphology and to investigate the influence of morphological variations on gland function and ocular surface and tear film parameters.

METHODS

One hundred fifty subjects were enrolled. The examinations included tear osmolarity, tear meniscus height, bulbar conjunctival hyperemia, noninvasive tear film breakup time, lid margin thickness, foam secretion, meibomian gland expressibility, count of functioning glands, corneal and conjunctival staining, fluorescein breakup time, lid wiper epitheliopathy, and Schirmer test. Patient symptoms were assessed using the Ocular Surface Disease Index questionnaire. Images from noncontact meibography were analyzed using an automated method that objectively estimates dropout area, number of glands, gland length and width, and gland irregularity.

RESULTS

Gland irregularity highly correlated with dropout area (r = -0.4, P < 0.001) and showed significant partial correlations with fluorescein breakup time (r = 0.162, P = 0.049) and the Ocular Surface Disease Index questionnaire (r = -0.250, P = 0.002) Subjects with dropout area <32% were divided into 2 groups: high and low irregularity. Gland expressibility was statistically significantly different between the 2 groups (U = 319.5, P = 0.006). In the high irregularity group, gland irregularity correlated with the Schirmer test (r = 0.530, P = 0.001) and corneal fluorescein staining (r = -0.377, P = 0.021).

CONCLUSIONS

Automated morphological analysis of meibomian gland structure provides additional quantitative and objective information regarding gland morphology. The link between dropout area and gland function is not clear. Assessment of gland irregularity might better predict gland function and its effects on ocular surface and tear film parameters.

Comparison of the iLUX and the LipiFlow for the Treatment of Meibomian Gland Dysfunction and Symptoms: A Randomized Clinical Trial

Purpose

To compare the effects of eyelid treatment with the iLUX MGD Treatment System and the LipiFlow Thermal Pulsation System on objective and subjective parameters of meibomian gland function and symptoms.

Patients and Methods

In this randomized, open-label, controlled, multicenter clinical trial, both eyes of 142 patients aged ≥18 years with Ocular Surface Disease Index (OSDI) scores ≥23, total meibomian gland scores (MGS) ≤12 in the lower eyelid of each eye, and tear break-up time (TBUT) <10 s were randomized 1:1 to iLUX or LipiFlow treatment, with stratification by test center. The primary effectiveness endpoints were changes in total MGS (masked) and TBUT from baseline to 4 weeks. The secondary effectiveness endpoint was changed in OSDI score from baseline to 4 weeks.

Results

Both devices significantly improved effectiveness outcomes, with no differences between the two devices. At the 4-week visit, mean MGS, TBUT, and OSDI scores improved at least 16.9 ± 11.5, 2.6 ± 3.2 s, and 28.0 ± 22.8, respectively, across treatment groups and treated eyes. Four device/procedure-related events occurred in the iLUX group, compared with none in the LipiFlow group, but there were no device-related adverse events that involved changes in lid margins, eyelids, or lash integrity. Corneal staining, intraocular pressure, and visual acuity did not differ in the two groups.

Conclusion

Both treatments produced significant improvements in meibomian gland function and symptoms. For all effectiveness measures, there were no statistically significant differences between the two treatments.

Impact of pterygium on the ocular surface and meibomian glands

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Novel Automated Approach for Infrared-Based Assessment of Meibomian Gland Morphology

Purpose

We present and validate a new methodology for analyzing, in an automated and objective fashion, infrared images of the meibomian glands (MG).

Methods

The developed algorithm consists of three main steps: selection of the region of interest, detection of MG, and analysis of MG morphometric parameters and dropout area (DOA). Additionally, a new approach to quantify the irregularity of MG is introduced. We recruited 149 adults from a general population. Infrared meibography, using Keratograph 5M, was performed. Images were assessed and graded subjectively (Meiboscore) by two experienced clinicians and objectively with the proposed automated method.

Results

The correlation of subjective DOA assessment between the two clinicians was poor and the average percentage of DOA estimated objectively for each Meiboscore group did not lie within their limits. The objective assessment showed lower variability of meibography grading than that obtained subjectively. Additionally, a new grading scale of MG DOA that reduces intraclass variation is proposed. Reported values of MG length and width were inversely proportional to the DOA. Gland irregularity was objectively quantified.

Conclusions

The proposed automatic and objective method provides accurate estimates of the DOA as well as additional morphologic parameters that could add valuable information in MG dysfunction understanding and diagnosis.

Translational Relevance

This approach highlights the shortcomings of currently used subjective methods, and provides the clinicians with an objective, quantitative and less variable alternative for assessing MG in a noninvasive and automated fashion. It provides a viable alternative to more time-consuming subjective methods.

Characteristics of meibomian gland dysfunction in patients with Stevens-Johnson syndrome

To evaluate the characteristics of meibomian gland dysfunction (MGD) in patients with Stevens-Johnson Syndrome (SJS) and investigate the risk factors for severe MGD.Sixteen patients with a history of SJS were evaluated for MGD. To assess the SJS severity acute ocular involvement score (AOS), acute systemic involvement score (ASS), and chronic ocular manifestation score (COMS) were measured. Meibomian gland parameters were evaluated using meibomian gland dropout score (meiboscore - using a Keratograph 5 M), meibum expression score (MES), meibum quality score (MQS), and lid margin abnormality score (LMAS). Correlations between severity of meibomian gland parameters and degree of ocular and systemic involvement of SJS were analyzed. Risk factors for development of severe MGD were identified.The patients' mean age was 32.0 ± 14.3 years. Four patients were men and 12 were women. MGD had developed in 14 patients (87.5%). The meibomian gland parameters were significantly correlated with ocular and systemic degree of SJS as evaluated using AOS (P < .01), ASS (P < .01), and COMS (P < .01). Patients with severe MGD had a higher AOS (P < .01) and COMS (P = .02) values than those without severe MGD. On multivariate analysis, AOS higher than 2 was a significant risk factor for developing severe MGD (P = .03).MGD was a common ocular manifestation with SJS patients. Severity of meibomian gland parameters was correlated with AOS, ASS, and COMS, and the presence of acute ocular complications was a risk factor for severe MGD in patients with SJS.

Meibomian Gland Dysfunction in Patients Who Underwent Transconjunctival Approach Surgery for Inferior Orbital Wall Fractures

PURPOSE

To investigate whether transconjunctival approach surgery caused meibomian gland dysfunction in patients with inferior orbital wall fractures.

METHODS

Twenty consecutive patients who underwent reconstruction surgery for unilateral inferior orbital wall fracture via a transconjunctival approach were enrolled in this study. All patients were asked to complete the Ocular Surface Disease Index questionnaire for each separate eyelid. Both eyelids of each patient underwent slit lamp examination to determine the lid margin abnormality scores. The structure of the meibomian gland was assessed using meibography. Intraindividual comparison of outcome measurements between both eyelids was performed using the Wilcoxon signed-rank test. The contralateral eyelid of each patient was used as a normal control.

RESULTS

The mean Ocular Surface Disease Index score of the operated eyelid was 46.5 ± 8.9, which was significantly higher than that of the contralateral normal eyelid (23.4 ± 7.3; P = 0.02). The lid margin abnormality score of the operated eyelid (1.2 ± 0.7) was higher than that of the normal eyelid (0.5 ± 0.7; P = 0.033). The meibography score of the eyelid on the operated side (1.8 ± 0.8) was greater than that of the contralateral eyelid (1.0 ± 1.0; P = 0.015).

CONCLUSIONS

Compared to paired normal eyelids, eyelids that underwent transconjunctival approach surgery exhibited significant signs of meibomian gland dysfunction. Clinicians should be aware of such ocular symptoms in patients after transconjunctival approach surgery.

Longitudinal analysis of meibomian gland dropout in patients with ocular graft-versus-host disease

PURPOSE

To evaluate morphological changes in meibomian glands (MGs) over 1 year in patients diagnosed with chronic ocular graft-versus-host disease (GVHD), and to determine the association between MG loss and ocular surface parameters in such patients.

METHODS

This retrospective, observational study included 37 patients diagnosed with ocular GVHD who were followed-up for at least 1 year in the ophthalmology department. All patients received treatment during the follow-up period. The Ocular Surface Disease Index (OSDI) score, tear breakup time (TBUT), corneal staining score, lid margin score, Schirmer test I value, and noncontact infrared meibography findings were evaluated at baseline and after 1 year of follow-up for ocular GVHD. Both eyes were included in the analyses.

RESULTS

OSDI (p = 0.0391), corneal fluorescein scores (p = 0.0352 and 0.0181 for the right and left eyes, respectively), and upper and lower eyelid meiboscores (right eye: p = 0.0039 and 0.0156, respectively: left eye: p = 0.0273 and 0.0156, respectively) were significantly higher at 1 year than at baseline. Infrared meibography showed MG loss in 18.9% of eyes, improvement in 5.4% of eyes, and no changes in 75.7% of eyes, respectively. The Schirmer value for the right eye negatively correlated with the upper eyelid meiboscore at 1 year (p = 0.0103, r = -0.46), whereas the corneal fluorescein score for the left eye positively correlated with both upper and lower eyelid meiboscores at 1 year (p = 0.0368, r = 0.40; p = 0.0387, r = 0.39, respectively).

CONCLUSIONS

Rapid and aggressive MG destruction may occur in patients with ocular GVHD. Further studies with larger patient samples and longer follow-up periods are mandatory to validate these conclusions.

Classifying signs and symptoms of dry eye disease according to underlying mechanism via the Delphi method: the DIDACTIC study

Background/aims

Dry eye disease (DED) is categorised by pathophysiology as aqueous deficient dry eye (ADDE), evaporative dry eye (EDE) or mixed. Treatment should be tailored to DED pathophysiology, but this is challenging to determine. This Delphi consultation aimed to categorise and weight signs and symptoms to help identify the evaporative or aqueous deficient DED origin.

Methods

A panel of French DED experts created an initial list of 77 DED signs and symptoms. In a Delphi consultation, experts categorised items by DED pathophysiology. Likert scoring was used to indicate whether items were strongly or moderately indicative of ADDE or EDE. Items could also be judged non-applicable to DED, with the opportunity to suggest alternative diagnoses.

Results

Experts attributed 19 items (of which 11 were strongly indicative) to a pathophysiology of EDE and 12 items (of which four were strongly indicative) to ADDE. Items scored strongly indicative with agreement >90% for EDE were previous chalazia, rosacea/rhinophyma, telangiectasias of eyelid margin and thick non-expressible meibomian gland secretions, and for ADDE were Sjögren syndrome or associated disease, and Schirmer <5 mm after 5 min (without anaesthesia). Seventeen items indicated neither pathophysiology and 18 items were found to be suggestive of alternative diagnoses.

Conclusions

This Delphi consultation categorised signs and symptoms, using an innovative weighting system to identify DED pathophysiology. An algorithm integrating the weighting of each sign and symptom of an individual patient would be valuable to help general ophthalmologists to classify the DED subtype and tailor treatment to DED underlying mechanism.

The utility of a normal tear osmolarity test in patients presenting with dry eye disease like symptoms: A prospective analysis

OBJECTIVE

To explore the diagnostic utility of normal tear osmolarity in patients with symptoms suggestive of dry eye disease (DED).

METHODS

Prospective observational cohort study of 100 patients that underwent tear osmolarity testing (TearLab^™) if they endorsed one or more symptoms of potential DED. Patients were included for the study if they had a normal tear osmolarity test (value <308 mOsm/L in each eye, and an inter-eye difference <8 mOsm/L). The main outcome measure was the presence of any alternate diagnosis to explain the patient's symptoms. Results were recorded and descriptive and univariate statistics were employed.

RESULTS

Mean tear osmolarity was 293.40 mOsms/L (±6.82), with a mean absolute difference of 2.85 mOsms/L (±1.98) between the eyes. A possible alternate diagnosis was established in 89% of patients with normal tear osmolarity testing. The most frequent diagnoses included anterior blepharitis (26%) and allergic conjunctivitis (21%).

CONCLUSIONS

Common symptoms of DED overlap significantly with a wide variety of other ocular surface diseases, and a normal tear osmolarity test should increase clinical suspicion for alternate causes of those symptoms. Anterior blepharitis and allergic conjunctivitis were the most common diagnoses made in symptomatic patients with normal tear osmolarity who may have otherwise been misdiagnosed and treated for DED.

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

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

A single vectored thermal pulsation treatment for meibomian gland dysfunction increases mean comfortable contact lens wearing time by approximately 4 hours per day

Purpose

To evaluate the effect of a single vectored thermal pulsation (VTP) treatment in contact lens wearers with meibomian gland dysfunction (MGD) and dry eye symptoms.

Methods

The prospective, nonsignificant risk, open-label, randomized, multi-center clinical trial included 55 soft contact lens (SCL) wearers with MGD and evaporative dry eye. Subjects were randomized to the single VTP treatment group or an untreated control. The controls received a crossover VTP treatment at 3 months (crossover treatment group). Primary effectiveness measures were meibomian gland secretion (MGS) score and Standard Patient Evaluation of Eye Dryness (SPEED) that were evaluated at baseline, at 1 and 3 months post-VTP treatment, and at 1 month post-VTP treatment in the crossover treatment group. Exploratory variables included fluorescein tear break-up time (TBUT), lid wiper epitheliopathy (LWE), lid parallel conjunctival folds (LIPCOF), ocular surface staining, frequency of over-the-counter (OTC) drop use, and hours of comfortable contact lens wear.

Results

At 3 months, the treatment group showed significantly greater mean change from baseline in MGS (12.4±9.1 vs 1.4±6.4, p<0.0001), SPEED (−8.4±4.7 vs −0.7±4.4, p<0.0001) and significantly greater improvement in exploratory variables (TBUT, LWE, and frequency of OTC drop use) relative to the controls. Mean comfortable contact lens wearing time increased by 4.0±3.9 hours at 1 month. This was sustained for 3 months with no change in the control group. The crossover treatment group demonstrated similar results to the treatment group at 1 month post-VTP.

Conclusion

In SCL wearers with MGD, a single VTP treatment significantly improved mean meibomian gland function and significantly reduced dry eye signs and symptoms compared to an untreated control. The treatment increased mean comfortable lens wearing time by 4 hours (approximately doubling the pretreatment findings). This was sustained for up to 3 months post-treatment on average.