Moderate-severe peripheral neuropathy in diabetes associated with an increased risk of dry eye disease.

SIGNIFICANCE: This study establishes an increased risk of developing dry eye disease (DED) in patients with diabetic peripheral neuropathy using validated diagnostic criteria for both conditions. PURPOSE: The disruption of ocular surface homeostasis has been associated with diabetes. However, it remains unclear if this association is independently influenced by peripheral neuropathy secondary to diabetes. This study aimed to investigate the clinical signs and symptoms of DED and their association with the severity of peripheral neuropathy in participants with type 2 diabetes. METHODS: This prospective cross-sectional study recruited 63 participants with type 2 diabetes. All participants underwent a detailed assessment of DED using dry eye questionnaires (Ocular Surface Disease Index, Dry Eye Questionnaire-5), tear osmolarity, lipid layer thickness, noninvasive keratographic tear breakup time, phenol red thread test (PRT), and ocular surface staining. Corneal nerve morphology was imaged using corneal confocal microscopy. Based on the Total Neuropathy Scale, participants were stratified into no/mild (n = 48) and moderate/severe (n = 15) neuropathy groups. RESULTS: Dry eye disease was diagnosed in 31 participants (50%) of the total cohort, and the odds of developing DED in the moderate/severe neuropathy group were four times (95% confidence interval, 1.10 to 13.80; p=0.030) higher compared with the no/mild neuropathy group. The Dry Eye Questionnaire-5 scores were significantly higher (p=0.020), and PRT values (p=0.048) and corneal nerve fiber length (p<0.001) were significantly reduced in the moderate/severe neuropathy group compared with the no/mild neuropathy group. In regression analysis, neuropathy scores were independently associated with PRT measurements (ß = -0.333, p=0.023) and nerve fiber length (ß = -0.219, p=0.012) while adjusting for age, gender, hemoglobin A1c, and duration of diabetes. CONCLUSIONS: Type 2 diabetic patients with peripheral neuropathy have a risk of developing DED, which increases with the severity of neuropathy. The observation that worsening peripheral neuropathy is associated with reduced tear secretion suggests that it may contribute to aqueous insufficiency.

Impact of SGLT2 Inhibitors on Corneal Nerve Morphology and Dendritic Cell Density in Type 2 Diabetes.

PURPOSE: This study aims to determine the effects of SGLT2 inhibitors on corneal dendritic cell density and corneal nerve measures in type 2 diabetes. METHODS: Corneal dendritic cell densities and nerve parameters were measured in people with type 2 diabetes treated with SGLT2 inhibitors (T2DM-SGLT2i) [n = 23] and those not treated with SGLT2 inhibitors (T2DM-no SGLT2i) [n = 23], along with 24 age and sex-matched healthy controls. RESULTS: There was a reduction in all corneal nerve parameters in type 2 diabetes groups compared to healthy controls (All parameters: p < 0.05). No significant differences in corneal nerve parameters were observed between T2DM-SGLT2i and T2DM-no SGLT2i groups (All parameters: p > 0.05). Central corneal dendritic cells were significantly reduced [mature (p = 0.03), immature (p = 0.06) and total (p = 0.002)] in the T2DM-SGLT2i group compared to the T2DM-no SGLT2i group. Significantly, higher mature (p = 0.04), immature (p = 0.004), total (p = 0.002) dendritic cell densities in the T2DM-no SGLT2i group were observed compared to the healthy controls. In the inferior whorl, no significant difference in immature (p = 0.27) and total dendritic cell densities (p = 0.16) between T2DM-SGLT2i and T2DM-no SGLT2i were observed except mature dendritic cell density (p = 0.018). No differences in total dendritic cell density were observed in the central (p > 0.09) and inferior whorl (p = 0.88) between T2DM-SGLT2i and healthy controls. CONCLUSION: The present study showed a reduced dendritic cell density in people with type 2 diabetes taking SGLT2 inhibitors compared to those not taking these medications.

Automated analysis of corneal nerve tortuosity in diabetes: implications for neuropathy detection.

CLINICAL RELEVANCE: There is potential benefit in analysing corneal nerve tortuosity as a marker for assessment and progression of systemic diabetic neuropathy. BACKGROUND: The aim of this work was to determine whether tortuosity significantly differs in participants with type 1 (T1DM) and type 2 (T2DM) diabetes compared to controls and whether tortuosity differed according to neuropathy status. METHODS: Corneal nerves of 164 participants were assessed across T1DM, T2DM and control groups. Images of corneal nerves were captured via in vivo corneal confocal microscopy. Diabetic neuropathy status was examined using the Total Neuropathy Score (TNS). Tortuosity was assessed with Cfibre v0.097. Results were compared between groups with a linear mixed model accounting for location of image and controlling for age, producing Tortuosity Factor (TF), an estimate of the marginal means of each group. RESULTS: Tortuosity was significantly reduced in the T1DM group compared to controls (TF = 0.241, 95%CI = 0.225-0.257 vs. TF = 0.272, 95%CI = 0.252-0.292; mean difference = -0.031, p = 0.02) and in the T2DM group compared to controls (TF = 0.261, 95%CI = 0.244-0.278 vs. TF = 0.289, 95%CI = 0.270-0.308; mean difference = -0.029, p = 0.03). Tortuosity did not significantly differ between participants with T1DM and T2DM accounting for age and TNS (TF = 0.240, 95%CI = 0.215-0.265 vs. 0.269, 95%CI = 0.244-0.293, mean difference = -0.029, p = 0.11). Tortuosity was significantly reduced in participants with neuropathy (TNS≥2) compared to participants with no neuropathy (TNS< 2) (TF = 0.248, 95%CI = 0.231-0.265 vs. TF = 0.272, 95%CI = 0.260-0.283; mean difference = -0.024, p = 0.03). CONCLUSIONS: Tortuosity is significantly reduced in participants with T1DM and T2DM compared to age matched controls and in participants with neuropathy compared to those without neuropathy.

Impact of Chronic Kidney Disease on Corneal Neuroimmune Features in Type 2 Diabetes.

Aim: To determine the impact of chronic kidney disease on corneal nerve measures and dendritic cell counts in type 2 diabetes. Methods: In vivo corneal confocal microscopy images were used to estimate corneal nerve parameters and compared in people with type 2 diabetes with chronic kidney disease (T2DM-CKD) (n = 29) and those with type 2 diabetes without chronic kidney disease (T2DM-no CKD) (n = 29), along with 30 healthy controls. Corneal dendritic cell densities were compared between people with T2DM-CKD and those with T2DM-no CKD. The groups were matched for neuropathy status. Results: There was a significant difference in corneal nerve fiber density (p < 0.01) and corneal nerve fiber length (p = 0.04) between T2DM-CKD and T2DM-no CKD groups. The two diabetes groups had reduced corneal nerve parameters compared to healthy controls (all parameters: p < 0.01). Immature central dendritic cell density was significantly higher in the T2DM-CKD group compared to the T2DM-no CKD group ((7.0 (3.8−12.8) and 3.5 (1.4−13.4) cells/mm2, respectively, p < 0.05). Likewise, central mature dendritic cell density was significantly higher in the T2DM-CKD group compared to the T2DM-no CKD group (0.8 (0.4−2.2) and 0.4 (0.6−1.1) cells/mm2, respectively, p = 0.02). Additionally, total central dendritic cell density was increased in the T2DM-CKD group compared to T2DM-no CKD group (10.4 (4.3−16.1) and 3.9 (2.1−21.0) cells/mm2, respectively, p = 0.03). Conclusion: The study showed that central corneal dendritic cell density is increased in T2DM-CKD compared to T2DM-no CKD, with groups matched for peripheral neuropathy severity. This is accompanied by a loss of central corneal nerve fibers. The findings raise the possibility of additional local factors exacerbating central corneal nerve injury in people with diabetic chronic kidney disease.

The ability of face masks to reduce transmission of microbes.

CLINICAL RELEVANCE: Optometrists have been advised to wear face masks during the COVID-19 pandemic. This study examined whether face masks were equally protective against transmission of microbes. BACKGROUND: The aim of the current study was to examine the ability of face masks to reduce transmission of microbes in aerosols and during speech. METHODS: Different face masks, surgical, medical 3-ply and cloth masks with different layers were used. The masks were tested under the ASTM standard F2101-1 to measure their ability to reduce the transmission of aerosolised Staphylococcus aureus. Bacterial cells in different sized aerosols were captured on agar plates. The ability of masks to reduce the transmission of bacteria during speech over 30 cm was measured. Bacteria were captured in masks or on agar plates at a distance of 30 cm during the speech. RESULTS: All masks reduced the transmission of aerosolised S. aureus (p ≤ 0.007). The medical 3-ply and cloth masks with three layers reduced the transmission of S. aureus aerosols (3.3 µm) by 98% and surgical and seven-layer masks reduced this by 100%. An antibacterial silver mask showed significantly greater transmission of S. aureus in aerosols of 4.7 µm (16 ± 6 cells) and 3.3 µm (122 ± 66 cells) compared to all other masks (0-3 cells and 0-15 cells, respectively; p ≤ 0.016). Surgical and three-layer masks had significantly worse filtration of 1.1 µm aerosols than for other aerosol sizes. Wearing a mask reduced the transmission of bacteria during speech, but the inner surface of these masks became contaminated with 528-3060 bacterial cells. CONCLUSIONS: Face masks effectively reduce the transmission of microbes in laboratory tests. Face masks made with seven layers were very effective at stopping transmission of S. aureus in all aerosol particle sizes. However, face masks become rapidly contaminated during wear. If masks are to be re-used, they should be regularly replaced or appropriately washed.

The role of nitric oxide in ocular surface physiology and pathophysiology.

Nitric oxide (NO) has a wide array of biological functions including the regulation of vascular tone, neurotransmission, immunomodulation, stimulation of proinflammatory cytokine expression and antimicrobial action. These functions may depend on the type of isoform that is responsible for the synthesis of NO. NO is found in various ocular tissues playing a pivotal role in physiological mechanisms, namely regulating vascular tone in the uvea, retinal blood circulation, aqueous humor dynamics, neurotransmission and phototransduction in retinal layers. Unregulated production of NO in ocular tissues may result in production of toxic superoxide free radicals that participate in ocular diseases such as endotoxin-induced uveitis, ischemic proliferative retinopathy and neurotoxicity of optic nerve head in glaucoma. However, the role of NO on the ocular surface in mediating physiology and pathophysiological processes is not fully understood. Moreover, methods used to measure levels of NO in the biological samples of the ocular surface are not well established due to its rapid oxidation. The purpose of this review is to highlight the role of NO in the physiology and pathophysiology of ocular surface and propose suitable techniques to measure NO levels in ocular surface tissues and tears. This will improve the understanding of NO's role in ocular surface biology and the development of new NO-based therapies to treat various ocular surface diseases. Further, this review summarizes the biochemistry underpinning NO's antimicrobial action.

Antimicrobial resistance of ocular microbes and the role of antimicrobial peptides.

Isolation of antimicrobial-resistant microbes from ocular infections may be becoming more frequent. Infections caused by these microbes can be difficult to treat and lead to poor outcomes. However, new therapies are being developed which may help improve clinical outcomes. This review examines recent reports on the isolation of antibiotic-resistant microbes from ocular infections. In addition, an overview of the development of some new antibiotic therapies is given. The recent literature regarding antibiotic use and resistance, isolation of antibiotic-resistant microbes from ocular infections and the development of potential new antibiotics that can be used to treat these infections was reviewed. Ocular microbial infections are a global public health issue as they can result in vision loss which compromises quality of life. Approximately 70 per cent of ocular infections are caused by bacteria including Chlamydia trachomatis, Staphylococcus aureus, and Pseudomonas aeruginosa and fungi such as Candida albicans, Aspergillus spp. and Fusarium spp. Resistance to first-line antibiotics such as fluoroquinolones and azoles has increased, with resistance of S. aureus isolates from the USA to fluoroquinolones reaching 32 per cent of isolates and 35 per cent being methicillin-resistant (MRSA). Lower levels of MRSA (seven per cent) were isolated by an Australian study. Antimicrobial peptides, which are broad-spectrum alternatives to antibiotics, have been tested as possible new drugs. Several have shown promise in animal models of keratitis, especially treating P. aeruginosa, S. aureus or C. albicans infections. Reports of increasing resistance of ocular isolates to mainstay antibiotics are a concern, and there is evidence that for ocular surface disease this resistance translates into worse clinical outcomes. New antibiotics are being developed, but not by large pharmaceutical companies and mostly in university research laboratories and smaller biotech companies. Antimicrobial peptides show promise in treating keratitis.

The Effect of Age, Gender and Body Mass Index on Tear Film Neuromediators and Corneal Nerves.

Purpose: To evaluate the effect of age, gender and body mass index (BMI) on the levels of tear film neuromediators and corneal nerve parameters in healthy individuals.Methods: Twenty-six healthy subjects were screened for any neurological deficits. The concentration of substance P and calcitonin gene-related peptide (CGRP) in tears was measured by enzyme-linked immunosorbent assay. Corneal nerve fibers were imaged using confocal microscopy and assessed by automated image analysis software. Associations between the clinical variables were analyzed using Pearson or Spearman correlation. Univariate general linear regression was performed to examine the independent relationship between age, BMI and gender of the subjects with concentrations of substance P, CGRP and corneal nerve fiber parameters.Results: Fifteen (58%) of the study participants were male. The mean age of the study cohort was 36 ± 12 years (range, 21-59) with an average BMI of 25 ± 4 kg/m2. The median [IQR] concentrations of substance P and CGRP was 715 [372-1463] pg/mL and 38 [15-74] ng/mL respectively. Moderate but significant positive correlations were found between the concentration of substance P and corneal nerve fiber density (r = 0.467, P = .016), nerve fiber length (r = 0.528, P = .006) and nerve fractal dimension (rs = 0.614, P = .002). There was a significant age-dependent reduction in the concentration of substance P (-6% pg/mL per year, P = .001) and CGRP (-8% ng/ml per year, P < .001). Corneal nerve fiber density (-0.171 no./mm2 per year, P = .029) and nerve fractal dimension (-0.001 per year, P = .021) showed reductions with advancing age. Gender and BMI did not influence any of the measurements.Conclusions: The concentrations of substance P and CGRP in tears, as well as corneal nerve fiber density and nerve fractal dimension, are significantly reduced with advancing age. Age should be considered when evaluating patients for diagnosis and follow-up of corneal neuropathy or ocular surface disorders.

Association of corneal nerve loss with markers of axonal ion channel dysfunction in type 1 diabetes.

OBJECTIVE: Corneal confocal microscopy (CCM) has been identified as a non-invasive technique to assess corneal nerve fiber morphology. It is not known how corneal nerve changes relate to measures of peripheral nerve function in diabetic peripheral neuropathy (DPN). The present study investigates the relationship between nerve structure and function in DPN. METHODS: Fifty participants with type 1 diabetes (T1DM) and 29 healthy controls underwent CCM to assess corneal nerve fiber density (CNFD), branch density (CNBD), fiber length (CNFL), total branch density (CTBD), nerve fractal dimension (CNFrD) and inferior whorl length (IWL). The severity of DPN was assessed as Total Neuropathy Score (TNS). Motor nerve axonal excitability tests were conducted to assess axonal function. RESULTS: Significant correlations were noted between CNFD (rho = -0.783; P < 0.01) or superexcitability (rho = 0.435; P < 0.01) and TNS. CNFrD was significantly correlated with peak response to stimulus (r = 0.414; P < 0.01) and superexcitability (r = -0.467; P < 0.01) measurements. CONCLUSION: Corneal nerve loss demonstrates a significant association with axonal ion channel dysfunction in T1DM. SIGNIFICANCE: Detection of altered corneal nerve morphology may lead to the earlier diagnosis of DPN.

Corneal nerve fiber loss in diabetes with chronic kidney disease.

AIMS: Patients with chronic kidney disease (CKD) in type 2 diabetes typically manifest with severe peripheral neuropathy. Corneal confocal microscopy is a novel technique that may serve as a marker of nerve injury in peripheral neuropathy. This study examines the changes that occur in corneal nerve morphology as a result of peripheral neuropathy due to renal dysfunction in people with type 2 diabetes. METHODS: Sixty-two participants (mean age, 62 ± 12 years) with type 2 diabetes and 25 age-matched healthy controls underwent a comprehensive assessment of neuropathy using the total neuropathy score (TNS). The corneal sub-basal nerve plexus was imaged using corneal confocal microscopy. Corneal nerve fiber length, fiber density, branch density, total branch density, nerve fractal dimension, inferior whorl length and inferior whorl nerve fractal dimension were quantified. Based on the eGFR, participants were classified into those with diabetic CKD (eGFR < 60; n = 22) and those without CKD (eGFR ≥ 60; n = 40). RESULTS: Participants with diabetic CKD had significantly lower corneal nerve fiber density (P = 0.037), length (P = 0.036) and nerve fractal dimension (P = 0.036) compared to those without CKD. Multiple linear regression analysis revealed that reduced corneal nerve fiber density (ß coefficient = 0.098, P = 0.017), length (ß coefficient = 0.006, P = 0.008) and nerve fractal dimension (ß coefficient = 0.001, P = 0.007) was associated with low eGFR levels when adjusted for age, duration of diabetes and severity of neuropathy. CONCLUSION: Corneal confocal microscopy detects corneal nerve loss in patients with diabetic CKD and reduction in corneal nerve parameters is associated with the decline of kidney function.

A Comparative Study on the Diagnostic Utility of Corneal Confocal Microscopy and Tear Neuromediator Levels in Diabetic Peripheral Neuropathy.

AIMS: To determine the utility of corneal confocal microscopy and tear neuromediator analysis in the diagnosis of diabetic peripheral neuropathy (DPN) as a result of type 1 and type 2 diabetes. METHODS: Seventy individuals with either type 1 diabetes or type 2 diabetes (T1D/T2D) underwent corneal confocal microscopy to assess the corneal nerve morphology. The concentration of substance P and calcitonin gene-related peptide (CGRP) in tears was measured by enzyme-linked immunosorbent assay. Motor excitability studies were conducted on the median nerve to assess axonal ion channel function. Based on total neuropathy score (TNS), participants were stratified into DPN (DPN+ve; TNS ≥ 2; T1D, n = 19; T2D, n = 16) and without DPN (DPN-ve; TNS ≤ 1; T1D, n = 19; T2D, n = 16). Areas under the receiver operating characteristic curves (AUCs) were calculated to obtain specificity and sensitivity of the measures to diagnose DPN. RESULTS: In T1D, the concentration of substance P and confocal microscopy measures were significantly reduced (P < .010) in DPN+ve. Also, for the nerve excitability measures, mean peak response, percentage of threshold electrotonus at peak and after 90-100 ms, superexcitability and subexcitability were significantly reduced (P < .050) in DPN+ve. In T2D, except for inferior whorl length (P = .190), all other corneal confocal microscopy measures were significantly reduced (P < .010) in DPN+ve, but there was no difference in substance P concentration. For the diagnosis of DPN in T1D, the AUC for inferior whorl length (0.910), mean peak response (0.800) and concentration of substance P (0.770) were high and in T2D, the AUC for corneal nerve fiber length (0.809) and nerve fractal dimension (0.777) were high. CONCLUSION: Corneal confocal microscopy parameters provide a better diagnostic ability to detect DPN in T1D and T2D than nerve excitability measures or concentrations of tear neuromediators. The concentration of substance P could also be useful in diagnosing DPN but for T1D only.

Tear film substance P: A potential biomarker for diabetic peripheral neuropathy.

OBJECTIVE: To explore the changes that occur in the concentrations of substance P (SP) and calcitonin gene-related peptide (CGRP) in tears as a result of corneal denervation and its association with diabetic peripheral neuropathy (DPN). METHODS: Sixty-three individuals with type 1 diabetes/type 2 diabetes (T1D/T2D) and 34 age-matched healthy controls underwent a detailed assessment of neuropathy using the Total Neuropathy Score (TNS). The concentration of SP and CGRP in tears was measured by enzyme-linked immunosorbent assay. The corneal sub-basal nerve plexus was imaged using corneal confocal microscopy. Corneal nerve fibre length, fibre density, branch density, total branch density, nerve fractal dimension and inferior whorl length were quantified. RESULTS: In T1D, the median [IQR] concentration of SP in tears was significantly reduced in those with DPN, (130 [61-692]pg/mL) compared to both control subjects (763 [405-1555]pg/mL, P < 0.01) and in those without DPN (914 [339-1832]pg/mL, P = 0.01); the concentration of CGRP was not changed. In T2D, there was no difference in neuropeptides between participants with diabetes and controls, regardless of neuropathic status. In T1D and T2D, corneal nerve parameters were significantly different between those with DPN or without DPN and controls. A significant correlation was noted between the concentration of tear film SP and TNS in T1D (r = -0.49; P < 0.001) and corneal nerve fibre density (r = 0.45; P < 0.001). The concentration of tear film CGRP was correlated significantly with the reduction of corneal nerve fibre density (r = 0.41; P = 0.01) in T1D. CONCLUSION: Tear film SP may provide a potential non-invasive biomarker for assessing neuropathy in T1D.

The impact of diabetes on corneal nerve morphology and ocular surface integrity.

Diabetes mellitus is a chronic disease that results from inadequate insulin production or ineffective insulin utilization. It is one of the most common systemic diseases worldwide with increasing prevalence. Diabetes mellitus is associated with premature mortality, macrovascular complications such as cardiovascular disease, and microvascular complications, including nephropathy leading to kidney failure, potentially blinding diabetic retinopathy, and diabetic neuropathy. While the retinal complications of diabetes are well recognized by eye care professionals, the effects on the ocular surface are poorly understood. Recent studies have reported on the association between peripheral neuropathy and corneal neuropathy, showing the latter to be of predictive value for the systemic disease. Corneal neuropathy can lead to loss of corneal sensation and can ultimately result in neurotrophic ulcers and significant visual morbidity. The epithelial fragility and poor wound healing that result from reduced epithelial adhesion to the underlying basement membrane in diabetes, together with corneal neuropathy, are thought to increase the susceptibility to persistent corneal erosions and infection, as well as to increase the risk of post-surgical complications. The aim of this article is to review the impact of diabetes on corneal nerve morphology and ocular surface integrity. Changes in the tear film and ocular surface microbiome are highlighted in discussion of the mechanisms that underpin ocular surface changes that increase the susceptibility to corneal erosion and infection.

Efficacy of axial and tangential corneal topography maps in detecting subclinical keratoconus.

PURPOSE: To investigate and compare the efficacy of axial and tangential corneal topography maps obtained using the Orbscan IIz scanning-slit device to distinguish differences in eyes with subclinical keratoconus from normal eyes. SETTING: LV Prasad Eye Institute, Hyderabad, India. DESIGN: Retrospective cross-sectional study. METHODS: Axial and tangential maps of the anterior and posterior corneal surfaces were obtained in eyes of patients with subclinical keratoconus (normal fellow eye of an eye with clinically diagnosed keratoconus). The following measurements were obtained from each map and compared between the 2 groups: location of the corneal apex in millimeters relative to the corneal vertex, dioptric power at the corneal apex and corneal vertex, corneal irregularity indices at 3.0 mm and 5.0 mm, anterior-posterior apex ratio, and inferior-superior dioptric asymmetry value. RESULTS: Maps were obtained in 71 eyes (71 patients) with subclinical keratoconus and 76 normal eyes (76 patients). The tangential posterior apex curvature was significantly steeper than the axial posterior apex curvature in both groups (P < .001). The anterior-posterior apex ratio on the tangential map demonstrated the highest area under the receiver operating characteristic (ROC) curve of 0.992 (cutoff ≥-6.97, sensitivity 98.6%, specificity 98.7%) followed by the posterior irregularity index in the 5.0 mm zone with an area under the ROC curve of 0.938 (cutoff ≥0.4, sensitivity 98.6%, specificity 84.2%) in differentiating subclinical keratoconus eyes from normal eyes. CONCLUSIONS: The anterior-posterior apex ratio on the tangential map and 5.0 mm irregularity index of the posterior corneal surface were highly sensitive and specific for early detection of subclinical keratoconus. Tangential corneal topography maps should be considered in preoperative subclinical keratoconus screening. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of corneal elevation and thickness indices in pellucid marginal degeneration and keratoconus.

PURPOSE: To determine and compare corneal elevation and thickness indices, thereby formulating a reliable index to distinguish eyes with pellucid marginal degeneration (PMD) from keratoconus eyes and normal (control) eyes. SETTING: LV Prasad Eye Institute, Hyderabad, India. DESIGN: Initial model-building retrospective study. METHODS: Anterior and posterior corneal elevations and thickness indices were obtained from the Orbscan IIz topographer. These values were analyzed and compared between PMD patients, keratoconus patients, and control subjects. RESULTS: Of the indices, the mean values of anterior elevation (AE), ratio of the AE to the anterior best-fit sphere, ratio of the average power values of nasal quadrant to the average power values of inferior quadrant, and difference between maximum keratometry (K) and minimum K were significantly different between the 3 groups (P<.05). The highest area under the receiver-operating-characteristic (AROC) curve in discriminating PMD from keratoconus was for asphericity (0.974; cutoff ≥-0.07; sensitivity 93.3%; specificity 90.6%) followed by the ratio of average power values of the nasal and temporal quadrants to the average power values of the inferior and superior quadrants (Avg NT((D))/IS((D))) (0.959; cutoff ≥1.005; sensitivity 96.7%; specificity 90.6%). The PMD index (AROC curve, 0.935), with a cutoff of 3.45 or higher had 90% sensitivity and 93.7% specificity to distinguish PMD from keratoconus and had 100% sensitivity and 100% specificity to distinguish PMD from control eyes, with a cutoff of 2.46 or higher (AROC curve, 1.000). CONCLUSIONS: The PMD index appeared to be highly sensitive and specific for diagnosing PMD. Asphericity and Avg NT((D))/IS((D)) were clinically relevant in discriminating PMD from other groups.