The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland

Reproducibility and within-subject variability of HRK-9000A meibography in normal young participants

PURPOSE

Reliable assessment is critical for diagnosing and managing meibomian gland dysfunction. Multi-functional diagnostic devices, such as meibographers, streamline clinical workflows by integrating multiple ocular assessments. Ensuring reproducibility across examiners is vital for accurate diagnosis and monitoring of treatment. This prospective study determined the inter-examiner reproducibility (IER), inter-rater reproducibility (IRR) and within-subject variability (WSV) of the Huvitz HRK-9000A meibographer.

METHODS

Meibomian glands (MGs) of both eyelids of healthy participants were captured during the same session by Examiner 1 (E1) and Examiner 2 (E2) in a counter-balanced design. The images were rated offline by E1, E2 and an Independent rater (R1). The inter-examiner reproducibility (IER between E1 vs. E2) and inter-rater reproducibility (IRR between E1 vs. R1 and E2 vs. R1) were determined based on non-parametric Bland-Altman plots, intraclass correlation coefficients (ICCs) and weighted Kappa (κ) values. Within-subject variability (WSV) was determined using ICCs.

RESULTS

Mean MG loss of the upper (E1: 1.0 ± 0.8 vs. R1: 0.9 ± 0.8, E2: 1.2 ± 0.8 vs. R1: 0.9 ± 0.7) and lower eyelids (E1: 1.9 ± 0.9 vs. R1: 2.1 ± 1.1, E2: 1.5 ± 1.0 vs. R1: 1.8 ± 1.0) of 35 participants (mean age 22 ± 3 years, range 19-30) was significantly correlated (p < 0.001) for all pairs of examiners (E1-E2, E1-R1 and E2-R1), but was significantly different for the upper eyelids of E2 vs. E1 (p < 0.002) and E2 vs. R1 (p < 0.003). Median differences between pairs of raters for both eyelids were close to zero, with >74% of comparisons falling within the interquartile range, except for the upper eyelids of E2 vs. E1 and E2 vs. R1 (63% and 66%, respectively). IRR demonstrated moderate agreement (0.43-0.57) with good reliability (ICC range 0.76-0.86) for the upper eyelids and good agreement (0.60-0.65) with good reliability (ICC range 0.85-0.88) for the lower eyelids. The WSV was excellent (ICCs for repeated measurements > 0.90).

CONCLUSIONS

The HRK-9000A meibographer demonstrated excellent reliability, with good inter-examiner and inter-rater reproducibility. It is suitable for meibographic assessment, follow-up or treatment.

An update on emerging pharmacological treatments for meibomian gland dysfunction

INTRODUCTION

Meibomian Gland Dysfunction (MGD) represents the most common cause of dry eye disease (DED). Traditional treatments mainly rely on heating and liquifying the meibum to favor its expression. However, recent knowledge advances have led to the development of novel therapies specifically designed for patients with MGD.

AREAS COVERED

Literature search was conducted on current and novel treatments for MGD. Conventional treatment strategies, non-pharmacological approved device-based therapies, approved dry eye therapies and both recently approved and emerging pharmacological treatments specifically designed to address MGD are discussed.

EXPERT OPINION

The better understanding of MGD and DED pathophysiology has allowed to develop drugs able to target the primary mechanisms of the disease. Miebo has been the first FDA approved drug for patients with DED associated with MGD and its ability to reduce the tear film layer evaporation rate and the minimal impact on the quality of vision are important innovations. Great expectations also accompany the phase 3 study of AZR-MD-001, understood to be a keratolytic and lipogenic agent able to improve meibum quantity and quality. The chance to specifically target MGD represents an important step forward and will allow more tailored treatment for each type of ocular surface disease.

A modified calculation formula for meibomian gland grading

This study aimed to establish a modified calculation formula for the grading of meibomian glands. Meibography images from 102 participants by different examiners on separate machines on two consecutive days were analyzed, quantified and compared side-by-side. Measure and calculate the ratio of the MGs area to the whole eyelid area and the ratio of the MGs to the corneal base area. Our findings demonstrate that there were significant differences in the ratio of the meibomian gland area to the whole eyelid area between two measurements, but not in the ratio of the meibomian gland area to the corneal base area. The measurement of the eyelid area showed bigger variations and poorer repeatability than the meibomian gland area and the corneal base area. As such, the ratio of the meibomian gland area to the corneal base area is a more stable indicator for the grading of meibomian glands over multiple measurement.

AZR-MD-001 0.5% selenium sulfide ophthalmic ointment for the treatment of contact lens discomfort: A vehicle-controlled, randomized, clinical trial

BACKGROUND

Contact lens discomfort (CLD) is a common problem for CL wearers, and patients with CLD often have changes in meibomian gland function and structure. In a Phase 2 trial AZR-MD-001 0.5% (AZR) ophthalmic ointment improved meibomian gland dysfunction (MGD) in non-lens wearers. The current study evaluated the efficacy and safety of AZR in participants with CLD and concomitant MGD.

METHODS

Adults with CLD (Contact Lens Dry Eye Questionnaire-8 >12, range 0-37) and MGD (Meibomian Gland Secretion Score [MGS] ≤12, range 0-45) were randomized (1:1) to AZR:vehicle applied twice-weekly in a three-month multicenter, prospective, double-masked study. Endpoints included difference in change from baseline (CFB) in the number of Meibomian Glands Yielding Liquid Secretion (MGYLS), MGS, the ability to wear their lenses as long as desired, and safety.

RESULTS

At Month 3, AZR (n=34) significantly increased the MGYLS and MGS versus vehicle (n=33), with least squares mean difference (LSMD) CFB in MGYLS of 5.0 (SE = 0.47) for AZR and 1.6 (0.45) for vehicle, P<0.0001; MGS of 13.8 (SE = 0.67) for AZR and 3.8 (SE = 0.68) for vehicle, P<0.0001. Significantly more participants treated with AZR were able to wear lenses as long as desired (43% vs. 6%, P=0.0023). The most common treatment-emergent adverse event (TEAE) was eye irritation (61.8% AZR; 0% vehicle). All TEAEs related to treatment were mild/moderate, transient, and did not result in discontinuation.

CONCLUSION

AZR-MD-001 0.5% significantly improved MGD signs and hours of comfortable CL wear, demonstrating good efficacy, safety, and tolerability in those with CLD.

Caffeine's protective role in dry eye disease and meibomian gland Dysfunction: Insights from clinical and Experimental models

PURPOSE

Inflammation and apoptosis contribute to the development of dry eye disease (DED) and meibomian gland dysfunction (MGD). This study aimed to investigate the effect of caffeine on the ocular surface and tear inflammatory cytokines through clinical, in vivo, and in vitro experiments.

METHODS

In the clinical study, comprehensive ophthalmic examinations of participants in the control and the caffeine groups were compared, including ocular surface and tears inflammatory cytokines. For in vitro study, rat meibomian gland epithelial cells (RMGECs) and human corneal epithelial cells (HCECs) were pretreated with or without caffeine and then stimulated with lipopolysaccharide (LPS). Inflammatory responses, apoptosis, and differentiation in cells were analyzed. In vivo study, apolipoprotein E knockout (ApoE-/-) mice were given caffeine-diet or no caffeine-diet, and their meibomian glands (MGs) and cornea tissue were compared.

RESULTS

Participants in the caffeine group exhibited significantly healthier ocular surface, lower tears inflammatory cytokines and a reduced prevalence of DED compared to the control group. In vitro study, caffeine pretreatment attenuated inflammatory responses, apoptosis and differentiation in LPS-induced RMGECs. Meanwhile, caffeine also markedly suppressed inflammatory responses and apoptosis in LPS-induced HCECs. In vivo study showed that ApoE-/- mice with caffeine-diet had more normal morphology of MGs and corneas compared to those without caffeine-diet, along with reduced inflammatory responses, cells apoptosis and ductal keratinization. Both in vitro and in vivo studies indicated that caffeine treatment was observed to inactivate of unclear factor kappa B (NF-κB) phosphorylation.

CONCLUSIONS

Our study indicated that caffeine may be a protective potential of ocular surface, providing a new perspective on clinical treatment for DED and MGD.

Mental burden of ocular surface discomfort

OBJECTIVE

This research investigates the associations between Dry Eye Disease (DED), pain perception, and mental health, focusing on how neuropathic pain influences treatment efficacy and patients' quality of life.

METHODS AND RESULTS

The study delves into the complexity of DED by assessing the correlation between ocular pain, depression, PTSD, and systemic pain conditions. It highlights the role of chronic neuropathic pain in DED and the nociceptive hypothesis, which suggests that psychological stress can exacerbate DED symptoms. Additionally, it explores diagnostic and management strategies for DED, emphasizing the importance of considering psychological aspects to improve patient care.

CONCLUSIONS

The intricate nature of DED, closely linked to mental health issues, requires a comprehensive diagnostic and therapeutic approach. Addressing neuropathic pain and psychological factors is crucial for effective DED management. Future efforts should focus on developing specific interventions targeting DED's physical and emotional impacts to enhance overall patient well-being.

Randomized clinical trial: MGrx versus standard debridement and expression for meibomian gland dysfunction

SIGNIFICANCE

Evaporative dry eye disease, due to meibomian gland dysfunction, causes significant suffering for millions of people globally, yet satisfactory long-term treatment remains elusive for many. Investigation of potential therapies for meibomian gland dysfunction is therefore of high importance to clinicians and their patients.

PURPOSE

This study aimed to compare the efficacy of a new device for meibomian gland debridement and expression to that of the conventional way of providing this treatment.

METHODS

Thirty participants (mean age, 36.4 ± 15.4 years; 77% female) fulfilling current Tear Film & Ocular Surface Society diagnostic criteria for dry eye disease and meibomian gland dysfunction were recruited (Research Registry, 10340). Fifteen participants each were randomized to receive a single treatment with either traditional debridement (using a golf-club spud), heating (10 minutes of Blepha EyeBag, Théa Laboratories, Clermont-Ferrand, France) and expression (with forceps), or the multimodal MGrx, which comprises a handheld device with heated debridement, massage, and expression attachments. Symptomatology, tear film, and ocular surface measures were assessed at baseline and at 4 and 8 weeks post-treatment.

RESULTS

Ocular Surface Disease Index, 5-Item Dry Eye Questionnaire, and Symptom Assessment in Dry Eye symptom questionnaire scores all improved significantly with both treatments (all p<0.001), with no subsequent deterioration for at least 8 weeks. The improvement was similar between treatment groups (all p>0.05). Clinical signs, of blink rate, tear film quality and quantity, ocular surface characteristics, and meibomian gland expressibility, were all unchanged with both treatments (all p>0.05) except for noninvasive tear breakup time, which deteriorated in the conventional treatment group (p=0.006) between 4 and 8 weeks post-treatment. No adverse reactions were reported, and all participants were able to tolerate treatment.

CONCLUSIONS

A single application of meibomian gland debridement and expression resulted in sustained improvements in the symptoms of dry eye disease, in both treatment groups. The MGrx device provides a safe and effective in-office treatment for evaporative dry eye disease, and has time and space advantages compared with conventional treatment.

13-cis Retinoic Acid-Mediated Modulation of Human Meibomian Gland Epithelial Cells Development: Implications for In Vitro Modeling of Meibomian Gland Dysfunction

Purpose: This study aimed to investigate the effect of 13-cis retinoic acid (13-cis RA) on human meibomian gland epithelial cells (HMGECs) and explore the potential of using this experimental model as an in vitro approach for studying meibomian gland dysfunction (MGD). Methods: First, HMGECs were cultured with 13-cis RA at different doses and times, and cell viability and proliferation rates were assessed to determine the appropriate stimulation concentration and time. Subsequently, during the proliferation stage, the expression of proliferation, inflammation, and oxidative stress genes and their products were evaluated. The meibum synthesis capacity was determined during the differentiation stage. Additionally, the peroxisome proliferator-activated receptor gamma (PPARγ) antagonist GW9662 was used as a control to assess the impact of 13-cis RA on PPARγ. Results: 13-cis RA significantly inhibited cell viability and proliferation in a time-dose response manner. Under the stimulation of 2 and 5 μM for 48 h during the proliferation stage, a significant decrease was observed in the expression of cell proliferation markers Ki67, antioxidant SOD-2, and Nrf-2. However, the expression of the pro-inflammatory factors IL-1β, IL-8, MMP9, and oxidative stress markers NOX-4 and reactive oxygen species increased. During the differentiation stage, it suppressed meibum synthesis and the expression of meibocyte differentiation-related proteins adipose differentiation-associated protein 4 (ADFP4), elongation of very long chain fatty acid protein 4 (ELOVL4), sterol regulatory element-binding protein 2 (SREBP-2), and PPARγ. Conclusion: 13-cis RA inhibited cell viability, promoted inflammation and oxidative stress, and suppressed meibum synthesis through the PPARγ pathway. Our study shed light on the effect of 13-cis RA on HMGECs and provided a promising direction for studying MGD in vitro.

Correlation between meibomian gland dysfunction and sebaceous adenitis in dogs

BACKGROUND

Sebaceous adenitis (SA) is an immune-mediated disease targeting the sebaceous glands. Meibomian gland dysfunction is a disease affecting meibomian glands with inflammatory features. Sebaceous and meibomian glands share anatomical, physiological and embryological similarities. The involvement of meibomian glands in dogs with SA is currently unknown.

OBJECTIVES

To evaluate meibomian glands in dogs affected by SA and compare them with healthy dogs.

ANIMALS

Eighteen dogs were enrolled. Nine dogs with SA were retrospectively identified from clinical records and represented the case group. Nine healthy, breed- and age-matched dogs were prospectively enrolled in the control group.

MATERIALS AND METHODS

Both groups underwent dermatological examination, Schirmer tear test-1 (STT-1), tear meniscus height (TMH), slit-lamp biomicroscopy, interferometry (INT) and noncontact infrared meibography (NIM).

RESULTS

One third of SA dogs presented subepithelial crystalline opacities. No significant difference between groups was observed in TMH (p = 0.944) and STT-1 values (p = 0.066). INT (p = 0.016) and NIM grades (p = 0.010) were significantly higher and lower in the SA group compared to the control group, respectively. INT values decreased with age (η = 0.930), while NIM scores (η = 0.935) increased.

CONCLUSIONS

Clinical Relevance: Subepithelial crystalline opacities in SA dogs might reflect a reduced tear film quality. In the absence of standardised methods, INT and NIM proved to be noninvasive and useful methods to examine meibomian glands. Dogs with SA showed a thinner lacrimal lipid layer and more severe meibomian gland abnormalities than control dogs, which seemed to progress with age.

Inflammation in Dry Eye Disease-Pathogenesis, Preclinical Animal Models, and Treatments

Dry eye disease (DED) is a rapidly growing ocular surface disease with a significant socioeconomic impact that affects the patients' visual function and, thus, their quality of life. It is distinguished by a loss of tear film homeostasis, leading to tear film instability, hyperosmolarity, ocular surface inflammation, and neurosensory abnormalities, with all of these playing etiological roles in the propagation of the vicious DED circle. While current treatments primarily focus on reducing tear film instability and hyperosmolarity, increasingly more attention is being placed on tackling the underlying inflammation that propagates and potentiates these factors. As such, preclinical models are crucial to further elucidate the DED pathophysiology and develop novel therapeutic strategies. This review outlines the role of inflammation in DED, highlighting related signs and diagnostic tools before focusing on relevant preclinical animal models and potential therapeutic strategies to tackle DED-associated inflammation.

Efficacy and safety of AZR-MD-001 selenium sulfide ophthalmic ointment in adults with meibomian gland dysfunction over six months of treatment: A Phase 2, vehicle-controlled, randomized extension trial

PURPOSE

To determine the efficacy and safety of AZR-MD-001 (0.5% and 1.0%) ophthalmic ointment, relative to vehicle, over 3-6 months of treatment, in participants with meibomian gland dysfunction (MGD).

METHODS

This was a Phase 2, randomized, vehicle-controlled, multicenter extension clinical trial. Eligible participants were adults with MGD (meibomian gland secretion score (MGS) ≤12 out of 15 glands) who discontinued all other dry eye or MGD treatments. Participants were randomized 1:1:1 to apply AZR-MD-001 1.0%, 0.5%, or vehicle to the lower eyelids, twice weekly. Key exploratory endpoints included the least-squared mean difference between groups in the change from baseline in clinical signs (meibomian gland yielding score; MGYLS) and symptoms (Ocular Surface Disease Index; OSDI), at clinic visits at Month 4.5 and 6, and safety measures from 3-6 months.

RESULTS

Participants (66.5% female) were randomized, at baseline, to AZR-MD-001 0.5% (n=82), 1.0% (n=83), or vehicle (n=80). Statistically significant improvements, compared to vehicle, were observed at Month 6 in MGYLS for both AZR-MD-001 groups (0.5% group: 1.9, 95% CI 0.9 to 2.8, P=0.002; 1.0% group: 1.1, 95% CI 0.2 to 2.1, P=0.026), and in OSDI score for the 0.5% group (-4.5, 95% CI -8.0 to -0.9, P=0.0135). The most common adverse events for AZR-MD-001 were application site pain, superficial punctate keratitis and eye pain; most were mild to moderate in severity, and decreased in incidence over time.

CONCLUSIONS

AZR-MD-001 (0.5%) was efficacious in treating signs and symptoms of MGD over six months, with a lower observed incidence of new adverse events over time.

How Eyelid Changes May Impact on Tears

This article examines the impact of eyelid margin diseases on tear film composition and associated ocular surface disorders. It highlights the prevalence of blepharitis and meibomian gland dysfunction, discussing risk factors and diagnostic considerations. Various therapeutic approaches, including eyelid hygiene, antibiotics, and innovative treatments, are explored. Emphasizing the chronic nature of these conditions, the article underscores the need for patient compliance. Overall, it provides a concise overview of eyelid-related issues and potential management strategies.

LipiFlow for the treatment of dry eye disease: A Cochrane systematic review summary

PURPOSE

To evaluate the effectiveness and the safety of LipiFlow for treating signs and symptoms of dry eye disease (DED) in adults.

METHODS

The following databases were searched for randomized trials: CENTRAL, MEDLINE Ovid, Embase.com, PubMed, LILACS, ClinicalTrials.gov, and WHO ICTRP on 24 October 2022. The included studies were conducted in adults (≥18 years) with DED or meibomian gland dysfunction (MGD) as defined by the investigators. Standard Cochrane methodology was applied.

RESULTS

This study included 13 trials that randomized a total of 1,155 participants (66 % female; age range = 19 to 86 years). Five trials compared LipiFlow with basic warm compresses. Analyzing symptom scores in these trials yielded conflicting evidence of a difference in symptoms between LipiFlow and basic warm compresses after 4 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 5 trials compared LipiFlow with thermostatic devices. Analysis of symptom scores in these trials at 4 weeks showed that thermostatic devices had reduced Ocular Surface Disease Index (OSDI) scores by a mean difference of 4.59 as compared with LipiFlow. The remaining 3 included trials could not be grouped for comparisons. The overall evidence was of low or very low certainty, with most trials being assessed as having a high risk of bias. No trial reported any intervention-related, vision-threating adverse events.

CONCLUSIONS

LipiFlow performs similarly to other DED treatments. Further research with adequate masking and a standardized testing methodology is still needed.

Efficacy of indirect intense pulsed light irradiation on meibomian gland dysfunction: a randomized controlled study

AIM

To investigate the efficacy and mechanisms of indirect intense pulsed light (IPL) irradiation on meibomian gland dysfunction (MGD).

METHODS

A total of 60 MGD patients was included in this prospective randomized controlled trial. Patients were randomly assigned 1:1 into two groups (3-mm group and 10-mm group) in which IPL was applied at distances from the lower eyelid margin of 3 and 10 mm, respectively. Both groups received three times treatment with 3-week interval. Meibomian gland yield secretion score (MGYSS), standard patient evaluation of eye dryness (SPEED) questionnaire, tear break-up time (TBUT), corneal fluorescein staining (CFS), and in vivo confocal microscopy were performed at baseline and after every treatment.

RESULTS

After three IPL treatments, both groups had significant improvement in MGYSS (both P<0.05). The non-inferiority test showed that improvement in 10-mm group was not inferior to that in 3-mm group (P<0.001). In both groups, temporal regions of both upper and lower eyelids showed significant improvement in MGYSS. Scores of SPEED questionnaire in both groups declined significantly (both P<0.001) and changes of SPEED had no difference between two groups (P=0.57). Density of central corneal subepithelial nerves and TBUTs showed no statistically significant changes. The 3-mm group had improvement on corneal fluorescein staining (P=0.048) and meibomian gland morphology (acini wall thickness P=0.003, hyperreflective points P=0.024) while the 10-mm group had not.

CONCLUSION

The efficacy of IPL indirect irradiation in improving meibomian gland secretion and alleviating dry eye symptoms remains unchanged with increase in treatment distance. IPL may primarily act on the functional improvement of the meibomian glands and corneal nerves.

Evaluation of meibomian gland morphology in keratoconus patients wearing scleral contact lenses

PURPOSE

We aimed to evaluate the morphological changes in meibomian glands in keratoconus patients using scleral contact lenses and compare them with keratoconus and healthy controls.

METHODS

The study included 34 eyes of 20 patients who were wearing scleral contact lenses due to keratoconus, as well as 31 age- and sex-matched keratoconus controls and 31 healthy controls. Slit-lamp biomicroscopy, non-invasive tear film break-up time assessment, Schirmer I test, meibography, and corneal staining with fluorescein were performed. Subjective symptoms were assessed using the Ocular Surface Disease Index.

RESULTS

In this study, the lower and upper percentage meibomian gland loss was statistically higher in the scleral contact lens group than in the keratoconus and healthy control groups (p < 0.001 and p = 0.013, respectively). There was a positive correlation between scleral contact lens wear duration and the lower eyelid percentage meibomian gland loss and upper eyelid gland curling scores (rho: 0.396; p = 0.021 and rho: 0.344; p = 0.047, respectively). The lower and upper eyelid percentage meibomian gland loss, and upper eyelid gland curling values were higher, and the Schirmer 1 values were found to be lower in patients who used scleral contact lenses for more than three years than those who wore them less than three years.

CONCLUSION

In patients using scleral contact lenses for more than three years, meibomian gland curling values and percentages of meibomian gland loss in both eyelids are higher.

Evaluation of Perfluorohexyloctane Eyedrops in Habitual Contact Lens Wearers

Background

Dry eye disease is one of the most common disorders we see in practice today. Perfluorohexyloctane (PFHO) ophthalmic solution (MIEBO®) (©Bausch + Lomb) is a novel, non-aqueous, single entity, preservative-free ophthalmic drop recently approved by the FDA for treatment of the signs and symptoms of dry eye disease.

Purpose

While the safety and efficacy of PFHO has been demonstrated in non-contact lens wearers, its safety and potential benefits in habitual contact lens wearers have not been explored. This report presents the results of a trial designed to evaluate the safety of PFHO and its effect on contact lens comfort, specifically in established contact lens wearers.

Patients and methods

The study included 47 patients who were adjusted contact lens wearers with a best corrected visual acuity of 20/25 or better at distance. All the patients were healthy contact lens wearers with no dry eye symptoms.

Results

A significant improvement in comfort scoring was observed without any significant changes in osmolarity, meibography scores, and total fluorescein staining.

Conclusion

These findings suggest that PCHO is safe for contact lens wearers to use and shows promise to reduce contact lens dropout.

Perfluorohexyloctane ophthalmic solution for dry eye disease: pooled analysis of two phase 3 clinical trials

Background

Dry eye disease (DED) is commonly caused by excessive tear film evaporation due to Meibomian gland dysfunction (MGD). There is a need for DED treatment options that address tear evaporation and benefit patients across a broad range of demographic and disease characteristics. This study evaluated treatment effects of perfluorohexyloctane ophthalmic drop (formerly NOV03) in the pooled dataset from 2 pivotal clinical trials in patients with DED associated with MGD, both in the overall population and in patient subgroups based on sex, age, and baseline severity of eye dryness.

Methods

Pooled data from 2 similarly designed, phase 3, randomized controlled trials (GOBI, MOJAVE) were analyzed. Patients aged ≥18 years with DED administered perfluorohexyloctane (n=614) or hypotonic (0.6% solution) saline control (n=603) four times daily for 8 weeks. Primary endpoints were total corneal fluorescein staining (tCFS) score (National Eye Institute scale, 0-15) and eye dryness visual analog scale (VAS) score (0-100). Efficacy was evaluated using analysis of covariance among patient subgroups (male and female, older [≥65 years] and younger [18 to <65 years], tCFS score <7 and ≥7, VAS eye dryness score <70 and ≥70, MGD score <7 and ≥7, Schirmer I test <10 mm and ≥10 mm).

Results

Reductions in tCFS and VAS eye dryness scores were greater for perfluorohexyloctane versus control. In the overall patient population, least-squares mean treatment difference was -1.1 (95% CI: -1.41 to -0.79; p<0.0001) for tCFS and -9.0 (95% CI: -11.90 to -6.00; p<0.0001) for VAS eye dryness. Treatment favored perfluorohexyloctane over control in all patient subgroup analyses of tCFS and VAS eye dryness. Overall, the most common adverse event with perfluorohexyloctane was blurred vision (2.1% of patients), which was mild and transient.

Conclusions

Compared with a hypotonic saline control, perfluorohexyloctane improved both the signs and symptoms of DED, including in patients with greater self-reported severity of eye dryness.

Clinical trial registration

This study represents an integrated analysis of 2 previous clinical trials: GOBI (ClinicalTrials.gov, NCT04139798) and MOJAVE (ClinicalTrials.gov, NCT04567329).

Intraepithelial Sebaceous Gland Carcinoma: A Multicenter Retrospective Case Series

PURPOSE

Intraepithelial sebaceous gland carcinoma is a rare form of sebaceous gland carcinoma, with 10 published case reports to date. The authors report the clinical, histological, and prognostic features of this rare carcinoma.

METHODS

This is a multicenter retrospective case series of patients from 3 Australian sites. Information collected included patient demographics, clinical risk factors, initial and subsequent presentations, histology results, management, and outcomes.

RESULTS

Twelve cases were identified. The average age of presentation was 72 years (range 52-92 years), with more females (n = 8) affected than males. The most common symptoms and signs were ocular irritation (n = 9) and eyelid mass (n = 8), with a predilection toward upper lid involvement. Five cases of sebaceous gland carcinoma were confirmed on initial histology. Initial management included wide local excision with margin control (n = 11), and primary topical mitomycin C (n = 1). Adjunctive conjunctival mapping biopsy was performed in 5 cases. Recurrence occurred in 7 cases, at an average of 31 months (range 7-83 months) after initial treatment. There were no cases of distant metastasis, however, 2 cases developed local invasion. Management of recurrences included exenteration (n = 2), further excisions alone (n = 3), and excision with adjuvant mitomycin C (n = 2).

CONCLUSIONS

Clinicians and pathologists should have a high index of suspicion for primary intraepithelial sebaceous gland carcinoma on the upper eyelid. Close follow-up is recommended, given the high risk of local recurrence.

Presentation of Meibomian Acini Compared to Dermal Papillae of the Eyelid Margin, Using Confocal Laser Scanning Microscopy and Corresponding Histology

BACKGROUND

Numerous studies have investigated the eyelid margin using confocal laser scanning microscopy (CLSM) and have presented morphological alterations of the examined structures, which were presumed to be Meibomian acini. However, recent data confirm that these structures are the cross-sections of dermal papillae of the dermoepidermal junction. This study aims to present the morphological appearance of Meibomian acini examined by confocal laser scanning microscopy in comparison to dermal papillae, and to reveal the corresponding patterns with specific histological sections.

METHODS AND MATERIAL

Twenty healthy patients were examined with a CLSM device in vivo at the marginal edge of the eyelid. Twenty-two samples of full-thickness eyelid wedges from 22 patients treated surgically with ectropion were collected, of which 11 freshly excised samples were imaged on the incision surface with CLSM ex vivo and 11 eyelids underwent conventional histological preparation. The represented structures on CLSM images were compared to Meibomian acini on histological sections in terms of area, longest and shortest diameter, as well as depth and density.

RESULTS

On in vivo CLSM images, Meibomian orifices, epidermal cells, and dermal connective tissue could be identified, the latter in a cross-sectional view of the dermal papillae surrounded by basal cells of the epidermis, forming reflective ring-like structures. All morphological parameters of these structures differed from Meibomian acini measured on histological sections. In contrast, the CLSM images of the incision surface showed acinar units with the same morphology as the Meibomian acini seen in the histological images and no statistically significant difference was found between the corresponding parameters.

CONCLUSION

The morphological appearance of Meibomian acini differs from the structures that were previously presumed as Meibomian glands on CLSM images. In vivo imaging of Meibomian glands by commonly used in vivo CLSM cannot be performed.

Topical glaucoma medications - Possible implications on the meibomian glands

One of the most common causes of blindness on a global scale is glaucoma. There is a strong association between glaucoma and increased intraocular pressure (IOP). Because of this, adequate IOP-lowering is the most important treatment strategy, mostly through topical eyedrops. Well-functioning meibomian glands are paramount for maintaining a stable tear film, and their dysfunction is the most common cause of dry eye disease. There is a growing concern that both topical glaucoma medications themselves and their added preservatives damage the meibomian glands, and consequently, the ocular surface. Preserved topical glaucoma medications appear to cause dysfunction and atrophy of the meibomian glands. Upon comparison, preserved formulations caused more symptoms of dry eye, tear film instability, inflammatory changes and meibomian gland dropout than the preservative-free counterpart. However, although seemingly less detrimental, unpreserved alternatives may diminish glandular efficacy, and, depending on the active ingredient, lead to glandular death. This negatively impacts quality of life, adherence to treatment regimens and prognosis. In this review, we explore the available evidence regarding the effects of IOP-lowering eye drops on the meibomian glands.

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.

Changes in Human Meibum Lipid Composition Related to the Presence and Severity of Meibomian Gland Dysfunction

Purpose: Changes in meibum composition and quantity in meibomian gland dysfunction (MGD) result in tear film instability and dry eye. This exploratory study aimed to identify changes in (O-acyl)-ω-hydroxy fatty acid (OAHFA) and hydrocarbon chain (HC) unsaturation levels in meibum related to the presence and severity of MGD. Methods: Meibum samples were collected from 3 cohorts of adults with no MGD, mild-to-moderate MGD, and severe MGD in a noninterventional clinical trial (NCT01979887). OAHFAs, cholesterol esters (CE), HC unsaturation, and HC length in the meibum samples were quantified with 1H-nuclear magnetic resonance spectroscopy using 2 methods of normalization. Results: Meibum samples from 62 subjects were analyzed: 21 non-MGD, 21 mild-to-moderate MGD, and 20 severe MGD. Meibum OAHFA and CE levels and HC unsaturation were reduced with increasing severity of MGD, with most pairwise comparisons significant (P < 0.05, t-tests), following the order non-MGD > mild-to-moderate MGD > severe MGD. Regardless of the resonances used for normalization, each pairwise comparison of OAHFA, CE, and HC unsaturation levels in MGD (combined severities) versus non-MGD samples was significant (P < 0.01, t-test). Analysis using various normalization equations showed reductions of 20%-22% for OAHFAs, 51%-57% for CE, and 36%-66% for HC unsaturation in MGD (combined severities) compared with non-MGD. HC length was not altered in MGD (combined severities) compared with non-MGD samples (t-test). Conclusions: Meibum OAHFA, CE, and HC unsaturation levels were reduced in MGD and were lowest in the severe MGD cohort. These findings may contribute to the understanding of the pathophysiology of MGD.

Effect of low-level light therapy in individuals with dry eye disease

INTRODUCTION

Low-level light therapy (LLLT) or photobiomodulation, the application of red light to the eye, is used for the treatment of dry eye. Limited studies have investigated the efficacy of LLLT as a stand-alone treatment. The investigation aimed to evaluate the effect of LLLT on signs and symptoms of dry eye.

METHODS

Participants with mild to moderate dry eye were recruited for this three-visit study. Visits were 7 (±3) days apart and all participants received 633 nm LLLT (eye-light®) for 15 min at each visit. Clinical measures including first and average non-invasive keratograph tear break-up time (NIKBUT), tear meniscus height (TMH), meibomian gland (MG) loss for upper and lower eyelids, ocular surface disease index (OSDI) score, tear film lipid layer thickness, meibum quality score, Schirmer's test, corneal fluorescein staining and eyelid temperature for external upper (EUL) and external lower (ELL) eyelids were measured from the right eye of participants before and after treatment.

RESULTS

Thirty participants (mean [SD] age: 31.1 [9.5] years) completed the study. Treatment with LLLT resulted in significant differences in first and average NIKBUT, TMH, tear film lipid layer thickness, OSDI score, Schirmer's test, meibum quality score and eyelid temperature over time (all p < 0.05). Compared to baseline, TMH, tear film lipid layer thickness and eyelid temperature significantly increased by 0.06 mm (95% CI: 0.01-0.11), 12.9 nm (95% CI: 1.18-24.55), and 7.0°C, respectively, for both EUL (95% CI: 6.17-7.84) and ELL (95% CI: 6.17-7.73). The respective decrease in the OSDI score and Schirmer's test was 10.2 (95% CI: -15.15 to -5.26) and 4.4 mm (95% CI: -7.31 to -1.42; all p < 0.05). There was no significant difference in corneal fluorescein staining and MG loss after LLLT.

CONCLUSION

Low-level light therapy treatment significantly improved signs and symptoms of dry eye in the early phases of treatment, suggesting its efficacy for dry eye management.

A comparative study on the lipid layer thickness analysis of medical staff before and after work

Background & Aims

To study the change of the lipid layer thickness analysis in medical staff (MS) before and after work, and to explore the significance of measuring lipid layer thickness (LLT) respectively in four quadrants.

Methods

Ocular Surface Disease Index (OSDI) questionnaire and video display terminal using time for 55 MS were collected (the informed consent was obtained from all patients). Noninvasive tear break-up time, LLT, tear meniscus height (TMH), meibomian glands (MG) dropout, and blink pattern before and after work (worked for more than 4 h) of 110 eyes were measured by Gaush iDea Ocular surface analyzer. Lid margin abnormalities were evaluated by the slit-lamp microscopy.

Results

The average OSDI score of 55 MS was 25.68 ± 14.91. The average LLT of 110 eyes after work (65.12 ± 3.63 nm) was significantly reduced compared to before work (66.54 ± 4.16 nm), p < 0.05. The LLT in the superior quadrant was significantly thinner than that in the other three quadrants, p < 0.01. The average LLT was positively correlated with the LLT in the inferior (r = 0.822, p < 0.001), nasal (r = 0.261, p < 0.001), and temporal quadrant (r = 0.372, p < 0.001), while was negatively correlated with the MG dropout in lower lid (r = -0.209, p = 0.002). There was a significant correlation between the LLT in the inferior quadrant and the VDTt (r = -0.173, p = 0.01). The LLT of inferior quadrant were positively related to the TMH (r = 0.149, p = 0.027) and negatively related to MG dropout in lower lid (r = -0.162, p = 0.017).

Conclusion

The LLT significantly decreases after work in MS. The distribution of the lipid layer on the ocular surface is uneven. It is unreasonable for current detection instruments to measure the inferior quadrant LLT alone to represent average LLT.

Comprehensive Assessment of the Meibomian Glands by Meibography: Why the Upper Eyelids Matter

ABSTRACT

The clinical value of upper eyelid meibographic imaging remains relatively underexplored; consequently, it is not commonly used in clinical assessments. However, its significance could be particularly important for the early detection of various ocular diseases and systemic conditions related to the eyes. An analysis of the current literature from the PubMed database, covering the years 2005 to 2023, with additional relevant papers added from cited references was conducted. Failure to diagnose dry eye disease and meibomian gland dysfunction associated with conditions such as Sjögren syndrome or thyroid eye disease in the early stages and taking appropriate action may result in persistent signs and symptoms. This could potentially lead to the development of chronic conditions that directly affect a patient's visual quality, functionality, and overall well-being. Therefore, this review aimed to demonstrate the potential clinical significance of upper eyelid examination as an integral component of comprehensive meibomian gland evaluation.

Cytarabine chemotherapy induces meibomian gland dysfunction

PURPOSE

Cytarabine (Ara-C) chemotherapy causes symptoms resembling meibomian gland dysfunction (MGD), suggesting potential associations between Ara-C and MGD. In this study, the pathological effects of Ara-C on MGD were investigated in a rodent model.

METHODS

Mice received Ara-C with or without rosiglitazone (PPARγ agonist) for 7 consecutive days. Slit-lamp biomicroscope was used for ocular examinations. Immunofluorescence detected acinar cell proliferation, differentiation, and ductal keratinization in the meibomian gland (MG). Lipid accumulation was evaluated by Oil Red O and LipidTox staining. Lipogenic status, FoxO1/FoxO3a cellular localization, and oxidative stress were visualized via immunohistochemistry. Western blotting assessed relative protein expression and AKT/FoxO1/FoxO3a pathway phosphorylation.

RESULTS

Ara-C (50 mg/kg) did not affect mouse survival but induced damage to ocular surface microenvironment, including corneal epithelial defects, MG orifice plugging and acinar dropout, and lacrimal gland (LG) dysfunction. Ara-C intervention inhibited proliferation and caused progenitor loss in the MG, as evidenced by reduced PCNA + labeling and P63+/Lrig1+ basal cell numbers. The MG ducts of Ara-C-treated mice exhibited marked dilatation, lipid deposition, and hyperkeratinization (K1/K10 overexpression). Ara-C disrupted MG lipid metabolism by downregulating PPARγ and its downstream lipogenic targets AWAT2/SOAT1/ELOVL4 and upregulating HMGCR. Dephosphorylation of AKT and the subsequent nuclear translocation of FoxO1/FoxO3a contributed to Ara-C-induced PPARγ downregulation. Ara-C triggered oxidative stress with increases in 4-HNE and 8-OHdG and Keap1/Nrf2/HO-1/SOD1 axis dysregulation. Rosiglitazone treatment ameliorated MGD-associated pathological manifestations, LG function, MG lipid metabolism, and oxidative stress in Ara-C-exposed mice.

CONCLUSIONS

Systemic Ara-C chemotherapy exerted topical cytotoxic effects on the ocular surface, and PPARγ restoration by rosiglitazone mitigated Ara-C-induced MGD alterations.

The effects of age and dysfunction on meibomian gland population dynamics

PURPOSE

While meibomian gland dysfunction (MGD) is widely recognized as a major cause of evaporative dry eye disease, little is known about normal gland differentiation and lipid synthesis or the mechanism underlying gland atrophy and abnormal lipid secretion. The purpose of this study was to use single-cell and spatial transcriptomics to probe changes in cell composition, differentiation, and gene expression associated with two murine models of MGD: age-related gland atrophy in wild-type mice and altered meibum quality in acyl-CoA wax alcohol acyltransferase 2 (Awat2) knockout (KO) mice.

METHODS

Young (6 month) and old (22 month) wild type, C57Bl/6 mice and young (3 month) and old (13 month) Awat2 KO mice were used in these studies. For single-cell analysis, the tarsal plate was dissected from the upper and lower eyelids, and single cells isolated and submitted to the UCI Genomic Core, while for the spatial analysis frozen tissue sections were shipped to Resolve Biosciences on dry ice and sections probed in duplicate using a meibomian gland specific, 100 gene Molecular Chartography panel.

RESULTS

Analysis of gene expression patterns identified the stratified expression of lipogenic genes during meibocyte differentiation, which may control the progressive synthesis of meibum lipids; an age-related decrease in meibocytes; and increased immune cell infiltration. Additionally, we detected unique immune cell populations in the Awat2 KO mouse suggesting activation of psoriasis-like, inflammatory pathways perhaps caused by ductal dilation and hyperplasia.

CONCLUSION

Together these findings support novel mechanism controlling gland function and dysfunction.

Comparison of upper eyelid pressure and ocular surface parameters in dry eye disease and benign essential Blepharospasm: A cross-sectional study

PURPOSE

To compare the upper eyelid pressure (UEP) and ocular surface parameters between dry eye disease (DED) and DED coexisting with benign essential blepharospasm (BEB), exploring which parameters could assist in distinguishing between DED and BEB, as potential risk factors for DED with BEB.

METHODS

All enrolled participants diagnosed with DED or DED coexisting with BEB were initially subjected to ocular surface disease index (OSDI) determination. Subsequently, the upper eyelid pressure was recorded using an innovative eyelid pressure measurement device, followed by a series of ocular surface examinations. The two groups were compared using the independent t-test and Mann-Whitney U test. A logistic regression analysis was performed to identify which parameters can predict the onset of blepharospasm.

RESULTS

The BEB group achieved a higher upper eyelid pressure (101.9 ± 23.5mN vs 88.4 ± 18.1mN, P = 0.009), lower number of total blink (6.2 ± 4.2 vs 7.1 ± 4.1, P = 0.016), higher corneal fluorescein staining score (4.0 ± 1.9 vs 3.0 ± 1.7, P = 0.046), higher partial blink rate (0.9 ± 0.2 vs 0.5 ± 0.4, P = 0.000) and the lower grade of meibum expressibility (1 (1, 2) vs 2 (1, 3), P = 0.000) and meibum quality (1 (1, 1) vs 1 (1, 1), P = 0.033) compared with the DED group. The upper eyelid pressure (OR = 1.123), partial blink rate (OR = 0.014) and the grade of meibum expressibility (OR = 10.804) showed significant associations with BEB (P < 0.05).

CONCLUSION

Despite similar OSDI scores, DED coexisting with BEB exhibited higher upper eyelid pressure, lower corneal fluorescein staining score, lower partial blink rate, more total blinks, lower grades of meibum expressibility, and lower meibum quality compared to DED alone. Among these, higher upper eyelid pressure, lower partial blink rate, and worse grade of meibum expressibility were identified as risk factors for BEB in DED.

Effect of laughter exercise versus 0.1% sodium hyaluronic acid on ocular surface discomfort in dry eye disease: non-inferiority randomised controlled trial

OBJECTIVE

To assess efficacy and safety of laughter exercise in patients with symptomatic dry eye disease.

DESIGN

Non-inferiority randomised controlled trial.

SETTING

Recruitment was from clinics and community and the trial took place at Zhongshan Ophthalmic Center, Sun Yat-sen University, the largest ophthalmic centre in China, between 18 June 2020 to 8 January 2021.

PARTICIPANTS

People with symptomatic dry eye disease aged 18-45 years with ocular surface disease index scores ranging from 18 to 80 and tear film break-up time of eight seconds or less.

INTERVENTIONS

Participants were randomised 1:1 to receive laughter exercise or artificial tears (0.1% sodium hyaluronic acid eyedrop, control group) four times daily for eight weeks. The laughter exercise group viewed an instructional video and participants were requested to vocalise the phrases "Hee hee hee, hah hah hah, cheese cheese cheese, cheek cheek cheek, hah hah hah hah hah hah" 30 times per five minute session. Investigators assessing study outcomes were masked to group assignment but participants were unmasked for practical reasons.

MAIN OUTCOME MEASURES

The primary outcome was the mean change in the ocular surface disease index (0-100, higher scores indicating worse ocular surface discomfort) from baseline to eight weeks in the per protocol population. The non-inferiority margin was 6 points of this index score. Main secondary outcomes included the proportion of patients with a decrease from baseline in ocular surface disease index score of at least 10 points and changes in dry eye disease signs, for example, non-invasive tear break up time at eight weeks.

RESULTS

299 participants (mean age 28.9 years; 74% female) were randomly assigned to receive laughter exercise (n=149) or 0.1% sodium hyaluronic acid (n=150). 283 (95%) completed the trial. The mean change in ocular surface disease index score at eight weeks was -10.5 points (95% confidence interval (CI) -13.1 to -7.82) in the laughter exercise group and -8.83 (-11.7 to -6.02) in the control group. The upper boundary of the CI for difference in change between groups was lower than the non-inferiority margin (mean difference -1.45 points (95% CI -5.08 to 2.19); P=0.43), supporting non-inferiority. Among secondary outcomes, the laughter exercise was better in improving non-invasive tear break up time (mean difference 2.30 seconds (95% CI 1.30 to 3.30), P<0.001); other secondary outcomes showed no significant difference. No adverse events were noted in either study group.

CONCLUSIONS

The laughter exercise was non-inferior to 0.1% sodium hyaluronic acid in relieving subjective symptoms in patients with dry eye disease with limited corneal staining over eight weeks intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04421300.

Epidemiology and Risk Factors of Dry Eye Disease: Considerations for Clinical Management

Dry eye disease is a multifactorial condition characterised by tear film instability, hyperosmolarity and ocular surface inflammation. Understanding the epidemiology of dry eye disease and recognising both modifiable and non-modifiable risk factors can assist eye care practitioners in assessing, treating, and managing patients with the condition. This review considers current knowledge surrounding its incidence and prevalence, as well as associated demographic, systemic, ocular, and iatrogenic, and lifestyle-related modifiable risk factors. Population-based prevalence estimates vary according to the diagnostic criteria used to define dry eye disease, as well as severity and demographic characteristics of the population. Considering recent data and variable population demographics, conservative prevalence estimates suggest that 10-20% of the population over 40 years of age report moderate to severe symptoms and/or seek treatment for dry eye disease. Individuals with specific non-modifiable demographic risk factors may be at increased risk of developing dry eye disease. Advanced age, female sex and East Asian ethnicity have been identified as key non-modifiable demographic features predisposing individuals to dry eye disease. Systemic conditions that have been associated with an increased risk of dry eye disease include migraine, Sjögren syndrome, connective tissue disorders, mental health disorders, diabetes mellitus and androgen deficiency. Medications that may contribute to this risk include antidepressants, antihistamines, and hormone replacement therapy. Ocular and iatrogenic risk factors of dry eye disease include blepharitis, Demodex infestation, ocular surgery, blink completeness, contact lens wear, and topical ophthalmic medications. A range of modifiable lifestyle factors that can increase the risk of dry eye disease have also been identified, including low humidity environments, digital screen use, quality of sleep, diet, and eye cosmetic wear. Dry eye is a common disease affecting millions globally. Increasing knowledge regarding its associated risk factors can better prepare the eye care practitioner to successfully manage patients with this ocular surface disease.

Meibomian gland dropout of upper eyelids as a novel biomarker for early diagnosis of primary Sjögren's syndrome: a pilot study

Background

Early diagnosis of primary Sjögren's syndrome (pSS) remains difficult due to its insidious onset.

Objectives

To identify whether meibomian gland dropout (MGD) is a sensitive and noninvasive predictor of pSS by studying its association with histopathology in labial salivary gland biopsy in patients with clinically suspected pSS.

Design

Prospective, randomized, multicenter, comparative effectiveness study.

Methods

The study was conducted from July 2022 to July 2023. In all, 56 eligible participants with clinically suspected pSS were recruited from three combined ophthalmology medicine/rheumatology SS clinics. All participants with suspected pSS were evaluated and diagnosed by ophthalmology and rheumatology consultants and underwent infrared imaging of the meibomian glands using Keratograph 5M and histopathological evaluation of labial salivary gland biopsies. The length, width, and tortuosity of the meibomian glands were measured; the dropout rate in the nasal, temporal, and total eyelids was analyzed; and the dropout score was calculated using meibography grading scales.

Results

Among the 56 participants, 34 were identified with pSS, and 22 were diagnosed with non-SS dry eye (NSSDE) and served as the control group. We recorded significant differences in the temporal and total MGD rates of the upper eyelids between the pSS and NSSDE groups (all p < 0.01). Improved prediction accuracy was achieved with the temporal and total MGD rates in the upper eyelids, with area under the curve values of 0.94 and 0.91, and optimal cutoff points of 0.78 and 0.75, respectively.

Conclusion

MGD in the upper eyelids, especially in the temporal portion, is strongly associated with the histopathological outcome of labial salivary gland biopsy in pSS and is proposed as a highly predictive and noninvasive biomarker for the early diagnosis of pSS.

Trial registration

ClinicalTrials.gov identifier: ChiCTR2000038911.

Understanding Ocular Graft-versus-Host Disease to Facilitate an Integrated Multidisciplinary Approach

Ocular graft-versus-host disease (oGVHD) remains a challenging and potentially devastating complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Although oGVHD significantly impacts the quality of life of affected survivors, it often goes unrecognized, particularly in the early stages. Targeting all providers in the HSCT community who see patients regularly and frequently for their post-allo-HSCT care, this review and opinion piece introduces the basic concepts of ocular surface pathophysiology, dissects the different stages of clinical presentation of oGVHD, explains why the current diagnostic criteria tend to capture the late disease stages, and highlights the warning signs of early disease development to facilitate prompt referral of oGVHD suspects for ocular specialist care. Along with introducing a comprehensive list of treatment options, this review emphasizes basic therapeutic strategy and options that can be safely and effectively initiated by any care provider. We believe in empowering patients as well as care providers beyond disciplinary boundaries to provide the most cohesive and integrated care in a multidisciplinary approach.

Efficacy and safety of the disposable eyelid warming masks in the treatment of dry eye disease due to Meibomian gland dysfunction

BACKGROUND

Warm compresses are the routine treatment for Meibomian gland dysfunction (MGD) in daily life, but in order to achieve satisfactory efficacy, the treatment needs to be sustained over a long time, which can have an impact on the patient compliance. A more convenient warm compresses will help improve the patient compliance. Therefore, the purpose of the study is to investigate the efficacy and safety of the disposable eyelid warming masks for treatment of dry eye disease (DED) due to MGD.

METHODS

This was a randomized, controlled, non-masked, two-center clinical trial. One hundred and forty-four patients were treated by the masks or the hot towel twice daily for 12 weeks. Patients were evaluated at baseline, 4-week and 12-week visits for subjective symptoms, objective signs and safety assessments, including ocular symptom scores, ocular surface disease index (OSDI), tear break-up time (BUT), corneal fluorescein staining (CFS), Schirmer I test (SIT), meibum quality, meibum expressibility, and adverse events (AEs).

RESULTS

A totle of 134 patients were followed in the study. The mean age of the masks group (14 males and 52 females) and the hot towel group (20 males and 48 females) was 43.7 ± 13.5 years and 39.5 ± 13.9 years, respectively. At 4-week visit, there were significant statistical differences in ocular symptom scores, OSDI and CFS between two groups (P < 0.05). Except for SIT, the treatment group showed a greater improvement in subjective symptoms and objective signs than the control group at 12-week visit. (P < 0.05). In addition, 40 AEs occurred in 27 patients (37.5%) in the treatment group, and 34 AEs occurred in 21 patients (29.17%) in the control group. No serious AEs were reported.

CONCLUSIONS

The masks had a good efficacy and safety in the treatment of DED due to MGD, and might offer an attractive treatment option for some patients.

TRIAL REGISTRATION

The study was registered at Chinese Clinical Trial Registry (ChiCTR1900025443) on August 26, 2019.

Tear Film Conditions and Depression Symptoms in Persons with Obesity

Most persons with obesity who have undergone gastric bypass surgery present depressive symptoms. Depression and anxiety have been associated with tear film disorders. This study aimed to investigate whether there is a correlation between tear film conditions and depression symptoms in patients subjected to bariatric surgery. The participants completed a Patient Health Questionnaire to detect depression symptoms. The break-up time and Schirmer test were subsequently applied; the measurements were performed three times, and the average time was subsequently recorded. The results revealed that the Schirmer test score and PH-9 score were negatively correlated, but this was not the case for the break-up time test. Depression symptoms may correlate with lower tear production from the principal tear gland, but they may not have the same effect on meibomian gland production in adults undergoing bariatric surgery. In addition to routine control, bariatric surgery patients should be periodically evaluated by an ophthalmologist and/or psychologist who is aware of potential comorbidities. Furthermore, the observed association between depression symptoms and tear deficiencies highlights the importance of further investigations to gain a better understanding of these mechanisms.

Identification of Meibomian gland stem cell populations and mechanisms of aging

Meibomian glands secrete lipid-rich meibum, which prevents tear evaporation. Aging-related Meibomian gland shrinkage may result in part from stem cell exhaustion and is associated with evaporative dry eye disease, a common condition lacking effective treatment. The identities and niche of Meibomian gland stem cells and the signals controlling their activity are poorly defined. Using snRNA-seq, in vivo lineage tracing, ex vivo live imaging, and genetic studies in mice, we identified markers for stem cell populations that maintain distinct regions of the gland and uncovered Hh signaling as a key regulator of stem cell proliferation. Consistent with this, human Meibomian gland carcinoma exhibited increased Hh signaling. Aged glands displayed decreased Hh and EGF signaling, deficient innervation, and loss of collagen I in niche fibroblasts, indicating that alterations in both glandular epithelial cells and their surrounding microenvironment contribute to age-related degeneration. These findings suggest new approaches to treat aging-associated Meibomian gland loss.

Meibography signal intensity as a novel image biomarker for meibomian gland function: evidence from cross-sectional and longitudinal analyses

Background

Meibomian gland dysfunction (MGD), one of the most common ocular surface diseases, can induce dry eye and reduce patients' quality of life. Methodological limitations have resulted in contradictory interpretations of gland function. This study sought to investigate the correlation between meibography signal intensity (SI) and meibomian gland (MG) function and to validate an MGD classification strategy based on different levels of SI.

Methods

A multicenter, cross-sectional analysis was conducted on 817 eyes from 361 patients with MGD and 52 healthy controls. Additionally, 78 eyes from 39 patients with MGD who had undergone LipiFlow treatment were recruited for longitudinal analyses. The SI value was obtained via meibography using an automated analyzer, and all participants underwent ocular surface examinations. A cross-sectional analysis was performed to determine SI distribution and its relationship to clinical characteristics via a generalized estimating equation model. Longitudinal analyses were conducted on the treatment cohort using a mixed-effects model to explore the outcome in different SI levels.

Results

Regression analysis revealed significant correlations between SI and lipid layer thickness (β=0.016), meibum expressibility (β=-0.676), meibum quality (β=-0.251), and fluorescein-stained tear-film break-up time (FBUT) (β=0.064) (all P values <0.001 for the above associations). Low-level SI MGD cases exhibited the most severe clinical signs, including the worst meibum expressibility (16% for level 3) and quality scores (19% for level 3), the shortest FBUT (3.82±0.13 s), and the thinnest lipid layer (65.68±2.58 nm), (all P values <0.05, respectively). Patients with medium SI showed the lowest ocular surface disease index (OSDI) value (26.64±1.06), the longest FBUT (4.56±0.08 s), and the thickest lipid layer (80.20±2.90 nm). After treatment, the high SI values reduced significantly at each follow-up point compared to baseline (all P values <0.05). The medium SI group demonstrated the greatest improvement in symptoms and signs, followed by the high SI group, and the low SI group.

Conclusions

Automated measurements of SI can effectively reflect MG secretory activity. The proposed low, medium, and high SI classifications represent different functional subtypes of MGD.

Elucidating the role of genetically determined metabolites in Diabetic Retinopathy: insights from a mendelian randomization analysis

AIMS

Diabetic retinopathy (DR) results from complex genetic and metabolic interactions. Unraveling the links between blood metabolites and DR can advance risk prediction and therapy.

METHODS

Leveraging Mendelian Randomization (MR) and Linkage Disequilibrium Score Regression (LDSC), we analyzed 10,413 DR cases and 308,633 controls. Data was sourced from the Metabolomics GWAS server and the FinnGen project.

RESULTS

Our research conducted a comprehensive MR analysis across 486 serum metabolites to investigate their causal role in DR. After stringent selection and validation of instrumental variables, we focused on 480 metabolites for analysis. Our findings revealed 38 metabolites potentially causally associated with DR. Specifically, 4-androsten-3beta,17beta-diol disulfate 2 was identified as significantly associated with a reduced risk of DR (OR = 0.471, 95% CI = 0.324-0.684, p = 7.87 × 10- 5), even after rigorous adjustments for multiple testing. Sensitivity analyses further validated the robustness of this association, and linkage disequilibrium score regression analyses showed no significant genetic correlation between this metabolite and DR, suggesting a specific protective effect against DR.

CONCLUSIONS

Our study identifies 4-androsten-3beta,17beta-diol disulfate 2, a metabolite of androgens, as a significant protective factor against diabetic retinopathy, suggesting androgens as potential therapeutic targets.

The effect of airborne particulate matter 2.5 (PM2.5) on meibomian gland

Exposure to particulate matters in air pollution of 2.5 μm or less (PM2.5) was associated with loss of meibomian glands. The aim of this study was to verify that PM2.5 could directly impact meibomian gland epithelial cells and damage their function. To investigate the impact of PM2.5 on meibomian gland, immortalized human meibomian gland epithelial cells were treated with various concentrations of PM2.5in vitro. Meibomian gland cell microstructure, cell viability, expression of proliferating cell nuclear antigen and IL-1β, and intracellular accumulation of acidic vesicles were measured by transmission electron microscopy, cell counting, Western blot and LysoTracker staining, respectively. To further study the effect of PM2.5in vivo, male C57BL/6J mice were treated with 5 mg/ml PM2.5 or vehicle for 3 months. Corneal fluorescein staining and ocular examinations were done before and after the treatment. Eyelids tissues were processed for morphological studies, immunostaining and Oil Red O staining. Our data suggest that exposure to PM2.5 caused significant meibomian gland dropout, clogged gland orifice and increased corneal fluorescein staining that were consistent with the clinical presentations of meibomian gland dysfunction. Prominent changes in the morphology and ultrastructure of meibomian glands was observed with PM2.5 treatment. PM2.5 promoted ductal keratinization, inhibited cell proliferation, induced cell apoptosis and increased Interleukin-1β production in meibomian gland epithelial cells. This study may explain the association between PM2.5 exposure and meibomian gland dropout observed in clinic. PM2.5 resuspension instillation could be used to induce a meibomian gland dysfunction animal model.

Quantitative evaluation of morphological and functional changes in meibomian glands and lipid layer thickness in patients with and without keratoconus

PURPOSE

To quantitatively evaluate the morphological parameters of meibomian glands (MGs) and lipid layer thickness (LLT) in patients with keratoconus (KC).

METHODS

In this prospective, cross-sectional study, 164 eyes of 164 keratoconus patients and 64 eyes of 64 age-matched control subjects were included. An advanced automatic MG analyzer was used to quantitatively measure the morphological and functional parameters of MGs. Morphological and functional parameters of MGs, LLT, and other ocular surface parameters were compared between the control and KC groups.

RESULTS

The mean meibomian gland diameter, length, square, and gland area ratio (GA) were all significantly decreased in the KC group (all P < 0.05), while no significant difference was observed in the gland tortuosity index (TI) and gland signal index (SI) between the KC and control groups (all P > 0.05). There was no significant difference in the number of total and incomplete blinking among patients with different stages of keratoconus (all P > 0.05). The gland diameter, square, and TI were all negatively associated with KC severity (all P < 0.05), while no significant difference was observed among all stages of KC in gland length, GA, and SI (all P > 0.05). Moreover, the LLTs were positively correlated with the gland diameter, square, GA, and TI and negatively correlated with anterior corneal curvature or KC severity (all P < 0.05).

CONCLUSIONS

Atrophic morphological changes in the meibomian glands were closely correlated with the severity of keratoconus. Gland diameter may be a sensitive functional morphology metric of meibomian glands in patients with keratoconus.

Meibomian Gland Shortening Is Associated With Altered Meibum Composition

Purpose

The purpose of this study was to investigate differences in the composition of meibum extracted from human meibomian glands displaying different morphological characteristics.

Methods

Adult participants with evidence of meibomian gland shortening were enrolled. Glands were observed using infrared meibography, and meibum was collected from one short and one long gland from the lower eyelid of the same eye. Total protein concentration was evaluated using the detergent compatible (DC) protein assay and lipid analysis was performed using liquid chromatography mass spectrometry.

Results

Fifteen participants (8 women and 7 men) completed the study (mean age = 34.7 ± 7.7 years). The average volume of meibum collected from the short and long glands was 0.02 ± 0.01 and 0.05 ± 0.03 µL, respectively (P = 0.01). Average protein concentration in the short glands was significantly higher compared to the long glands (0.10 ± 0.03 vs. 0.08 ± 0.02 mg/mL, P = 0.01). Among the non-polar lipids, the mole percent of cholesterol esters (CEs; P = 0.02), triacylglycerols (TAGs; P = 0.04), and ceramide (Cer; P = 0.03) was significantly lower in short glands compared with long glands. Among the polar lipids, the mole percent of (O-acyl)-ω-hydroxy fatty acid (OAHFA; P = 0.01) was significantly lower in short glands, whereas phosphatidylcholine (PC; P = 0.02) and sphingomyelin (SM; P = 0.01) were significantly higher in short glands than long glands.

Conclusions

Meibum composition differed between short and long glands. The lower mole percent of CE, TAG, OAHFA, and Cer and a higher mole percent of PC and SM among short glands may indicate disease activity. This information may clarify the natural history of meibomian gland dysfunction and future targets for therapy.

Analysis of Factors Associated with Anterior Location of Marx's Line

PURPOSE

The study aimed to investigate the factors associated with anterior location of Marx's line in ocular surface and living habits, especially in tear film.

MATERIALS AND METHODS

This cross-sectional study enlisted 483 participants with meibomian gland dysfunction, who were divided into two groups: 160 participants with mild anterior location of Marx's line and 323 participants with moderate-to-severe anterior location. Participants completed a survey of demographic characteristics (sex, age, length of visual terminal use, sleep duration, skin property), and the Ocular Surface Disease Index and Standard Patient Evaluation of Eye Dryness questionnaires. They also underwent slit-lamp examinations of the lids, and measurements of non-invasive tear break up time, tear meniscus height, fluorescein tear break up time, lipid layer thickness, partial blink rate, lid wiper epitheliopathy, and meibomian gland dropout.

RESULTS

The tear meniscus height (mild:0.21(0.18-0.25), moderate-to-severe:0.19(0.16-0.23), p = 0.004), fluorescein tear break up time(mild:3(2-4),moderate to severe:2(1-3), p = 0.000), max LLT(mild:87(62-100), moderate-to-severe:99(69-100), p = 0.04), average LLT(mild:64.5(47.5-96.75), moderate-to-severe:74(53-100), p = 0.012), min LLT(mild:52(38-75), moderate-to-severe:59(41-85), p = 0.029) differed significantly between mild and moderate-to-severe anterior location of Marx's line, and associated to the anterior location of Marx's line(r=-0.134, p = 0.03; r=-0.194, p = 0.000; r = 0.093, p = 0.041; r = 0.119, p = 0.009; r = 0.105, p = 0.022) However, no statistical significance was observed in the OSDI, SPEED, partial blink rate, non-invasive tear breakup time, lipid layer thickness, meibomian gland dropout and lid wiper epitheliopathy(p > 0.05). Meanwhile, in the demographic characteristics, statistically significant correlations were associated with skin property(r = 0.154, p = 0.001) and sleep duration(r=-0.124, p = 0.006), but not with age, sex, and the length of visual terminal use (p > 0.05).

CONCLUSIONS

Lower TMH and shorter TBUT positively correlated with anterior location of the Marx's line, and were risk factors. Meanwhile, participants with oily skin and shorter sleep duration were more likely to exhibit anterior location of Marx's line.

HDAC1/2 and HDAC3 play distinct roles in controlling adult Meibomian gland homeostasis

PURPOSE

To investigate the roles of HDAC1/2 and HDAC3 in adult Meibomian gland (MG) homeostasis.

METHODS

HDAC1/2 or HDAC3 were inducibly deleted in MG epithelial cells of adult mice. The morphology of MG was examined. Proliferation, apoptosis, and expression of MG acinus and duct marker genes, meibocyte differentiation genes, and HDAC target genes, were analyzed via immunofluorescence, TUNEL assay, and RNA in situ hybridization.

RESULTS

Co-deletion of HDAC1/2 in MG epithelium caused gradual loss of acini and formation of cyst-like structures in the central duct. These phenotypes required homozygous deletion of both HDAC1 and HDAC2, indicating that they function redundantly in the adult MG. Short-term deletion of HDAC1/2 in MG epithelium had little effect on meibocyte maturation but caused decreased proliferation of acinar basal cells, excessive DNA damage, ectopic apoptosis, and increased p53 acetylation and p16 expression in the MG. By contrast, HDAC3 deletion in MG epithelium caused dilation of central duct, atrophy of acini, defective meibocyte maturation, increased acinar basal cell proliferation, and ectopic apoptosis and DNA damage. Levels of p53 acetylation and p21 expression were elevated in HDAC3-deficient MGs, while the expression of the differentiation regulator PPARγ and the differentiation markers PLIN2 and FASN was downregulated.

CONCLUSIONS

HDAC1 and HDAC2 function redundantly in adult Meibomian gland epithelial progenitor cells and are essential for their proliferation and survival, but not for acinar differentiation, while HDAC3 is required to limit acinar progenitor cell proliferation and permit differentiation. HDAC1/2 and HDAC3 have partially overlapping roles in maintaining survival of MG cells.

Physiological Effects of Soat1 Inactivation on Homeostasis of the Mouse Ocular Surface

Purpose

Soat1/SOAT1 have been previously reported to be critical for the biosynthesis of cholesteryl esters (CEs) in the mouse Meibomian glands (MGs) as the loss of function led to an arrest of CE production and a substantial accumulation of nonesterified cholesterol in the meibum, causing an increase in its melting temperature. The purpose of this study was to further investigate the role of Soat1 in meibogenesis and ocular surface physiology.

Methods

The mouse ocular features of knockout Soat1-/- and wild type (WT) mice were studied using various ophthalmic and histological techniques, mouse lipidomes were monitored using liquid chromatography/mass spectrometry, whereas their transcriptomes were compared to characterize the effects of the mutation on the gene expression profiles in the MG and cornea.

Results

Soat1-/- mice displayed increased tear production and severe corneal abnormalities, such as corneal thinning, (neo)vascularization, ulceration, and opacification that progressed with aging. Transcriptomic analyses led to identification of a range of significantly disrupted pathways, which included general and specific lipid metabolism-related pathways, keratinization, angiogenesis/(neo)vascularization, muscle contraction, and several other pathways. In addition, histological and histochemical experiments revealed morphological changes in the MG, cornea, and conjunctiva in Soat1-/- mice. Notably, the mRNA microarray expression level of Soat1 in WT MGs (log2 17.5) was 1000 × of that in the mouse cornea (log2 7.5).

Conclusions

These findings suggest a direct involvement of Soat1/SOAT1 in MGs in maintaining ocular surface homeostasis, in general, and corneal health, specifically.

Ocular surface changes in moderate-to-severe acne vulgaris

AIM

To investigate ocular surface disorders and tear function changes in patients with acne vulgaris and explore the potential relationship between acne vulgaris and dry eye.

METHODS

This cross-sectional study included right eyes of 53 patients with acne vulgaris and 54 healthy controls. The participants completed the Ocular Surface Disease Index (OSDI) questionnaire. The following ocular surface-related parameters were measured: tear meniscus height (TMH), noninvasive tear breakup time (NIBUT), Schirmer I test (SIT), lipid layer thickness (LLT) score of the tear film, meibum score, meibomian gland orifice obstruction score, the ratio of meibomian gland loss, conjunctival hyperemia score, and corneal fluorescein staining (CFS) score.

RESULTS

The stability of the tear film decreased in acne vulgaris patients. In the acne group, the TMH and NIBUT were lower, whereas the OSDI, meibum score, meibomian gland orifice obstruction score, ratio of meibomian gland loss, and conjunctival hyperemia score were higher compared with controls (P<0.05). There were no significant differences in the CFS score, SIT, or LLT score between the groups (P>0.05). In two dry eye groups, the TMH, NIBUT, and LLT score were lower in the acne with dry eye (acne-DE) group, and the meibum score, meibomian gland orifice obstruction score, ratio of meibomian gland loss and conjunctival hyperemia score in the acne-DE group were higher (P<0.05). There were no significant differences between OSDI, SIT, and CFS score (P>0.05).

CONCLUSION

Patients with moderate-to-severe acne vulgaris are more likely to experience dry eye than those without acne vulgaris. Reduced tear film stability and meibomian gland structure dysfunction are more pronounced in patients with moderate-to-severe acne and dry eye.

Quantitative Assessment of Lid Margin Vascularity Using Swept-Source Optical Coherence Tomography Angiography

Purpose

To evaluate the ability of swept-source optical coherence tomography angiography (SS-OCTA) to assess lid margin vascularity.

Methods

This prospective, cross-sectional trial enrolled 125 participants, including 15 control subjects and 110 meibomian gland dysfunction (MGD) patients. Lid margin blood flow density (LMBFD) was obtained using SS-OCTA. LMBFD was assessed for repeatability in 54 of 125 participants and for reproducibility in 23 of 125 participants. The efficacy of LMBFD was validated in the 125 participants, who were divided into mild (n = 46), moderate (n = 42), and severe groups (n = 37) according to the lid margin vascularity severity shown in the slit-lamp photographs. Correlations between LMBFD and MG-related parameters, such as ocular surface disease index (OSDI), fluorescein tear break-up time (FTBUT), cornea fluorescein staining (CFS), lid margin score (LMS), and meibomian gland expressibility (ME), were analyzed in all 125 participants.

Results

Repeatability and reproducibility coefficients were satisfactorily high in the scan mode with a scan area of 6 mm × 6 mm (intraclass correlation coefficient [ICC] repeatability = 0.905; ICC reproducibility = 0.986) and a scan area of 9 mm × 9 mm (ICC repeatability = 0.888; ICC reproducibility = 0.988). The LMBFD gradually increased in the mild, moderate, and severe groups (P < 0.001). LMBFD was significant correlated with OSDI (r = 0.290, P = 0.001), FTBUT (r = -0.195, P = 0.030), CFS (r = 0.352, P < 0.001), ME (r = 0.191, P = 0.033), and LMS (r = 0.370, P < 0.001).

Conclusions

LMBFD may be a noninvasive, repeatable, reproducible, and efficient index for the quantitative evaluation of eyelid margin vascularity in the future.

Translational Relevance

We demonstrated that SS-OCTA has the potential to evaluate the eyelid margin vascularity in MGD patients and guide future treatment strategies in clinics.

Comparing meibomian gland visibility on optical coherence tomography and Keratograph 5M images using objective and subjective grading methods

PURPOSE

To investigate if there is a visible difference in meibomian gland (MG) length between images captured with the Visante optical coherence tomography (OCT; wavelength = 1,310 nm) and the OCULUS Keratograph 5M (K5M; wavelength = 880 nm).

METHODS

Adults between 18 and 40 years were recruited. Baseline dry eye disease was evaluated with the Standard Patient Evaluation of Eye Dryness (SPEED) and tear meniscus height and tear breakup time with the K5M. Right upper and lower eyelid MGs were imaged with the K5M and Visante OCT. Each image was graded with the 0 to 3 meiboscore scale. The central 5 MGs were evaluated with ImageJ for percent gland length visibility.

RESULTS

Thirty participants were analyzed with a median (interquartile range [IQR]) age of 23.0 (5.0) years (53.3 % female). Overall, participants were asymptomatic and had normal tear films. Meiboscores based on K5M and Visante OCT was significantly different for the lower eyelid (0[1] vs 1[2]; p = 0.007) but not the upper eyelid (0[1] vs 0[1]; p = 1.00). The mean percent gland visibility of the upper eyelid (82.7[9.6] vs 75.2[13.5]; p < 0.001) and the lower eyelid (81.2[12.7] vs 64.1[17.6]; p < 0.001) were significantly greater on the Visante OCT than the K5M images, respectively.

CONCLUSION

OCT images had significantly greater percent visible MG lengths than the K5M images. This suggests viable segments of the MGs may be missed with typical imaging, which may explain how it is possible that studies have found less post-treatment MG atrophy.

Influential Signs of Dry Eye-Related Ocular Symptoms in Participants With Unstable Tear Film

PURPOSE

The aim of this study was to investigate the factors influencing dry eye disease (DED)-related ocular symptoms in participants with short fluorescein tear break-up time (FTBUT).

METHODS

This cross-sectional study included 82 participants with short FTBUT (<10 seconds). Examinations included Ocular Surface Disease Index (OSDI), FTBUT, average noninvasive tear break-up time (NIBUTave), lid wiper epitheliopathy, lipid layer thickness, blink rate, partial blink, tear meniscus height, and meibomian gland (MG) evaluation which included ratio of residual MG area (RMGA) and MG grade in tarsal plates. One-way analysis of variance was used to detect differences between symptomatic tear film instability group (FTBUT <5 s, OSDI ≥13), asymptomatic tear film instability group (FTBUT <5 s, OSDI <13), and control group (FTBUT ≥5 s, OSDI <13). A bivariate correlation, partial correlation, and multiple linear regression analyses were used to identify major factors. Only the right eye was included.

RESULTS

Among the participants with FTBUT <5 seconds, symptomatic group showed less upper RMGA ( P < 0.001) and NIBUTave ( P = 0.010). OSDI was negatively associated with upper RMGA ( r = -0.450, P < 0.001) and NIBUTave ( r = -0.414, P = 0.001), and positively associated with upper MG grade ( r = 0.277, P = 0.027). Linear regression analysis showed that the upper RMGA significantly affected OSDI (B = -41.895, P = 0.001), while not significantly correlated with age, upper MG grade, and NIBUTave.

CONCLUSIONS

The upper RMGA might be the main factor affecting DED-related discomfort in participants with unstable tear film, indicating an early ocular change in DED.

Safety and Efficacy of Topical Vitamin D in the Management of Dry Eye Disease Associated With Meibomian Gland Dysfunction: A Placebo-Controlled Double-Blind Randomized Controlled Trial

PURPOSE

The aim of this study was to investigate the safety and efficacy of topical vitamin D in the management of dry eye disease associated with meibomian gland dysfunction (MGD).

METHODS

In this randomized controlled trial, patients with symptomatic MGD were divided into 2 groups to receive topical vitamin D drops or placebo in their randomized eyes. The exclusion criteria consisted of patients with vitamin D deficiency, previous ocular surgery, and patients with ocular diseases affecting the tear film. Patients and researchers were masked to the study groups. The outcomes included the score of Dry Eye Questionnaire (DEQ) 5 and Ocular Surface Disease Index (OSDI), corneal and conjunctival staining score, tear breakup time (TBUT), Schirmer, and MG expressibility score evaluated at baseline and weeks 4 and 8.

RESULTS

Twenty-eight eyes of 28 patients were recruited in each group. In addition to the improvement of subjective parameters in both groups, there was a statistically significantly greater improvement in the vitamin D group compared with control for average scores of OSDI (13.38 ± 7.32 vs. 27.94 ± 7.49) and DEQ5 (9.67 ± 1.86 vs. 14.14 ± 2.45) at week 8 (Ps <0.001). In addition, a significant improvement in TBUT and Schirmer test was observed in both groups in weeks 4 and 8 ( P value <0.05). There was a significant difference between the treatment and control groups after 8 weeks for OSDI, DEQ5, Schirmer, TBUT, corneal fluorescein staining, and MG expressibility score ( P value <0.05).

CONCLUSIONS

The preliminary results of this randomized controlled trial suggested that use of topical vitamin D drops with a lipid vehicle could be safe and might significantly improve the symptoms and signs of dry eye associated with MGD.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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