Dry Eye in Graves’ Ophthalmopathy: Correlation with Corneal Hypoesthesia

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.

Predictive markers for anti-inflammatory treatment response in thyroid eye disease

Anti-inflammatory treatment is the primary and vital therapeutic approach for active, moderate-to-severe thyroid eye disease (TED). Accurate pretreatment prediction of treatment response is of paramount importance for the prognosis of patients. However, relying solely on the clinical activity score asa determinant of activity has led to unsatisfactory treatment outcomes. In recent years, significant advancements have been made in identifying predictive markers for anti-inflammatory treatment response in TED, clinical markers, body fluid biomarkers and imaging biomarkers. Several clinical studies have developed prediction models based on these markers. However, there is still a lack of comprehensive elucidation or comparison between the different markers. Therefore, this review aims to provide a detailed analysis of the definition, characteristics, and application of predictive markers for anti-inflammatory treatment response in TED. Through detailed literature search, 26 articles applying anti-inflammatory treatment effect prediction with a total of 1948 TED patients were used for analysis and discussion. By gaining a better understanding of the current research on predictive markers, we can accelerate and guide the exploration of treatment prediction strategies, leading us towards an era of precise therapy for TED.

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.

Ocular surface and the upper eyelid contour after surgical treatment of upper eyelid retraction in thyroid eye disease

BACKGROUND: Most of the thyroid eye disease (TED) patients have dry eye syndrome. Upper eyelid retraction (UER) is the most common TED symptom and one of dry eye causes. There are two groups of UER surgical treatment methods: transconjunctival and transcutaneous, which can influence on upper eyelid contour, tear film and ocular surface. AIM: To evaluate the influence of different methods of UER surgery on upper eyelid contour and ocular surface. MATERIALS AND METHODS: 12 patients (19 eyes) were included in the study. Visual acuity test, measurements of UER and palpebral fissure height, Shirmer 1 test, LIPCOF-test and tear break-up time test, Meibomian gland dysfunction staging, corneal and conjunctival fluorescein staining and determination of the ocular surface disease index (OSDI) were performed before surgery and 1 week, 1 and 3 months after. Patients were divided into two groups. Patients of group 1 had UER less than 4 mm and they underwent an upper tarsal muscle extirpation. Patients of group 2 had UER 4 mm and more and they underwent a recession of the levator palpebrae superioris muscle apouneurosis. RESULTS: In all patients UER and the height of the palpebral fissure decreased 7 days after surgery and increased again after 3 months, and the dynamics of this change was more pronounced in group 2. There was one patient (both sides) with poor upper eyelid contour after surgery in both groups. BCVA and OSDI improved, while other parameters had a large scatter of data. CONCLUSIONS: We have found that surgical treatment of UER caused by TED improves the contour of the eyelid, increases visual acuity and leads to a subjective improvement in the condition of the ocular surface.

Improvement of Ocular Surface Disease by Lateral Tarsoconjunctival Flap in Thyroid-Associated Orbitopathy Patients with Lid Retraction

There is a high incidence of ocular surface disease (OSD) in thyroid-associated orbitopathy (TAO) patients as a result of incomplete eyelid closure and chronic inflammatory eyelid status. This study was performed to evaluate the efficacy of a lateral tarsoconjunctival flap (LTF) in improving OSD in TAO patients from the perspective of correcting eyelid closures. As a study design, TAO patients were enrolled in this study to evaluate OSD perioperatively before they were scheduled for LTF surgery. Additional lid surgery was also recorded. The outcome was evaluated with perioperative OSD measurements and tear inflammatory mediators at baseline and one month and three months postoperatively. As a result, 42 patients (5 male, 37 female) underwent LTF surgery, and 13 patients received medial pretarsal support with collagen grafts. Eleven patients underwent blepharotomy, and 6 patients received Botox injections for upper lid retraction. The mean age of the participants was 46.4 years old, and the mean follow-up period was 10.6 months. Their clinical activity score (CAS) at the time of the operation was 2.1. Dry eye parameters, such as ocular surface disease index, tear breakup time, Schirmer’s I test score, and meibomian gland dropout were all significantly improved 3 months postoperatively. Tear osmolarity and inflammatory mediators in tear fluid, such as IL-6, IL-8, IL-18 and MCP-1, were also significantly improved after the procedures. After the surgery, all complications were mild and temporary. As a conclusion, LTF could provide TAO patients with both lid retraction correction and improvement of ocular surface disorders. Dry eye parameters significantly improved 3 months postoperatively. This method can serve as an alternative treatment option for lid correction in TAO patients.

Dry eye disease, a prominent manifestation of systemic autoimmune disorders

OBJECTIVES

Dry eye disease (DED) is arguably the most frequent ocular disease encountered in ophthalmic clinical practice. DED is frequently an underestimated condition causing a significant impact on visual function and quality of life. Many systemic autoimmune diseases (SAIDs) are related to moderate to severe DED. The main objective of this review is to enhance the awareness among ophthalmologists of the potential association of an underlying SAID in a high-risk patient with DED.

METHODS

An exhaustive literature search was performed in the National Library of Medicine's Pubmed, Scopus, Web of Science, and Google Scholar databases for all English language articles published until November 2021. The main keywords included "dry eye disease" associated with autoimmune, connective tissue, endocrine, gastrointestinal, hematopoietic, vascular, and pulmonary diseases. Case reports, series, letters to the editor, reviews, and original articles were included.

RESULTS

Although DED is frequently associated with SAIDs, its diagnosis is commonly delayed or missed, producing significant complications, including corneal ulceration, melting, scleritis, uveitis, and optic neuritis resulting in severe complications detrimental to visual function and quality of life. SAID should be suspected in a woman, 30 to 60 years old with a family history of autoimmunity, presenting with DED symptoms and extraocular manifestations including arthralgias, dry mouth, unexplained weight and hair loss, chronic fatigue, heat or cold intolerance, insomnia, and mood disorders.

CONCLUSIONS

Establishing the correct diagnosis and treatment of DED associated with SAIDs is crucial to avoid its significant burden and severe ocular complications.

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.

Ocular manifestations of endocrine disorders

Endocrinopathies are prevalent diseases that typically affect multiple organs, and the eye and orbital tissues are often involved in endocrine disorders. Some conditions, such as diabetes and thyroid gland dysfunction, may cause serious eye pathology and even blindness. A clear insight into the pathogenesis of endocrinopathies and their ocular manifestations would enhance preventive and therapeutic measures and reduce the incidence of sight-threatening complications. This review discusses the ocular manifestations of several endocrine disorders that eye care providers are likely to encounter in clinical practice.

Corneal Endothelium: A Promising Quantitative Index for Graves Ophthalmopathy Activity Evaluation

PURPOSE

To investigate the corneal endothelium damage in Graves ophthalmopathy (GO) and its role as a promising quantitative index to evaluate GO activity.

DESIGN

Cross-sectional study.

METHODS

This study included 128 eyes of 64 patients with GO. All subjects underwent ophthalmologic examinations, including proptosis, tear break-up time (BUT), corneal fluorescein staining, and Schirmer test. Corneal endothelium was measured by noncontact specular microscope and ocular biometric parameters were measured by IOLMaster 700. Each eye was assigned a specific clinical activity score (CAS), then grouped as active (CAS ≥3 points) or inactive (CAS <3 points). Ocular parameters between the 2 groups were compared using generalized estimating equations accounting for inter-eye correlation, and receiver operating characteristic (ROC) curves were also obtained. Main outcome measures were parameters of corneal endothelium.

RESULTS

Among the included eyes, 81 eyes had inactive GO and 47 eyes had active GO. Corneal endothelial cell morphology was altered in active GO compared with inactive GO. The coefficient variation of cell area (CV) was significantly higher in active GO compared with inactive GO (37.0 [34.4-41.2]% vs 33.9 [30.9-36.8]%, P = .001), and positively correlated with CAS (r = 0.322, P < .001). Moreover, CV showed a diagnostic capacity to differentiate the active eyes from inactive eyes. The area under the ROC curve was 0.705.

CONCLUSIONS

Active GO had morphologic changes in corneal endothelium compared with inactive GO. CV is a sensitive indicator to reflect corneal endothelial function, and has the potential to be adopted as a noninvasive, objective, and quantitative index for evaluating the activity status of GO patients.

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.

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.

Bulbar Conjunctival Microvascular Alterations in Thyroid-Associated Ophthalmopathy Patients with Different Activities

Purpose: To evaluate the morphologic and hemodynamic changes of bulbar conjunctival vessels in thyroid-associated ophthalmopathy (TAO) patients and the correlations with the activity.Methods: Patients diagnosed as TAO with different clinical activity scores (CAS) and healthy participants were recruited. All subjects underwent a complete ophthalmic examination and functional slit-lamp biomicroscope. Vascular variables including the vessel density, vessel complexity, average diameter, blood flow velocity and blood flow rate in microvascular networks were measured. The correlations among microvascular parameters, CAS and exophthalmos were analyzed. Areas under the receiver operating characteristic curves (AUROCs) were applied to evaluate the diagnostic accuracy of microvascular alterations for active TAO.Results: A total of 46 eyes were enrolled in our study. The vessel complexity and blood flow velocity increased in the active TAO group significantly compared with the inactive group and healthy controls (P < .05). Meanwhile, the vessel complexity and blood flow rate were positively correlated with CAS (r = 0.641 and r = 0.526). Bulbar conjunctival microvascular parameters performed a good ability in distinguishing the active stage of TAO (AUROC = 0.793).Conclusions: Increasing bulbar conjunctival vessel complexity and blood flow were evident in TAO with severe inflammation. The measurements of bulbar conjunctival microvasculature could be a reference to evaluate activity in TAO.

Investigation of Meibomian Gland Function and Dry Eye Disease in Patients with Graves' Ophthalmopathy

We prospectively evaluated the relationship between meibomian gland dysfunction (MGD) and Graves’ ophthalmopathy (GO) in 19 patients (38 eyes) with subjective dry eye symptoms, compared to 14 age-matched normal participants (14 eyes). Extraocular muscle and lacrimal gland enlargement were evaluated by magnetic resonance imaging (MRI). Ocular surface examinations included fluorescein staining for keratoconjunctival epithelial damage, tear breakup time (TBUT) evaluation, and Schirmer’s test. Dry eye symptoms were evaluated with the Dry Eye-related Quality-of-Life Score (DEQS) questionnaire. Lid-margin abnormalities, meibum grade, and meiboscores were assessed using meibography. Clinical activity scores and T2 signal intensity ratios were used to define GO activity. All GO patients had obstructive MGD and 79% exhibited levator muscle enlargement. Ocular surface parameters of TBUT (p = 0.000), meibum score (p = 0.000), eyelid vasculitis (p = 0.000), meiboscore of the upper lid (p = 0.002), total meiboscores (p = 0.001), and DEQS (p = 0.000) significantly differed between GO patients and normal subjects. In addition, GO patients had significantly more abnormalities of the central region of the upper eyelid than normal subjects (p = 0.000). Thus, MGD might be related to eye discomfort and deterioration of the ocular surface in GO patients. Inflammation and morphological meibomian gland changes might be characteristic of GO.

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.

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.

Air Pollutants are associated with Dry Eye Disease in Urban Ophthalmic Outpatients: a Prevalence Study in China

BACKGROUND

Although previous prevalence studies of DED were reported from some countries worldwide, national data are unavailable in China. We aimed to conduct an up-to-date national survey on the prevalence of DED in China and find out the potential risk factors including air pollutant.

METHODS

23,922 eligible outpatients were recruited from ophthalmic clinics of 32 cities in China in 2013 by registration orders. The patients' demographic characteristics, history of keratorefractive surgery, diseases and medication history were collected and the daily air pollutant data in 2013. Multivariate logistic analysis was performed to identify the potential risk factors associated with DED. The association between related factors and dry eye diseases subtypes evaluated as p value and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Among 23,922 outpatients, the prevalence of DED was 61.57%, and that of the male patients was 57.64% and of the female was 65.32% (P < 0.0001). Multivariate logistic regression suggested that the possible risk factors for DED included: female, older age, history of keratorefractive surgery, presence of arthritis, thyroid diseases, and antihistamine, diuretic, duodenal ulcer drugs, diazepam. Air pollutants including O3, PM2.5, and SO2 were also identified as the risk factors.

CONCLUSION

The prevalence of DED among ophthalmic outpatients in China was considerably high. Age, gender, history of keratorefractive surgery, diseases, medication history, and air pollutants were associated with DED prevalence.

TFOS DEWS II Sex, Gender, and Hormones Report

One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.

Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease

Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.

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.

Dry Eye Syndrome in Non-Exophthalmic Graves' Disease

BACKGROUND

The present study aims to assess qualitative and quantitative characteristics of tear film and corneal related impairment and to evaluate the quality of life in a cohort of non-exophthalmic Graves' disease (GD) patients.

METHODS

The series comprised 50 eyes from 25 newly diagnosed GD patients with no proptosis. As control group, 56 eyes of 28 thyroid disease-free subjects were enrolled.

RESULTS

The results of Schirmer I and II, break-up time, and Oxford scheme showed a significant difference between GD and controls. By ocular surface disease index (OSDI) questionnaire, eleven (44%) GD patients had normal ocular surface, while two (8%) had mild, four (16%) had moderate, and eight (32%) had severe dry eye. The mean score of the OSDI in the GD group was significantly (p < 0.001) higher with respect to the control group.

CONCLUSIONS

This study shows that the tear film and cornea are damaged in newly non-exophthalmic GD subjects.