The Relation of Ocular Surface Irregularity and Visual Disturbance in Early Stage Acanthamoeba Keratitis.

PURPOSE: To evaluate the relation between ocular surface irregularity and visual disturbance in early stage Acanthamoeba keratitis (AK). METHODS: Fifteen patients with culture-proven AK underwent routine ophthalmic examinations, including best-corrected visual acuity (BCVA) measurement, slitlamp biomicroscope examination, and corneal fluorescein dye staining test, in both the eyes. We also evaluated the corneal sensitivity with Cochet-Bonnet esthesiometer, tear functions by Schirmer's test, and ocular surface irregularity by corneal topography and compared the results with the contralateral healthy eyes in this study. RESULTS: The mean logarithm of the minimum angle of resolution BCVA (0.71±0.77) was significantly lower in the eyes with AK (P=0.002). Epithelial disorders were present in all eyes, and radial keratoneuritis in 14 eyes (93.3%). The mean corneal sensitivity (39.3±24.1 mm) was significantly lower in eyes with AK compared with the healthy eyes (P=0.005). The mean Schirmer's test value (22.5±12.0 mm) in eyes with AK was significantly higher compared with the healthy eyes (P=0.01). The ocular surface irregularity indices (the surface regularity index, 2.47±0.42; the surface asymmetry index, 3.24±1.31) were significantly higher in eyes with AK compared with contralateral healthy eyes (P<0.0001 and P<0.0001, respectively). CONCLUSIONS: The ocular surface disease in AK is associated with decrease in corneal sensitivity and increase in Schirmer's test value and ocular surface irregularity indices. The visual disturbance in AK may owe not only to corneal haze but also to ocular surface irregularity.

The impact of tear functions on visual outcome following keratoplasty in eyes with keratoconus.

BACKGROUND: To investigate the impact of preoperative and postoperative tear functions on visual outcome and the recovery of visual function following keratoplasty in eyes with keratoconus. METHODS: Twenty-five eyes of 25 consecutive patients (5 females, 20 males, mean age: 34.3 ± 15.8 years (range: 19-70 years) with keratoconus who underwent either penetrating keratoplasty (PKP) or deep anterior lamellar keratoplasty (DALK) were included in this prospective study. One patient who had a rejection episode during the follow-up period was excluded. All subjects underwent best corrected visual acuity (BCVA), corneal topography (refractive cylinder, surface regularity index: SRI and surface asymmetry index: SAI), Schirmer I test, tear film break-up time (BUT), corneal sensitivity, and fluorescein staining score measurements before as well as 1, 3, 6 and 12 months after keratoplasty. The relation between the tear functions and the duration until the achievement of maximum BCVA was also evaluated. Linear regression analysis was performed to study the statistical significance of the correlations and the time wise change of each examined parameter. RESULTS: SRI, SAI, and BCVA significantly improved after keratoplasty. The postoperative corneal sensitivity was still significantly low even at 12 months postoperatively. Postoperative BCVA at 3, 6 months and maximum BCVA showed a significant linear negative correlation with the preoperative BUT (3 months; r = -0.461, p = 0.036, 6 months; r = -0.494, p = 0.023, maximum BCVA; r = -0.473, p = 0.030). The duration until the achievement of maximum BCVA showed a significant negative correlation with the preoperative Schirmer test (r = -0.429, p = 0.036). BCVA at 1 and 3 months postoperatively showed significant linear negative correlations with BUT value at the respective periods (1 month; r = -0.665, p = 0.0036, 3 months; r = -0.580, p = 0.0059). CONCLUSION: Preoperative tear functions appeared to have an influence on postoperative BCVA and the duration of visual recovery in keratoconus patients undergoing keratoplasty. Postoperative tear film stability appears to play an important role for obtaining a better BCVA in the early postoperative period after keratoplasty.

Punctal and canalicular anatomy: implications for canalicular occlusion in severe dry eye.

PURPOSE: To characterize the microscopic anatomy of the lacrimal punctum and canaliculi in relation to the tarsal plate, muscle of Riolan, and Horner muscle; and to report a novel technique to excise the horizontal canaliculus in severe dry eye patients. DESIGN: Observational anatomic study and a retrospective case series. METHODS: The microscopic anatomy was studied in 86 eyelids of 25 cadavers (age range: 45-96 years, mean: 79.5 years). Surgery was performed on 18 canaliculi of 7 patients with dry eyes (age range: 37-69 years, mean: 59.9 years). In the microscopic study, 32 eyelids were incised sagittally, 38 eyelids were incised horizontally (1 mm from the eyelid margin), and 16 eyelids were incised parallel to the tarsal plate. All specimens were stained with Masson trichrome. In the surgical group, probe-guided horizontal canalicular excision with incision of the Horner muscle to the lateral edge of the lacrimal caruncle was performed. Both canalicular stumps were cauterized. RESULTS: In the microscopic anatomic study, the punctum and the vertical canaliculus were part of the tarsal plate with the muscle of Riolan, whereas the horizontal canaliculus was surrounded by the Horner muscle. In the surgical group, all the operated canaliculi were completely occluded without recanalization 12 months postoperatively. No complications were recorded. CONCLUSIONS: Based on microscopic anatomic findings that the lacrimal punctum and the vertical canaliculus are part of the tarsal plate, and that the horizontal canaliculus is surrounded by the Horner muscle, excision of the horizontal canaliculus may be an effective technique to treat patients with severe dry eyes.

Evaluation of tear stability after surgery for conjunctivochalasis.

PURPOSE: To evaluate the efficacy of surgical treatment for conjunctivochalasis using the Tear Film Stability Analysis System. METHODS: Fifteen eyes of 15 patients (74.5 ± 4.8 years; 14 females and 1 male) who had surgical reconstruction of the tear meniscus for conjunctivochalasis underwent evaluation with a symptom questionnaire, Schirmer I test, fluorescein tear film break-up time (FBUT), and break-up time index (BUI) measurement by Tear Film Stability Analysis System examinations that were performed preoperatively and 3 months after the surgery. Changes of these tear parameters were statistically analyzed using the paired t test. RESULTS: After the surgery, the mean FBUT and BUI values significantly improved from 5.7 ± 3.2 s and 42.8 ± 18.7, respectively, to 8.4 ± 2.5 s and 60.7 ± 16.5, respectively (FBUT, p = 0.0438; BUI, p = 0.0036). The mean Schirmer test value showed no significant changes before and after surgery (p = 0.9064). Fourteen eyes (93.3%) had improvement of ocular symptoms after surgery. One eye (6.7%) with no improvement of ocular symptoms, FBUT, and BUI after surgery appeared to have aqueous tear deficiency. CONCLUSIONS: Surgical treatment for conjunctivochalasis was associated with improvement of tear stability and clinical dry eye symptoms.

The sparkle of the eye: the impact of ocular surface wetness on corneal light reflection.

PURPOSE: To measure the sparkle of the human eye evaluated by the intensity of corneal light reflection in normal subjects and dry eye patients to investigate whether ocular surface wetness has an impact on the sparkle of the eye. DESIGN: Prospective case-control study. METHODS: We examined a consecutive series of eight dry eye patients with Sjögren syndrome (SS, 15 eyes), as well as eight normal subjects (16 eyes). The specular corneal surface light reflection was quantitatively measured with an ophthalmic slit-lamp microscope and image capturing system under fixed conditions of light source, incident angle, and detector sensitivity. The intensity of images from subjects' corneal light reflection was quantified with image analysis software along with the measurement of grade of self-reported brilliancy of the eye, corneal fluorescein staining score, tear film break-up time, and Schirmer test value. The intensity of corneal light reflection was also compared before and after dry eye treatment. RESULTS: The mean intensity of corneal light reflection was significantly lower in dry eye patients (125.0 ± 40.1) than normal subjects (167.6 ± 36.6, P=.004). Grade of self-reported brilliancy of the eye, corneal fluorescein staining scores, tear film break-up time, and Schirmer test values showed good correlation to the intensity of corneal light reflection. After punctal plug treatment, the intensity of corneal light reflection significantly increased from 125.0 ± 40.1 to 167.2 ± 45.0 (P<.0001). CONCLUSIONS: The intensity of corneal light reflection representing the sparkle of the eye was significantly more intense in normal subjects compared to dry eye patients, and was increased after punctal plug treatment. The intensity of corneal light reflection appeared to correlate well with tear film stability, volume, and ocular surface desiccation. We showed that tears contributed not only to ocular surface wetness but also to the extent of the light reflection from the eye.

Surgical punctal occlusion with a high heat-energy releasing cautery device for severe dry eye with recurrent punctal plug extrusion.

PURPOSE: To report the rate of recanalization and the efficacy of punctal occlusion surgery with a high heat-energy-releasing cautery device in patients with severe dry eye disease and recurrent punctal plug extrusion. DESIGN: Prospective, interventional case series. METHODS: Seventy puncta from 44 eyes of 28 dry eye patients underwent punctal occlusion with thermal cautery. All patients had a history of recurrent punctal plug extrusion. A high heat-energy-releasing thermal cautery device (Optemp II V; Alcon Japan) was used for punctal occlusion surgery. Symptom scores, best-corrected visual acuity, fluorescein staining score, rose bengal staining score, tear film break-up time, and Schirmer test values were compared before and 3 months after the surgery. Rate of punctal recanalization also was examined. RESULTS: Three months after surgical cauterization, symptom score decreased from 3.9 ± 0.23 to 0.56 ± 0.84 (P < .0001). Logarithm of the minimal angle of resolution best-corrected visual acuity improved from 0.11 ± 0.30 to 0.013 ± 0.22 (P = .003). Fluorescein staining score, rose bengal staining score, tear film break-up time, and the Schirmer test value also improved significantly after the surgery. Only 1 of 70 puncta recanalized after thermal cauterization (1.4%). CONCLUSIONS: Punctal occlusion with the high heat-energy-releasing cautery device not only was associated with a low recanalization rate, but also with improvements in ocular surface wetness and better visual acuity.

Interferometry in the evaluation of precorneal tear film thickness in dry eye.

PURPOSE: To compare tear film thickness between normal subjects and aqueous tear deficiency dry eye patients by tear interferometry. DESIGN: Prospective case-control study. METHODS: Central precorneal tear film thickness was measured noninvasively using an interference thin-film thickness measurement device (Quore MSPA1100; Mamiya-OP). Tear film thickness of 14 eyes from 14 normal subjects and of 28 eyes from 28 aqueous tear deficiency dry eye patients were compared along with noninvasively measured tear meniscus height, DR-1 (Kowa) dry eye severity grading, fluorescein and rose bengal staining scores, tear film break-up time, and Schirmer test results. Among dry eye patients, 13 eyes underwent punctal occlusion, and tear film thickness was compared before and after the surgery. RESULTS: Tear film was significantly thinner in dry eye patients (2.0 ± 1.5 µm) than normal subjects (6.0 ± 2.4 µm; P < .0001). Tear film thickness showed good correlation with other dry eye examinations. After punctal occlusion, tear film thickness increased significantly from 1.7 ± 1.5 µm to 4.9 ± 2.8 µm (P = .001) with the improvement of tear meniscus height, fluorescein and rose bengal staining scores, tear film break-up time, and Schirmer test values. CONCLUSIONS: Interferometric tear film thickness measurement revealed impaired precorneal tear film formation in aqueous tear deficiency dry eyes and was useful for showing the reconstruction of tear film after punctal occlusion surgery. Interferometry of precorneal tear film may be helpful for the evaluation of aqueous tear deficiency in conjunction with other dry eye examinations.

Agreement between stratus and visante optical coherence tomography systems in tear meniscus measurements.

AIM: To compare the tear meniscus height (TMH) measurements provided by the Stratus and Visante optical coherence tomography systems. METHODS: A cross-section image of the lower tear meniscus was captured with both instruments in 26 volunteers. An external application was used to manually measure the TMH as imaged by the Stratus; measurements by the Visante were analyzed by the internal software. Only 1 eye for each subject was considered for statistical analysis. RESULTS: The mean (+/-SD) TMH was higher when measured by the Visante (0.28 +/- 0.12 mm) compared with the Stratus (0.23 +/- 0.07 mm, P = 0.029). Measurements were correlated (R = 0.38, P = 0.0008), but Bland-Altman analysis showed low agreement (95% limits of agreement: -0.15 to +0.26 mm). CONCLUSIONS: Visante and Stratus cannot be used interchangeably to measure the TMH. The differences between the 2 instruments are likely to be related both to the dynamic nature of the tear meniscus and to the distortion of Stratus images, which are not dewarped and calibrated for anterior segment imaging.

Autologous serum eye drops for the treatment of dry eye diseases.

Conventional treatment of dry eye mainly consists of the use of preservative-free artificial eye drops and punctal occlusion. None of the commercially available artificial tear preparations include essential tear components such as epidermal growth factor, hepatocyte growth factor, fibronectin, neurotrophic growth factor, and vitamin A-all of which have been shown to play important roles in the maintenance of a healthy ocular surface epithelial milieu. We reported previously that autologous serum (AS) eye drops contain these essential factors and that AS eye drops are beneficial in the treatment of ocular surface diseases such as persistent epithelial defects, superior limbic keratoconjunctivitis, keratoconjunctivitis sicca, and neurotrophic keratopathy. However, there is some controversy regarding the efficacy of AS treatment. We demonstrated that this modality is more effective than artificial tears in a randomized control study. In in vivo and in vitro experiments, AS eye drops showed marked suppression of apoptosis in the conjunctival and corneal epithelium. Albumin, the major protein in serum, improved ocular surface damage in vivo and rescued apoptosis after serum deprivation in vitro. The biological background of AS eye drops and previous clinical studies of these medications for the treatment of dry eye are discussed.

Management of evaporative dry eye in ectrodactyly-ectodermal dysplasia-clefting syndrome.

PURPOSE: The purpose of this study is to report the features of dry eye and ocular surface disease in an unusual case of ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome. CASE REPORT: A single observational case report of a 22-year-old Japanese male with evaporative dry eye and corneal epithelial disease because of lipid layer abnormality resulting from meibomian gland agenesis was treated successfully with low dose lipid base ointment application. DISCUSSION: The clinical features of the dry eye and ocular surface disease and management issues are discussed. CONCLUSION: Low dose lipid base ointment application may be a promising treatment modality for the ocular surface disease in ectrodactyly-ectodermal dysplasia (EEC)-clefting syndrome, which seems to help in alleviating the subjective complaints and in improving the objective clinical findings.

Tear film with "Orgahexa EyeMasks" in patients with meibomian gland dysfunction.

PURPOSE: To evaluate the efficacy of a new Orgahexa eye warmer mask for patients with simple meibomian gland dysfunction (MGD) in a prospective comparative study. METHODS: Twenty right eyes of 20 patients with simple MGD, and 22 right eyes of 22 healthy controls were studied. Subjects were allocated to Orgahexa or conventional eye mask wear for 10 min (short-term study), and for 2 weeks (long-term study). Eyelid temperature measurements, slit lamp examination, tear film break-up time, Schirmer test, vital staining, tear film lipid layer interferometry, and dry eye symptomatology scoring with visual analog scales were performed. RESULTS: The Orgahexa eye warmer improved both tear function and ocular surface status, and decreased symptoms significantly without any complications. CONCLUSIONS: The Orgahexa eye warmer is a simple, safe, and convenient method, which seems to improve the ocular surface status and tear functions in patients with simple MGD.

Tear cytokine and ocular surface alterations following brief passive cigarette smoke exposure.

PURPOSE: To prospectively investigate the effects of acute passive cigarette smoke exposure on the ocular surface and tear film in healthy non-smokers. METHODS: Twelve right eyes of 12 subjects without any ocular diseases were examined before, 5 min, and 24h after 5 min of passive cigarette smoke exposure in a controlled smoke chamber. Tear samples were obtained before, 5 min and 24 h after smoke exposure to detect tear hexanoyl-lysine (HEL), acrolein and inflammatory cytokine concentrations. Tear evaporation rate, DR-1 tear film lipid layer interferometry, tear film break-up time (TBUT), ocular surface fluorescein staining (FS) and Rose Bengal staining (RB), Schirmer I test were performed before, 5 min, and 24h after smoke exposure. Conjunctival impression cytology (IC) and brush cytology (BC) were carried out before and 24h after smoke exposure. RESULTS: Tear evaporation rate, tear lipid spread time, tear film break-up time, and vital staining scores showed significant worsening with passive smoke exposure. Tear HEL and IL-6 concentrations increased significantly 24 h after smoke exposure. Tear acrolein level showed an insignificant increase at 5 min. IC and RT-PCR revealed a significant reduction in goblet cell density, a shift toward higher squamous metaplasia grades and a significant downregulation of MUC5AC mRNA expression at 24 h. CONCLUSION: Even brief passive exposure to cigarette smoke in healthy non-smoker subjects was associated with adverse effects on the ocular surface health as evidenced by an increase of tear inflammatory cytokines, tear lipid peroxidation products and decrease of mucosal defense resulting in tear instability and damage to the ocular surface epithelia.

Quantitative videographic analysis of blink patterns of newscasters.

BACKGROUND: To determine the blink patterns of newscasters. METHODS: The blink patterns of 39 professional newscasters (24 Japanese and 19 non-Japanese, 19 men and 20 women, mean age: 34.5 +/- 6.5 years) were analyzed by a blink analyzer in this observational case series. Sixty-four normal Japanese volunteers (35 men and 29 women, mean age: 31.2 +/- 7.6 years) were used as lay normal controls. RESULTS: The maximum, mean, and coefficient of variation (CV) of interblinking time (IBT: the time between one blink and the next) in newscasters were 2.36 +/- 0.90 s (P < 0.0005), 0.95 +/- 0.27 s (P < 0.0005), and 0.76 +/- 0.25 (P < 0.0005), respectively, while those of the controls were 8.87 +/- 3.96 s, 4.01 +/- 2.05 s, and 0.55 +/- 0.21, respectively. The maximum, mean, and CV of the blinking time (BT: the length of time for each blink) of newscasters were 0.71 +/- 0.43 s (P < 0.0005), 0.29 +/- 0.11 s (P < 0.0005), and 0.55 +/- 0.25 (P < 0.0005), respectively. The values were longer when compared with normal controls, which were also significantly different, 0.35 +/- 0.12 s, 0.20 +/- 0.04 s and 0.23 +/- 0.09, respectively. CONCLUSIONS: The six blink-related factors varied between newscasters and normal controls. Newscasters blink more often with greater irregularity.

The challenge of dry eye diagnosis.

The currently available methods for the diagnosis of dry eye are still far from being perfect for a variety of reasons. This review attempts to highlight the advantages and disadvantages of both traditional tests (such as Schirmer's test, break-up time and ocular surface staining) and innovative noninvasive procedures, including tear meniscus height measurement, corneal topography, functional visual acuity, tear interferometry, tear evaporimetry and tear osmolarity assessment.

Spontaneous lacrimal punctal occlusion associated with ocular chronic graft-versus-host disease.

PURPOSE: To investigate the clinical features of spontaneous lacrimal punctal occlusion (SLPO) after allogeneic hematopoietic stem cell transplantation (HSCT). METHODS: One hundred nineteen recipients after HSCT who visited Keio University between 2001 and 2004 were examined. The condition of the lacrimal punctum, severity of dry eye, meibomian gland secretion, and presence of systemic chronic graft-versus-host disease (cGVHD) were determined with or without SLPO by retrospective chart review. RESULTS: Among the 119 recipients, SLPO was diagnosed in 8. All the patients with SLPO after HSCT had meibomian gland dysfunction (MGD), dry eye, and systemic cGVHD. The percentage of patients with dry eye, MGD, and systemic cGVHD were significantly higher in recipients with SLPO than non-SLPO recipients (p < 0.0013, p < 0.00015, p < 0.0008, respectively). CONCLUSIONS: SLPO is a clinical presentation of ocular cGVHD and may be an indicator of the severity of dry eye and systemic cGVHD after HSCT.

Tear evaporation rates in Sjögren syndrome and non-Sjögren dry eye patients.

PURPOSE: To reinvestigate tear evaporation rates in Sjögren syndrome (SS) and non-Sjögren (non-SS) dry eye patients with a recently reported ventilated chamber evaporimeter system. DESIGN: Prospective case-control study. METHODS: A ventilated chamber evaporimeter system was used to measure tear evaporation rates. A DR-1 camera (Kowa, Nagoya, Japan) was used for tear lipid layer interference image acquisition. The Yokoi severity grading system was used for DR-1 image evaluation. Twenty-four aqueous tear deficiency (ATD) eyes of 21 consecutive patients with SS were studied (SS ATD group). Twenty-one ATD eyes of 12 non-SS patients (non-SS ATD group) were examined as control subjects. RESULTS: Tear evaporation rates of the SS ATD group (5.9 +/- 3.5 [10(-7) g/cm(2) per second]) were significantly higher than those of the non-SS ATD group (2.9 +/- 1.8 [10(-7) g/cm(2) per second]; P = .0009). The severity grading of DR-1 tear interference images of the SS ATD group was significantly higher (P = .03), along with significantly worse meibomian gland expressibility and vital staining scores, compared with those of the non-SS ATD group. CONCLUSIONS: Tear evaporation rates were higher in eyes of the SS ATD group compared with the non-SS ATD group. Tear evaporation assessed in conjunction with tear lipid layer findings and meibomian gland expressibility provides an increased understanding in the differential diagnosis of dry eye states.

Noninvasive interference tear meniscometry in dry eye patients with Sjögren syndrome.

PURPOSE: To compare noninvasive tear meniscus height (NI-TMH) using a tear interference device in normal subjects and dry eye patients with Sjögren syndrome (SS), and to investigate the applicability of this new method before and after the punctal occlusion procedure. DESIGN: Prospective case control study. METHODS: Tear meniscus was visualized noninvasively using a tear interference device (Tearscope plus, Keeler, Windsor, United Kingdom). Tear interference image was captured with digital video camera (SP-321, JFC Sales Plan Co, Tokyo, Japan) attached to the slit-lamp. Lower lid margin NI-TMH was measured using image analysis software. NI-TMH of 28 eyes from 17 normal subjects and 46 eyes from 27 aqueous tear deficiency (ATD) dry eye patients with SS were compared. The change of NI-TMH three weeks after the successful punctal occlusion was examined in 11 eyes of eight dry eye subjects. RESULTS: Tear meniscus was well visualized with the tear interference device in all cases. Lower lid margin NI-TMH was 0.22 +/- 0.065 mm in normal subjects, and 0.13 +/- 0.042 mm in SS subjects, respectively (P < .0001). After the punctal occlusion, lower lid margin NI-TMH increased significantly from 0.12 +/- 0.026 mm to 0.42 +/- 0.21 mm (P = .001). CONCLUSIONS: NI-TMH was substantially lower in SS subjects and also significantly improved after punctal occlusion. This method is expected to be helpful in the diagnosis and in the evaluation of the efficacy of punctal occlusion in ATD dry eyes such as SS.