A novel classification of senile dermatochalasis: insights from clinical and histological analysis.

PURPOSE: Dermatochalasis is a common disorder of the elderly, often requiring upper blepharoplasty. Although it is mainly accepted as a process of aging, its clinical and histological findings vary among patients. The aim of this study was to classify types of dermatochalasis based on their clinical and histological findings. METHODS: This retrospective study included patients with dermatochalasis who had undergone senile blepharoplasty at a single center. Clinical parameters such as margin-to-reflex distance 1 (MRD1), eyelid contour, visual field, and pre-existing medical conditions were assessed. Histological analysis was conducted of eyelid tissues stained with hematoxylin and eosin (H&E) and D2-40 to evaluate dermal edema, inflammation, lymphatic changes, and stromal depth. RESULTS: This study included 67 eyes of 35 patients. The mean age of the patients was 69.0 ± 8.3 years, and the average MRD1 was 1.8 ± 1.3 mm. In correlation analysis, two distinct types of dermatochalasis based on the histological findings were identified: lymphangiectasia-dominant and stromal edema-dominant types. The difference between nasal and temporal side MRD1(NT-MRD1) showed the area under the ROC curve of 0.718 of for distinguishing the two histological types of dermatochalasis was 0.718. CONCLUSION: Our novel classification of senile dermatochalasis based on morphological and histological analysis provides insights into the underlying pathology and may help to predict surgical outcomes and complications.

Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension.

BACKGROUND: Lower eyelid defects are traditionally classified based on depth and 25 percent increments in defect width. The authors propose a new classification system that includes the vertical defect component to predict functional and aesthetic outcomes. METHODS: A retrospective review of patients who underwent lower lid reconstruction performed by a single surgeon was performed. Defects were classified into four categories based on the vertical component: (1) pretarsal; (2) preseptal; (3) eyelid-cheek junction; and (4) complex pretarsal/preseptal. Preoperative and postoperative central and lateral marginal reflex distance-2 values were obtained. Aesthetic outcomes were evaluated by three blinded reviewers. Outcomes were compared using one-way analysis of variance and analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width. RESULTS: Thirty-four patients underwent reconstruction of lower eyelid defects. There were 12 pretarsal defects (type I), nine preseptal defects (type II), nine eyelid-cheek defects (type III), and four complex pretarsal/preseptal defects (type IV). Postoperative retraction was highest in the complex pretarsal/preseptal group at 75 percent, with a significantly greater change from preoperative to postoperative central and lateral marginal reflex distance-2 compared with the other groups (p < 0.01) and worse postoperative mean aesthetic scores (p < 0.001). Type IV patients had significantly more revision operations (mean, 5.5) compared with the other groups (p < 0.001). CONCLUSIONS: The vertical dimension of lower eyelid defects is an important variable. A new classification system is proposed that supplements width-based methods for improved surgical planning and prediction of postoperative outcomes in lower eyelid reconstruction. CLINICAL QUESTION/LEEVL OF EVIDENCE: Therapeutic, IV.

Lid-parallel conjunctival fold (LIPCOF) morphology imaged by optical coherence tomography and its relationship to LIPCOF grade.

PURPOSE: Lid-parallel conjunctival folds (LIPCOF) are a well-accepted clinical sign in dry eye diagnosis. Commonly, LIPCOF is classified by grading the number of folds observed by slit-lamp microscope. This study investigated the relationship between subjective grading scale and LIPCOF morphology imaged by optical coherence tomography (OCT). METHODS: Temporal and nasal LIPCOF of 42 subjects (mean age 27.3 ± 8.4 (SD) years; 13 M, 29 F) were observed and classified by an experienced optometrist using the Pult LIPCOF grading scale (0: no permanent, lid-parallel conjunctival fold; 1: one fold; 2: two folds, 3: three or more folds). Additionally, LIPCOF cross-sectional area (LIPCOF-A) and fold count (LIPCOF-C), as imaged by OCT (Cirrus HD; Carl Zeiss Meditec, Jena, Germany), were analysed with ImageJ 1.50 (http://rsbweb.nih.gov/ij). Correlations between subjective grading and LIPCOF-A and LIPCOF-C were analysed by Spearman correlation, differences between subjective grading and LIPCOF-C were analysed by Wilcoxon test. RESULTS: For temporal and nasal sectors, mean subjective LIPCOF grade was 1.43 ± 0.86 grade units and 0.57 ± 0.80 grade units, mean LIPCOF-C was 1.67 ± 0.82 folds and 0.69 ± 0.78 folds, and mean LIPCOF-A was 0.0676 ± 0.0236mm2 and 0.0389 ± 0.0352 mm2, respectively. Subjective temporal and nasal LIPCOF grade was significantly correlated to LIPCOF-C (r = 0.610, p < 0.001 and r = 0.645, p < 0.001, respectively), and to LIPCOF-A (r = 0.612, p < 0.001 and r = 0.583, p < 0.001, respectively). LIPCOF-C was not statistical different to subjective LIPCOF grade (p = 0.07 and p = 0.239; temporal and nasal sectors, respectively). CONCLUSIONS: OCT allows for better imaging of finer details of LIPCOF morphology, and especially of LIPCOF area. OCT evaluation of LIPCOF area correlated well with subjective grading and appears to be a promising objective method for LIPCOF classification.

Development of Definitive and Reliable Grading Scales for Meibomian Gland Dysfunction.

PURPOSE: To develop and validate grading scales for meibomian gland dysfunction (MGD) that allow consistent diagnosis of MGD and are suitable for clinical studies. DESIGN: Development and validation study of grading scales. METHODS: Lid margin and meibomian gland photographs were taken in the multicenter, prospective cross-sectional study for MGD and control subjects. New grading scales for MGD signs (abnormal lid margin findings of vascularity, plugging of gland orifices, lid margin irregularity, lid margin thickening, partial glands, and gland dropout) in both upper and lower eyelids were developed. Three MGD experts, 3 general ophthalmologists, and 3 non-physicians independently tested the scales by evaluating photographs. The levels of interrater and intrarater agreement for each grading scale were estimated with the use of kappa statistics. RESULTS: Thirty-eight patients with MGD and 20 control subjects were enrolled and photographed. New grading scales were developed using a total of 226 photographs. The interrater kappa values for MGD experts and for general ophthalmologists and non-physicians with reference to an MGD expert ranged from 0.36 to 0.87 (median of 0.66), 0.41 to 0.73 (0.60), and 0.30 to 0.77 (0.59), respectively. Those for intrarater reliability for 2 MGD experts ranged from 0.49 to 0.93 (0.82). CONCLUSIONS: New grading scales for MGD signs were developed and found to have appropriate inter- and intrarater reliabilities for grading MGD. These grading scales are suitable for MGD diagnosis and application to multicenter trials.

[A new classification for meibomian gland diseases with in vivo confocal microscopy]. / Une nouvelle classification des dysfonctionnements meibomiens en microscopie confocale in vivo.

INTRODUCTION: Meibomian gland dysfunction (MGD) is a frequent disorder often associated with dry eye disease. Slit-lamp examination with digital expression of the tarsal Meibomian glands allows examination of the contents of the distal Meibomian gland and the meatus. However, the Meibomian epithelium, interglandular space and proximal secretions cannot be clinically assessed. In vivo confocal microscopy (IVCM) is a rapid and non-invasive imaging technique that provides high-resolution images of the ocular surface and eyelids. The primary objective of the present study was to establish a classification of MGD with IVCM. Secondary objectives were to evaluate this scoring system by analyzing the correlation with OSDI, infrared (IR) meibography and Demodex infestation. MATERIAL AND METHODS: Forty-six dry eye patients (Ocular Surface Disease Index [OSDI] >13) associated with MGD were enrolled. Ten healthy subjects without dry eye disease or blepharitis were also included as controls. An OSDI questionnaire, clinical examination, IVCM and infrared meibography of the lower lid were performed in all subjects by the same examiner. RESULTS: A new MGD score was established based on IVCM findings: the first stage was Meibomian obstruction with a clear epithelium, the second stage was an inflammatory state with Meibomian gland obstruction, epithelial and interglandular inflammation, and the last stage was glandular fibrosis. This score was significantly correlated with the meiboscore obtained with infrared meibography (correlation coefficient 0.47, CI95% [0.22-0.66]). CONCLUSION: IVCM of the Meibomian gland complex complements the clinical examination by determining the stage of dysfunction and may help clinicians evaluate and treat MGD.

Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction.

Meibomian gland dysfunction (MGD) is the most frequent cause of dry eye disease (DED). Eyelid inflammation, microbial growth, associated skin disorders as well as potentially severe corneal complications culminate to make MGD a complex multifactorial disorder. It is probable that MGD is a heterogeneous condition arising from any combination of the following five separate pathophysiological mechanisms: eyelid inflammation, conjunctival inflammation, corneal damage, microbiological changes and DED resulting from tear film instability. The pathogenesis of both MGD and DED can be described in terms of a 'vicious circle': the underlying pathophysiological mechanisms of DED and MGD interact, resulting in a double vicious circle. The MGD vicious circle is self-stimulated by microbiological changes, which results in increased melting temperature of meibum and subsequent meibomian gland blockage, reinforcing the vicious circle of MGD. Meibomian gland blockage, dropout and inflammation directly link the two vicious circles. MGD-associated tear film instability provides an entry point into the vicious circle of DED and leads to hyperosmolarity and inflammation, which are both a cause and consequence of DED. Here we propose a new pathophysiological scheme for MGD in order to better identify the pathological mechanisms involved and to allow more efficient targeting of therapeutics. Through better understanding of this scheme, MGD may gain true disease status rather than being viewed as a mere dysfunction.

Classification by causes of dark circles and appropriate evaluation method of dark circles.

BACKGROUND: Dark circles refer to a symptom that present darkness under the eyes. Because of improvement in the quality of life, the dark circles have been recognized as one of major cosmetic concerns. However, it is not easy to classify the dark circles because they have various causes. METHODS: To select suitable instruments and detailed evaluation items, the dark circles were classified according to the causes through visual assessment, Wood's lamp test, and medical history survey for 100 subjects with dark circles. After the classification, were newly recruited for instrument conformity assessment. Through this, suitable instruments for dark circle evaluation were selected. We performed a randomized clinical trial for dark circles, a placebo-controlled double-blind study, using effective parameters of the instruments selected from the preliminary test. RESULTS: Dark circles of vascular type (35%) and mixed type (54%), a combination of pigmented and vascular types, were the most common. Twenty four subjects with the mixed type dark circles applied the test product (Vitamin C 3%, Vitamin A 0.1%, Vitamin E 0.5%) and placebo on randomized split-face for 8 weeks. The effective parameters (L*, a, M.I., E.I., quasi L*, quasi a* and dermal thickness) were measured during the study period. Result showed that the L* value of Chromameter(®) , Melanin index (M.I.) of Mexameter(®) and quasi L* value obtained by image analysis improved with statistical significance after applying the test product compared with the placebo product. CONCLUSION: We classified the dark circles according to the causes of the dark circles and verified the reliability of the parameter obtained by the instrument conformity assessment used in this study through the efficacy evaluation. Also based on this study, we were to suggest newly established methods which can be applied to the evaluation of efficacy of functional cosmetics for dark circles.

Improving Care for Patients with Dry Eye Symptoms: See What the Experts Say.

A panel of experts was invited to discuss the following questions: Why does the prevalence of dry eye disease (DED) appear to be increasing? Are you satisfied with the current definition and classification of DED-aqueous deficiency versus evaporative dry eye? Beyond the innate human factors (e.g., genetics), what external factors might contribute to DED? What areas related to DED need to be more fully understood? In examining a patient complaining of dry eye, what is your strategy (e.g., tests, questionnaire)? What is your strategy in unraveling the root cause of a patient's dry eye symptoms that may be shared by many anterior segment diseases? What are the two or three most common errors made by clinicians in diagnosing DED? Why do contact lens (CL) patients complain of dry eye while wearing lenses but not when not wearing lenses? What areas related to CL discomfort need to be more fully understood? What is your most effective strategy for minimizing CL discomfort? With current advances in biotechnology in dry eye diagnostics and management tools, do you think our clinicians are better prepared to diagnose and treat this chronic condition than they were 5 or 10 years ago? Do you foresee any of these new point-of-care tests becoming standard clinical tests in ocular surface evaluation? What treatments are effective for obstructed Meibomian glands secondary to lid margin keratinization? What level of DED would prevent you from recommending an elected ophthalmic surgery? What strategy do you use to help your patients comply with the recommended home therapies? How do you best manage patients whose severity of dry eye symptoms does not necessarily match clinical test results, especially in cases of ocular surface neuropathy? Where do you see dry eye diagnosis and treatment in 10 years or more?

Severity of acute ocular involvement is independently associated with time to resolution of ocular disease in toxic epidermal necrolysis patients.

PURPOSE: Toxic epidermal necrolysis (TEN) is a severe, life-threatening mucocutaneous disorder that frequently involves the ocular surface. This study aims to investigate the natural history and resolution of acute ocular involvement in patients with TEN admitted to the intensive care unit (ICU). METHODS: Case notes of patients admitted to ICU with TEN at a tertiary referral centre in a 9-year period were retrospectively reviewed. Patients' characteristics, severity of ocular involvement, SCORTEN systemic severity score and treatment were correlated with resolution of ocular involvement and time to resolution. RESULTS: Nine out of 10 (90%) patients had ocular involvement with 4 graded as mild, 2 as moderate and 3 as severe. All had bilateral ocular disease. The median length of hospital stay was 28 days and the median time to resolution of ocular involvement was 19 days. Four out of 9 (44%) patients still had active ocular disease at the time of discharge. Only older age (p=0.032) and a milder grade of ocular disease (p=0.001) were significantly associated with resolution of ocular disease. In a multivariable Cox-regression model, only a milder grade of ocular disease remained independently associated with time to resolution of ocular disease (p=0.006). CONCLUSIONS: Grading of acute ocular disease severity does not reflect systemic disease severity and is significantly associated with resolution and time to resolution of ocular involvement in TEN. The high rate of ocular involvement in patients with TEN and relatively large proportion of patients with active disease on discharge reiterates the need for constant ophthalmological monitoring of these patients.

[Revisiting meibomian gland dysfunction]. / Revisiter les dysfonctionnements meibomiens.

Meibomian gland dysfunctions (MGD) are frequent affections, sometimes asymptomatic, more often responsible for disabling, potentially severe, manifestations. MGD is indeed the most frequent cause of dry eye, through the induction of tear film instability. However, eyelid inflammation, microbial proliferation that modifies melting temperature of meibum, frequent association with skin diseases, as well as potentially severe corneal complications make them complex multifactorial disorders. Complementary mechanisms combine to actually result in a vicious circle, or more accurately a double vicious cycle. The first one is self-stimulated by the microbiological changes, which create their own conditions for MGD development. The second one is related to tear film instability that results from MGD and is also self-stimulated through hyperosmolarity and inflammatory phenomena, which are both consequence and cause of dry eye. We herein propose a new pathophysiological schema on MGD, in order to better identify mechanisms and more efficiently target therapeutics.

Prevalence of chronic ocular complications in Stevens-Johnson syndrome and toxic epidermal necrolysis.

PURPOSE: The aim of this study is to identify and grade the severity of chronic ocular complications in patients who suffered from Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) treated in Cape Town, South Africa. METHODS: A total of 54 patients with SJS or TEN for 6 months or longer were examined. The ocular complications were classified into corneal, eyelid and conjunctival complications. The complications were graded from 0 to 3 depending on the severity. RESULTS: A total of 108 eyes were included in the study. Medications caused SJS or TEN in all cases, and the most common associated drugs were anti-retroviral medications. 59.3% of patients were HIV-positive, with CD4 counts ranging from 6 to 521. Although only 11% of patients with SJS or TEN had acute ocular complications during the initial illness, 89% developed chronic ocular complications. Loss of the palisades of Vogt was the most common corneal complication. Among the six components of conjunctival and eyelid complications, irregularity of the mucocutaneous junction abnormalities was the most common, followed by mild conjunctival hyperemia. There was no statistically significant difference in the severity of chronic ocular complications between HIV-positive and HIV-negative patients (P = 0.4). In addition, the severity of chronic ocular complications was not statistically significantly associated with visual acuity loss (P = 0.3). CONCLUSION: We conclude that almost 90% of patients who are diagnosed with SJS or TEN will develop chronic ocular complications. Unless eyelids are severely affected, most chronic complications are mild to moderate ocular surface abnormalities and not necessarily vision-threatening complications.

Floppy eyelid syndrome: the coventry experience.

PURPOSE: Floppy eyelid syndrome is a condition that is difficult to identify and diagnose and with no clear guidelines on its management. We propose a method of reliably grading this syndrome and have proposed a management algorithm based on the grading. MATERIALS AND METHODS: Retrospective data collection of patients diagnosed with Floppy eyelid syndrome and treated under the care of a single oculoplastic surgeon over a 9 year period. RESULTS: First, 102 patients were included and were classified into 3 groups. Grade 1 (F1) 7.5%, Grade 2 (F2) 36.5% and Grade 3 (F3) 56%. Only 12% of our cohort required surgery, and 92% of these patients demonstrated improvement in their symptoms. DISCUSSION: Clinical grading of Floppy eyelid syndrome patients will help determine patient's management plan. In our experience, operating on both upper and lower eyelids at the same time where indicated helps to maintain the normal anatomical relationship and improve epiphora.

Effects of topical loteprednol etabonate on tear cytokines and clinical outcomes in moderate and severe meibomian gland dysfunction: randomized clinical trial.

PURPOSE: To assess tear cytokine levels and clinical outcomes in moderate and severe meibomian gland dysfunction (MGD) after 2 months of treatment with topical loteprednol etabonate and eyelid scrubs with warm compresses vs eyelid scrubs with warm compresses alone. DESIGN: Randomized controlled trial. METHODS: Patients with moderate and severe MGD were randomized into 2 groups: topical loteprednol etabonate and eyelid scrubs with warm compresses (Group I, 34 eyes) or eyelid scrubs with warm compresses (Group II, 36 eyes). We evaluated cytokine levels, tear film break-up time (TBUT), corneal and conjunctival fluorescein staining, biomicroscopic examination of lid margins and meibomian glands, and the Ocular Surface Disease Index before initiating treatment and 1 month and 2 months after treatment. RESULTS: There were significant decreases in the levels of interleukin (IL)-6, IL-8, and IL-1ß in Group I, and IL-6 and IL-8 in Group II. Moreover, the observed decreases of these cytokines in Group I were attributed to a remarkable decrease between treatment and 1 month after treatment. In Group I, there were improvements in all of the clinical outcomes, with prominent improvement in TBUT, corneal and conjunctival fluorescein staining, and meibum quality after 1 month of treatment, compared with Group II. An improvement in meibomian gland expressibility and MGD stage reduction were more remarkable in Group I. CONCLUSIONS: Topical loteprednol etabonate and eyelid scrubs with warm compresses were tolerated and efficacious for the treatment of moderate and severe MGD. We suggest that such beneficial effects could manifest after 1 month.

The clinical characteristics and new classification of sticky eyelid syndrome in East Asian patients.

PURPOSE: The aim of this study was to demonstrate the characteristics of sticky eyelid syndrome (SES) and to suggest a modified definition and new classification of the disease in relation to the severity of the syndrome in East Asian patients. METHODS: Forty-four eyes of 31 patients with sticky eyelid syndrome were included in this study. The medical records of patients who were diagnosed with sticky eyelid syndrome were retrospectively reviewed. Sticky eyelid syndrome was defined as an abnormal adhesion between the upper and lower eyelids during blinking. We divided the subjects into four grades according to the severity of the disease. RESULTS: Among 31 patients, there were 10 men and 21 women. The mean age of patients was 62.5 years. A total of 13 patients had SES bilaterally. All patients had meibomian gland dysfunction (MGD). Thirty-three eyes had dermatochalasis, and 30 eyes had involutional ptosis. Horizontal lower lid laxity was observed in 23 eyes, and reverse ptosis found in 15 eyes. Patients were classified into four groups as follows: G1: 11 (25%), G2: 24 (54.5%), G3: 6 (13.6%) and G4: 3 eyes (6.8%). Patients in Grade 1 tended to improve only with medical treatment for MGD. However, surgical management was necessary for patients in Grades 3 and 4. CONCLUSIONS: Meibomian gland dysfunction is a fundamental risk factor for developing sticky eyelid syndrome. Further, combined upper lid ptosis or lower lid laxity may be aggravating factors. According to the grading, medical or surgical management can be chosen.

Repeatability of grading meibomian gland dropout using two infrared systems.

PURPOSE: To determine the interobserver and intraobserver repeatability in using the OCULUS Keratograph 4 (K4) and 5M (K5M) to grade meibomian gland (MG) dropout using meibography grading scales. METHODS: The inferior and superior eyelids of 40 participants (35 women, 5 men; mean age = 32 years) were imaged three times each on both instruments. The images were split into one training and two study sets; the latter were graded (four-point meibography scale) by two observers on two separate occasions (24 hours apart) to determine repeatability. Semiobjective quantification of percentage MG dropout was conducted using ImageJ on K4 and K5M images. A finer seven-point meibography scale was used to grade a separate set of K5M images. RESULTS: For the four-point scale, interobserver mean difference (MD) (±SD) was 0.08 (±0.55) on day 1 and 0.13 (±0.50) on day 2, and the concordance correlation coefficient (CCC) was 0.79 and 0.81 on days 1 and 2, respectively. Intraobserver MD (±SD) was 0.04 (±0.54), CCC = 0.79 for observer 1; intraobserver MD (±SD) was -0.09 (±0.60), CCC = 0.74 for observer 2. For the seven-point scale, interobserver MD (±SD) was 0.05 (±0.45), CCC = 0.89 on day 1, and interobserver MD (±SD) was 0.01 (±0.41), CCC = 0.91 on day 2. Intraobserver MD (±SD) was -0.10 (±0.35), CCC = 0.93 for observer 1, and intraobserver MD (±SD) was -0.06 (±0.30), CCC = 0.95 for observer 2. Percentage dropout measured between the K4 and K5M images showed lack of agreement, with 21.8% coefficient of repeatability. There was no significant correlation (r < 0.2; p > 0.05) between meibography score and clinical signs (corneal staining, gland expressibility, telangiectasia, vascularity, lash loss); however, there was a high correlation (r = 0.77; p < 0.05) between meibography score with percentage dropout. CONCLUSIONS: Observers graded from -1 to +1 grade units between and within themselves for a four-point scale, 95% of the time. Although the interobserver and intraobserver repeatability of the K4 and K5M were very similar, a high rate of disagreement in percentage dropout between K4 and K5M images suggests that the two instruments cannot be interchanged. Meibomian gland dropout scores did not correlate significantly with clinical signs. Using a finer scale may be beneficial for detecting change.

Associations between the grade of meibomian gland dysfunction and dyslipidemia.

PURPOSE: To examine the relationship between dyslipidemia and the severity of meibomian gland dysfunction (MGD). METHODS: A prospective cohort study of 132 subjects with and 104 without MGD were recruited. A correlation between serum fasting lipids and MGD severity was performed. RESULTS: Mean age for all candidates was 49.4 years; and 57% were women. In all, 42.9% had no MGD, 14.8% had grade 1 MGD, 17.4% had grade 2 MGD, and 23.7% had grade 3 MGD. High cholesterol was found in 37.1% of grade 1 MGD, 43.9% of grade 2 MGD, and 50% of grade 3 MGD. High triglyceride was found in 5.7% of grade 1, 14.6% of grade 2, and 39.3% of grade 3 patients. High low-density lipoprotein was found in 17.1% of grade 1, 29.3% of grade 2, and 35.7% of grade 3 patients. The mean age of the control group was 41.2 years; and 55.4% were women. High cholesterol was found in 42.3%, triglyceride in 7.7%, low-density lipoprotein in 23.1%, low high-density lipoprotein in 3.8%, and high high-density lipoprotein in 3.8%. CONCLUSIONS: Although the presence of MGD does not have any correlation with dyslipidemia, the prevalence of high triglyceride and low-density lipoprotein levels increases with the increasing severity of MGD. This might highlight the significance of monitoring fasting serum lipids due to its association with the potential correlation with the progression of MGD.

Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections.

BACKGROUND: To evaluate the efficacy of subconjunctival triamcinolone injection for treating upper eyelid retraction caused by thyroid-associated ophthalmopathy (TAO). METHODS: Prospective single blind randomized clinical trial. Patients diagnosed with TAO-associated eyelid retraction and/or swelling <6 months before study onset were randomly assigned to triamcinolone-injected (group I; 55 patients, 75 eyes) or observation-only (group II; 40 patients, 59 eyes) populations. Group I received 1-3 injections of 20 mg triamcinolone acetate into the subconjunctival eyelid, between the conjunctiva and Muller's muscle, at 3-week intervals. Group I was followed up at 3, 6, 9, and 24 weeks post-injection, and group II was evaluated at 9 and 24 weeks after initial visit. Eyelid swelling and retraction were each graded on a 0-3 scale. Treatment was stopped after 1-2 injections if both swelling and retraction resolved completely or if retraction and swelling scored 0/1 or 1/0 without functional or cosmetic patient concerns. Treatment success was defined at 9 and 24 weeks post-injection if eyelids were normal or when treatment was terminated because of early clinical resolution. We compared baseline clinical data between success and failure group evaluated at 9 and 24 weeks in group I, and investigated short-term and long-term success prognostic factor using multiple logistic regression analysis in each group I and II. RESULTS: Swelling and retraction decreased significantly more in group I than in group II. Significantly more eyes had severe swelling (≥ grade 2) in group I (67 %) than in group II (34 %) upon initial evaluation (p < 0.01); this difference disappeared at 9 and 24 weeks. Fewer severely retracted eyes were observed in group I than in group II at 9 and 24 weeks (p < 0.01). Significantly more eyes in group I achieved success at both 9 and 24 weeks (59 %, 75 %) than in group II (39 %, 57 %) (p = 0.03, p = 0.04 respectively). Higher initial retraction grades (2-3) predicted a higher chance of post-injection failure versus the reference group (grade 0-1) at 9 and 24 weeks in group I, with adjusted odds ratios (aOR) 45.4 (95 % CI = 5.9-351.1, p < 0.01) and aOR 11.6 (95 % CI = 2.3-58.5, p < 0.01) respectively. Similarly in group II, initial retraction grade was associated with the failure at 9 and 24 weeks, with aOR 10.3 (95 % CI = 1.8-59.6, p < 0.01) and aOR 5.9 (95 % CI = 1.3-25.9, p < 0.05) respectively. Transient intraocular pressure elevation was observed in three eyes of two patients, although all ocular pressures were normalized within 1 month using anti-glaucoma medication. CONCLUSIONS: Subconjunctival triamcinolone injections were very effective in resolving eyelid swelling and retraction in recent-onset TAO. However, the symptom-reducing effect of triamcinolone was modest and less effective in patients initially presenting with severe retraction grades. As intraocular pressure may rise after steroid injection at upper eyelid, the treatment should be avoided in patients suspected to have glaucoma.

Improving awareness, identification, and management of meibomian gland dysfunction.

Ocular surface disorder--and dry eye, in particular--is a leading reason for visits to eye care professionals. It has been generally accepted that meibomian gland dysfunction (MGD) is a leading cause of evaporative dry eye, as well as being associated with aqueous-deficient dry eye. Yet, researchers and clinicians have lacked a global consensus on the definition of MGD, its epidemiology, pathophysiology, and management. Various systemic diseases and medications have been associated with the progression of both dry eye and MGD, as have several ocular disorders beyond those directly affecting the surface. It is in the best interest of patients for clinicians to be able to better identify and diagnose MGD, differentiating it from other ocular surface disorders, and to recognize the effects of MGD on the ocular surface, and thus initiate appropriate therapy. This CME activity provides expert insight into the Tear Film and Ocular Surface Society's International Workshop on MGD consensus report, offering practical application of its findings to better manage MGD patient care, particularly for those patients facing or undergoing ocular surgery.

Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study.

PURPOSE: To evaluate in a general clinic-based cohort of patients with dry eye disease (DED) the distribution of patients with aqueous-deficient or evaporative subtype of DED. METHODS: Schirmer tests and meibomian gland dysfunction (MGD) (Foulks-Bron scoring) were evaluated in both eyes of 299 normal subjects and DED patients (218 women and 81 men) across 10 sites in the European Union and the United States. Using the more severe measurement of the 2 eyes, subjects were considered to have pure aqueous-deficient dry eye (ADDE) with Schirmer values of <7 mm and MGD grades of ≤5. Patients were classified as purely evaporative dry eye with MGD grades of >5 and Schirmer values of ≥7 mm. Subjects were placed into the mixed (hybrid) category if they exhibited both a low Schirmer value of <7 and evidence of MGD with a grade >5. RESULTS: Of the 224 subjects classified with DED using an objective, composite, disease severity scale, 159 were classified into 1 of 3 categories: 79 were classified with only MGD, whereas only 23 were classified as purely aqueous deficient, and 57 showed evidence of both MGD and aqueous deficiency. Overall, 86% of these qualified DED patients demonstrated signs of MGD. The remaining 65 patients showed evidence of DED through other clinical signs, without overt evidence of MGD or ADDE, possibly because of the inherent variability of these signs. CONCLUSIONS: The proportion of subjects exhibiting signs of evaporative dry eye resulting from MGD far outweighs that of subjects with pure ADDE in a general clinic-based patient cohort.

Association of contact lens-related allergic conjunctivitis with changes in the morphology of meibomian glands.

PURPOSE: To observe morphological changes in the meibomian glands of patients with contact lens-related allergic conjunctivitis (CLAC) and to assess the relations between the morphological changes and eyelid and tear film parameters. METHODS: We observed subjects in four groups: 64 eyes of 64 contact lens (CL) wearers with CLAC, 77 eyes of 77 CL wearers without CLAC, 55 eyes of 55 patients with perennial allergic conjunctivitis (perennial AC), and 47 eyes of 47 healthy volunteers. The following tests were performed: slit-lamp examination, measurement of tear film breakup time, grading of morphological changes in meibomian glands (meiboscore) as assessed by noncontact meibography, grading of meibomian gland distortion in meibography, tear production as assessed by Schirmer's I test, and grading of meibum expression. RESULTS: The mean score for meibomian gland distortion was significantly higher in the CL wearers with CLAC than in the CL wearers without CLAC (p < 0.0001); it was also significantly higher in the non-CL wearers with perennial AC than in the non-CL wearers without perennial AC (p < 0.0001). There was no significant difference between the mean scores for meibomian gland distortion of the non-CL wearers with perennial AC and the CL wearers with CLAC (p = 0.27). The score for meibomian gland distortion was significantly positively correlated with the meibum score in the CL wearers with CLAC and with the meiboscore in the CL wearers without CLAC. CONCLUSION: CLAC is associated with an increase in meibomian gland distortion. Allergic reaction, rather than CL wear, appears to be responsible for the increase in meibomian gland distortion in patients with CLAC.