The international workshop on meibomian gland dysfunction: report of the clinical trials subcommittee

Is Meibomian Gland Dysfunction One Disease? Heterogeneity Among Phenotypes

PURPOSE

The purpose of this study was to examine ocular surface symptoms, tear metrics, and tear cytokines by Meibomian gland dysfunction (MGD) features.

METHODS

Symptom questionnaires and an ocular surface evaluation were performed on 40 individuals with varied MGD signs (Meibomian gland [MG] plugging, eyelid vascularity, meibum quality, and MG dropout). Tear proteins were extracted off Schirmer strips and analyzed for 23 human inflammation-related proteins. Statistical analysis was performed to examine associations between dry eye metrics inflammatory proteins and MGD features.

RESULTS

The study involved 40 South Florida veterans with a mean age of 61 ± 13 years; most individuals were male (95%), White (31%), and non-Hispanic (85%). MGD features differentially related to dry eye signs. Eyelid vascularity, meibum quality, and MG dropout, but not MG plugging, correlated with higher corneal staining and lower tear production. MGD features also differentially related to tear cytokines. Eyelid vascularity most closely related to inflammation with significant correlations for interferon-gamma-γ (r = 0.36, P = 0.02), interleukin-4 (IL-4) (r = 0.43, P = 0.006), IL-17A (r = 0.42, P = 0.007), matrix metalloproteinase-2 (r = 0.39, P = 0.01), C-X-C motif chemokine ligand 5 (Regulated upon Activation, Normal T-Cell Expressed and presumably Secreted [RANTES]) (r = 0.32, P = 0.04), and tumor necrosis factor α (r = 0.36, P = 0.02). The other 3 MGD signs were less related to inflammation. Multivariable models revealed IL-4 to be most closely related to eyelid vascularity (standardized β = 0.39, P < 0.0001).

CONCLUSIONS

Eyelid vascularity was the MGD sign most closely related to inflammatory cytokines, suggesting that different MGD features may be driven by different pathophysiological mechanisms.

Safety and Efficacy of Dry Eye Intelligent Therapeutic Device in the Treatment of Meibomian Gland Dysfunction in Rabbits

PURPOSE

To assess the safety and efficacy of the dry eye intelligent therapeutic device in rabbits with meibomian gland dysfunction.

METHODS

The meibomian gland dysfunction-afflicted rabbits were subjected to treatment using the dry eye intelligent therapeutic device. Various parameters, including eyelid margin, meibomian gland opening, redness, meibomian gland area, keratoconjunctival fluorescence staining, and intraocular pressure, were examined and analyzed using an ocular surface comprehensive examination instrument, slit lamp, and tonometer at corresponding times points. Hematoxylin and eosin staining was performed to examine the mucosal epithelium and meibomian gland.

RESULTS

In this study, eyelid margin congestion and meibomian gland opening obstruction were significantly improved after 3 weeks and 4 weeks of treatment, respectively (p < .01, p < .05). The treatment group showed a significant increase in tear meniscus height after 2 weeks, 3 weeks and 4 weeks of treatment (p < .001, p < .01, p < .05). No significant changes were noted in meibomian gland area, redness, intraocular pressure, and keratoconjunctival fluorescence staining of rabbits before and after treatment. Hematoxylin and eosin staining revealed a complete structure of mucosal epithelium and meibomian gland in the treatment group and that the expansion of the blocked meibomian gland duct was reduced.

CONCLUSION

The utilization of the dry eye intelligent therapeutic device in treating meibomian gland dysfunction-afflicted rabbits exhibits potential promising safety, efficacy, and overall benefits, thereby offering a novel alternative for managing meibomian gland dysfunction patients in clinical settings.

Intense Pulsed Light Therapy for Dry Eye Disease: Analyzing Temporal Changes in Tear Film Stability and Ocular Surface between IPL Sessions

BACKGROUND

Dry eye disease (DED), a prevalent condition with a multifactorial etiology, significantly impacts global health by causing discomfort and visual disturbance. This historical cohort study evaluates the efficacy of Intense Pulsed Light (IPL) therapy on meibomian gland dysfunction (MGD)-related evaporative DED.

METHODS

The study involved 110 patients (220 eyes) who underwent IPL therapy. Ethical approval was secured, and informed consent was obtained from all participants. A Tearcheck® (ESWvision, Houdan, France) device was used for ocular surface evaluation, measuring tear film stability (NIFBUT, NIABUT), tear film quantity (CTMH, TTMH), and inflammation (OSIE). The study assessed tear film and ocular surface health across multiple IPL sessions.

RESULTS

Significant improvements were observed in subjective symptoms (EFT score increased from 29.10 ± 8.87 to 35.91 ± 7.03, p < 0.01), tear film stability (NIFBUT increased from 9.37 ± 6.04 to 10.78 ± 5.83 s, p < 0.01; NIABUT increased from 11.07 ± 4.98 to 12.34 ± 4.66 s, p < 0.01), and tear film surface evaluation (TFSE score decreased from 337.78 ± 414.08 to 206.02 ± 240.44, p < 0.01). Tear film quantity remained unchanged (CTMH and TTMH, p > 0.05).

CONCLUSIONS

IPL therapy is a promising treatment for DED, improving symptoms and ocular surface health. Further research is warranted to explore long-term efficacy and optimization.

Efficacy and safety of intense pulsed light delivered by the C.STIM® for treatment of Meibomian gland dysfunction

INTRODUCTION

Intense pulsed light (IPL) appears to be a promising treatment for Meibomian gland dysfunction (MGD), the most common cause of dry eye disease. C.STIM® is a new IPL device. We report the first safety and efficacy study in clinical practice.

MATERIALS AND METHODS

Patients with moderate MGD treated with C.STIM® were included. Three IPL sessions were performed at D0, D15 and D45 with 4 shots per side (fluence of 8J/cm2). Clinical evaluation was performed at D0, D45 and M3 with several parameters: BUT, OSDI and Oxford scales, meibomian gland evaluation (morphology, quality and expressibility of meibum). The Lacrydiag® imaging device was used for objective evaluation of interferometry, meibography, tear meniscus height and NIBUT. The primary endpoint was the change in NIBUT between D0 and M3. Data collection was retrospective. Longitudinal analysis and a non-parametric linear mixed-effects model (R software) were used for statistical analysis.

RESULTS

Thirty-five patients were included. NIBUT increased significantly between D0 and M3, with a mean difference of 2.6seconds (95% CI 2.0; 3.1, P<0.001). The other parameters studied also changed significantly, except for meibography (percentage of loss and morphology) and tear meniscus height. No adverse event was noted.

CONCLUSION

C.STIM® appears safe and effective in the treatment of MGD, although a randomized controlled trial is needed to validate these results.

Clinical features and comprehensive treatment of persistent corneal epithelial dysfunction after cataract surgery

OBJECTIVE

Evaluation of clinical efficacy and safety of tobramycin/dexamethasone eye ointment in treating persistent corneal epithelial dysfunction (PED) after cataract surgery.

METHODS

26 cases diagnosed as PED after cataract surgery accept the tobramycin/dexamethasone ophthalmic ointment and intense pulse light treatment in the Xiamen University of Xiamen eye center between September 2016 and April 2022 were retrospectively analyzed, mainly including clinical manifestations, characteristics of morphological changes imaged by in vivo confocal microscopy, meibomian glands infrared photography, lipid layer thickness (LLT), management and therapeutic effects.

RESULTS

There were 26 eyes, include 8(35%) males and 15(65%) females with an average age of 69.6 ± 5.2 years(50 to 78 years). The mean hospitalization time was (18.4 ± 7.5) days after cataract surgery. Twenty patients had meibomian gland dysfunction. Infrared photography revealed varying loss in the meibomian glands, with a mean score of 3.8 ± 1.2 for gland loss. The mean LLT was 61.6 ± 8.4 nm. After treatment, 20 patients were cured, and 3 received amniotic membrane transplantation. After treatment, the uncorrected visual acuity (UCVA) and best-corrected vision activity (BCVA) improved (P < 0.001), and there was no significant difference in intraocular pressure (IOP) before and after treatment (P > 0.05).

CONCLUSIONS

The early manifestation of PED after surgery is punctate staining of the corneal epithelium. Tobramycin and dexamethasone eye ointment bandages have a good repair effect. The meibomian gland massage combined with intense pulse light treatment can effectively shorten the course of the disease.

Efficacy of far infrared functional glasses in the treatment of meibomian gland dysfunction-related dry eye

Meibomian gland dysfunction (MGD)-related dry eye disease (DED) is a significant subtype of DED. In this research, we investigate the effectiveness of far infrared (FIR) functional glasses in the treatment of MGD-related DED. According to the TFO DEWS II diagnostic criteria, 61 eyes with MGD-related DED were included. All participants wore functional FIR glasses throughout the day for a period of 4 weeks and were followed up three times during the treatment. All subjects were followed up thoroughly in accordance with the DED clinical examination procedure. Ultimately, the treatment's impact was assessed. We found the Visual Analogue Scale and Ocular Surface Disease Index scores after FIR treatment were significantly lower than the baseline values (p < 0.05). Compared with the baseline, fluorescein tear breakup time and corneal fluorescein staining score after FIR treatment were significantly improved (p < 0.05). The eyelid margin signs, meibum quality, and meibomian gland expressibility after the 4-week treatment were significantly better than those at baseline (p < 0.05). We can see that wearing the FIR functional glasses significantly relieves the symptoms and signs of patients. We believe FIR therapy could be considered as a new method of MGD-related DED.

Comparison Between Optimal Pulsed Technology and Meibomian Gland Massage Treatment for Contact Lens-Related Meibomian Gland Dysfunction

Objective: The purpose of this study was to compare the effectiveness of optimal pulsed technology (OPT) and meibomian gland massage (MGM) in alleviating the signs and symptoms of contact lens-related meibomian gland dysfunction (CL-MGD). Methods: This prospective, randomized, controlled study included 90 patients (180 eyes) diagnosed with CL-MGD and were assigned to the OPT group (n = 60 eyes), MGM group (n = 60 eyes), and control group (n = 60 eyes). All participants were examined at baseline (D0), day 21 (D21), and day 42 (D42) for the ocular surface disease index (OSDI), noninvasive tear break-up time (NITBUT), noninvasive tear meniscus height (NITMH), meibomian gland score (MGS), meibomian gland score (MGYSS), best-corrected visual acuity, and intraocular pressure. Results: The OSDI scores and NITBUT improved after treatment in all the three groups. The OSDI scores in OPT and MGM groups were significantly lower compared with that in the control group at D21 and further decreased at D42. The NITBUT in OPT and MGM groups increased compared with the control group at D21 and further increased at D42, and the NITBUT in OPT group increased compared with the MGM group at D21 and D42. The MGYSS both improved after treatment in the OPT and MGM groups, The MGYSS in OPT and MGM groups decreased compared with the control group at D21 and further decreased at D42, and the MGYSS in the OPT group decreased compared with the MGM group at D21 and D42. The NITMH and MGS had no differences after treatment. Conclusions: Results imply that OPT or MGM treatment can be safely used to relieve symptoms of CL-MGD. In addition, OPT treatment was found to be more effective in improving the general stability of the tear-film in CL-MGD.

Hot towels: The bedrock of Meibomian gland dysfunction treatment - A review

BACKGROUND

Meibomian gland dysfunction (MGD) reduces quality-of-life and hinders work productivity of millions of patients, with high direct and indirect societal costs. Thickened meibum obstructs the glands and disrupts ocular surface health. Heating the eyelids to soften and express meibum from the glands can be beneficial. The most accessible method for eyelid warming uses heated, wet towels. However, the efficacy of this treatment is reliant on the methodology, and evidence-based best-practice recommendations are needed.

PURPOSE

To evaluate the literature on hot towels in MGD treatment and recommend a best-practice protocol for future research and patient treatment.

METHODS

Studies were identified through PubMed on the May 28, 2021, with the search terms: (warm* OR heat* OR thermal* OR towel OR wet towel) AND (meibomian OR MGD OR eyelid OR "dry eye" OR DED). All relevant original articles with English full-text were included.

RESULTS

The search yielded 903 results, of which 22 met the inclusion criteria. Across studies, hot towels were found to be effective at reducing ocular symptoms. However, without reheating, the temperature quickly fell below the therapeutic range, which was deemed to be between 40 °C and 47 °C. Towels heated to around 45 °C and reheated every-two minutes were most effective at increasing eyelid temperature, comparable or better than several commercially available eyelid warming devices. No adverse effects were reported in the studies.

CONCLUSION

Hot towel treatment effectively warms the eyelids and reduces ocular symptoms, but must be standardized, and towels reheated to achieve maximum benefit. Future research should assess patient satisfaction with different hot towel treatment methods that reheat or replace the towel at least every-two minutes, to establish which methods yield the greatest compliance. Guidelines or clinical recommendations that do not mention the need for regular reheating during hot towel compress treatment should be updated to include this.

Efficacy of intense pulsed light and meibomian gland expression treatments in meibomian gland dysfunction: A meta-analysis of randomized controlled trials

PURPOSE

This review aimed to evaluate the efficacy and safety of intense pulsed light treatment combined with meibomian gland expression treatments in meibomian gland dysfunction.

METHODS

We conducted a meta-analysis of randomized controlled trials that compared the efficacy of intense pulsed light treatment and meibomian gland expression treatments in the treatment of dry eye disease. The meibomian gland yielding secretion score was the primary outcome, whereas the secondary outcomes included the Meiboscore, tear breakup time in seconds, standard patient evaluation for eye dryness and corneal fluorescein staining.

RESULTS

This study consisted of 6 trials with 326 patients. Significantly greater improvement was observed in meibomian gland yielding secretion score at 1 month [mean difference (MD): 13.69 (95% CI, 11.98, 15.40)] and at 3 months [MD: 11.03 (95% confidence interval (CI), 10.27, 11.80)], low meibomian gland yielding secretion score at 1 month [MD: 6.92 (95% CI, 5.49, 8.34)] and at 3 months [MD: 6.80 (95% CI, 5.01, 8.59)], up meibomian gland yielding secretion score at 1 month [MD: 6.41 (95% CI, 4.12, 8.70)] and at 3 months [MD: 8.06 (95% CI, 5.70, 10.42)] and tear breakup time at 1 month [MD: 2.38 (95% CI, 1.83, 2.92)] and at 3 months [MD: 1.82 (95% CI, 1.48, 2.19)] in the IPL-MGX group than in the MGX group.

CONCLUSIONS

IPL-MGX is safer and more efficacious as compared to the MGX alone in the treatment of patients with meibomian gland dysfunction-related dry eye. We recommend discussing the decision with the ophthalmologist for an appropriate choice.

Application of orthokeratology on myopia control and its effect on ocular surface and meibomian gland function in Chinese myopic adolescents

Purpose

This study aimed to investigate the influence of orthokeratology (OK) on myopia control and ocular surface and meibomian gland function in myopic adolescents.

Methods

A prospective study was conducted over a 12-month period. The subjects were classified into two groups, namely, the OK lens group and the frame glasses control group. Axial length, corneal curvature, ocular surface, and meibomian gland parameters were measured at baseline, 1, 3, 6, and 12 months after wearing OK lenses.

Results

The axial length growth rate in the OK group was significantly slower than in the control group (P < 0.01). The naked eye vision and the ocular surface disease index (OSDI) scores recorded 1, 3, 6, and 12 months after wearing OK lenses were significantly higher than the scores recorded before wearing OK lenses. There was no significant difference in other ocular parameters at each follow-up time point compared with pre-wearing (P > 0.05). After using the OK lens for 6 months, the OSDI score and corneal fluorescein staining (CFS) score increased significantly (P < 0.001), but there were no significant differences in other parameters among the groups. No infectious keratitis occurred during the study.

Conclusion

These results provide evidence that the use of OK lenses can control the axial growth and progress rate of myopia compared with frame glasses. During the 12-month follow-up, although wearing OK lenses may have aggravated dry eye symptoms, each patient's ocular surface and meibomian gland function did not change significantly, indicating that the use of OK lenses is a relatively safe modality for the control of myopia in adolescents.

Metagenomic nanopore sequencing of ocular microbiome in patients with meibomian gland dysfunction

PURPOSE

To explore the composition of the ocular microbiome in patients with Meibomian gland dysfunction (MGD) using metagenomic nanopore sequencing.

METHODS

A total of 98 participants were recruited from September to December 2021, including 86 patients with MGD and 12 controls. Symptoms and signs of dry eye were assessed, and bacterial samples in the conjunctival sac (CS) and meibomian gland (MG) secretions were then identified by bacterial culture identification and metagenomic nanopore sequencing.

RESULTS

The positive rate of CS bacterial culture in the MGD group was significantly higher than that in the normal group. A more complex composition of bacterial genera was detected in the mild and moderate MGD groups than in the control. However, the severe MGD groups had the simplest composition of bacteria. Metagenomic nanopore sequencing detected more species of bacteria than traditional culture.

CONCLUSION

The CS and MG of MGD patients may have different degrees of bacterial microbiota imbalance. Metagenomic nanopore sequencing technology provides a new way for us to understand the composition of "real-world" ocular surface microorganisms.

Topical corticosteroids for dry eye

BACKGROUND

Dry eye disease (DED), arising from various etiologic factors, leads to tear film instability, ocular surface damage, and neurosensory changes. DED causes symptoms such as ocular dryness, burning, itching, pain, and visual impairment. Given their well-established anti-inflammatory effects, topical steroid preparations have been widely used as a short-term treatment option for DED. Because of potential risks of ocular hypertension, cataracts, and infections associated with the long-term use of topical steroids, published trials comparing the efficacy and safety of topical steroids (versus placebo) have mostly been of short duration (three to eight weeks).

OBJECTIVES

To evaluate the effectiveness and safety of topical corticosteroids compared with no treatment, placebo, other steroidal or non-steroidal therapies, or a combination of therapies for DED.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 8); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), without restriction on language or year of publication. The date of the last search was 20 August 2021.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which topical corticosteroids, alone or in combination with tobramycin, were compared with no treatment, artificial tears (AT), vehicles, AT plus tobramycin, or cyclosporine A (CsA).

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology.

MAIN RESULTS

We identified 22 RCTs conducted in the USA, Italy, Spain, China, South Korea, and India. These RCTs reported outcome data from a total of 4169 participants with DED.  Study characteristics and risk of bias All trials recruited adults aged 18 years or older, except one trial that enrolled children and adolescents aged between 3 and 14 years. Half of these trials involved predominantly female participants (median 79%, interquartile range [IQR] 76% to 80%). On average, each trial enrolled 86 participants (IQR 40 to 158). The treatment duration of topical steroids ranged between one week and three months; trial duration lasted between one week and six months. Eight trials were sponsored exclusively by industry, and four trials were co-sponsored by industry and institutional or governmental funds. We assessed the risk of bias of both subjective and objective outcomes using RoB 2, finding nearly half of the trials to be at high risk of bias associated with selective outcome reporting. Findings Of the 22 trials, 16 evaluated effects of topical steroids, alone or in combination with tobramycin, as compared with lubricants (AT, vehicle), AT plus tobramycin, or no treatment. Corticosteroids probably have a small to moderate effect on improving patient-reported symptoms by 0.29 standardized mean difference (SMD) (95% confidence interval [CI] 0.16 to 0.42) as compared with lubricants (moderate certainty evidence). Topical steroids also likely have a small to moderate effect on lowering corneal staining scores by 0.4 SMDs (95% CI 0.18 to 0.62) (moderate certainty evidence). However, steroids may increase tear film break-up time (TBUT) slightly (mean difference [MD] 0.70 s, 95% CI 0.06 to 1.34; low certainty evidence) but not tear osmolarity (MD 1.60 mOsm/kg, 95% CI -10.47 to 13.67; very low certainty evidence).  Six trials examined topical steroids, either alone or in combination with CsA, against CsA alone. Low certainty evidence indicates that steroid-based interventions may have a small to moderate effect on improving participants' symptoms (SMD -0.33, 95% CI -0.51 to -0.15), but little to no effect on corneal staining scores (SMD 0.05, 95% CI -0.25 to 0.35) as compared with CsA. The effect of topical steroids compared to CsA alone on TBUT (MD 0.37 s, 95% CI -0.13 to 0.87) or tear osmolarity (MD 5.80 mOsm/kg, 95% CI -0.94 to 12.54; loteprednol etabonate alone) is uncertain because the certainty of the evidence is low or very low. None of the included trials reported on quality of life scores. Adverse effects The evidence for adverse ocular effects of topical corticosteroids is very uncertain. Topical corticosteroids may increase participants' risk of intraocular pressure (IOP) elevation (risk ratio [RR] 5.96, 95% CI 1.30 to 27.38) as compared with lubricants. However, when compared with CsA, steroids alone or combined with CsA may decrease or increase IOP elevation (RR 1.45, 95% CI 0.25 to 8.33). It is also uncertain whether topical steroids may increase risk of cataract formation when compared with lubricants (RR 0.34, 95% CI 0.01 to 8.22), given the short-term use and study duration (four weeks or less) to observe longer-term adverse effects.  AUTHORS' CONCLUSIONS: Overall, the evidence for the specified review outcomes was of moderate to very low certainty, mostly due to high risk of bias associated with selective results reporting. For dry eye patients whose symptoms require anti-inflammatory control, topical corticosteroids probably provide small to moderate degrees of symptom relief beyond lubricants, and may provide small to moderate degrees of symptom relief beyond CsA. However, the current evidence is less certain about the effects of steroids on improved tear film quality or quantity. The available evidence is also very uncertain regarding the adverse effects of topical corticosteroids on IOP elevation or cataract formation or progression. Future trials should generate high certainty evidence to inform physicians and patients of the optimal treatment strategies with topical corticosteroids in terms of regimen (types, formulations, dosages), duration, and its time-dependent adverse profile.

A retrospective study of the efficacy of intense pulsed light delivered by the Lacrystim® for meibomian gland dysfunction therapy

Background

Meibomian gland dysfunction is the most common etiology of dry eye disease worldwide and intense pulsed light appears to be a promising treatment with encouraging results. Lacrystim® is a new IPL device (CE marking in 2019) and no studies have yet been published on it. We propose the first study on this device with an objective assessment of its efficacy and an extended follow-up over 6 months.

Methods

Patients presenting with a dry eye disease (DED) with stable mild to moderate MGD and having received Lacrystim® treatment between june 2019 and june 2020 were included. 3 IPL sessions were performed at D0, D15 and D45 with 4 shots per side at a fluence of 8 mJ/cm2. DED clinical evaluation was performed at D0, D15, D45, 3rd month and 6th month: Oxford scale and break up time, Schirmer test and Ocular Surface Disease Index (OSDI) questionnaire. Lacrydiag® imaging device carried out an objective examination of tear film: interferometry, meibography, tear meniscus height and non-invasive break up time (NIBUT). The primary endpoint was the evolution in NIBUT between the first visit D0 and 3rd month. Data collection was done retrospectively. Statistical analysis was done using a linear mixed-effects model and a non-parametric linear mixed-effects model (R software).

Results

Forthy five consecutive patients were included. NIBUT significantly increased between D0 and 3rd month: mean difference of 1.63 seconds, IC95% [0.51; 2.62], (p = 0.002) with a prolonged effect at 6th month. OSDI and OXFORD scores and interferometry were also significantly improved at 3rd month and 6th month. There was no significant change in BUT, Schirmer test and tear meniscus height. No adverse event was noted.

Conclusions

IPL delivered by Lacrystim® appears effective and safe to treat MGD although a randomized controlled trial is needed to validate its results.

Trial registration

This work was approved by a local ethics committee “Terre d’éthique” (institutional review board number: IRBN672019/CHUSTE) and registered on the clinicaltrial.gov website (NCT04147962, 01/11/2019).

Comparison Between Heated Eye Mask and Intense Pulsed Light Treatment for Contact Lens-Related Dry Eye

Background: Contact lens-related dry eye (CLDE) is common in contact lens (CL) wearers and can lead to ocular pain, decreased visual quality, and reduced quality of life. Objective: The purpose of this prospective, randomized, examiner masked study was to compare the effectiveness of intense pulsed light (IPL) and heated eye mask (HEM) for relieving CLDE. Methods: The final analysis included 60 patients (30 in the IPL group and 30 in the HEM group) who were using CL and had been suffering contact lens discomfort for more than a year. The IPL treatment group had two IPL treatments spaced 3 weeks apart, whereas the HEM group received HEM daily for 6 weeks (42 days). Non-invasive tear break-up time (NITBUT), tear-film lipid layer (TFLL), conjunctival fluorescein staining, meibum gland quality and expression, conjunctival redness score, ocular surface disease index (OSDI), best-corrected visual acuity, endothelial cell count, and intraocular pressure were assessed at baseline: first visit (V1), second visit (V2), and third visit (V3). Results: The mean age of the IPL group was 28.6 ± 4.3 years (16 females, 53%) and that of the HEM group was 28.6 ± 4.2 years (16 females, 53%). Mean NITBUT for the IPL group at V2 was 5.53 ± 0.77 sec (p < 0.001) and at V3 was 7.72 ± 0.88 sec (p < 0.001); the IPL group demonstrated a clinically and statistically significant improvement in mean NITBUT. In addition, the HEM group showed a clinically and statistically significant improvement in mean NITBUT at V3 (5.86 ± 0.76 sec, p < 0.001). At V3, the C-OSDI, TFLL score, and meibum gland quality and expressibility all increased considerably (p < 0.05) in both groups. Conclusions: Our results imply that IPL or HEM treatment of CLDE can be safely used to relieve symptoms of CLDE. In addition, IPL treatment is more effective in improving the general stability of the tear-film and decreasing the need for artificial tears in CLDE.

Mean Tear-Film Lipid Layer Thickness and Video Display Terminal Time as Risk Factors for Abnormal Blinking in Children

Objective: To explore the risk factors for abnormal blinking in children and the role of the tear-film lipid layer thickness (LLT) as a function of duration of video display terminal (VDT) use in children. Methods: Children attending the Optometry Clinic of Xinhua Hospital affiliated with Shanghai Jiao Tong University were recruited for the study between June 2019 and June 2020. Time spent viewing a VDT (VDTt) over the previous 6 months was recorded. Incomplete blinking (IB) and blinking rate were measured over a 10 s period using the Lipiview^® interferometer (Tear Science, Morrisville, NC, USA), and participants were allocated into groups with normal blinking (NBG, blink rate < 20 blinks/min) and abnormal blinking (ABG, blink rate ≥ 20 blinks/min). T-test, chi-square test and Mann-Whitney U-test were used to compare the differences in tear film (TF) stability indexes and meibomian gland function indexes between the two groups. Binary logistic analysis was used to analyze the risk factors for abnormal blinking and protective factors related to children's use of VDT, and receiver operating characteristic (ROC) curve analysis was also conducted. Results: A total of 167 children were included, with no statistically significant differences in age or sex between the two groups. According to the t-test, VDTt was significantly higher in ABG than NBG, while TF stability indices including tear break up time, LLT and the height of the tear meniscus, were significantly higher in NBG than ABG (P < 0.001). The results also showed better meibomian gland function in NBG than ABG (P < 0.05). Binary logistic analysis showed that VDTt is an important risk factor for abnormal blinking, and the average of LLT (AVG) was found to be an important protective factor for children using a VDT for long periods, with a cut-off value of 1.5 h and 57.5 nm, respectively. ROC curve analysis showed that the area under the curve value of VDTt and AVG was 0.833 and 0.969, respectively (P < 0.001). Conclusion: In children, VDTt is an important risk factor for abnormal blinking, and the AVG is an important protective factor for children using VDT for long periods.

Video display terminal use and other risk factors for abnormal blinking in children: gender differences

OBJECTIVE

To explore the risk factors for abnormal blinking in children and compare these between boys and girls.

METHODS

Children attending the Children's Optometry Clinic between June 2019 and June 2020 were recruited for the study. The time they had spent viewing video displays (VDTt) over the past 6 months was recorded. Incomplete blinking (IB) and blinking rate were measured and all participants were allocated to groups based on their blink rate (<20 times/min = normal blinking group, NBG; ≥20 times/min = abnormal blinking group, ABG). Tear film (TF) stability was also evaluated. The corresponding statistical methods are used to analyze the data.

RESULTS

A total of 87 boys and 80 girls were enrolled in the study. No significant difference in age was found between the 2 groups. There was a significant difference in TF stability between the two groups (P<0.05). According to binary logistic analysis, VDTt and ocular protection index (OPI) are important risk factors for abnormal blinking, with cut-off values of 1.75 hours and 1.014 respectively in boys; and 1.25 hours and 1.770 respectively in girls. The average of lipid layer thickness was an important protective factor for children using VDT for long periods, with a cut-off value of 58.5 nm in boys and 53.5nm in girls.

CONCLUSION

Risk factors for abnormal blinking in both boys and girls include VDTt and OPI.

Meibomian gland dysfunction is highly prevalent among first-time visitors at a Norwegian dry eye specialist clinic

To investigate the prevalence of meibomian gland dysfunction (MGD) in patients presenting with subjective dry eye-related symptoms at their first-time consultation in a Norwegian specialized ocular surface clinic. Additionally, to explore the accuracy of the ocular surface disease index score (OSDI) as an extensively applied tool to assess the severity of dry eye symptoms and MGD diagnosis. Patients with subjective dry eye-related complaints (n = 900) attending the clinic for the first time, from 2012 to 2016, were included in the study. At the baseline, patients completed the OSDI questionnaire. Subsequently, objective clinical tests, including fluorescein break-up time (FBUT), Schirmer-I test, ocular surface staining (OSS), and meibomian gland function assessment using gland expressibility and meibum quality were performed. The association between MGD and its severity in relation to symptom severity defined by OSDI-score was examined. MGD was found in 93.8% of the study group. MGD prevalence was not significantly different between groups based on age (p = 0.302) or sex (p = 0.079). There was a significant association between severity of MGD and dry eye-related symptoms (p = 0.014). OSS was significantly higher in patients with severe symptoms (p = 0.031). Sensitivity and specificity of positive symptom-score (OSDI ≥ 13) for disclosing MGD were 85.5% and 30.4%, respectively. MGD was highly prevalent, not associated with age and sex. OSDI ≥ 13 had high sensitivity and high positive predictive value (PPV), but low specificity and negative predictive value (NPV) for disclosing MGD. This underscores the importance of meibomian gland assessment in patients with dry eye-related symptoms.

Chambered warm moist air eyelid warming devices - a review

BACKGROUND

Eyelid warming is an important treatment for meibomian gland dysfunction (MGD). Specialized chambered devices, using warm moist air have been developed.

PURPOSE

To critically evaluate the literature on the safety and efficacy of chambered warm moist air devices in MGD treatment and pinpoint areas of future research.

METHODS

PubMed and Embase were searched on 06 June 2021. The search term was '(warm OR heat OR steam OR goggle OR spectacle OR moist air) AND (meibomian OR MGD OR blepharitis OR eyelid OR dry eye OR DED)'. All relevant articles with available English full text were included.

RESULTS

Eighteen articles assessing the application of chambered warm moist air eyelid warming devices were identified. In single-application studies, steam-based eyelid warming increased the eyelid temperature and improved symptoms, lipid layer thickness, and tear film breakup time (TBUT). In treatment studies, the steam-based devices improved TBUT and symptom scores. However, in the only randomized controlled trial (RCT) comparing chambered steam-based heat to hot towel treatment, there was no difference between groups for the primary outcome measure; the proportion of subjects noting symptom improvement after 4 weeks.

CONCLUSION

Currently available chambered warm moist air eyelid warming devices are safe and effective at raising eyelid temperature to therapeutic levels and improving signs and symptoms of dry eye. However, it is not clear if they provide a greater benefit than other eyelid warming therapies. Further well-conducted RCTs comparing moist and dry heat devices should be conducted on patients across the range of DED severities and subtype spectrum.

Treatment of contact lens related dry eye with intense pulsed light

AIM

The prevalence of contact lens related dry eye (CLDE) is high and can lead to ocular discomfort, reduced quality of vision and life. The aim of this study was to assess the efficacy of intense pulsed light (IPL) treatment in alleviating signs and symptoms of CLDE.

DESIGN

Prospective, randomised, examiner masked study.

METHODS

This prospective study was conducted on 152 eyes of 76 patients (IPL group, n = 76 eyes; control group, n = 76 eyes) wearing contact lens (CL) and experiencing CLDE for more than 1 year. The IPL treatment group underwent two IPL treatment sessions at 3-week intervals while the control group received sham IPL treatment. Best-corrected visual acuity (BCVA), ocular surface disease index (OSDI), non-invasive breakup time (NITBUT), tear film lipid layer (TFLL) quality, fluorescein staining (FS), meibum gland (MG) quality and expression, endothelial cell count (ECC) and intraocular pressure (IOP) were assessed at baseline (D-0), day-21 (D-21) and day-42 (D-42) after IPL treatment.

RESULTS

The mean age of treatment group and control group was 28.47 ± 5.16 years (21 females, 28 %) and 28.58 ± 4.33 years (23 females, 30 %) respectively. IPL treatment group had clinically and statistically significant improvement in mean NITBUT was observed at D14 (5.24 s, P<0.001) and D28 (6.08 s, P<0.001). OSDI, TFLL score and MG quality and expressibility all improved significantly (P<0.001) at D-42, whereas BCVA, ECC and IOP showed no significant changes at D-21 and D-42 in IPL treatment group. The control group showed no significant improvement in all parameters at D-21 and D-42.

CONCLUSION

Our findings suggest that CL related DE can be safely alleviated with IPL treatment as it reduced the severity of symptoms, improved the overall tear film stability and reduced artificial tear use in participants with CLDE.

Effect of Intense Pulsed Light on Anterior Corneal Aberrations and Quality of Vision in Patients with Evaporative Dry Eye

Objective: To evaluate the improvement in the tear film lipid layer (TFLL) and its subsequent impact upon corneal aberrations following intense pulsed light (IPL) treatment in patients with evaporative dry eye disease (DED) due to meibomian gland dysfunction (MGD). Background: The prevalence of DED is common and can lead to ocular discomfort, reduced visual acuity, and lowered quality of vision (QoV) and life. Methods: In this self-control study, patients with moderate-to-severe evaporative DED due to MGD were consecutively enrolled and underwent two IPL treatments at 3-week intervals. Clinical assessments, such as Ocular Surface Disease Index (OSDI) and QoV questionnaires, anterior corneal aberrations, noninvasive tear breakup time (NITBUT), interferometric fringe pattern as determined by TFLL quality, corneal fluorescein staining (CFS), meibum gland (MG), conjunctival hyperemia (CH), best-corrected visual acuity, endothelial cell count, and intraocular pressure, were conducted at pretreatment (D-0), day 21 (D-21), and day 42 (D-42) after IPL treatment. Results: The final analysis included 124 eyes of 62 patients (29 females, 33 males; mean age 35.66 ± 11.09 years). Clinically and statistically significant improvement in NITBUT was observed at D-42 (p < 0.01). OSDI, QoV, TFLL score, and MG quality and expressibility all improved significantly (p < 0.05) at D-42, whereas CH (p = 0.073) and CFS (p = 0.058) showed minor not significant improvements at D-42 of assessment. Anterior corneal aberrations also improved significantly at D-42 of assessment (p < 0.05). Conclusions: IPL treatment reduced the severity of symptoms and improved the overall tear film (TF) stability in patients with moderate-to-severe evaporative dry eye (DE) due to MGD. Additionally, the significant improvement in QoV in DE patients can be attributed to the reduction in anterior corneal aberrations due to improved TF stability.

Intense Pulse Light for Treating Post-LASIK Refractory Dry Eye

Objective: Optimal pulse technology-intense pulse light (OPT-IPL) treatment on patients with post-LASIK refractory dry eye (DE). Background: The prevalence of dry eye disease is common and can lead to ocular discomfort, reduced visual acuity, lowered quality of vision and life. Materials and methods: A prospective study was conducted on 72 eyes of 36 patients (treatment group, n = 42 eyes; control group, n = 30 eyes) who had previously undergone myopic LASIK correction with subsequent refractory DE. All eyes fulfilled the Japanese DE criteria and had not responded to conventional DE treatment. The treatment group underwent two OPT-IPL treatment sessions at 2-week intervals, while the control group received no treatment. Best-corrected visual acuity (BCVA), ocular surface disease index (OSDI), noninvasive breakup time (NITBUT), tear film lipid layer (TFLL) quality, corneal fluorescein staining, meibum gland (MG), endothelial cell count (ECC), and intraocular pressure (IOP) were assessed at baseline (D0), day-14 (D14) and day-28 (D28) after OPT-IPL treatment. Results: The mean age of treatment group and control group was 30.48 ± 5.16 years (12 females, 57%) and 31.00 ± 4.33 years (8 females, 53%), respectively. Treatment group had clinically and statistically significant improvement in NITBUT and was observed at D14 (p < 0.001) and D28 (p < 0.001). OSDI, TFLL score, and MG quality and expressibility improved significantly (p < 0.05) at D28, whereas BCVA, ECC, and IOP showed no significant changes at D14 and D28 between the groups. Conclusions: Our results suggest that post-LASIK refractory DE is safely treated with OPT-IPL treatment. OPT-IPL treatment reduced the severity of symptoms and improved the overall tear film stability in patients with severe refractory DE post-LASIK surgery. In addition, the frequency of artificial tears usage was significantly less and can be attributed to the reduction in OSDI scores due to improved TFLL and tear film stability.

Assessment of tear film lipid layer thickness in patients with Meibomian gland dysfunction at different ages

BACKGROUND

To evaluate the correlations between lipid layer thickness (LLT) and morphology and function of the meibomian glands in patients who were diagnosed as meibomian gland dysfunction (MGD) in different age groups.

METHODS

Patients who have diagnosed as obstructive MGD were included in this prospective, cross-sectional study. Patients were divided into three groups: young (ages 20-39 years), middle-aged (ages 40-59 years), and older (aged ≥60 years). All patients completed an Ocular Surface Disease Index (OSDI) questionnaire and were evaluated for LLT, tear meniscus height (TMH), noninvasive tear film break-up time (NI-BUT) measurement, invasive TBUT (ITBUT), corneal fluoresceinstaining (CFS) score, eyelid margin abnormalities, Schirmer I test, and MG function and morphology, by using the Keratograph 5 and LipiView interferometer.

RESULTS

Two hundred and nine patients (209 eyes) were included. The median LLT of all patient was 57 nm (IQR, 36.5 nm), and the LLT values were significantly different among the young group (median, 51 nm; IQR, 23.5 nm), middle-aged group (median, 59.5 nm; IQR 46.5 nm) and older group (median, 62 nm; IQR, 42.5 nm) (P = 0.033, Kruskal-Wallis test). In regression analyses controlling for confounder factors sex and MG loss, the LLT was positively correlated with age (β = 5.539, P = 0.001). There was a negative correlation between LLT and MG dropout in the all (r = - 0.527, P < 0.001), young (r = - 0.536, P < 0.001), middle-aged (r = - 0.576, P < 0.001), and older (r = - 0.501, P < 0.001) groups. LLT was positively correlated with the MG expressibility in the all (r = 0.202, P = 0.003), middle-aged (r = 0.280, P = 0.044) and older (r = 0.452, p < 0.001) groups, but it was no statistical significance in the young group (r = 0.007, P = 0.949).

CONCLUSIONS

The thickness of LLT was increased with age and significantly correlated with both MG secretion and morphology in middle-aged and older patients with obstructive MGD. LLT measurement is a useful screening tool for detecting obstructive MGD and age as an influential factor should be accounted for when interpreting the meaning of the LLT value.

TRIAL REGISTRATION

NCT02481167 ; Registered 25 June, 2015.

Analysis of tear film spatial instability for pediatric myopia under treatment

In Taiwan, the prevalence of myopia in children between 6 and 18 years old is over 80%, and high myopia accounts for over 20%, which turned out to be in the leading place worldwide. Orthokeratology and low-dose atropine are proven treatments to reduce myopia progression, though the potential corneal disturbances remain an issue in young populations. The alteration of the tear film is widely discussed but there is no consensus to date, so we aim to investigate the tear film spatial instability in children with myopia control using atropine or orthokeratology. Thirty-eight treatment-naïve participants and 126 myopic children under treatments were enrolled. The ocular surface homeostasis, spatial distribution of tear break-up, and high-order aberrations (HOAs) of the corneal surface were assessed. We found out that myopic children treated with either atropine or orthokeratology showed ocular surface homeostasis similar to that in treatment-naïve children. Nevertheless, children treated with orthokeratology presented higher HOAs (p < 0.00001) and a tendency of the first tear break-up zone at the inner half of the cornea (p = 0.04). This unique spatial instability of the tear film associated with myopia treatment might provide a more focused way of monitoring the pediatric tear film instability.

Dry Eye in Systemic Sclerosis Patients: Novel Methods to Monitor Disease Activity

Background: In systemic sclerosis (SSc) patients, dry eye syndrome (DES) is the most frequent ocular feature. The aim of this study was to investigate ocular DES-related SSc patients and to establish any correlation with the severity of the disease. Methods: Retrospectively, data from 60 patients with SSc underwent ophthalmic examination, where non-invasive film tear break-up time (NIF-TBUT), tear film lipid layer thickness (LLT), anesthetic-free Schirmer test I, tear osmolarity measurement (TearLab System), and modified Rodnan skin score (mRSS) data were collected. The visual analog scale (VAS) and Symptom Assessment in Dry Eye (SANDE) methods were utilized. The results were correlated with mRSS and the duration of SSc. Results: Severe DES occurred in 84% of cases, and was more severe in women. The eyelids were involved in 86.6%, secondary to meibomian gland disease (MGD). A direct correlation was found between the tear osmolarity (mean 328.51 ± 23.8 SD) and skin score (mRSS) (r = 0.79; p < 0.01). Significantly reduced NIF-TBUT, LLT, and Schirmer test I values were observed in the case of severe skin involvement. Conclusions: SSc patients show lipid tear dysfunction related to the severity and duration of the disease due to inflammation and the subsequent atrophy of the meibomian glands.

Impact of the 2011 International Workshop on Meibomian Gland Dysfunction on clinical trial attributes for meibomian gland dysfunction

PURPOSE

The 2011 International Workshop on Meibomian Gland Dysfunction was organized to build consensus on various disease aspects of MGD. The purpose of this review was to examine the influence of the MGD Workshop on clinical trials by examining their attributes prior to and after the Workshop.

METHODS

A search for clinical trials using the terms "Meibomian Gland Dysfunction" was conducted using the "Interventional Studies" filter on ClinicalTrials.gov, and selecting studies with posting and start dates prior to (2004-2010) and after the Workshop (2012-2018). The inclusion criteria, outcome measures, and study designs and rigor were examined.

RESULTS

A total of 32 post-Workshop and 5 pre-Workshop clinical trials were identified with the search. The proportion of pre-Workshop trials using generic diagnosis and systematic assessments to define MGD was similar to that of post-Workshop trials. In both pre- and post-Workshop trials, symptoms, altered gland secretions, and alteration in tear film were the most frequent clinical attributes used to define MGD. The most frequent outcome measures used for pre-Workshop and post-Workshop trials were also similar: symptoms, meibum quality/expressibility, and tear stability.

CONCLUSIONS

The nature of the inclusion criteria, and the clinical attributes used to define MGD during the pre-Workshop period were similar to those of the post-Workshop period, suggesting that the MGD Workshop has had a minimal impact on the design of interventional trials for MGD.

Pathogens in the Meibomian gland and conjunctival sac: microbiome of normal subjects and patients with Meibomian gland dysfunction

Objective

To explore the composition of the ocular microbiome in normal subjects and patients with Meibomian gland dysfunction (MGD).

Subjects and methods

Seventy subjects (140 eyes) were enrolled in our study. Signs of dry eye were evaluated and bacterial species in the conjunctival sac (CS) and Meibomian gland (MG) secretions were then identified by 16S rRNA gene sequencing. Additionally, 17 subjects (34 eyes) were further evaluated to determine differences in the microbiomes in the surface and deep layers of MG using a segmental secretion analysis.

Results

The positive bacterial isolation rate was markedly higher in MG secretions than in the CS. The bacterial composition of the control and mild group was simple, whereas the composition of bacteria was more complex as the severity of MGD increased. The positive bacterial isolation rate and number of bacterial types were significantly higher in the severe MGD group than those in the control, mild and moderate MGD groups. Corynebacterium macginleyi was only detected in the severe MGD group, with an isolation rate of up to 26.3%. Furthermore, a new grading system for bacterial severity of MGD was proposed and the severity of MGD appeared to be positively correlated with a higher grade of bacterial severity. The segmental secretion analysis showed severe MGD had a significantly higher incidence of bacterial discordance rate.

Conclusion

The severity of MGD was positively correlated with a higher isolation rate, a greater number of bacterial species, and a higher grade of bacterial severity, which implied that MGD might be correlated with bacterial changes. This study provided some basis for the indications of antibiotic in clinical practice.

Tear eicosanoids in healthy people and ocular surface disease

Meibomian gland (MG) dysfunction is the leading cause of evaporative dry eye and it leads to inflammation of the ocular surface. Eicosanoids may be involved in inflammation of dry eye. This study aimed to profile tear eicosanoid levels in healthy individuals and those with MG dysfunction, and to examine if these levels are associated with clinical factors and expressibility of MG. Forty participants with MG dysfunction and 30 healthy controls were recruited in this study. Clinical signs of MG dysfunction were assessed, and tear lactoferrin concentration was evaluated. Tear eicosanoids were extracted from Schirmer's strips and analyzed using mass spectrometry. We were able to quantify 38 tear eicosanoids and levels were increased in older individuals. In participants with MG dysfunction, higher 5-HETE, LTB₄, 18-HEPE, 12-HEPE and 14-HDoHE were associated with poorer MG expressibility. The eicosanoids PGF_2α, 18-HEPE, 20-HDoHE and 17-HDoHE were elevated with increased corneal staining; higher 5-HETE, LTB₄ were associated with lower tear lactoferrin levels. The receiver-operating-characteristics analysis shows higher levels of 5-HETE, LTB₄ and 18-HEPE were able to predict poor expressibility of MGs. In conclusion, tear eicosanoid levels are age-dependent and specific eicosanoids may be indicators of clinical obstruction of MG or the severity of ocular surface damage.

Development of a Meibomian Gland Dysfunction-Specific Symptom Questionnaire

OBJECTIVES

The aim of this study was to develop and evaluate, using psychometric approaches, a meibomian gland dysfunction (MGD)-specific questionnaire in noncontact lens wearers.

METHODS

The MGD subjects were recruited and classified as the MGD dry eye subtype based on accepted tests (e.g., Schein symptom survey, tear breakup time, corneal and conjunctival staining, abnormal meibum or meibomian gland atrophy, and a normal Schirmer test). The MGD questionnaire items were drawn from published and anecdotal sources. The preliminary instrument contained 24 items targeting the frequency and intensity of 12 symptoms. Rasch analysis was used for psychometric evaluation of the survey items.

RESULTS

Sixty nine MGD subjects completed the survey and clinical testing. Sample severity levels were as follows: none subclinical, 10 minimal, 43 mild, 16 moderate, and none severe. Three iterations of analysis, eliminating INFIT and OUTFIT scores <, and >3.0, and using subject responses reduced the final questionnaire to seven question pairs. Final analysis for the remaining 14 items demonstrated an excellent fit to the Rasch model (e.g., for persons, INFIT MNSQ=0.97; ZSTD=-0.2; OUTFIT MNSQ=0.96; ZSTD=-0.2; item fit statistics were similar). Construct validity also seems good (e.g., correlation to Schein and change with treatment).

CONCLUSIONS

The MGD-specific instrument is a valid quantitative measure of the symptoms stemming from MGD sufferers. Further research is necessary to determine whether diagnostic efficacy is sufficient to differentiate the MGD dry eye subtype in an independent sample of normals and both major dry eye subtypes exhibiting a broad severity range.

Therapies for Meibomian Gland Dysfunction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction

Meibomian Gland Dysfunction (MGD) is a common, often overlooked, chronic condition affecting eyes for which various therapies are being evaluated. Considering the absence of a systematic review and meta-analysis, the present review was carried out.

Methods

An appropriate search strategy eligibility criteria were framed and electronic databases were scrutinized for appropriate literature. Randomized Controlled Trials (RCTs) enrolling patients diagnosed with MGD were included. Outcome measures were Tear Break Up Time (TBUT), Schirmer's test, Meibomian Gland (MG) secretion score, MG plugging score, OSDI and SPEED. Cochrane's tool was used to assess the risk of bias and Forest plot were generated either with fixed or random effects model, with Standardized Mean Difference (SMD).

Results

TBUTs, Schirmer's test and OSDI scores for systemic antimicrobials with placebo were 1.58 [1.33, 1.83], 2.93 [0.78, 5.09] and -3.58 [-4.28, -2.89] respectively. No quantitative synthesis was attempted for either mebiomian plugging or meibomian secretion scores and no significant changes were observed with any other outcome parameter.

Conclusion

Only the systemic antimicrobials were found to improve the clinical features of meibomian gland dysfunction. Varying effects of different therapeutic agents (heat therapies, omega-3-fatty acids and castor oil) were identified for MGD but the risk of bias pertaining to randomization and allocation concealment was found to be associated with most of the current RCTs. More high quality evidence is required to confirm the findings of the present review.

Clinical relationship of meibometry with ocular symptoms and tear film stability

PURPOSE

To evaluate the relationship between meibometry with both ocular symptoms and tear film stability by: (1) to find out whether meibometry is able to differentiate between dry eye symptomatic and asymptomatic subjects classified by standardized dry eye questionnaires (OSDI and McMonnies), and (2) to assess the clinical relationship between meibometry with both tear break-up time (BUT) and maximum blink interval (MBI).

METHODS

140 Patients were recruited for the study. Using Meibometer MB550, five curves were generated for each patient. Subjects performed OSDI and McMonnies questionnaires and were stratified following a two- and a three-subgroup stratification for each questionnaire. BUT/MBI were repeated three times (by video recordings), and they were determined by counting their frames.

RESULTS

Subjects grouped by OSDI showed a trend to present lower meibometry values as the OSDI score were higher (ANOVA, p≤0.044). For McMonnies questionnaire this was only true for the two-subgroup stratification (ANOVA, p=0.04), but not for three-subgroup stratification (one-way ANOVA, p=0.30). On the other hand, meibometry values showed a statistical correlation with both BUT (r=0.305, p<0.001) and MBI (r=0.265, p<0.001). When the sample was divided in three groups regarding BUT value (≤5s, between 5 and 10s and≥10s), significant differences of meibometry values were found between BUT subgroups (p=0.008).

CONCLUSION

Meibometer MB550 can discriminate asymptomatic from dry eye symptomatic patients. Furthermore, there is a relationship between meibometry and the tear film stability.

Assessment of meibomian glands and tear film in post-refractive surgery patients

IMPORTANCE

Corneal refractive surgery may impact meibomian gland and tear film in post-refractive surgery patients.

BACKGROUND

To compare ocular surface parameters between post-refractive surgery patients and normal controls.

DESIGN

Cross-sectional single centre study.

PARTICIPANTS

A total of 120 eyes of 120 subjects were divided into three groups: (i) 60 controls and 60 patients underwent corneal refractive surgery at least 12 months ago; (ii) 30 post-laser in-situ keratomileusis (LASIK) patients and (iii) 30 post-laser epithelial keratomileusis (LASEK)/photo-refractive keratectomy (PRK) patients.

METHODS

Tear meniscus height, non-invasive keratographic tear film break-up time and meibography were measured using the Keratograph^® 5M. Fluorescein break-up time, ocular surface staining, examination of lid margins and meibomian glands, Schirmer's test and Ocular Surface Disease Index questionnaire were performed.

MAIN OUTCOME MEASURES

Ordinary logistic regression was performed to evaluate the impact of clinical variables including refractive surgery on the meiboscores.

RESULTS

In post-LASIK patients, ocular surface parameters including Ocular Surface Disease Index scores, fluorescein break-up time and staining scores, except Schirmer's scores, were significantly worse than those in controls (P < 0.050). Ocular surface staining scores in post-LASEK/PRK patients was higher than that in the controls (P = 0.001). In post-refractive surgery patients, grade of meibomian gland parameters and meiboscores were worse than those of controls (all P < 0.050). Histories of refractive surgery were associated with high meiboscore (β = 1.100, P = 0.043 for LASIK and β = 1.039, P = 0.042 for LASEK/PRK).

CONCLUSIONS AND RELEVANCE

Corneal refractive surgery may adversely affect the ocular surface, and a reduction of functional meibomian glands can contribute to chronic tear film dysfunction after corneal refractive surgery.

Intense pulsed light treatment and meibomian gland expression for moderate to advanced meibomian gland dysfunction

BACKGROUND

The aim was to evaluate the efficacy of periocular intense pulsed light therapy combined with meibomian gland expression for chronic dry eye due to moderate to advanced meibomian gland dysfunction.

METHODS

This single-institution, open-label prospective study involved 26 participants who received bilateral treatments using a proprietary intense pulsed light device (E > Eye, E-Swin, Paris, France) combined with therapeutic meibomian gland expression at baseline, Week 2 and Week 6. Clinical evaluations performed at baseline, Week 4, Week 8 and Week 12 were symptom scores (Ocular Surface Disease Index [OSDI], Ocular Comfort Index [OCI], daily lubricant use, tear break-up time and ocular surface staining). Tear secretion, tear osmolarity, InflammaDry tear immunoassay, corneal sensation, meibomian secretion quality and expressibility, bulbar conjunctival, limbal and lid margin redness and eyelid margin bacterial swab for cultures and colony counts were performed at baseline and Week 8 only.

RESULTS

Significant improvements occurred at Week 8 in meibomian gland expressibility (p = 0.002), meibum quality (p = 0.006), tear break-up time (p = 0.002), corneal staining (p = 0.001), lid margin redness (p = 0.001), bulbar redness (p = 0.05) and limbal redness (p = 0.001). Symptom survey outcomes, eyelid margin bacteria colony counts, Schirmer I test, tear osmolarity, corneal sensitivity and daily lubricant use were unchanged. At Week 12, significant improvements in symptoms (OSDI p = 0.025; OCI p = 0.003), tear break-up time (p = 0.001) and corneal staining (p = 0.001) occurred. Improvement in OSDI score was correlated to the improvement in ocular surface staining (R = 0.43, p = 0.03) and associated with baseline meibomian gland expressibility (Kendall tau: the distributions are ordered the same, p = 0.1). There were no adverse effects of treatment.

CONCLUSIONS

Serial intense pulsed light therapy combined with meibomian gland expression significantly improved dry eye symptoms and clinical signs, including meibomian gland secretion quality and expressibility and ocular surface inflammation. Treatment effects were cumulative and sustained for at least six weeks after the final treatment.

A novel noninvasive ocular surface analyzer for the assessment of dry eye with Meibomian gland dysfunction

Meibomian gland dysfunction (MGD) is a major cause of dry eye, and the purpose of the present study was to evaluate the differences between dry eye patients with MGD and controls using a novel noninvasive ocular surface analyzer. A total of 33 dry eye patients with MGD and 31 controls were enrolled in the present study. Testing included administration of the Ocular Surface Disease Index (OSDI), followed by Keratogragh 5M (Oculus, Wetzlar, Germany), measurements of the noninvasive tear film break-up times (NITBUTs), the first tear film break-up point and the morphology of meibomian gland. Meibomian gland loss (MGL) on the upper lid was evaluated using noncontact meibography. The first NITBUT (NITBUTf) was significantly shorter than the average NITBUT (NITBUTav; Mann-Whitney U-test, P<0.01). There was a weak negative Spearman correlation between NITBUTf and OSDI (rs=-0.251, P=0.046) as well as between NITBUTav and OSDI (rs=-0.250, P=0.046). Furthermore, MGL showed a statistically significant Spearman correlation with OSDI (rs=0.562; P<0.01). In the MGD group, NITBUTf was significantly shorter (P<0.01), and MGL and OSDI score were significantly greater (P<0.01 and <0.01, respectively) than in the control group. In the MGD group, the first tear film break-up point was most frequently located in the inferonasal quadrant, while it was most frequently located in the supertemporal quadrant in the control group, and there was a significant difference with this regard (χ²=3.937, P=0.047). In the MGD group, there were significantly more breakups in the lower quadrant than in the upper quadrant (P=0.011), whereas no differences in the number of breakups in each quadrant were observed in the control group (P=0.429). Furthermore, there was no significant difference in the breakups in the lower quadrants of the two groups (χ²=0.525, P=0.469). In the MGD group, there were significantly more breakups in the lower quadrant than in the upper quadrant (P=0.011), whereas no differences in the number of breakups in each quadrant were observed in the control group (P=0.429). Furthermore, there was no significant difference in the breakups in the lower quadrants of the two groups (χ²=0.525, P=0.469). As the NITBUTs showed only a weak correlation with OSDI, they may not be a strong indicator of the OSDI. However, MGL indicated changes of meibomian gland morphology in the MGD group and the first tear film break-up point was likely located in the inferonasal quadrant in the MGD group.

In vivo Confocal Microscopy Evaluation of Meibomian Gland Dysfunction in Dry Eye Patients with Different Symptoms

Background:

Dry eye patients suffer from all kinds of symptoms. Sometimes, the clinical signs evaluation does not disclose any obvious difference in routine examination; in vivo confocal microscopy (IVCM) is a powerful tool for ocular surface disease. This study aimed to clarify meibomian gland (MG) alterations in dry eye patients with different symptoms and to compare the findings using IVCM.

Methods:

A total of sixty patients were recruited, all subjected to Ocular Surface Disease Index (OSDI) and Salisbury Eye Evaluation Questionnaire (SEEQ), and questionnaires for the assessment of dry eye symptoms before clinical sign examinations were given to the patients. Finally, IVCM was applied to observe MG's structure. Statistical analysis was performed using the t-test, Mann-Whitney U-test and Spearman correlation analysis. The differences were statistically significant when P < 0.05.

Results:

In the severe symptom group, OSDI and SEEQ scores were significantly higher (P < 0.05) compared with the mild symptoms group. All other clinical sign examinations had no statistical difference in the two groups (P > 0.05). However, all the IVCM-observed data showed that patients with severe symptoms had more significant fibrosis in MG (acinar unit area 691.87 ± 182.01 μm² for the severe, 992.17 ± 170.84 μm² for the mild; P < 0.05) and severer decrease in the size of MG acinar units than those observed in patients with mild symptoms (MG acinar unit density [MGAUD] 70.08 ± 18.78 glands/mm², MG acinar unit longest diameter [MGALD] 51.50 ± 15.51 μm, MG acinar unit shortest diameter [MGASD] 20.30 ± 11.85 μm for the severe, MGAUD 89.53 ± 39.88 glands/mm², MGALD 81.57 ± 21.14 μm, MGASD 42.37 ± 14.55 μm for the mild; P < 0.05). Dry eye symptoms were negatively correlated with MG confocal microscopic parameters and positively correlated with conjunctival inflammatory cells and Langerhans cells (P < 0.05).

Conclusions:

IVCM application provides a strong support to differentiate dry eye patients with different symptoms: meibomian gland dysfunction (MGD) plays a pivotal role in dry eye aggravation, and using IVCM to observe MG fibrosis, changes in size and density of MG as well as status of inflammation cells can help not only correctly diagnose the type and severity of dry eye, but also possibly prognosticate in routine eye examination in the occurrence of MGD.

Topical treatments for blepharokeratoconjunctivitis in children

BACKGROUND

Blepharokeratoconjunctivitis (BKC) is a type of inflammation of the surface of the eye and eyelids that involves changes of the eyelids, dysfunction of the meibomian glands, and inflammation of the conjunctiva and cornea. Chronic inflammation of the cornea can lead to scarring, vascularisation and opacity. BKC in children can cause significant symptoms including irritation, watering, photophobia and loss of vision from corneal opacity, refractive error or amblyopia.Treatment of BKC is directed towards modification of meibomian gland disease and the bacterial flora of lid margin and conjunctiva, and control of ocular surface inflammation. Although both topical and systemic treatments are used to treat people with BKC, this Cochrane review focuses on topical treatments.

OBJECTIVES

To assess and compare data on the efficacy and safety of topical treatments (including antibiotics, steroids, immunosuppressants and lubricants), alone or in combination, for BKC in children from birth to 16 years.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE ( January 1946 to 11 July 2016), Embase (January 1980 to 11 July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 July 2016. We searched the reference lists of identified reports and the Science Citation Index to identify any additional reports of studies that met the inclusion criteria.

SELECTION CRITERIA

We searched for randomised controlled trials that involved topical treatments in children up to 16 years of age with a clinical diagnosis of BKC. We planned to include studies that evaluated a single topical medication versus placebo, a combination of treatments versus placebo, and those that compared two or multiple active treatments. We planned to include studies in which participants received additional treatments, such as oral antibiotics, oral anti-inflammatories, warm lid compresses and lid margin cleaning.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the literature search (titles and abstracts) to identify studies that met the inclusion criteria of the review and applied standards as expected for Cochrane reviews. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included one study from the USA that met the inclusion criteria. In the study, 137 children aged zero to six years old with blepharoconjunctivitis were randomised to treatment in one of four trial arms (loteprednol etabonate/tobramycin combination, loteprednol etabonate alone, tobramycin alone or placebo) for 15 days, with assessments on days 1, 3, 7 and 15. We judged the study to be at high risk of attrition bias and bias due to selective outcome reporting. The study did not report the number of children with improvement in symptoms nor with total or partial success as measured by changes in clinical symptoms.All children showed a reduction in blepharoconjunctivitis grade score, but there was no evidence of important differences between groups. Visual acuity was not fully reported but the authors stated that there was no change in visual acuity in any of the treatment groups. The study reported ocular and non ocular adverse events but was underpowered to detect differences between the groups. Ocular adverse events were as follows: loteprednol/tobramycin 1/34 (eye pain); loteprednol 4/35 (eye pain, conjunctivitis, eye discharge, eye inflammation); tobramycin 0/34; placebo (vehicle) 0/34. The evidence was limited for all these outcomes and we judged it to be very low certainty.There was no information on clinical signs (aside from grade score), disease progression or quality of life.

AUTHORS' CONCLUSIONS

There is no high-quality evidence of the safety and efficacy of topical treatments for BKC, which resulted in uncertainty about the indications and effectiveness of topical treatment. Clinical trials are required to test efficacy and safety of current and any future treatments. Outcome measures need to be developed which can capture both objective clinical and patient-reported aspects of the condition and treatments.

Evaluation of the Safety and Effectiveness of Intense Pulsed Light in the Treatment of Meibomian Gland Dysfunction

Purpose. This study aims to explore the safety and efficacy of a novel treatment-intense pulsed light (IPL) in MGD eyes. Methods. This study is a prospective and open label study. Forty eyes of 40 MGD patients were recruited in the study and received 4 consecutive IPL treatments on day 1, day 15, day 45, and day 75. Ten ocular surface symptoms were evaluated with a subjective face score at every visit. Best spectacle corrected visual acuity, intraocular pressure (IOP), conjunctival injection, upper and lower tear meniscus height (TMH), tear break-up time (TBUT), corneal staining, lid margin and meibomian gland assessments, and meibography were also recorded at every visit, as well as the adverse effects on the eye and ocular surface. Results. Significant improvements were observed in single and total ocular surface symptom scores, TBUT, and conjunctival injection at all the visits after the initial IPL treatment (P < 0.05). Compared to baseline, the signs of eyelid margin, meibomian gland secretion quality, and expressibility were significantly improved at every visit after treatments. There was no regional and systemic threat observed in any patient. Conclusion. Intense pulsed light (IPL) therapy is a safe and efficient treatment in relieving symptoms and signs of MGD eyes.

Systemic treatment for blepharokeratoconjunctivitis in children

BACKGROUND

Blepharokeratoconjunctivitis (BKC) is a type of inflammation of the surface of the eye and eyelids which can affect children and adults. BKC involves changes of the eyelids, dysfunction of the meibomian glands, and inflammation of the conjunctiva and cornea. Chronic inflammation of the cornea can lead to scarring, vascularisation and opacity. BKC in children can cause significant symptoms which include irritation, watering, photophobia and loss of vision. Loss of vision in children with BKC may be due to corneal opacity, refractive error or amblyopia.BKC treatment is directed towards the obstruction of meibomian gland openings, the bacterial flora of lid margin and conjunctiva, and ocular surface inflammation. Dietary modifications that involve increased intake in essential fatty acids (EFAs) may also be beneficial. Both topical and systemic treatments are used; this Cochrane review focuses on systemic treatments.

OBJECTIVES

To assess and compare data on the efficacy and safety of systemic treatments (including antibiotics, nutritional supplements and immunosuppressants), alone or in combination, for BKC in children aged between zero to 16 years.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to April 2016), EMBASE (January 1980 to April 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 April 2016.

SELECTION CRITERIA

We searched for randomised controlled trials that involved systemic treatments in children aged between zero to 16 years with a clinical diagnosis of BKC. We planned to include studies that evaluated a single systemic medication versus placebo, and studies that compared two or multiple active treatments. We planned to include studies in which participants receive additional treatments, such as topical antibiotics, anti-inflammatories and lubricants, warm lid compresses and lid margin cleaning.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature search results (titles and abstracts) to identify studies that possibly met the inclusion criteria of the review. We divided studies into 'definitely include', 'definitely exclude' and 'possibly include' categories. We made a final judgement as to the inclusion or exclusion of studies in the 'possibly include' category after we obtained the full text of each article.

MAIN RESULTS

No report or trial met the inclusion criteria of this Cochrane review; no randomised controlled trials have been carried out on this topic. There is a lack of standardised outcome measures.

AUTHORS' CONCLUSIONS

There is currently no evidence from clinical trials regarding the safety and efficacy of systemic treatments for BKC. Trials are required to test efficacy and safety of current and future treatments. Outcome measures need to be developed which can capture both objective clinical and patient-reported aspects of the condition and treatments.

Comparative study of the efficacy of different treatment options in patients with chronic blepharitis

OBJECTIVE

To compare the efficacy of 3 treatment options in patients with chronic blepharitis.

METHODOLOGY

An experimental, randomized, controlled study was conducted on 45 patients (female 67%; Mean age: 40.5 years) diagnosed with chronic blepharitis, in order to compare the effectiveness of three treatment options. Group 1: eyelid hygiene with neutral shampoo three times/day; group 2: neutral shampoo eyelid hygiene plus topical metronidazole gel 0.75% twice/day; group 3: neutral eyelid hygiene with shampoo plus neomycin 3.5% and polymyxin 10% antibiotic ointment with 0.5% dexamethasone 3 times/day. The symptoms and signs were assessed by assigning scores from 0: no symptoms and/or signs; 1: mild symptoms and/or signs, 2: moderate symptoms and/or signs; and 3: severe symptoms and/or signs.

RESULTS

A significant improvement was observed in the signs and symptoms in all 3 treatment groups. While groups 1 and 2 had more improvement in all variables studied (P<.05), Group 3 showed no clinical improvement for itching (P=.16), dry eye (P=.29), eyelashes falling (P=.16), and erythema at the eyelid margin (P=.29).

CONCLUSIONS

Shampoo eyelid hygiene neutral and neutral shampoo combined with the use of metronidazole gel reported better hygiene results than neutral shampoo lid with antibiotic ointment and neomycin and polymyxin dexamethasone.

Validity of subjective assessment as screening tool for dry eye disease and its association with clinical tests

AIM

To determine the role of subjective assessment using McMonnies dry eye questionnaire in diagnosing dry eye disease and its association with clinical tests.

METHODS

There were 500 patients screened for dry eye using McMonnies dry eye questionnaire between May to October 2013 at the outpatient Department of Ophthalmology of a medical college hospital. All 500 patients were subjected to clinical tests. Dry eye was defined as having one or more symptoms often or all the time. Positive signs were if one or both eyes revealed tear film breakup time (TBUT) of ≤10s, a Schirmer test score of ≤10 mm, a Rose Bengal staining score of ≥1, a Lissamine green staining score of ≥1 or existence of meibomian gland disease (≥grade 1). Statistical analysis was performed to describe the distribution of symptoms and signs, to assess the correlations between McMonnies score (MS) and variable clinical signs of dry eye, and to explore the association between dry eye symptoms and variable clinical signs. Analysis was performed using software package Epi info. A Probability (P) value using Chi-square test of <0.005 was taken as significant.

RESULTS

Dry eye prevalence with symptoms (questionnaire), Schirmer test, TBUT, Rose Bengal staining and Lissamine green staining was 25.6%, 15.20%, 20.80%, 23.60%, and 22.60% respectively. Among those with severe symptoms (MS>20), 75.86% had a low TBUT (<10s), 58.62% had a low Schirmer's I test (≤10 mm), 86.20% had Rose Bengal staining score of ≥1, 79.31% had Lissamine green staining score of ≥1. We found statistically significant associations between positive Schirmer test and arthritis (P<0.002), dryness elsewhere (P<0.001), contact lens use (P<0.002), systemic medication (P<0.0001), sleeping with eyes partly open (P<0.002), history of dry eyes treatment (P<0.0001), environmental factors (P<0.001), swimming (P<0.001).

CONCLUSION

Subjective assessment plays an important role in diagnosing dry eye disease. There is strong correlation between MS and Schirmer test, TBUT, Rose Bengal staining and Lissamine green staining in normal as well as marginal and pathological dry eye.

Matrix metalloproteinase 9 and transglutaminase 2 expression at the ocular surface in patients with different forms of dry eye disease

OBJECTIVE

To evaluate the expression of matrix metalloproteinase 9 (MMP9) and transglutaminase 2 (TG2) in different forms of dry eye.

DESIGN

Case control study.

PARTICIPANTS

Seventy-five female subjects divided into 3 groups: group 1, 15 healthy controls; group 2, 30 subjects with Sjögren syndrome (SS); and group 3, 30 subjects with Meibomian gland dysfunction (MGD).

METHODS

A clinical assessment was carried out and impression cytologic specimens were processed for immunoperoxidase staining for MMP9 and TG2 and real-time polymerase chain reaction analyses were carried out for MMP9, TG2, interleukin-6, interferon-γ, B-cell lymphoma 2, and caspase 3. To study MMP9 and TG2 expression after anti-inflammatory treatment, patients were divided into 2 subgroups, one treated with saline and the other treated with saline plus topical corticosteroid eye drops (0.5% loteprednol etabonate) 4 times daily for 15 days. For statistical analysis, Student t test, Mann-Whitney U test, and Spearman's correlation coefficient were used as appropriate.

MAIN OUTCOME MEASURES

Conjunctival expression of MMP9 and TG2.

RESULTS

MMP9 and TG2 expression were higher in both patient groups than in controls (P < 0.0001). Group 2 patients showed higher expression than group 3 (P < 0.0001). The Spearman's correlation coefficient showed in group 2 a positive correlation between MMP9 and TG2 expression (ρ = 0.437; P = 0.01), but no correlation in group 3 (ρ = 0.143; P = 0.45). Corticosteroid treatment significantly reduced MMP9 and TG2 expression in both groups, ameliorating symptoms and signs. A much higher percentage reduction was observed in SS.

CONCLUSIONS

The pathogenic mechanisms of the 2 forms of dry eye give an account for the different MMP9 and TG2 expressions in the 2 groups of patients. The higher expression in SS is determined by the direct autoimmune insult to the ocular surface epithelia, whereas in MGD patients, with an epithelial damage due to an unbalanced tear secretion, the molecules expression is significantly lower, although higher than in controls. The corticosteroid treatment induced a reduction of both molecules, although higher in SS than in MGD, because of its direct inhibitory effect on inflammation.

Total cholesterol and lipoprotein composition are associated with dry eye disease in Korean women

Background

This study aimed to determine the relationship between dyslipidemia and dry eye disease (DED) in a Korean population.

Methods

This population-based study enrolled 5,627 adults (aged >19 years) who were participating in the first year of the fifth annual Korea National Health and Nutrition Examination Survey from 2010 to 2011. Clinically diagnosed DED and its symptoms were surveyed, and biochemical blood analysis data were collected. Dyslipidemia was defined as any of the following: hypercholesterolemia (total cholesterol > 200 mg/dL), hypertriglyceridemia (triglyceride > 150 mg/dL), low levels of high-density lipoprotein (<40 mg/dL), or high levels of low-density lipoprotein (>100 mg/dL).

Results

After adjusting for demographics (age and body mass index), lifestyle (smoking, drinking, exercise, and residential district), and medical factors (diabetes, hypertension, previous ophthalmic surgery, menopause, and rheumatologic disease), elevated serum cholesterol level was found to be associated with increased likelihood of DED (odds ratio, 1.77; 95% confidence interval, 1.127–2.78) in women.

Conclusions

DED in a Korean population was found to be associated with high serum cholesterol levelsThe results of this study highlight the significance of eye examinations and independent lipid profile monitoring in patients with dyslipidemia because of its possible correlation with DED progression.

Rasch analysis of the Ocular Surface Disease Index (OSDI)

PURPOSE

The Ocular Surface Disease Index (OSDI) is a 12-item scale for the assessment of symptoms related to dry eye disease and their effect on vision. Its reliability and validity have been investigated within the classical test theory framework and, more recently, using Rasch analysis. The purpose of the present analysis was to more completely investigate the functioning of its response category structure, the validity of its three subscales, and the unidimensionality of the latent construct it is intended to assess.

METHODS

Responses to the OSDI from 172 females participating in the Dry Eye in Postmenopause (DEiM) study who had previously been diagnosed with dry eye or reported significant ocular irritation and dryness were analyzed. Response category structure and item fit statistics were evaluated for assessment of model fit. Person separation statistics were used to examine the validity of the subscales. Unidimensionality was assessed by principal component analysis (PCA) of model residuals.

RESULTS

The recommended five-category response structure resulted in disordered response thresholds. A four-category structure resulted in ordered thresholds. Item infit statistics were acceptable for all 12 items. Person separation with this category structure was adequate, with a person separation index of 2.16. None of the three subscales demonstrated adequate person separation. PCA showed one other significant factor onto which the three environmental items loaded significantly.

CONCLUSIONS

All items demonstrated acceptable fit to the model after collapsing categories to order the response thresholds. The original subscales did not prove valid, and there is some evidence of multidimensionality and poor targeting.