Topical Cyclosporine in Thyroid Orbitopathy-Related Dry Eye: Clinical Findings, Conjunctival Epithelial Apoptosis, and MMP-9 Expression

Systematic review of ocular surface treatments in the setting of thyroid eye disease

Introduction

Approximately 85% of patients with thyroid eye disease experience ocular surface symptoms. Although corneal exposure plays a role in inducing inflammatory changes to the ocular surface, multiple studies reveal more complexity to the abnormal tear film composition and parameters in thyroid eye disease patients including those who do not have proptosis or increased corneal exposure. Currently, a majority of cases of thyroid associated dry eye symptoms are given treatments intended for ocular surface disease arising from different etiologies.

Methods

Medline via Ovid, Cochrane CENTRAL, PubMed, and Google Scholar were systematically searched for articles evaluating the efficacy of treatments for dry eye symptoms in patients with thyroid eye disease. Articles were from all geographic regions and dates ranged from inception until October 2023.

Results

Seven papers ultimately met inclusion criteria and were included in this review. These papers revealed that multiple topical and non-topical treatment modalities address dry eye symptoms in thyroid eye disease and improve subjective and objective ocular surface parameters. However, due to the few studies that exist and due to disparities in sample size and study design, no overwhelming best practices were identified that could influence clinical practice.

Conclusion

This systematic review identifies the current treatments that exist and highlights the clear unmet need for a large population suffering with dry eye symptoms. Ideally, further well-designed investigations into this area would target topical, non-invasive modalities to develop first line options for thyroid eye disease patients.

Risk Factors for Ocular Surface Irritation Symptoms in Inactive Mild and Moderate-to-Severe Graves' Orbitopathy

INTRODUCTION

This study aims to analyze risk factors for ocular surface irritation symptoms in patients with non-corneal-damage inactive mild and moderate-to-severe Graves' orbitopathy (GO).

METHODS

This retrospective study enrolled 307 patients with non-corneal-damage inactive GO admitted to Sun Yat-sen Memorial Hospital from April 2017 to September 2023. The activity and severity of GO were evaluated using the Clinical Activity Score (CAS) and the European Group on Graves' Orbitopathy (EUGOGO) classification, respectively. Multivariate logistic regression analysis was performed to analyze risk factors for ocular surface irritation symptoms.

RESULTS

Among patients with inactive GO, for mild cases, CAS (P < 0.001), upper eyelid lag (P = 0.049), and extraocular muscle involvement (P = 0.019) in the symptomatic group were greater than those in the asymptomatic group, and multivariate logistic regression analysis demonstrated that upper eyelid lag (P = 0.048), CAS 1 (P < 0.001), CAS 2 (P = 0.005), and extraocular muscle involvement (P = 0.029) were risk factors for ocular surface irritation symptoms; for moderate-to-severe cases, CAS (P = 0.004), extraocular muscle involvement (P < 0.001), marginal reflex distance 1 (MRD1) (P = 0.030), and thyroid-stimulating hormone (TSH) (P = 0.034) in the symptomatic group were greater than those in the asymptomatic group, while multivariate logistic regression analysis indicated that extraocular muscle involvement (P = 0.018) and MRD1 (P = 0.012) were risk factors for ocular surface irritation symptoms.

CONCLUSION

In non-corneal-damage inactive mild and moderate-to-severe GO, eyelid malposition and periocular muscle inflammation are risk factors for ocular surface irritation symptoms.

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

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.

A clinical study of topical treatment for thyroid-associated ophthalmopathy with dry eye syndrome

INTRODUCTION

Clinically, thyroid-associated ophthalmopathy (TAO) patients were suffered from dry eye syndrome. Only a few relevant studies were about this topic. Our study was determined to provide high-level evidence for the treatment of TAO with dry eye syndrome.

PURPOSE

To compare the clinical effects of vitamin A palmitate eye gel and sodium hyaluronate eye drop forTAO patients with dry eye syndrome.

METHODS

The study was conducted in the Ophthalmology Department of the Ninth People's Hospital Affiliated with the Medical College of Shanghai Jiao Tong University from May to October 2020. A total of 80 mild or moderate-to-severe TAO patients with dry eye syndrome were randomly divided into two groups. The disease stages of all subjects were inactive. Patients in group A were treated with vitamin A palmitate eye gel three times/day for one month and sodium hyaluronate eye drop in group B. The index including break-up time (BUT) and Schirmer I test (ST), corneal fluorescence staining (FL), ocular surface disease index (OSDI), and adverse reactions were recorded by the same clinician at baseline and 1 month after treatment. The data were analyzed by SPSS 24.0.

RESULTS

Finally, 65 subjects completed the treatment. The average age of the patients in Group A was 38.1 ± 11.4 years, and that in Group B was 37.26 ± 10.67 years. 82% of the subjects in group A were female and 74% in group B. There was no significant difference between the two groups at baseline, including the value of ST, BUT, OSDI, and FL grade. After the treatment, the effective rate was 91.2% in group A, of which the value of BUT and FL grade was significantly improved (P < 0.001). The effective rate in group B was 67.7%, of which the value of OSDI score and FL grade was significantly improved (P = 0.002). In addition, the BUT value of group A was significantly longer than that of group B (P = 0.009).

CONCLUSION

InTAO patients with dry eye syndrome, vitamin A palmitate gel and sodium hyaluronate eye drop improved the dry eye and promoted corneal epithelial repair. Vitamin A palmitate gel improves the stability of tear film, while sodium hyaluronate eye drop improves patients' subjective discomfort.

A randomized multicenter evaluation of the efficacy of 0.15% hyaluronic acid versus 0.05% cyclosporine A in dry eye syndrome

Hyaluronic acid (HA) and cyclosporine A (CsA) eyedrops are commonly prescribed in dry eye syndrome (DES). The effectiveness of each preparation in DES is well-known, yet the superiority of one over another has been studied little. We assessed the efficacy and tolerability of 0.15% HA compared to combinations of 0.05% CsA plus 0.5% carboxymethylcellulose (CMC), and 0.15% HA plus 0.05% CsA in patients with moderate to severe DES. Total 438 patients with moderate to severe DES were recruited and randomized for one of the three treatments for 12 weeks. Effectiveness was assessed at baseline, 4- and 12-weeks. The primary endpoint was change in corneal staining score. The secondary endpoints were tear break-up time (TBUT), strip meniscometry (SM) score, ocular surface disease index (OSDI) score, and tolerability questionnaire. The change in corneal staining score for 0.15% HA from the baseline was non-inferior to that of 0.05% CsA. Corneal staining score, TBUT, SM score, and OSDI score improved in all groups without statistically significant intergroup differences. Better tolerability and lower prevalence of adverse drug reactions were seen in 0.15% HA. Our findings suggest that 0.15% HA may be equivalently effective and safer than 0.05% CsA in treating moderate to severe DES.

Comparative Clinicopathological Evaluation of the Ocular Surface in Newly Diagnosed Patients of Hyperthyroidism and Hypothyroidism Compared to Healthy Subjects

Introduction Thyroid eye disease is a multifactorial disorder affecting the tear film and ocular surface, which leads to dry eye. The aim of the study is to evaluate the tear function test and ocular surface changes clinically and to correlate pathologically using impression cytology in recently diagnosed cases of thyroid dysfunction, including both hyperthyroid and hypothyroid patients, and to compare the results with healthy subjects. Methods This was a cross-sectional analytical study. Thirty diagnosed patients with hyperthyroidism and hypothyroidism, each within three months, and 30 healthy age-matched controls were included. All patients and controls underwent an assessment of proptosis, palpebral fissure height (PFH), tear function test, Ocular Surface Disease Index (OSDI) questionnaire, Schirmer's test, tear break-up time (TBUT), and impression cytology for ocular surface assessment. These parameters were compared between cases and controls. Standard statistical analysis was used. Results Mean proptosis and PFH showed no significant difference among groups (P-value = .071). The mean value of OSDI was 42.33+22.67, 41.15+16.03, and 29.33+6.84 in the hyperthyroid, hypothyroid, and controls groups, respectively; the difference being statistically significant (p=0.001). Mean TBUT was 7.13+3.28 sec, 6.38+2.46 sec, and 11.15+2.39 sec in hyperthyroidism, hypothyroidism, and controls, respectively (p=0.001). The mean value of the Schirmer tear test was 12.93+5.81 mm, 13.30+4.44 mm, and 17.55+7.35 mm in hyperthyroidism, hypothyroidism, and controls, respectively (p=0.001). Eighty percent (80%) of patients in the hyperthyroidism group had grade 2-3 squamous metaplasia as compared to 70% in hypothyroidism patients and 24.4% in controls, signifying ocular surface damage (p<0.05). Conclusions The mean PFH and proptosis did not differ between the three groups. However, increased OSDI score, decreased Schirmer's test value, decreased TBUT, and grades 2-3 squamous metaplasia in patients with thyroid dysfunction suggest the presence of dry eyes. Despite no clinically visible signs of thyroid ophthalmopathy, there is ocular surface damage right from the early stages of thyroid dysfunction, possibly attributable to the evaporative mechanism as well as ocular surface inflammation and instability of the tear film.

Changes in Eyelid Pressure and Dry Eye Status after Orbital Decompression in Thyroid Eye Disease

The aim of this prospective observational study was to examine changes in eyelid pressure and dry eye status after orbital decompression in thyroid eye disease (TED). In 16 patients (29 sides), upper eyelid pressure at plateau phase and maximum pressure were measured. TED status was evaluated through the Hertel exophthalmometric value and margin reflex distance (MRD)-1 and 2. Dry eye status was quantified through corneal fluorescein staining, tear break-up time, Schirmer test I results, meibomian gland dysfunction (MGD), tear meniscus height, and superior limbic keratoconjunctivitis (SLK). Patients were classified into two groups: patients with decreased eyelid pressure (Group 1) and those with elevated pressure (Group 2). Consequently, neither the maximum upper eyelid pressure nor pressure at plateau phase significantly changed after surgery (p > 0.050). Some parameters about MGD improved after surgery, but the other parameters on dry eye, MGD, and SLK worsened or did not change. MRD-1 decreased more (p = 0.028), and the ratio of patients in whom SLK improved after surgery was larger in Group 1 (p = 0.030). These results indicate that upper eyelid pressure tends to decrease postoperatively in patients with a high upper eyelid position, resulting in improvement of SLK.

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.

Inhibition of matrix metalloproteinase-9 for the treatment of dry eye syndrome; a review study

Dry eye syndrome (DES) and tear dysfunction are multifactorial conditions affecting meibomian glands, lacrimal glands, and ocular surface. This ocular disorder can cause eye irritation, irregular cornea, corneal barrier disruption, and blurred vision. Uncontrolled increase in matrix metalloproteinase-9 (MMP-9) level and activity has been detected in the tears and ocular surface in the patients with DES, which has been proved to be related to disruption of tight junctions in apical corneal epithelium associated with severe signs of DES. These uncontrolled activities of MMP-9 lead to desquamation of ocular surface epithelia. Therefore, this review study was conducted to summarize the evidence regarding MMP-9 contribution in DES, and inhibition of MMP-9, as a therapeutic target for treatment of DES. For this purpose, herein, the related studies designed novel pharmaceutical compounds for direct and indirect inhibition of MMP-9 as treatment approaches for DES were reviewed. These compounds were designed to improve corneal barrier function, reduce inflammation on ocular surface, and restore tear production.

The negative effects of dry eye disease on quality of life and visual function

In recent years, dry eye has become a hot topic within ophthalmology and optometry, especially in regards to new frontiers in treatment modalities which include novel devices, procedures, and medications. However, some of the more understudied areas in dry eye involve its impact on quality of life. Although ocular discomfort symptoms are well known to be associated with dry eye, its negative effects on visual function remain underrecognized. This paper reviews these topics within the currently published literature to heighten awareness among clinicians. Key Words: D ry eye, quality of life, visual function, functional visual acuity, patient questionnaire, OSDI, SPEED, SANDE, IDEEL, NEI VFQ-25

Progress in the pathogenesis of thyroid-associated ophthalmopathy and new drug development

Thyroid-associated ophthalmopathy (TAO) is the most common extrathyroidal manifestation of toxic diffuse goiter (Graves' disease), also known as Graves' ophthalmopathy/orbitopathy. As an organ-specific autoimmune disease, the pathogenesis of TAO is still unclear. In recent years, great progress has been made in revealing the mechanism of TAO. Various biological and immunosuppressive agents have emerged in an endless stream, showing encouraging results. Strengthening the basic research, establishing ideal animal models, deeply understanding the pathogenesis, and developing novel targeted drugs are of great significance to guide the clinical diagnosis and management of TAO and improve the prognosis of patients.

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.

An assessment of the ocular tear film in patients with thyroid disorders

Objective: To investigate the ocular tear film in patients with thyroid disorders using various tests. Methods: The study involved the assessment of the ocular tear film in 20 patients with thyroid disorders (6 men and 14 women) aged 18-43 years (mean±standard deviation=34.3±3.2 years). An age-matched control group consisting of 20 subjects (8 males and 12 females) ranging in age from 18 to 43 years (31.3±2.9 years) was also examined under similar conditions. All patients completed the Ocular Surface Disease Index questionnaire, followed by the tear ferning test within the right eye. A phenol red thread test was carried out 10 mins later followed by the fluorescein tear break-up test with a 10-min gap between the tests being implemented. Results: The median score for the Ocular Surface Disease Index (P<0.05) showed the condition of mild dry eyes [median (IQR)=15.5 (21.9)] in patients with thyroid disorders compared to the control group [5.6 (3.6)]. The mean score for the phenol red thread test within both the right and left eyes showed acceptable tear volumes of 11.7±8.1 and 10.5±7.4 mm, respectively, but this was much lower (P<0.05) compared to those recorded within the control group (22.2±6.5 and 20.7±5.2 mm, respectively). In addition, the mean for the tear break-up time (P<0.05) scores in both eyes within the patients with thyroid disorders revealed a certain degree of eye dryness (4.9±1.6 and 4.2±1.9 s), while the control group showed normal eye scores (13.2±2.6 and 12.3±2.2 s). The median score for tear ferning grades showed eye dryness [2.0 (2.2)] within the study group and normal eyes [1.2 (0.9)] within the control group. Conclusions: Patients with thyroid disorders have a significant level of eye dryness compared to normal eye subjects.

TFOS DEWS II pathophysiology report

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.

Dry Eye Management: Targeting the Ocular Surface Microenvironment

Dry eye can damage the ocular surface and result in mild corneal epithelial defect to blinding corneal pannus formation and squamous metaplasia. Significant progress in the treatment of dry eye has been made in the last two decades; progressing from lubricating and hydrating the ocular surface with artificial tear to stimulating tear secretion; anti-inflammation and immune regulation. With the increase in knowledge regarding the pathophysiology of dry eye, we propose in this review the concept of ocular surface microenvironment. Various components of the microenvironment contribute to the homeostasis of ocular surface. Compromise in one or more components can result in homeostasis disruption of ocular surface leading to dry eye disease. Complete evaluation of the microenvironment component changes in dry eye patients will not only lead to appropriate diagnosis, but also guide in timely and effective clinical management. Successful treatment of dry eye should be aimed to restore the homeostasis of the ocular surface microenvironment.

Clinical utility of cyclosporine (CsA) ophthalmic emulsion 0.05% for symptomatic relief in people with chronic dry eye: a review of the literature

To review the literature on the efficacy of cyclosporine (CsA) ophthalmic emulsion 0.05% on symptomatic relief in chronic dry eye disease. There is consistent evidence of objective improvements in chronic dry eye disease (Schirmer score, corneal and interpalpebral dye staining, and tear breakup time) with CsA, but variable results with symptomatic improvement, possibly due to patient tolerance of CsA, similar comforting effect with artificial tears and CsA vehicle, and the inherent subjective nature of symptom monitoring and analysis. This review explores the literature on CsA with special attention to symptomatic relief.

Very Low Prevalence of Keratoconus in a Large Series of Vernal Keratoconjunctivitis Patients

PURPOSE

To evaluate the prevalence of keratoconus (KC) and other corneal abnormalities by means of videokeratography and tomography in a large series of patients affected by vernal keratoconjunctivitis (VKC).

DESIGN

Cross-sectional study.

METHODS

Setting: Single-center children's hospital.

STUDY POPULATION

A total of 651 consecutive patients with VKC and a control group of 500 were prospectively recruited between May 1, 2012 and September 30, 2013, with a minimum follow-up of 12 months.

OBSERVATION PROCEDURE

All patients were evaluated by means of a Scheimpflug camera combined with a Placido corneal topographer. Keratoconus, suspected keratoconus, or its absence were determined in each patient. The corneal symmetry index of front (SI_f) and back curvature (SI_b), shape indices, and thicknesses were compared between the 2 groups.

MAIN OUTCOME MEASURES

Prevalence of keratoconus and corneal indices modifications.

RESULTS

Five out of 651 patients (0.77%) demonstrated topographic signs of KC. Two of them were bilateral. All patients were older than 7 years of age, and the mean age was 11.54 years. Four other patients (0.61%) were classified as KC suspects by the screening program. Of 304 patients older than 11 years (mean age 14.4 years), 4 (1.32%) were found to have KCN, and 4 (1.32%) were KC suspects. The corneal indices of patients in the VKC group were extremely similar to those in the control group. (P > .05).

CONCLUSIONS

The prevalence of KC in our patient population, compared with previous reports in the literature, is much lower. The similar corneal indices in both groups suggest the absence of permanent corneal deformation due to VKC.

Thyroid eye disease: a review

Thyroid eye disease is a multifactorial autoimmune disease with a spectrum of signs and symptoms. Oftentimes, the diagnosis of thyroid eye disease is straightforward, based upon history and physical examination. The purpose of this review is to assist the eye-care practitioner in staging the severity of thyroid eye disease (mild, moderate-to-severe and sight-threatening) and correlating available treatment modalities. Eye-care practitioners play an important role in the multidisciplinary team by assessing functional vision while also managing ocular health.

Matrix Metalloproteinase 9 Testing in Dry Eye Disease Using a Commercially Available Point-of-Care Immunoassay

PURPOSE

To measure matrix metalloproteinase 9 (MMP-9) in the tear film of patients with dry eye disease (DED) compared with controls and to correlate clinical findings.

DESIGN

In a prospective study, 101 patients and controls underwent MMP-9 testing of the tear film. Thereafter, they were evaluated for symptoms and signs of DED.

PARTICIPANTS

Included patients were those who showed 3 of the following 4 dry eye criteria: ocular surface disease index (OSDI) score of more than 12, tear film break-up time (TBUT) of 10 seconds or less, Schirmer test results without anesthesia of less than 10 mm/5 minutes, and corneal staining results of 1 or more. Fifty-four healthy eyes and 47 eyes fulfilling diagnostic criteria for DED of various levels of severity were included in this study.

METHODS

The tear film was analyzed for MMP-9 by a commercially available test (InflammaDry; Rapid Pathogen Screening, Inc, Sarasota, FL) detecting MMP-9 levels of more than 40 ng/ml. Symptoms and signs of DED were evaluated using the OSDI questionnaire, TBUT, conjunctival and corneal staining, Schirmer test results without anesthesia, and meibomian gland examination. These findings were correlated to results of the MMP-9 test in tears.

MAIN OUTCOME MEASURES

Positive MMP-9 results in tears.

RESULTS

In 19 of 47 patients confirmed with dry eye (40.4%) and in 3 of 54 controls (5.6%), the MMP-9 results were positive. This difference was statistically significant (P < 0.001). Thus, the MMP-9 results indicated a clinically significant inflammation in 40% of dry eye patients. Positive results correlated well with subjective symptoms of DED evaluated by OSDI (P = 0.001), TBUT of less than 5 seconds (P < 0.013), Schirmer test results (P < 0.001), conjunctival staining (P < 0.001), and corneal staining (P = 0.007). Moreover, MMP-9 results correlated with the number of obstructed meibomian ducts (P = 0.005) and a pathologic meibomian gland secretion (P = 0.001). The MMP-9 results were increased significantly in women (P < 0.001) and in patients with autoimmune disease (P = 0.005), especially Sjögren's syndrome (P = 0.001) and thyroid disease (P = 0.012).

CONCLUSIONS

Matrix metalloproteinase 9 testing in DED is a valuable new diagnostic tool. It correlated well with other dry eye tests and identified the presence of ocular surface inflammation in 40% of confirmed dry eye patients. It may be especially helpful to identify patients with ocular surface inflammation and autoimmune disease and may facilitate the decision to institute anti-inflammatory treatment in these patients.

The Matrix Metalloproteinase 9 Point-of-Care Test in Dry Eye

Dry eye is a common, multifactorial disease currently diagnosed by a combination of symptoms and signs. However, the subjective symptoms of dry eye poorly correlate to the current gold standard for diagnostic tests, reflecting the need to develop better objective tests for the diagnosis of dry eye. This review considers the role of ocular surface matrix metalloproteinase 9 (MMP-9) in dry eye and the implications of a novel point-of-care test that measures MMP-9 levels, InflammaDry (RPS, Sarasota, FL) on choosing appropriate therapeutic treatments.

Correlation of Tear Film Osmolarity and 2 Different MMP-9 Tests With Common Dry Eye Tests in a Cohort of Non-Dry Eye Patients

PURPOSE

Given that early-stage dry eye is difficult to diagnose, the purpose of this study was to evaluate the performance of matrix metalloproteinase 9 (MMP-9) and tear film osmolarity (TFO) in a cohort of elderly patients with potential dry eye disease (DED).

METHODS

A group of 20 patients, aged 60 years and above, previously undiagnosed with DED were selected. The following DED tests were performed: tear osmolarity, MMP-9 (InflammaDry), Schirmer test, tear film break-up time, Ocular Surface Disease Index (OSDI) questionnaire, corneal fluorescein staining, and conjunctival lissamine green staining. MMP-9 concentrations in tears collected through Schirmer strips were analyzed by an MMP-9 enzyme-linked immunosorbent assay [ELISA]. Subjects were classified by symptoms (classification A: OSDI ≥10, n = 9), based on suspected mild dry eye (classification B: n = 14), TFO difference >8 mOsm/L between both eyes (classification C: n = 13), and TFO cutoff at 308 mOsm/L (classification D: >308 mOsm/L, n = 11).

RESULTS

Eleven percent (1/9) of the symptomatic and 14% (2/14) of the suspected mild dry eye were positive for MMP-9. InflammaDry MMP-9 tests were confirmed to be accurate through an ELISA. Sixty-seven percent (6/9) of the symptomatic and 64% (9/14) of the suspected mild dry eye were positive for tear osmolarity. None of the evaluated tear film parameters showed a significant correlation, although tear osmolarity and symptoms trended toward significance (r = 0.433, P = 0.06), whereas MMP-9 and corneal staining showed a positive association (r = 0.376, P = 0.10).

CONCLUSIONS

Similar to corneal staining, the MMP-9 is likely a late-stage sign that is rarely overexpressed in mild subjects, whereas tear osmolarity tends to be a more frequent early indicator of ocular surface disequilibrium within mild subjects.

Observation of Corneal Langerhans Cells by In Vivo Confocal Microscopy in Thyroid-Associated Ophthalmopathy

PURPOSE

To examine the density and morphology of Langerhans cells (LCs) in the cornea of patients with thyroid-associated ophthalmopathy (TAO).

METHODS

Forty patients with TAO and 20 healthy volunteers were studied. All subjects underwent a thorough ophthalmic examination of both eyes. The ocular surface status was assessed by Ocular Surface Disease Index (OSDI) symptom questionnaires, tear break-up time (BUT), fluorescein staining and the Schirmer test. Laser scanning in vivo confocal microscopy was applied to evaluate the LC density and morphology in both central and peripheral cornea. The correlations between confocal microscopy data and clinical data were also analyzed.

RESULTS

The OSDI and fluorescein staining values were significantly higher, while BUT and Schirmer test scores were lower in both active and inactive TAO patients compared to the controls. Central LC densities of patients with active TAO (76.38 ± 67.77 cell/mm(2)) and inactive TAO (47.49 ± 38.58 cell/mm(2)) were both significantly higher than those of the controls (21.46 ± 21.74 cell/mm(2)). The number of LCs in the peripheral cornea was also significantly increased in the active TAO group (131.53 ± 74.18 cell/mm(2)) compared to the control group (70.21 ± 37.76 cell/mm(2)). Central LC morphology (LCM) values were significantly higher in both active (1.77 ± 0.63) and inactive (1.51 ± 0.63) TAO groups compared to the control group (1.01 ± 0.80), whereas peripheral LCM scores of the two TAO groups were increased without statistical significance. There were significant correlations between both central LC density and central LCM scores and clinical data, including clinical activity score, OSDI and Schirmer test scores, and between peripheral LC density and OSDI and Schirmer test scores. No significant correlations were found between peripheral LCM scores and clinical data.

CONCLUSIONS

The increase of corneal LCs in density and maturation in patients with TAO reflects an activated state of the local immune system, which indicates an inflammatory process in the cornea of TAO.

The relationship between Graves' ophthalmopathy and dry eye syndrome

Background

A complex relationship between Graves’ ophthalmopathy (GO) and dry eye syndrome exists. New research brings more insight into the association between these two diseases.

Methods

A review of the literature was conducted using the query terms “Graves’ Ophthalmopathy”, “Thyroid Eye Disease”, and “Dry Eye” in MedLine (PubMed) and Scopus. A total of 55 papers were reviewed. Case reports were excluded.

Conclusion

This review paper shows the close relationship between dry eye syndrome and GO. The underlying mechanisms behind their association suggest mechanical impairment of orbital muscles and immune-mediated lacrimal gland dysfunction as the causes of dry eye in GO patients. However, there are a variety of treatment options available for patients with GO with signs of dry eye, which help combat this issue.

The role and treatment of inflammation in dry eye disease

Dry eye syndrome is a common ocular surface problem, affects 10-30 % of the population, especially in those who are older than 40 years. As a consequence of the demographic pressure created by the aging population, its prevalence is expected to increase as well as its burden on ophthalmologic practices. Thus, understanding the complex underlying mechanisms and development of thoughtful, effective strategies that involve these mechanisms are critical. Many factors causing ocular surface damage and inflammation have been shown to contribute to the etiopathogenesis. Increased osmolarity induces ocular surface inflammation leading to disruption of both the quality and quantity of tears. Pathologic tear function and the ocular surface inflammation affects the neural arcade and increases apoptosis in the ocular surface cells thus creating a viscous cycle for dry eye by causing unstable and hyperosmolar tears. Thus, the treatment objective is to prevent severe dry eye complications via preventing inflammation and apoptosis of the ocular surface cells. The ultimate target is a normalized ocular surface, increased tear stability, and decreased osmolarity of the tear film. In the light of current literature, this review aims to elucidate the role of inflammation as the main etiological factor in dry eye disease and discuss current therapeutic approaches to overcome it.

In vivo confocal microscopy of bulbar conjunctiva in patients with Graves' ophthalmopathy

BACKGROUND/PURPOSE

To investigate the bulbar conjunctival changes in patients with Graves' ophthalmopathy (GO) using in vivo confocal microscopy.

METHODS

A total of 15 GO patients and 15 control patients were recruited. Images of the superior site and temporal bulbar conjunctivas were taken by the Heidelberg Retina Tomograph/Rostock Corneal Module. The conjunctival thickness and cell density of superior epithelium, basal epithelium, Langerhans cells, and goblet cells were analyzed. Conjunctival impression cytology was performed to assess the grading of squamous metaplasia of the conjunctival epithelium.

RESULTS

The superficial epithelial cell density in the superior bulbar conjunctiva of the GO group was 856.93 ± 461.68 cells/mm(2), which was significantly lower than that in the control group (1581.13 ± 556.34 cells/mm(2); p = 0.002). However, the difference in superficial epithelial cell density in the temporal bulbar conjunctiva between the two groups was not statistically significant. No significant differences in conjunctival thickness and the basal epithelial cell density were noted between the two groups. Increased Langerhans cell density and reduced goblet cell density were noted in the GO group. Impression cytology of the conjunctival epithelium revealed significantly higher degree of squamous metaplasia in the GO group. The superficial epithelial cell density in the upper bulbar conjunctiva showed negative correlation with marginal reflex distance in the GO group.

CONCLUSION

GO patients suffered from more severe bulbar conjunctival damage and inflammation with the superior site than the temporal site. In vivo confocal microscopy can be a rapid and noninvasive tool for the quantitative evaluation of ocular surface changes in patients with GO.

Contributions of ocular surface components to matrix-metalloproteinases (MMP)-2 and MMP-9 in feline tears following corneal epithelial wounding

Purpose

This study investigated ocular surface components that contribute to matrix-metalloproteinase (MMP)-2 and MMP-9 found in tears following corneal epithelial wounding.

Methods

Laboratory short-haired cats underwent corneal epithelial debridement in one randomly chosen eye (n = 18). Eye-flush tears were collected at baseline and during various healing stages. Procedural control eyes (identical experimental protocol as wounded eyes except for wounding, n = 5) served as controls for tear analysis. MMP activity was analyzed in tears using gelatin zymography. MMP staining patterns were evaluated in ocular tissues using immunohistochemistry and used to determine MMP expression sites responsible for tear-derived MMPs.

Results

The proMMP-2 and proMMP-9 activity in tears was highest in wounded and procedural control eyes during epithelial migration (8 to 36 hours post-wounding). Wounded eyes showed significantly higher proMMP-9 in tears only during and after epithelial restratification (day 3 to 4 and day 7 to 28 post-wounding, respectively) as compared to procedural controls (p<0.05). Tears from wounded and procedural control eyes showed no statistical differences for pro-MMP-2 and MMP-9 (p>0.05). Immunohistochemistry showed increased MMP-2 and MMP-9 expression in the cornea during epithelial migration and wound closure. The conjunctival epithelium exhibited highest levels of both MMPs during wound closure, while MMP-9 expression was reduced in conjunctival goblet cells during corneal epithelial migration followed by complete absence of the cells during wound closure. The immunostaining for both MMPs was elevated in the lacrimal gland during corneal healing, with little/no change in the meibomian glands. Conjunctival-associated lymphoid tissue (CALT) showed weak MMP-2 and intense MMP-9 staining.

Conclusions

Following wounding, migrating corneal epithelium contributed little to the observed MMP levels in tears. The major sources assessed in the present study for tear-derived MMP-2 and MMP-9 following corneal wounding are the lacrimal gland and CALT. Other sources included stromal keratocytes and conjunctiva with goblet cells.

Cyclosporine a 0.05% eye drops for the treatment of subepithelial infiltrates after epidemic keratoconjunctivitis

BACKGROUND

To evaluate the treatment with topical 0.05% cyclosporine A (CsA) in patients with subepithelial corneal infiltrates (SEI).

METHODS

We reviewed 16 patients (22 eyes) before and after the treatment with 0.05% CsA eye drops. All patients had been treated previously with topical corticosteroids without any improvement and also they had to stop the medication secondary to intraocular pressure elevation. The objective data recorded included best-corrected visual acuity (BCVA), evaluation of corneal subepithelial infiltrate scores (CSIS), intraocular pressure (IOP) prior to treatment and the last follow-up visit.

RESULTS

Six males (37.5%) and 10 females (62.5%), mean age of 35.2 ± 16.6 years, were included. The patients' average topical CsA use duration was 5.1 ± 3.5 months (1 - 13 months). The average follow up time of the patients was 9.2 ± 4.7 months (4 - 22 months). One patient, although he didn't have a 0 scale of SCIS, did not show up for follow up examinations after six months. The mean BCVA (logarithm of the minimum angle of resolution) before and after the treatment were 0.15 ± 0.15 and 0.07 ± 0.07 respectively, CSIS 1.68 ± 0.89 and 0.23 ± 0.53 respectively, IOP 18.50 ± 3.82 and 16.86 ± 2.76 mmHg respectively. There were statistically significant improvements in BCVA (p=0.002), reduction of CSIS (p=0.002) and reduction of IOP (p<0.001) prior to treatment and the last follow-up visit. 18 eyes (81.9%) showed clinical improvement and 4 (18.1%) had decreased SEI which did not fully disappear during the treatment period. The eyes which reached CSIS score 0 (18 eyes) were treated with CsA for 1 - 13 months; while the eyes which had clinical improvement but had not CSIS score 0 (4 eyes) were decided to discontinue of CsA treatment in last follow-up visit. There were recurrences in 2 eyes 3 months after the treatment. Patients reported reduction in the severity of symptoms after the treatment. Most of the patients reported no foreign body sensation, glare, or other side effects with topical CsA treatment. Overall, patients noted an improvement in vision and satisfaction with topical 0.05% CsA treatment.

CONCLUSIONS

Topical 0.05% CsA is a safe and effective alternative treatment in patients with SEI who do not respond to other treatment modalities or have undesired side effects from topical steroids.

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.

MMP-9 and the perioperative management of LASIK surgery

PURPOSE OF REVIEW

Hyperosmolarity is a central mechanism causing ocular surface inflammation and eye irritation in typical patients suffering from tear dysfunction. Tear composition in dry eyes, or dysfunctional tear syndrome, may destabilize the tear film and cause ocular surface epithelial disease. Increased activity of matrix metalloproteinases (MMPs), especially MMP-9, plays a critical role in wound healing and inflammation and is primarily responsible for the pathologic alterations to the ocular surface that leads to a dysfunctional tear state.

RECENT FINDINGS

Altered corneal epithelial barrier function is the cause for ocular irritation and visual morbidity in dry eye disease. The increased MMP-9 activity in dry eyes may contribute to deranged corneal epithelial barrier function, increased corneal epithelial desquamation, and corneal surface irregularity.

SUMMARY

Dry eye is one of the most common complications of photorefractive keratectomy and laser in-situ keratomileusis (LASIK). LASIK has both a neurotrophic effect on the cornea and leads to a physical change in corneal shape that results in a change in tear dynamics, leading to ocular surface desiccation. The reduction in tear function after LASIK may induce an increase in osmolarity and consequently raise the concentration of proinflammatory cytokines and MMP-9 in the tear film, which results in dry eyes and insufficient attachment between the corneal flap and the corneal bed. Appropriate diagnosis and management of dysfunctional tear syndrome may lead to less postoperative LASIK complications.