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

A novel nomogram to predict glucocorticoid response in thyroid-associated ophthalmopathy: findings from a pilot study

PURPOSE

Aimed to create a nomogram using clinical and eye-specific metrics to predict the efficacy of intravenous glucocorticoid (IVGC) therapy in patients with active and moderate-to-severe Thyroid-Associated Ophthalmopathy (TAO).

METHODS

This study was conducted on 84 eyes from 42 moderate-to-severe TAO patients who received systemic IVGC therapy, and 42 eyes from 21 controls. Data were collected retrospectively from June 2020 to December 2021. The least absolute shrinkage and selection operator (LASSO) method was used to identify predictive factors for "unresponsiveness" to IVGC therapy. These factors were then analyzed using logistic regression to create a nomogram. The model's discriminative ability was robustly assessed using a Bootstrap resampling method with 1000 iterations for receiver operating characteristic (ROC) curve analysis.

RESULTS

The LASSO analysis identified six factors with non-zero coefficients as significant, including Schirmer I test values, Meibomian gland (MG) diameter, MG length, disease duration, whole capillary vessel density (VD) in the radial peripapillary capillary (RPC), and whole macular VD for the superficial retinal capillary plexus (SRCP). The subsequent logistic regression model highlighted MG length, whole macular VD for SRCP, and disease duration as independent predictors of IVGC therapy response. The constructed nomogram demonstrated an area under the curve (AUC) of 0.82 (95% CI: 0.73-0.91), affirming the model's consistent and reliable ability to distinguish between responsive and non-responsive TAO patients.

CONCLUSION

Our nomogram, combining MG length (<4.875 mm), SRCP VD (<50.25%), and disease duration (>5.5 months), reliably predicts lower IVGC therapy effectiveness in active, moderate-to-severe TAO patients.

Ocular surface and meibomian gland evaluation in euthyroid Graves' ophthalmopathy

PURPOSE

Euthyroid Graves' ophthalmology (EGO) refers to the subgroup of thyroid eye disease patients with distinct clinical presentations. This study evaluated the ocular surface and meibomian gland changes in EGO patients.

METHODS

A cross-sectional study was conducted at The Chinese University of Hong Kong including 34 EGO patients and 34 age-and sex- matched healthy controls. Outcome measures include anterior segment examination, keratographic and meibographic imaging.

RESULTS

Between 34 EGO patients and 34 age and sex-matched healthy controls, EGO was associated with a higher ocular surface disease index (P < 0.01), higher severity of meibomian gland dropout (upper: P < 0.001, lower: P < 0.00001) and higher percentage of partial blinking (P = 0.0036). The worse affected eyes of the EGO patients were associated with corneal staining (P = 0.0019), eyelid telangiectasia (P = 0.0009), eyelid thickening (P = 0.0013), eyelid irregularity (P = 0.0054), meibomian gland plugging (P < 0.00001), expressibility (P < 0.00001), and meibum quality (P < 0.00001). When the two eyes of the same EGO patient were compared, the degree of meibomian gland dropout was higher among the worse affected eyes (upper: P < 0.00001, and lower: P < 0.00001). Tear meniscus height, lipid layer thickness, and noninvasive break-up time were comparable between the two eyes of EGO patients and also between EGO patients and healthy controls. TMH was positively correlated with the degree of exophthalmos (r = 0.383, P < 0.05).

CONCLUSION

EGO patients have more ocular surface complications and meibomian gland dropouts than healthy controls. Almost 60% of them had dry eye symptoms, but aqueous deficiency was not apparent. Further studies are warranted to clarify the mechanism of dry eye in EGO. (249 words).

Risk Factors for Chalazion Diagnosis and Subsequent Surgical Excision

PURPOSE

To identify factors associated with chalazion diagnosis and surgical excision.

METHODS

Patients with an incident chalazion diagnosis from 2002 to 2019 were compared 1:5 with matched controls. Multivariable logistic regression was performed to identify variables associated with diagnosis and surgical excision.

RESULTS

Chalazion patients (n = 134,959) and controls (678,160) were analyzed. Risk factors for diagnosis included female sex, non-white race, northeast location, conditions affecting periocular skin and tear film (blepharitis, meibomian gland dysfunction, rosacea, pterygium), non-ocular inflammatory conditions (gastritis, inflammatory bowel disease, sarcoidosis, seborrheic dermatitis, Graves' disease), and smoking (p < .001 for all comparisons). Thirteen percent of patients with chalazion underwent subsequent surgical excision. Diabetes and systemic sclerosis diagnoses decreased odds of diagnosis (p < .001). Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use increased odds of surgery (p < .001).

CONCLUSION

Female sex, non-white race, conditions affecting periocular skin and the tear film, several non-ocular inflammatory conditions, and smoking were risk factors for chalazion diagnosis. Male sex, rosacea diagnosis, Black and Hispanic race, antibiotic use, and doxycycline use were risk factors for surgical intervention for chalazion. Our results prompt further study of these variables and their relationship to chalazion diagnosis to understand physiology and improve clinical outcomes. Furthermore, the results of this study suggest early recognition and treatment of concomitant rosacea may serve an important role in the management of chalazion and in the prevention of surgical intervention.

Ocular Surface Disease Related to the Inflammatory and Non-Inflammatory Phases of Thyroid Eye Disease

Purpose

This study evaluated the ocular surface disease (OSD), especially dry eye disease (DED) parameters by combining qualitative and quantitative tools, including tear matrix metalloproteinase 9 (MMP-9), in patients with Graves' disease (GD) with and without Thyroid eye disease (TED).

Patients and Methods

A total of 17 active TED, 16 inactive TED, 16 GD without ophthalmopathy, and 16 healthy controls were included. All patients were assessed with CAS, ophthalmometry, qualitative tear MMP-9, Ocular Surface Disease Index (OSDI), ocular surface staining, Schirmer test, meibography, tear meniscus height, conjunctival hyperemia, and non-invasive tear film break-up time. Patients were classified into three subtypes of DED: aqueous tear deficiency, meibomian gland dysfunction (MGD) and mixed dry eye.

Results

Inactive TED was shown to be an associated factor with DED (odds ratio 14, confidence interval 2.24-87.24, p=0.0047), and presented more DED than healthy controls (87.5% versus 33.3%, p=0.0113). MGD was also more prevalent among these subjects than in healthy control (62.5% versus 6.7%; p=0.0273). No significant differences were found in other ophthalmological parameters, except for more intense conjunctival redness among active TED than GD without ophthalmopathy (p=0.0214). Qualitative MMP-9 test was more frequently positive in both eyes among active TED than in other groups (p < 0.0001).

Conclusion

Patients with GD were symptomatic and presented a high prevalence of ocular surface changes and DED, particularly the subgroup with inactive TED. Tear MMP-9 detection was associated with active TED suggesting a relationship between ocular surface changes and the initial inflammatory phase of ophthalmopathy.

The Association between Autoimmune Thyroid Disease and Ocular Surface Damage: A Retrospective Population-Based Cohort Study

Autoimmune thyroid diseases (ATDs) are potentially connected to lacrimal gland dysfunction and ocular surface disruption. This study aimed to evaluate the relationships between ATD, dry eye disease (DED), and corneal surface damage. In a matched nationwide cohort study, we used Taiwan's National Health Insurance research database to compare the incidences of DED and corneal surface damage between subjects with and without ATD. Multivariable Cox proportional hazards regression models were used to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for the ophthalmological outcomes. A total of 50,251 matched pairs with 748,961 person-years of follow-up were included for analysis. The incidence of DED was 16.37 and 8.36 per 1000 person-years in the ATD and non-ATD groups, respectively. ATDs were significantly associated with increased DED (aHR: 1.81, 95% CI: 1.73-1.89, p < 0.0001). This association was generally consistent across the subgroups of age, sex, different comorbidity levels, and use of systemic corticosteroids or not. Furthermore, patients with ATD had a higher risk of corneal surface damage compared with non-ATD subjects (aHR: 1.31, 95% CI: 1.19-1.44, p < 0.0001), including recurrent corneal erosions (aHR: 2.00, 95% CI: 1.66-2.41, p < 0.0001) and corneal scars (aHR: 1.26, 95% CI: 1.01-1.59, p = 0.0432). Other independent factors for corneal surface damage were age, sex, diabetes mellitus, Charlson Comorbidity Index scores, and use of systemic corticosteroids. Our results suggested that ATDs were associated with higher risks of DED and corneal surface damage. Considering the high prevalence of ATD, prophylactic and therapeutic strategies should be further developed to prevent irreversible vision loss in this susceptible population.

Ocular Surface Changes in Treatment-Naive Thyroid Eye Disease

OBJECTIVE

To investigate the association of meibomian gland dysfunction (MGD) and ocular surface exposure with tear film instability in untreated thyroid eye disease (TED) patients.

METHODS

A cross-sectional study of TED patients from September 2020 to September 2022 was conducted. Ocular surface parameters included ocular surface disease index (OSDI), tear meniscus height (TMH), non-invasive tear break-up time (NITBUT), partial blinking rate, lipid layer thickness (LLT), meibomian gland dropout (meiboscore), Schirmer's test, and corneal punctate epithelial erosions (PEE). Ocular surface exposure was assessed by the margin reflex distances of the upper and lower eyelid (MRD1 and MRD2), the amount of exophthalmos, lateral flare, and lagophthalmos.

RESULTS

In total, 152 eyes from 76 TED patients (64 females and 12 males, age 42.99 ± 12.28 years) and 93 eyes from 61 healthy controls (51 females and 10 males, age 43.52 ± 17.93 years) were examined. Compared with control eyes, TED eyes had higher OSDI, TMH, LLT, and PEE; shorter NITBUT; and worse meiboscore (all p < 0.05). They also had larger amounts of exophthalmos, longer MRD1, more lateral flare, and lagophthalmos. Multivariate analysis identified an association of the tear film instability with lagophthalmos (β = -1.13, 95%CI: -2.08, -0.18) and severe MGD in the lower eyelid (β = -5.01, 95%CI = -7.59, -2.43).

CONCLUSIONS

Dry eye in TED is mainly manifested as evaporative dry eye disease. Severe lower eyelid MGD and worse lagophthalmos were significantly associated with tear film instability in treatment-naive TED patients.

Symptoms and signs of dry eye in children with Graves' ophthalmopathy

PURPOSE

The purpose of this study is to evaluate the tear secretion and ocular surface properties in children with Graves' ophthalmopathy (GO) and to compare the results with those of healthy children.

METHODS

This was a cross-sectional study. Forty-three patients with GO (Group 1) and 41 healthy children without any ocular and/or systemic disorder (Group 2) were examined clinically and underwent tests for dry eye. We performed analyses including the Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's test under topical anesthesia (<5 mm was abnormal), slit-lamp biomicroscopy (corneal fluorescein staining and tear breakup time (TBUT) under blue-light illumination), and fundoscopic evaluation.

RESULTS

Dry eye symptoms and the mean OSDI score were significantly (P < 0.02) higher (15.6 ± 18.7) in patients with GO compared with controls (5.67 ± 3.6). The mean Schirmer's (basal tear secretion) tests value was significantly reduced in Group 1 (5.25 ± 3.1 mm) compared with Group 2 (17.1 ± 5.2), respectively. The difference was statistically significant (p < 0.005), suggesting inadequate tear production. The mean tear film breakup time in children was lower in patients with GO (8.3 ± 3.42 s,) compared with controls (13.2 ± 4.74 s), (P < 0.001) suggesting an unstable tear film. Decrease of corneal sensitivity (23.3%) was noted in patients with GO compared with controls. GO patients showed a significant increase of the frequency of corneal fluorescein staining (6.9%) in patients with GO compared with controls.

CONCLUSION

Patients with GO had a statistically significant higher incidence of dry eye symptoms and the increase of OSDI score. Significantly lower Schirmer's and TBUT tests results were seen in the study group when compared with the controls. These findings may indicate a tendency for dry eye in pediatric GO patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Meibomian gland morphological changes in ocular herpes zoster patients based on AI analysis

Varicella-zoster virus (VZV) infections result in a series of ophthalmic complications. Clinically, we also discover that the proportion of dry eye symptoms was significantly higher in patients with herpes zoster ophthalmicus (HZO) than in healthy individuals. Meibomian gland dysfunction (MGD) is one of the main reasons for dry eye. Therefore, we hypothesize that HZO may associate with MGD, affecting the morphology of meibomian gland (MG) because of immune response and inflammation. The purpose of this study is to retrospectively analyze the effect of HZO with craniofacial herpes zoster on dry eye and MG morphology based on an Artificial intelligence (AI) MG morphology analytic system. In this study, 26 patients were diagnosed as HZO based on a history of craniofacial herpes zoster accompanied by abnormal ocular signs. We found that the average height of all MGs of the upper eyelid and both eyelids were significantly lower in the research group than in the normal control group (p &lt; 0.05 for all). The average width and tortuosity of all MGs for both upper and lower eyelids were not significantly different between the two groups. The MG density of the upper eyelid and both eyelids were significantly lower in the HZO group than in the normal control group (p = 0.020 and p = 0.022). Therefore, HZO may lead to dry eye, coupled with the morphological changes of MGs, mainly including a reduction in MG density and height. Moreover, it is important to control HZO early and timely, which could prevent potential long-term severe ocular surface injury.

Dry eye disease and tear film assessment through a novel non-invasive ocular surface analyzer: The OSA protocol

We describe the role of OSA as a new instrument in the study of dry eye, and we recommend a protocol for conducting the tests as well as describe the advantages and disadvantages compared with other instruments. A comparison with other ocular surface devices (Tearscope Plus, Keratograph 5M, anterior-segment ocular coherence tomography, Easy Tear View-Plus, LipiView, IDRA, and LacryDiag) were presented due to manual or automatic procedure and objective or subjective measurements. The purpose of this study was to describe the OSA as new non-invasive dry eye disease diagnostic device. The OSA is a device that can provide accurate, non-invasive and easy-to-use parameters to specifically interpret distinct functions of the tear film. This OSA protocol proposed a lesser to higher non-invasive ocular surface dry eye disease tear film diagnostic methodology. A complete and exhaustive OSA and OSA Plus examination protocol was presented within the subjective questionnaire (Dry Eye Questionnaire 5, DEQ5), limbal and bulbar redness classification (within the Efron grade Scale, interferometry lipid layer thickness (LLT) (according to Guillon pattern), tear meniscus height (manually or automatic), first and mean non-invasive break up time (objective and automatic) and meibomian gland (MG) dysfunction grade and percentage (objective and automatic). The OSA and OSA Plus devices are novel and relevant dry eye disease diagnostic tools; however, the automatization and objectivity of the measurements can be increased in future software or device updates. The new non-invasive devices supposed represent a renewal in the dry eye disease diagnosis and introduce a tendency to replace the classic invasive techniques that supposed less reliability and reproducibility.

Changes in Dry Eye Status after Steroid Pulse and Orbital Radiation Therapies in Active Thyroid Eye Disease

This prospective, observational study examined changes in dry eye status after steroid pulse and orbital radiation therapies in 16 patients (32 eyes) with active thyroid eye disease (TED). TED status was evaluated through clinical activity score (CAS), margin reflex distance (MRD)-1 and 2, presence or absence of Graefe’s sign/lid lag, and Hertel exophthalmometric value. Dry eye status was quantified through presence or absence of superior limbic keratoconjunctivitis, corneal fluorescein staining (AD score), tear break-up time, Schirmer test I results, tear meniscus height, and dry eye-related quality of life score. Meibomian gland dysfunction (MGD) was evaluated through Marx line score, eyelid abnormalities (MGD score), meibum expression score, and meibomian gland loss score. Those items were measured before and 6 months after treatment, and the results were statistically compared. Consequently, CAS significantly improved, and MRD-1 significantly decreased after treatment (p < 0.050). Although a part of MGD status improved (p < 0.050), all items regarding dry eye status did not change significantly after treatment (p > 0.050). Steroid pulse and orbital radiation therapies did not largely alter most items regarding dry eye and MGD status.

Inflammatory and non-inflammatory thyroid eye disease: comparison of disease signs, symptoms and quality of life in US patients

OBJECTIVE

Thyroid eye disease (TED) is an autoimmune, inflammatory disease resulting in retro-orbital fat and extraocular muscle expansion. TED quiets ("inactivates") as inflammation wanes, but signs/symptoms often persist. Disease signs/symptoms and quality of life (QOL) impact were examined in non-inflammatory and inflammatory TED.

METHODS

Moderate-to-severe TED patient data were collected from treating physicians. Clinical activity score (CAS, 6/7 measures available) assessed TED as inflammatory (CAS≥3) or non-inflammatory (CAS=0-1). QOL impact was scored as 1="not at all impaired" to 7="extremely impaired." Non-inflammatory TED patients were further grouped into longer (>3 years) and shorter (≤3 years) disease.

RESULTS

Inflammatory (N=307) and non-inflammatory (N=281) patients had comparable age (50.0±13.3, 48.3±13.8 years), sex (66%, 64% female), TED duration (4.0±4.9; 4.6±5.5 years), and proportion smokers (15%, 11%). Most common non-inflammatory TED signs/symptoms included ocular dryness/grittiness (77%), proptosis (56%), excessive tearing (43%), soft tissue edema (42%), conjunctival redness (24%) decreased vision (24%) and eye muscle involvement (22%; 14% had diplopia). All were less reported than in patients with inflammatory TED. QOL was impacted by non-inflammatory TED, but to a lesser degree than inflammatory disease (3.6±1.5 vs. 4.7±1.4). However, mental health issues were similarly reported. Non-inflammatory TED patients with longer disease (9.0±6.0 years) had similar QOL impact, mental health diagnoses, and TED sign/symptoms as those with shorter disease (1.4±1.0 years).

CONCLUSION

TED signs/symptoms often chronically persist long after TED has "quieted," continuing to impact patient QOL and mental health. These data suggest that moderate-to-severe TED should be thought of as a robust symptomatic chronic disease, regardless of inflammatory status.

Statin Use Is Associated With a Lower Risk of Blepharitis: A Population-Based Study

Background

Blepharitis is a common eye disorder that may be overlooked by patients and clinical practitioners. The symptoms of blepharitis often manifest as irritation, a burning sensation, grittiness, and itchiness and may decrease visual acuity if not treated promptly. Meibomian gland dysfunction (MGD), a common cause of blepharitis, is believed to be associated with increased inflammatory marker levels that may disrupt the composition of lipids produced by the sebaceous glands in the eyelids and ultimately cause tear film instability.

Methods

This is a retrospective, population-based study using National Health Insurance Research Database (NHIRD) data from a 14-year period (2000–2015). Pearson chi-squared and Student's t-tests were used to assess the differences in categorical and continuous variables, respectively, between statin users and non-statin users. Univariate and multivariate Cox regression analyses were performed to calculate the hazard ratios (HRs) after adjusting for confounders. Kaplan-Meier analysis was used to assess the cumulative risk of blepharitis between the two cohorts.

Results

A total of 67,014 patients who used statins were enrolled as the study cohort, and 268,056 patients who did not use statins were enrolled as the comparison cohort. The incidence of blepharitis was 3.04% with statin treatment and 3.72% without statin treatment (p < 0.001). Patients who used statins had a lower risk of developing blepharitis [adjusted hazard ratio (aHR): 0.746, p < 0.001] than those who did not. In addition, diabetes mellitus (DM), hypertension, coronary heart disease (CHD), stroke, chalazion, rosacea, Sjogren syndrome, psoriasis and atopy were found to be possible risk factors for blepharitis.

Conclusion

Statin use can decrease the risk of developing blepharitis. However, further prospective studies are needed to evaluate statin treatment for various subtypes of blepharitis and to identify the associated mechanism.

Ocular surface disease in thyroid eye disease: A narrative review

Ocular surface disease (OSD) in the setting of thyroid eye disease (TED) is traditionally thought of as a natural consequence of anatomical changes such as proptosis and corneal exposure. However, a growing body of research suggests that ocular surface inflammation and multi-factorial changes to the homeostasis of the ocular surface contribute substantially to the OSD seen in TED patients. In this paper we review the existing literature which highlights the work and existing theories underlying this new paradigm shift.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ocular Surface Changes in Patients with Thyroid Eye Disease: An Observational Clinical Study

Background

This study aimed to compare ocular surface parameter changes in active and inactive thyroid eye disease (TED) patients and controls.

Methods

This is an observational clinical study that included 60 eyes divided into three groups following clinical activity score (CAS) assessment. The first group (Group A) comprised 20 eyes with active TED (CAS score ≥3/7), while the second group (Group B) comprised 20 eyes with inactive TED (CAS score <3/7) and the third group (Group C) comprised 20 eyes of controls without dry eye manifestations. The palpebral fissure height, degree of proptosis, degree of lagophthalmos, ocular surface disease index (OSDI), Schirmer test without anesthesia, corneal fluorescein staining (CFS), non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), lipid layer thickness (LLT), meiboscore, meibomian gland dysfunction (MGD), and thyroid antibodies were assessed and data were compared between study participants.

Results

The mean OSDI was 40.0 ±5.80 in Group A, which significantly differed from Group B with a mean of 26.5 ±5.10 (p=0.02). There were significant differences between the two groups regarding palpebral fissure height (p=0.02), amount of proptosis (p=0.008), and degree of lagophthalmos (p=0.001). Similarly, active TED patients had more decreased tear secretion than inactive TED patients (p=0.012). Moreover, active TED patients showed a significant increase in Meibomian gland loss areas in both upper and lower eyelids compared with inactive TED patients (p=0.001). Corneal fluorescein staining also revealed a statistically significant difference between the studied groups (p=0.0001).

Conclusion

This study showed differences regarding ocular surface parameter changes between both active and inactive TED and compared to controls. Further studies are needed to confirm these results.

Meibomian glands dropout in patients with inactive thyroid related orbitopathy

PURPOSE

To evaluate the structure and function of meibomian glands in patients with thyroid related orbitopathy (TRO) compared with age- and sex-matched controls without TRO.

METHODS

This cross-sectional study included 106 eyes of 53 patients with TRO and 106 eyes of 53 age- and sex-matched controls without TRO. Patients with TRO were assessed for thyroid hormone status, activity and severity of TRO. All participants completed OSDI questionnaires. Their meibomian glands' structure and function were assessed, including the area of meibomian gland dropout, lipid layer thickness (LLT), meibum expressibility and quality scores, tear break-up time (TBUT), corneal and conjunctival staining scores. A generalized estimating equation (GEE) was used to compare between the two groups. The correlations between the area of meibomian gland dropout with symptoms and signs of TRO were evaluated using GEE and Spearman correlation.

RESULTS

All patients with TRO had inactive status. The mean area of meibomian gland dropout was higher in the TRO group (34.5±11.2%) compared with that of controls (30.1±10.7%, P = 0.03). Both mean meibum quality (TRO, 1.6±0.7; Controls, 2.0 ±0.5) and expressibility (TRO, 1.5 ±0.7; Controls, 1.7 ±0.6) scores were slightly better in the TRO group compared with those of controls (P = 0.01). There was no significant difference in OSDI, corneal and conjunctival staining, TBUT and LLT. The area of meibomian gland dropout in patients with TRO was correlated with euthyroid status (P<0.05) and lagophthalmos (P = 0.03).

CONCLUSIONS

Patients with inactive TRO showed significantly higher meibomian gland dropout compared with that of age- and sex-matched controls without TRO.

Ocular surface changes in Graves' ophthalmopathy

Many patients with Graves' ophthalmopathy (GO) suffer from dry eye syndrome (DES), and this is one of the most common reasons of eye discomfort in patients with GO. The prevalence of DES in patients with GO is significantly higher than normal subjects. The ocular surface changes involving changes in tears, cornea, conjunctiva and glands occur in GO patients. However, the mechanism of how DES occurs in GO still remains unclear. In this review, the ocular surface changes were illustrated and analyzed the reasons for high prevalence of DES in GO patients.

CLEAR - Evidence-based contact lens practice

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

Ocular Surface Changes in Hashimoto's Thyroiditis Without Thyroid Ophthalmopathy

OBJECTIVE

We sought to evaluate ocular surface changes in patients with Hashimoto's thyroiditis without thyroid ophthalmopathy and elucidate the relationship between dry eye syndrome and meibomian gland dysfunction (MGD) in cases of Hashimoto's thyroiditis.

METHODS

This prospective study included 105 patients with Hashimoto's thyroiditis and 105 age- and sex-matched controls. The 12-item Ocular Surface Disease Index (OSDI) questionnaire was administered to all patients. Both eyes affected by Hashimoto's thyroiditis and normal eyes were evaluated and compared with regard to the following parameters: Hertel exophthalmometry, palpebral fissure height, tear-film breakup time (TBUT), Schirmer 1 test, area and density scores for corneal fluorescein staining, eyelid abnormality, meibomian gland expression, meibography scores, and areas of meibomian gland loss.

RESULTS

The eyes affected by Hashimoto's thyroiditis demonstrated significantly lower TBUTs (P<0.001), Schirmer 1 test scores (P<0.001), and meibomian gland expression (P<0.05) and significantly higher OSDI scores (P<0.001), corneal fluorescein staining results (P<0.05), eyelid abnormality scores (P<0.05), meibography scores (P<0.05), and areas of meibomian gland loss (P<0.05). Ocular Surface Disease Index scores were significantly positively correlated with eyelid abnormality scores (P=0.025), meibography scores (P<0.05), and areas of meibomian gland loss (P<0.05) and negatively correlated with meibomian gland expression (P<0.05). The duration of Hashimoto's thyroiditis was significantly positively correlated with MGD (P<0.05).

CONCLUSION

Dry eye syndrome and ocular discomfort symptoms are significantly more common among patients with Hashimoto's thyroiditis, even in the absence of thyroid ophthalmopathy. Dry eye syndrome in patients with Hashimoto's thyroiditis is believed to result from MGD and is correlated with the duration of the thyroid disease.

Tear inflammatory cytokines and ocular surface changes in patients with active thyroid eye disease treated with high-dose intravenous glucocorticoids

PURPOSE

To evaluate high-dose intravenous glucocorticoid treatment on tear inflammatory cytokines and ocular surface parameters in patients with active TED. Correlations between tear inflammatory cytokines and clinical parameters were also investigated.

METHODS

This prospective pilot study included 15 moderate-to-severe and active TED patients. Control group consist of 15 sex and age-matched healthy subjects. All TED patients were treated with high-dose intravenous methylprednisolone with cumulative dose of 4.5 g during the therapy subdivided into 12 weekly infusions. Tear concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-17A, tumor necrosis factor (TNF)-α, and vascular endothelial growth factor (VEGF) were measured by multiplex bead analysis in TED patients at baseline and 12 weeks after treatment. Ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescent staining, and Schirmer's test were obtained from TED and controls.

RESULTS

All baseline cytokine levels except for IL-17A were significantly elevated in active TED patients compared with controls. Concentrations of IL-1β, IL-6, IL-8, TNF-α, and VEGF were significantly decreased at 12 weeks compared with baseline. OSDI and TBUT showed significant improvement at 6 and 12 weeks. There were significant positive correlations between IL-6, IL-8, and CAS, and negative correlation was found between IL-6 level and TED duration before methylprednisolone treatment. The reduction of IL-6, IL-8, and VEGF were positive correlated with the reduction in CAS at 12 weeks.

CONCLUSIONS

High-dose glucocorticoids treatment improved ocular surface symptom, increased the tear film stability, and decreased tear inflammatory cytokines in active TED. The reduction of the inflammatory cytokines is consistent with the improvement of clinical parameters.

In Vivo Confocal Microscopy Morphometric Analysis of Meibomian Glands in Patients With Graves Ophthalmopathy

PURPOSE

To characterize meibomian glands (MGs) features in patients with Graves ophthalmopathy (GO) by in vivo confocal microscopy (IVCM) and to further investigate possible correlations with ocular surface characteristics.

METHODS

Consecutive patients with GO and controls were enrolled. The following ocular surface parameters were measured: tear break-up time, Schirmer test, and corneal fluorescein staining (Oxford score) were performed on each subject. IVCM of MGs was performed, and the scans were analyzed with ImageJ software for the calculation of the following: acinar unit density, total gland area, total lumen area (TLA), acinar longest diameter, and acinar shortest diameter. A nonparametric Mann-Whitney U test was used to compare variables between patients with GO and controls. The Spearman correlation analysis was used to evaluate the correlations between ocular surface and IVCM parameters.

RESULTS

Twenty-one patients with GO and 24 sex- and age-matched healthy controls were included. Acinar unit density was significantly lower in patients with GO compared with controls (24.5 ± 8.1 vs. 34.2 ± 7.5 U/mm; P < 0.001). In addition, patients with GO showed significantly higher values of TLA, acinar longest diameter, and acinar shortest diameter compared with controls (respectively, 3104.7 ± 1713.3 vs. 1393.8 ± 448.0 μm, 94.4 ± 21.2 vs. 64.3 ± 10.1 µm and 56.6 ± 15.3 vs. 42.2 ± 12.3 μm; always P < 0.05). In patients with GO, TLA showed a significant inverse correlation with Schirmer test (Rs = -0.467; P = 0.038).

CONCLUSIONS

IVCM allowed to detect distinctive features of MGs in patients with GO and could represent a surrogate tool for the assessment of MG status in these patients.

Determination of Tear Lipid Film Thickness Based on a Reflected Placido Disk Tear Film Analyzer

This study aims at determining the thickness of the tear lipid layer (LL) observed from a placido-disc-based tear film analyzer. We prospectively collected reflections of placido-disk LL images using a tear film analyzer (Keratograph^® 5M, Oculus) from subjects with dry eye symptoms. The LL thickness (LLT) over the inferior half of the cornea was estimated with the use of interference color analysis and the preprocessing of images with and without ring segmentation were obtained and analyzed. Moreover, LLTs before and after 1 h of applying topical ointment (Duratears, Alcon) were compared to validate the estimation of LLT. Our results suggested that the tear LLT can be assessed using a placido-disk-based tear film analyzer and interference color analysis. We verified a high correlation between non-segmented and segmented LL images and estimated LLT increase after applying ointment. In addition, we concluded that LLT can be evaluated by direct interference analysis without segmentation preprocessing.

Effects of Preservative-free 3% Diquafosol in Patients with Pre-existing Dry Eye Disease after Cataract Surgery: A Randomized Clinical Trial

Dry eye disease (DED) after cataract surgery has become a critical concern, and various therapeutic options have been developed. Recently, preservative-free diquafosol ophthalmic solution has been introduced; however, its therapeutic effect on DED after cataract surgery has not been reported. We investigated the efficacy of preservative-free diquafosol in patients with pre-existing DED after cataract surgery. We divided subjects who were diagnosed with DED and scheduled to undergo cataract surgery, into 3 groups (preservative-free diquafosol, group 1; preservative-containing diquafosol, group 2; preservative-free hyaluronate, group 3), and each eye drops was administered 6 times daily after surgery. Tear break up time (TBUT), Ocular Surface Disease Index (OSDI), corneal staining score, lid margin abnormality, and meibum quality improved over time in group 1. Groups 1 and 2 had significantly superior TBUT, meibomian gland dysfunction grade, and meibomian gland expressibility throughout the study period than group 3. Meibum quality of group 1 was significantly better than group 2 at 1 and 3 months after surgery. Preservative-free diquafosol showed better efficacy in treating DED after cataract surgery than preservative-containing diquafosol or preservative-free hyaluronate. Preservative-free diquafosol may serve as a reliable option for the management of patients with pre-existing DED after phacoemulsification.

Effects of Preservative-free 3% Diquafosol in Patients with Pre-existing Dry Eye Disease after Cataract Surgery: A Randomized Clinical Trial

Dry eye disease (DED) after cataract surgery has become a critical concern, and various therapeutic options have been developed. Recently, preservative-free diquafosol ophthalmic solution has been introduced; however, its therapeutic effect on DED after cataract surgery has not been reported. We investigated the efficacy of preservative-free diquafosol in patients with pre-existing DED after cataract surgery. We divided subjects who were diagnosed with DED and scheduled to undergo cataract surgery, into 3 groups (preservative-free diquafosol, group 1; preservative-containing diquafosol, group 2; preservative-free hyaluronate, group 3), and each eye drops was administered 6 times daily after surgery. Tear break up time (TBUT), Ocular Surface Disease Index (OSDI), corneal staining score, lid margin abnormality, and meibum quality improved over time in group 1. Groups 1 and 2 had significantly superior TBUT, meibomian gland dysfunction grade, and meibomian gland expressibility throughout the study period than group 3. Meibum quality of group 1 was significantly better than group 2 at 1 and 3 months after surgery. Preservative-free diquafosol showed better efficacy in treating DED after cataract surgery than preservative-containing diquafosol or preservative-free hyaluronate. Preservative-free diquafosol may serve as a reliable option for the management of patients with pre-existing DED after phacoemulsification.

Dry eye syndrome in thyroid eye disease patients: The role of increased incomplete blinking and Meibomian gland loss

PURPOSE

To compare the structure and function of the Meibomian gland and eyelid blinking patterns between thyroid eye disease (TED) patients with dry eye and nonthyroidal dry eye (DE) patients.

METHODS

This was a prospective, cross-sectional and observational study. Clinical measurements were performed as follows: (1) external examination, (2) Lipiview^® Interferometer (lipid layer thickness, incomplete blinking rate and meibography) and (3) slit-lamp biomicroscopy (corneal staining, tear break-up time (TBUT), meibum expression).

RESULTS

The TED and DE groups included 98 and 62 patients, respectively. The meiboscores of the upper eyelid in TED and DE groups were significantly different (1.21 ± 0.76 and 0.94 ± 0.71, respectively, p = 0.046). The rate of incomplete blinking was 53.3 ± 34.5 and 34.6 ± 36.3%, respectively, and was significantly higher in the TED group (p = 0.006). In the TED group, CAS was the only variable affecting the meiboscore of the upper and lower eyelids (p = 0.031, 0.039, respectively). Significantly, active TED patients had more decreased basal tear secretion than inactive TED patients (7.4 ± 2.1 mm versus 8.5 ± 1.5 mm, p = 0.024). Moreover, active TED patients had decreased meibum expression in both upper and lower eyelids compared with inactive TED patients (2.20 ± 0.88 versus 1.08 ± 0.84, p = 0.002 in upper eyelid, 2.10 ± 0.88 versus 1.18 ± 0.88, p = 0.007 in lower eyelid, respectively).

CONCLUSION

In TED patients, incomplete blinking and loss of Meibomian gland structure in the upper eyelid were more prominent than in DE patients. CAS was a factor affecting the structural loss of Meibomian glands in TED individuals.

[Modified meibography in malignant eyelid tumors of epithelial origin]

INTRODUCTION

Eyelid tumors can be diagnosed using various diagnostic techniques. However, capability of existing methods for determining the type and margins of the tumor at the preoperative stage remains insufficiently studied.

PURPOSE

To improve the noncontact infrared meibography technique and determine its diagnostic capabilities for studying structural changes in meibomian glands in malignant eyelid tumors of epithelial origin.

MATERIAL AND METHODS

The study included 49 people (66 eyelids), among which 21 (21 eyelids) with malignant eyelid tumors, 11 - with benign eyelid tumors (11 eyelids), and 17 (34 eyelids) comprised the control group. The mean age of patients was 64.8±1.56 years. Meibomian glands of the lower eyelids were photographed in infrared light. Receiver-operating characteristic (ROC) curves were constructed to estimate the sensitivity and specificity of the method.

RESULTS

Modified meibography showed 100% sensitivity and 90% specificity in the differential diagnosis of malignant and benign eyelid tumors in 32 patients. Unlike other methods, the modified meibography technique can clarify the margins of tumor growth, which is considered when planning the resection volume.

CONCLUSION

Modified meibography can indicate the margins of tumor invasion; it can be successfully used in the differential diagnostics of malignant eyelid tumors of epithelial origin and benign eyelid tumors.