Automated tear film break-up time measurement for dry eye diagnosis using deep learning.

In the realm of ophthalmology, precise measurement of tear film break-up time (TBUT) plays a crucial role in diagnosing dry eye disease (DED). This study aims to introduce an automated approach utilizing artificial intelligence (AI) to mitigate subjectivity and enhance the reliability of TBUT measurement. We employed a dataset of 47 slit lamp videos for development, while a test dataset of 20 slit lamp videos was used for evaluating the proposed approach. The multistep approach for TBUT estimation involves the utilization of a Dual-Task Siamese Network for classifying video frames into tear film breakup or non-breakup categories. Subsequently, a postprocessing step incorporates a Gaussian filter to smooth the instant breakup/non-breakup predictions effectively. Applying a threshold to the smoothed predictions identifies the initiation of tear film breakup. Our proposed method demonstrates on the evaluation dataset a precise breakup/non-breakup classification of video frames, achieving an Area Under the Curve of 0.870. At the video level, we observed a strong Pearson correlation coefficient (r) of 0.81 between TBUT assessments conducted using our approach and the ground truth. These findings underscore the potential of AI-based approaches in quantifying TBUT, presenting a promising avenue for advancing diagnostic methodologies in ophthalmology.

Ocular complications in adults with psoriasis: a cross-sectional study in a referral center in Brazil.

PURPOSE: There is limited literature on the ocular manifestations in patients with psoriasis. Therefore, this study aimed to identify the prevalence of and factors associated with ocular manifestations in adults with psoriasis. METHODS: This cross-sectional study included Brazilian adults with psoriasis. The dermatological evaluation included diagnosis, clinical form, Psoriasis Area and Severity Index (PASI) measurement, and location of the lesions. Patients underwent a full ophthalmological examination, including the Schirmer I test, Rose Bengala staining, and tear breakup time tests. The results were analyzed using chi-square and Pearson's linear correlation tests. RESULTS: Of the 130 patients assessed, 118 (90.8%) exhibited ocular abnormalities, with meibomian gland dysfunction (MGD) being the most prevalent (59.2%), followed by dry eye disease (DED) (56.2%). A significant correlation was observed between MGD and PASI (p = 0.05), and between MGD and certain treatment modalities. DED was significantly associated with PASI (p < 0.05). Concurrent use of acitretin was identified as an independent predictor of MGD (odds ratio [OR] = 3.5, p < 0.05), whereas PASI was a protective factor against DED (OR = 0.39, p < 0.01). CONCLUSION: Given the high prevalence of eye disease among individuals with psoriasis, routine ophthalmological assessments are recommended to prevent possible ocular complications.

The effect of sodium hyaluronate on dry eye and corneal epithelial thickness following cataract surgery.

PURPOSE: To evaluate the effects of sodium hyaluronate drops on dry eye parameters and corneal epithelial thickness following cataract surgery. METHODS: The study included 84 patients who underwent uncomplicated phacoemulsification. In Group A, 0.15% sodium hyaluronate drops were added to the postoperative antibiotic/anti-inflammatory treatment. In Group B, only antibiotic/anti-inflammatory treatment was applied. Preoperatively and at 1 week and 1 month postoperatively, all the patients were evaluated in respect of tear break-up time (TBUT), the Schirmer test under anesthesia, the corneal fluorescein staining (CFS) score, mean central corneal thickness (CCT) and mean central corneal epithelial thickness (CCET), and the two groups were compared. RESULTS: A statistically significant difference was determined between the two groups at postoperative 1 month in respect of TBUT, Schirmer test, CFS score, and CCET (p < 0.01). In Group A, a statistically significant increase was determined in the TBUT and Schirmer values at 1 month postoperatively (p < 0.01, p = 0.01, respectively) and in Group B, these values were decreased compared to preoperatively (p < 0.01). The CCET was determined to be significantly thinner in Group B 1 month postoperatively (p < 0.01). A significant increase in CCT was observed in both groups at postoperative 1 week (p < 0.01) and preoperative values were reached at 1 month postoperatively. CONCLUSION: In the patient group using sodium hyaluronate, significant differences were determined in all dry eye parameters and CCET. The use of hyaluronate sodium drops after cataract surgery was seen to improve dry eye parameters and contribute to a healthy ocular surface by ensuring continuity of the corneal epithelium.

Comparing meibomian gland visibility on optical coherence tomography and Keratograph 5M images using objective and subjective grading methods.

PURPOSE: To investigate if there is a visible difference in meibomian gland (MG) length between images captured with the Visante optical coherence tomography (OCT; wavelength = 1,310 nm) and the OCULUS Keratograph 5M (K5M; wavelength = 880 nm). METHODS: Adults between 18 and 40 years were recruited. Baseline dry eye disease was evaluated with the Standard Patient Evaluation of Eye Dryness (SPEED) and tear meniscus height and tear breakup time with the K5M. Right upper and lower eyelid MGs were imaged with the K5M and Visante OCT. Each image was graded with the 0 to 3 meiboscore scale. The central 5 MGs were evaluated with ImageJ for percent gland length visibility. RESULTS: Thirty participants were analyzed with a median (interquartile range [IQR]) age of 23.0 (5.0) years (53.3 % female). Overall, participants were asymptomatic and had normal tear films. Meiboscores based on K5M and Visante OCT was significantly different for the lower eyelid (0[1] vs 1[2]; p = 0.007) but not the upper eyelid (0[1] vs 0[1]; p = 1.00). The mean percent gland visibility of the upper eyelid (82.7[9.6] vs 75.2[13.5]; p < 0.001) and the lower eyelid (81.2[12.7] vs 64.1[17.6]; p < 0.001) were significantly greater on the Visante OCT than the K5M images, respectively. CONCLUSION: OCT images had significantly greater percent visible MG lengths than the K5M images. This suggests viable segments of the MGs may be missed with typical imaging, which may explain how it is possible that studies have found less post-treatment MG atrophy.

The impact of dry eye disease on retinal image quality in children.

BACKGROUND AND OBJECTIVES: Dry eye disease (DED) is increasingly prevalent, resultinginhigher morbidityamong children. This study evaluates the impact of DED severity on visual quality using double-pass technology, focusing on dynamic observation of the ocular light scatter in pediatric DED cases. METHOD: In this non-interventional, cross-sectional study, a mild DED group (37 cases, 37 eyes), a moderate DED group (40 cases, 40 eyes), and a control group of healthy children (35 cases, 35 eyes) were examined. Measurements included the Schirmer I test, tear film break-up time (BUT), and vision-related quality of life assessments using the Modified Ocular Surface Disease Index (OSDI) questionnaires. Participants underwent visual quality analysis using double-pass technology, which measured the modulation transfer function cut-off frequency value, Strehl ratio, objective scatter index (OSI), and OQAS-II value (OQAS-II value 100%, OQAS-II value 20%, and OQAS-II value 9%) under natural conditions. Additionally, dynamic changes in OSI post-blinking, Tear film mean-OSI , and the corresponding standard deviation OSI were recorded. RESULTS: Statistically significant differences were observed among the groups in modulation transfer function cutoff, Strehl ratio, OSI, OQAS-II value 100 %, OQAs-II value 20 %, OQAs-II value 9 %, tear film mean OSI, and standard deviation OSI (P < 0.05). As DED severity increased, tear film mean OSI significantly rose, while modulation transfer function cutoff, strehl ratio, OQAS-II value 100 %, OQAS-II value 20 %, OQAS-II value 9 % notably declined. All optical quality parameters were correlated with BUT, with no association observed with age, sex, or Schirmer I test. CONCLUSION: Dual-channel technology objectively assesses visual quality in pediatric DED, demonstrating that tear film scattering significantly affects retinal imaging and visual quality in children with DED.

Effects of Topical 0.05% Cyclosporine A on Dry Eye Symptoms and Parameters Following Small Incision Lenticule Extraction.

PURPOSE: To evaluate the effects of topical 0.05% cyclosporine A on Ocular Surface Disease Index (OSDI) score and ocular surface parameters after small incision lenticule extraction (SMILE) for myopia. METHODS: In this study, 151 patients who underwent SMILE were randomized into the control group (71 eyes) and the 0.05% cyclosporine A group (80 eyes). Both groups received standard treatment during the 1 month after SMILE. Over the next 3 months, The control group continued standard therapy (0.3% sodium hyaluronate) and the 0.05% cyclosporine A group received additional 0.05% cyclosporine A. OSDI total and subscale scores, non-invasive tear break-up time (NIBUT), tear lipid layer thickness (LLT), and tear meniscus height (TMH) were assessed preoperatively and postoperatively. RESULTS: Compared to baseline, the OSDI scores significantly increased in both groups (P < .001). The 0.05% cyclosporine A group exhibited lower OSDI total scores after administering 0.05% cyclosporine A versus the control group (P = .026). At 1 month of follow-up, NIBUT, LLT, and TMH values significantly decreased in both groups compared to baseline (P < .05). The 0.05% cyclosporine A group exhibited higher NIBUT, LLT, and TMH versus the control group, returning to preoperative values after 2 months. Overall, the OSDI total score and NIBUT values during follow-up were not significantly different between the two groups; however, the LLT and TMH values were significantly different between the two groups (P < .001 and .041, respectively) by repeated measures analysis of variance. CONCLUSIONS: Topical 0.05% cyclosporine A was effective in relieving subjective dry eye symptoms and maintaining ocular surface stability in the early postoperative period of SMILE. [J Refract Surg. 2024;40(4):e229-e238.].

Prevalence of dry eye disease among IT students in Pakistan.

BACKGROUND: Dry eye disease (DED) is a common tear film disorder caused by decreased tear production or increased tear evaporation. The increased use of computers in the workplace has brought about the development of ocular health concerns, including dry eye disease. Therefore, this study was designed to determine the prevalence of DED associated with computer work and recommend preventing or reducing its development. This study investigated the prevalence of DED among IT students in Dera Ghazi Khan. METHODS: A cross-sectional descriptive study was conducted among 327 undergraduate students of the IT department in the district of Dera Ghazi khan over 5 months from September 2021 to January 2022. DED was assessed subjectively with Ocular Surface Disease Index. Data were analysed using SPSS version 21. The quantitative analysis was presented as mean and standard deviation, and qualitative variables were introduced in frequency and percentages. The chi-square test (Fisher's exact test) was used to study the significance of associations between dependent and independent variables. RESULTS: The mean age of the participants was 20.25 ± 1.305 years (range 17-25). The prevalence of DED among computer programmers was 47.7%. This study showed that gender (p = 0.31), contact lens usage (p = 0.64), and duration of time spent on computer display units (p = 0.47) were not significant determinants of DED among computer programmers. CONCLUSION: DED is prevalent among IT students, along with different symptoms. However, further studies are required to adequately measure the prevalence of DED during longer exposure time to computer screens and explore environmental risk factors.

An important contributing factor in dry eye disease: somatization.

PURPOSE: Somatization is an important mental process that may causes medically unexplained and treatment-resistant somatic symptoms. The aim of the study is assess the presence of somatization in patients with dry eye disease (DED). METHODS: Eighty-eight patients with no objective DED finding and ongoing DED treatment were included in this prospective and observational study. Patients with subjective symptoms formed the symptom group and patients without subjective symptoms formed the control group. All patients were scored with the Turkish version of the Ocular Surface Disease Index (OSDI), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Symptom Checklist-90-R (SCL-90R) somatization subscale, Toronto Alexithymia Scale (TAS), Pain Catastrophizing Scale (PCS), and Symptom Interpretation Questionnaire (SIQ). RESULTS: Mean OSDI score was significantly higher in the symptom group than in the control group. The mean HAM-D and HAM-A outcomes did not differ between the groups. The mean SCL-90R somatization subscale, TAS, and PCS scores were significantly higher in the symptom group than in the control group. In the SIQ, somatic attributional style score was significantly higher in the symptom group than in the control group. The SCL-90R somatization subscale, PCS, and somatic attributional style scores had positive and mild-moderate correlation with OSDI scores in the symptom group. The TAS score had positive and moderate correlation with OSDI scores in all sample analyses. CONCLUSION: Somatization should be considered in patients with DED with chronic ocular surface symptoms. Presence of subjective symptoms resistant to treatment may be an indicator of somatization.

Impact of thermo-mechanical skin treatment on refraction and keratometry in patients with dry eye disease and the implications for cataract surgery.

PURPOSE: To determine the changes in keratometry measurements and refraction in patients having the thermo-mechanical periorbital skin treatment, Tixel®, to treat dry eye disease (DED). METHODS: A multi-centre, prospective, non-masked study was conducted. DED patients were recruited in 3 international centres and were evaluated in 5 visits separated by an interval of 2 weeks except for the last visit which took place after 18 weeks from visit 1. The same clinical examination was performed at all visits: OSDI questionnaire, tear stability, keratometry, best corrected visual acuity and refraction. Tixel® treatment was applied at the first 3 visits. RESULTS: 89 participants (24 males/65 females; mean age: 55.0 ± 14.2 years) were included: 20 presented moderate DED symptoms and 69 severe DED symptoms. Significant differences were found for the spherocylindrical refraction (vector analysis) between visit 1 and visits 2 and 3. Following cumulative analysis, 11.86 % and 16.94 % of participants had more than 0.5 dioptre (D) change in mean keratometry and keratometric astigmatism, respectively, at 3 months post-treatment. A total of 5.40 % had a sphere and cylinder change greater than 0.50D and 16.21 % had the axis changed more than 10 degrees (vector analysis). These changes were particularly significant in patients with severe DED symptoms. CONCLUSIONS: Keratometry readings and refraction can change following thermo-mechanical skin treatment for DED, especially in those patients with severe DED symptoms. This should be considered as potential errors in intraocular lens calculations may be induced.

Tear film stability in patients with symptoms of dry eye after instillation of dual polymer hydroxypropyl guar/sodium hyaluronate vs single polymer sodium hyaluronate.

PURPOSE: This study evaluated the tear film stability in patients with symptoms of dry eye after installation of dual polymer hydroxypropyl guar/sodium hyaluronate (DPHG/SH) vs single polymer SH. METHODS: Patients with recently diagnosed mild to moderate dry eye disease (OSDI score 23-32 points) were included. For each patient, the right eye was randomized to receive DPHG/SH or 0.15% SH. Just after the administration of the drop to the right eye, the fellow eye received the other eye drop. The first non-invasive Keratograph first break-up time (NIKBUT), average NIKBUT and tear meniscus height (TMH) were measured before administration of the eye drops, at 1-min, 15 min, 30 min, 60 min, 90 min, and 120 min after instillation. RESULTS: A total of 29 patients aged 22.8 ± 2.2 years participated in the study (21 women). No differences between the eye receiving DPHG/SH and single polymer SH were observed for the first NIKBUT (p = 0.45) and average NIKBUT (p = 0.24) variables at any time point. Both DPHG/SH and single polymer SH increased the TMH (p of time effect < 0.001), but with no difference between groups (p = 0.95). CONCLUSION: Both DPHG/SH and single polymer SH solutions provide lubrication of the eye surface, however, with no difference in NIKBUT and TMH evaluations for up to two hours following administration.

Validity and reliability of the Thai version of the ASCRS SPEED II preoperative OSD questionnaire in Thai cataract surgery candidates.

OBJECTIVES: To develop a Thai version of the American Society of Cataract and Refractive Surgery (ASCRS)-modified Standard Patient Evaluation of Eye Dryness (SPEED) II© preoperative ocular surface disease (OSD) questionnaire (ASCRS SPEED II-Thai) and evaluate its validity and reliability in Thai cataract surgery candidates. METHODS: The original English version of the questionnaire was translated and adapted cross-culturally to Thai language. The ASCRS SPEED II-Thai was evaluated for content validity, internal consistency, and test-retest reliability. Five experts in the ocular surface field critically reviewed the ASCRS SPEED II-Thai to measure the content validity indexes (CVI). A total of 105 cataract surgery candidates were recruited from an ophthalmology clinic to complete the questionnaire. Cronbach's alpha and intraclass correlation coefficient (ICC) were calculated to assess internal consistency and test-retest reliability, respectively. RESULTS: During the translation and cross-cultural adaptation processes, only two minor modifications were made to the original version for clarification without changing their meaning. All items in the ASCRS SPEED II-Thai had an item-level CVI of 1.00, representing complete agreement among content experts. The scale-level CVI was 1.00, indicating excellent content validity of the questionnaire. The participants found no difficulty in understanding each question in the pilot test. Cronbach's alpha for the ASCRS SPEED II-Thai was 0.82, indicating good internal consistency. The test-retest reliability was good to excellent, with ICC values ranging from 0.83 to 1.00 (P < 0.001). CONCLUSIONS: The ASCRS SPEED II-Thai is a valid clinical tool with adequate reliability for preoperative OSD screening among Thai cataract surgery candidates.

Assessment of tear film parameters in females with refractive errors using a single device: An observational study.

This observational study aimed to evaluate the use of a single portable device to assess the non-invasive tear break-up time (NITBUT), tear meniscus height (TMH), and lipid layer patterns (LLP) in young females with refractive errors (REs). The study was conducted at the College of Applied Medical Science (Female campus), Riyadh, Saudi Arabia between January 5, 2021 to May 15, 2021. Forty young females, with mean age of 23.0± 4.3 years with REs (-2.53 ± 2.05 D) and 40 females, mean age 23.8± 4.5 years with healthy eyes were recruited. The tests were administered in the following order: Ocular Surface Disease Index (OSDI), followed by NITBUT, TMH, and LLP. Significant differences (via Mann-Whitney U test) were noted in the median ocular surface disease index (OSDI; p˂0.001), NITBUT (p=0.035), TMH (p=0.009), and LLP (p˂0.001) scores between the study and control groups. Females with REs have significantly lower lipid layer, TMH, and NITBUT scores than those with healthy eyes.

Standardized clinical evaluation of dry anophthalmic socket syndrome in a real-world approach.

PURPOSE: To assess which signs and eye prosthesis care habits are related to subjective discomfort in patients with dry anophthalmic socket syndrome (DASS), using standardized tools from daily practice. METHODS: 62 anophthalmic sockets were compared with their healthy fellow eye using the Standard Patient Evaluation of Eye Dryness (SPEED) score. The correlations between SPEED questionnaire and the prosthesis care, discharge characteristics score, conjunctival inflammation score, meibomian gland dysfunction (MGD) scores and Schirmer I test were studied. RESULT: The anophthalmic sockets group achieved a higher SPEED test score (p < 0.01), discharge score (p < 0.01), conjunctival inflammation score (p < 0.01), MGD scores (p < 0.01) and lower Schirmer I test (p < 0.01) compared with their fellow, healthy eye. Patients with a prosthesis replacement of one year or less, those with a current fit time of one year or less and those with a cleaning frequency above one month reported better SPEED, (p < 0.01), conjunctiva inflammation (p < 0.01) and MGD scores (p < 0.01). CONCLUSION: Most anophthalmic patients suffer mild to severe DASS, which seems related to discharge, conjunctival inflammation and MGD. Moreover, certain practices related to the care of the prosthesis such as replacing with a frequency lower than yearly, current fitting time inferior to one year and a removing and cleaning regime above one month, were related to a lower discomfort sensation, conjunctival inflammation and MGD. Clinicians should consider the DASS when facing patients with anophthalmic socket and discomfort symptoms.

Effect of upper eyelid blepharoplasty on the ocular surface, tear film, and corneal microstructure.

PURPOSE: This study aimed to investigate the effect of upper eyelid blepharoplasty with the removal of the skin and a strip of orbicularis oculi muscle on the ocular surface, tear film, and dry eye-related symptoms. METHODS: Twenty-two eyes of 22 consecutive patients operated by a single surgeon (21 females; mean age, 61 years; age range, 41-75 years) were included. All subjects completed the Ocular Surface Disease Index questionnaire, underwent in vivo confocal microscopy, tear film breakup time measurements, the Schirmer test with anesthesia, and fluorescein and lissamine green staining measurements before, 1 month, and 6 months after upper blepharoplasty alone with preseptal orbicularis excision. RESULTS: A significant increase in Ocular Surface Disease Index, and corneal fluorescein and lissamine green staining and a significant decrease in tear film breakup time were observed after 1 month (p=0.003, p=0.004, p=0.029, and p=0.024 respectively) and 6 months (p=0.001 for all findings). No significant difference in the Schirmer test score was observed during the follow-up. None of the in vivo confocal microscopy parameters showed significant changes during the study. CONCLUSIONS: An increase in dry eye symptoms and a decrease in tear film stability along with ocular surface staining were observed in patients undergoing upper eyelid blepharoplasty.

Evaluation of therapeutic efficacy of Emustil drops for ocular discomfort and tear film osmolarity using different treatment management modes under dry environmental conditions.

BACKGROUND: We aimed to check the efficacy of Emustil (oil in water emulsion) drops on tear film index and ocular surface dynamics in dry environments through protection and relief treatment modalities. METHODS: The subjects were exposed to a dry environment using a Controlled Environment Chamber (CEC) where the relative humidity (RH) was 5% and the temperature was 21 °C and screened for ocular symptoms, tear osmolarity, ocular surface temperature (OST) and tear production using ocular Surface Disease Index questionnaire (OSDI), OcuSense TearLab Osmometer, FLIR System ThermaCAM P620 and Schirmer strips/phenol red test respectively. Tear production was calculated by the Tear Function Index test (TFI). RESULTS: The mean tear film osmolarity decreased significantly from 296.8 mOsm/l at 40% RH to 291 mOsm/l at 5%. (p = 0.01). Instillation of Emustil resulted in a significant increase in tear osmolarity in the relief method compared with osmolarity seen at 5% RH when no drop was used. The mean PRT value decreased from 26 ± 9 in normal conditions (40% RH) to 22 ± 4 mm in dry conditions (5% RH). Emustil drops did not induce any significant change in tear production in the PRT test. No significant change was found in OST following exposure to 5% RH. OST did not show a statistically significant change with the emulsion when used for relief (p > 0.05). The mean score of ocular discomfort observed was 70 at 5% RH. Still, the instillation of the oil-in-water emulsion (Emustil) resulted in a noticeable decrease in visual discomfort to 37 (p = 0.00) in protection and 59 in relief (p = 0.05). Emustil drops substantially improved tear film parameters under a desiccating environment, however, tear film parameters respond differently to the management modalities. In the protection method, tear film osmolarity was protected against a dry environment, while in the relief mode, tear production was improved. CONCLUSION: CEC allows for a thorough evaluation of tear film parameters and dry eye treatment protocols in labs, providing greater confidence when applying them to patients. In addition, our study showed that Emustil not only provides protection and relief for dry eyes but also helps to maintain ocular homeostasis in desiccating environments. This indicates a promising potential for improving dry eye treatment protocols.

Dry eye disease pathogenesis and clinical signs: searching for correspondence in the clinical practice.

BACKGROUND: Ocular surface alterations causing dry eye disease (DED) can be described as a vicious circle consisting of different consecutive stages. Among the factors involved, the ocular surface immune-inflammatory response has been established as a key player in the pathogenesis of the vicious circle of DED. Thus, the prompt recognition of the disruption of the immunoregulatory mechanisms is crucial for properly managing the ocular surface alterations. To increase awareness and knowledge of the identification and clinical interpretation of immunological mechanisms of dry eye in clinical practice, we present two clinical cases related to DED patients to provide a practical example of clinical examination application and interpretation of diagnostic parameters in daily practice. Moreover, a literature overview of the available clinical examinations to assess the immunological involvement in DED patients, with a particular focus on the correlation between diagnostic parameters and pathogenesis of clinical signs, is provided with an educational intent. CASE PRESENTATION: The presented clinical experiences suggested that in ocular surface pathologies, knowledge of the immune-inflammatory pathogenetic mechanisms underlying the observed clinical sign is of great help for understanding what is being observed in the patient and, consequently, for the choice of appropriate therapy. Literature evidence suggests that many different clinical examinations can be used to assess inflammation in DED patients, such as the assessment of hyperemia, staining of the ocular surface and measurement of hyperosmolarity and MMP-9 levels. The combination of impression cytology and flow cytometry to assess for markers of inflammation is considered the best technique to quantify the level of inflammation on the ocular surface, even if not always applicable in clinical practice. CONCLUSIONS: Literature evidence and clinical experiences suggest that basic diagnostic approaches (assessment of hyperemia, MMP-9 levels, and staining of the ocular surface with Lissamine green or fluorescein) represent useful tools to assess the inflammatory component of DED in everyday practice, providing a guide to establish the correct therapeutic strategy.

Diagnosis of Dry Eye Syndrome Using Ocular Surface Disease Index, Tear Film Break-up Time, and Schirmer Test.

OBJECTIVE: To evaluate the subjects of possible ocular surface dysfunction in dry eye syndrome (DES) by using Ocular Surface Disease Index (OSDI) questionnaire and correlating it with the tear film break-up time (TBUT) test and Schirmer test. STUDY DESIGN: Cross-sectional, observational study. Place and Duration of the Study: Armed Forces Institute of Ophthalmology (AFIO), National University of Medical Sciences (NUMS), Rawalpindi, Pakistan, from March to August 2022. METHODOLOGY:  Demographics and detailed ophthalmological examinations were carried out for all the patients using slit lamp biomicroscopy. The questionnaire for OSDI was filled to calculate the OSDI score, Schirmer test, and TBUT test were performed for all patients. For statistical analysis, the mean test score of both eyes was used. Correlations between tests were drawn and reported. RESULTS: This study was conducted on ninety-seven adult participants with mean age of 31.3 ± 10.7 years, comprising of forty-five (46.4%) females and fifty-two (53.6%) males. The mean score for OSDI, TBUT, and Schirmer test was found to be 16.03 ± 14.22 (range 0 - 62.5), 9.63 ± 4.54 seconds (range 2.5 - 22.5), and 24.6 ± 10.85 mm (range 4.5 - 35.5), respectively. An inverse correlation was found between the OSDI and Schirmer, and OSDI and TBUT test scores which was also statistically significant. Schirmer and TBUT test scores also showed significant correlation. CONCLUSION: The OSDI is quick, precise, feasible for self-assessment, and non-invasive standardised tool for evaluating symptoms of dry eye disease, hence it can aid in the diagnosis of DES. KEY WORDS: Dry eye syndrome, Ocular surface, Tear flim break-up time, Schirmer test.

Ocular surface and meibomian gland evaluation in euthyroid Graves' ophthalmopathy.

PURPOSE: Euthyroid Graves' ophthalmology (EGO) refers to the subgroup of thyroid eye disease patients with distinct clinical presentations. This study evaluated the ocular surface and meibomian gland changes in EGO patients. METHODS: A cross-sectional study was conducted at The Chinese University of Hong Kong including 34 EGO patients and 34 age-and sex- matched healthy controls. Outcome measures include anterior segment examination, keratographic and meibographic imaging. RESULTS: Between 34 EGO patients and 34 age and sex-matched healthy controls, EGO was associated with a higher ocular surface disease index (P < 0.01), higher severity of meibomian gland dropout (upper: P < 0.001, lower: P < 0.00001) and higher percentage of partial blinking (P = 0.0036). The worse affected eyes of the EGO patients were associated with corneal staining (P = 0.0019), eyelid telangiectasia (P = 0.0009), eyelid thickening (P = 0.0013), eyelid irregularity (P = 0.0054), meibomian gland plugging (P < 0.00001), expressibility (P < 0.00001), and meibum quality (P < 0.00001). When the two eyes of the same EGO patient were compared, the degree of meibomian gland dropout was higher among the worse affected eyes (upper: P < 0.00001, and lower: P < 0.00001). Tear meniscus height, lipid layer thickness, and noninvasive break-up time were comparable between the two eyes of EGO patients and also between EGO patients and healthy controls. TMH was positively correlated with the degree of exophthalmos (r = 0.383, P < 0.05). CONCLUSION: EGO patients have more ocular surface complications and meibomian gland dropouts than healthy controls. Almost 60% of them had dry eye symptoms, but aqueous deficiency was not apparent. Further studies are warranted to clarify the mechanism of dry eye in EGO. (249 words).

Optimising subjective grading of corneal staining in Sjögren's syndrome dry eye disease.

AIM: To assess whether smaller increment and regionalised subjective grading improves the repeatability of corneal fluorescein staining assessment, and to determine the neurological approach adopted for subjective grading by practitioners. METHODS: Experienced eye-care practitioners (n = 28, aged 45 ± 12 years), graded 20 full corneal staining images of patients with mild to severe Sjögren's syndrome with the Oxford grading scheme (both in 0.5 and 1.0 increments, globally and in 5 regions), expanded National Eye Institute (NEI) and SICCA Ocular Staining Score (OSS) grading scales in randomised order. This was repeated after 7-10 days. The digital images were also analysed objectively to determine staining dots, area, intensity and location (using ImageJ) for comparison. RESULTS: The Oxford grading scheme was similar with whole and half unit grading (2.77vs2.81,p = 0.145), but the variability was reduced (0.14vs0.12,p < 0.001). Regional grade was lower (p < 0.001) and more variable (p < 0.001) than global image grading (1.86 ± 0.44 for whole increment grading and 1.90 ± 0.39 for half unit increments). The correlation with global grading was high for both whole (r = 0.928,p < 0.001) and half increment (r = 0.934,p < 0.001) grading. Average grading across participants was associated with particle number and vertical position, with 74.4-80.4% of the linear variance accounted for by the digital image analysis. CONCLUSIONS: Using half unit increments with the Oxford grading scheme improve its sensitivity and repeatability in recording corneal staining. Regional grading doesn't give a comparable score and increased variability. The key neurally extracted features in assigning a subjective staining grade by clinicians were identified as the number of discrete staining locations (particles) and how close to the vertical centre was their spread, across all three scales.