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Eye Health
Advisor
®
A magazine from Johnson & Johnson Vision Care
Eye Dryness and
Contact Lenses
EDITION TWO 2011
Eye Health
Advisor
CO NT ENT
Introduction
Eye Health Advisor®
A magazine from Johnson & Johnson Vision Care
EDITION TWO 2011
2
Introduction
3
The role of dry eye
questionnaires – from
symptoms to signs and
diagnosis
by Beáta Tapasztó, Amarilla
Veres and János Németh
7
Current Diagnosis and
Management of Dry Eye
by Igor Petricek
13
Meibomian gland
dysfunction and contact
lenses… can we do better?
by Christina N Grupcheva
18
Top 10 Questions on Dry
Eye Symptoms
Answered by Eye Care
Professionals
T
his issue of the Eye Health Advisor ® newsletter is dedicated on dry
eye problems and contact lenses. Dry eye is the most common problem,
unfortunately underdiagnosed, in today’s contact lens practice.
The definition of the dry eye highlights the multifactorial nature of the
disease, as well as the potential damage to the ocular surface. However, the
disease results in more prominent symptoms (discomfort, visual disturbance)
than signs such as clinically detectable tear film instability. The most serious
obstacle remains the diagnosis, including non-invasive and invasive methods.
Questionnaires are easy, repeatable but obviously subjective non-invasive
methods for diagnosis based on symptoms.
Considering the leading role of discomfort and visual instability in diffrent
enviromental conditions, questionnaires appear to be the method of choice to
help eye care practitioners for screening patients for dry eye symptoms. The
power of different questionnaires in case of contact lens fitting is discussed
by B. Tapasztó, A. Veres and J. Németh in their overview: "The role of dry
eye questionnaires – from symptoms to signs and diagnosis". However,
the clinician must use specific methods for clinical diagnosis. Based on
his extensive experience, Igor Petricek discusses the currently available
diagnostic for dry eye methods in: "Current diagnosis and management of
dry eye", where also the principles of therapeutics are highlighted. In the
published literature there is agreement that most cases are evaporative
followed by mixed cases of dry eye. Commonly, evaporation increases with
Meibomian glands dysfunction. The problems related to are later discussed
by Christina Grupcheva in: "Meibomian gland dysfunction and contact
lenses... can we do better? ".
Although a number of clinical and research groups are working on dry eye
problems, there are still many decision related difficulties in everyday clinical
practice. The approaches are different and vary from practice to practice, from
country to country and depend on various factors, most important of which
is probably practical experience. That's why several experts from diffrent
countries have been asked specific questions and their comprehensive
answers are also published in this issue.
We hope that this edition of the Eye Health Advisor ® newsletter, dedicated
to dry eye problems and contact lenses, will be interesting and helpful for the
reader, in managing your dry eye patients, increasing thus their satisfaction
as healthy contact lens wearers.
2
Eye Health
Advisor
A magazine from Johnson & Johnson Vision Care
The role of dry eye questionnaires – from
symptoms to signs and diagnosis
Beáta Tapasztó, Amarilla Veres and János Németh+
INTRODUCTION
Dry eye is a multifactorial disease of the ocular surface
that results in symptoms of discomfort, visual disturbance
and tear film instability with potential damage to the ocular
surface.1,2 Contact lenses during their evolution have been
associated with mechanical irritation, hypoxia, toxicity
and decreased lacrimal gland secretion via the increased
inflammatory cytokines and corneal nerve damage.3
Tear film function is an important factor in contact lens
use.4,5 Contact lens wearers are 12 times more likely to
report dry eye symptoms compared to emmetropes and
five times more likely compared to spectacle-wearers.6
Discomfort and dryness are now the principal reasons for
wearers stopping or reducing their contact lens wear.1,2,3
DYNAMICS AND FUNCTIONS OF THE TEAR
FILM
The tear film is not stable in time. It builds up quickly
after the eyelids are opened, then evaporation starts,
and the tear film becomes thinner and finally breaks
up. Its stability plays an important role for vision from
the optical point of view.7 Németh et al. found, that
the corneal surface in most cases is significantly more
regular at 5 seconds than at 15 seconds after a blink,
which may be attributed to evaporation and thinning of
the tear film. However, in a few of the healthy subjects
there was an opposite trend: the tear film was found
to be more regular at the later time. They attributed
this contrary effect to the possibility of slow tear film
build-up, which results in the tear film’s only reaching
its best regularity later than 5 seconds after a blink. 8
Whether it takes the tear film a certain time after a blink
to build up and achieve the most regular surface a highspeed videotopographic examination technique was
developed. They found that after a blink, it takes the tear
film approximately 3 to 10 seconds (tear film build-up
time) to reach the most regular state. 9
The tear film forms the outer barrier of the eye against
harmful organisms and mechanical, chemical injuries.
The tear film involves elements of the innate immune
Beáta Tapasztó MD is an Hungarian
ophthalmologist who graduated with
scholarship of the Hungarian Academy
of Science in 1992 and became a
specialist in ophthalmology in 1996. She
is a member of a number of professional
societies including: European Contact
Lens Society, German Society of
Ophthalmology, International Society for Ophthalmic
Ultrasound, American Society of Ophthalmology. She
practises at Semmelweis University Budapest, Medical
School.
Amarilla Veres, MD, PhD is a Doctor
of Medicine since 1999, she holds a PhD
since 2004 and specialist in ophthalmology
since 2010. She participates in several
research projects including Phase-3
clinical studies and experimental basic
studies. Currently she is employed as
an Ophthalmologist at Semmelweis
University Budapest, Dept. of Ophthalmology.
Prof. med. habil. János Németh,
MD, PhD, DSc is Director of the
Department
of
Ophthalmology,
Semmelweis Univ., Budapest, Hungary
and full time professor since 2002.
He is President of the Hungarian
Ophthalmological Society, Chair of the
International Members Committee of
the Association for Research in Vision and Ophthalmology
(ARVO), Member of the Global Outreach Committee of
American Academy of Ophthalmology (AAO), Member
of the Board of Trustees of International Council of
Ophthalmology (ICO) and other professional societies.
He has published more than 264 peer reviewed articles,
9 books and 29 chapters, and presented more than 550
lectures.
system of the ocular surface via its anatomical, tissue,
cellular and biochemical immune protections. The tear
reflex flushes and dilutes foreign material from the
ocular surface, limits adhesion of microbes to facilitate
their clearance in aqueous tear flow. The tear film
phagocytic cells kill and remove microbes from corneal
surface and its antimicrobial proteins have multiple
functions that limit the ability of microbes to survive,
proliferate and adhere to the ocular surface epithelium.10
+ Department of Ophthalmology, Semmelweis University, Budapest, Hungary
EDITION TWO 2011
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Eye Health
Health
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3
NON-INVASIVE AND INVASIVE TECHNIQUES
OF OCULAR SURFACE DESCRIPTION
There are many diagnostic technologies to investigate,
monitor or diagnose dry eye disease. It has been shown
that there are only weak correlations between the
symptoms of dry eye patients and the results of different
objective clinical tests for dry eye. It is difficult to measure
the progression of the disease or the effect of treatments.
For the diagnosis of dry eye, non-invasive, minimally
invasive or invasive methods exist which are shortly
summarized in Table 1 according to the Dry Eye WorkShop
(DEWS) report. A non or minimally invasive technique has
the major advantage that it captures data from the surface
without significantly inducing reflex tearing.1
DRY EYE QUESTIONNAIRES
Dry eye disease is converted into symptoms in the point
of patients’ view. The External Eye Disease Working
Group summarized these symptoms in 13 points.15 To be
able to describe the typical dry eye symptoms the easiest
way is to detect their interference with daily activities.
INVASIVENESS
COMMENT
Non-invasive
Questionnairies
Non-to minimal
Optical sampling
s Meniscometry
s Lipid layer interferometry
s Tear stability analysis system
s High speed video-tear film dynamics
s OCT tear film imaging
s OCT imaging of LIPCOF
s Confocal microscopy
Tear fluid sampling
s Strip meniscometry
s Sampling for proteomic analysis
According to the DEWS report the impact of dry eye
on quality of life is mediated through 1) pain and irritative
symptoms, 2) effect on ocular and general health and
well-being, 3) effect on perception of visual function, and
4) impact on visual performance.1
Various methods are available to assess the effect of
dry eye on visual function and quality of life. Non-diseasespecific, "generic” tools like the Medical Outcome Study
Short Form-36 (SF-36) have been applied to dry eye. Utility
assessment, a tool used widely in medicine that permits
the comparison of the effect of different diseases on
quality of life based on strategies such as standard gamble,
or trading years of life for disease-free years, and other
techniques, has also been applied to dry eye.1
General vision-related questionnaires, such as the NEIVisual Function Questionnaire (NEI-VFQ), have been
used. Disease-specific tools, like the Ocular Surface
Disease Index (OSDI) and the Impact of Dry Eye on
Everyday Life (IDEEL) questionnaire have also been
developed and validated specifically for research on the
impact of dry eye.11
Practitioners may use validated questionnaires in
their clinics. According to their length and composition,
symptom questionnaires explore different aspects of
dry eye disease in varying depth, ranging from diagnosis
alone, to the identification of precipitating factors and
impact on quality of life.
Table 2 summarizes the validated dry eye questionnairies
used in clinical trials.1 The time taken to administer a tool
may influence the choice of questionnaire for general
clinical use. The Diagnostic Methodology Subcommittee
concluded that the administration of a structured form
to patients presenting to a clinic provides an excellent
opportunity for screening patients with potential dry eye
disease.1
s Osmolarity
Moderate
Meibomian sampling, Meibometry
Meibography
Invasive non-stress
Staining/digital photography of
surface staining
Impression and brush cytology-flow
cytometry
Lacrimal scintigraphy
Stress test
Functional vision acuity
Controlled adverse environment
Areal BUT while staring
Forceful blink test
OCT: Ocular Coherence Tomography
BUT: break-up time
LIPCOF: lid parallel conjunctival fold
Table 1: Emerging diagnostic technologies of dry eye, based on the DEWS
Report.1
4
Ocular Surface Disease Index (OSDI) is a set of questions
assessing the level of discomfort and interference with
activities of daily living produced by ocular surface disease.
It consists of 12 items: visual function, ocular symptoms,
environmental triggers, and frequency with 1-week recall
period. OSDI is validated in dry eye population and used as
outcome measure in randomized controlled trials.1
The Contact Lens Dry Eye Questionnaire (CLDEQ)
was developed to examine the distribution of dry eye
symptoms among contact lens wearers. This tool
measures the prevalence, frequency, and diurnal intensity
of ocular surface symptoms as eye discomfort, dryness,
visual disturbance, soreness and irritation, grittiness and
scratchiness, foreign body sensation, burning and stinging,
light sensitivity, and itching. Dryness and discomfort
were found to be the most frequently reported dry eye
A magazine from Johnson & Johnson Vision Care
QUESTIONNAIRE’S TITLE
DESCRIPTION / USE
QUESTIONNAIRE’S
SUMMARY
McMonnies Dry Eye
History Questionnaire
(McMonnies, Nichols)
Screening questionnaire
15 questions
Canada Dry Eye
Epidemiology Study
(CANDEES [Doughty])
Epidemiology of dry eye
symptoms in a large
random sample
13 questions
Ocular Surface Disease
Index (OSDI [Schiffman])
Measures the severity
of dry eye disease; and
environmental triggers
queried for the past week
12 items
Salisbury Eye Evaluation
(Schein, Bandeen-Roche)
Population-based
prevalence survey for
clinical and subjective
evidence of dry eye.
Relation between signs
and symptoms of dry eye
in the elderly
Standardized 6-question
questionnaire
Dry Eye Epidemiology
Projects (deep )
questionnaire (Oden)
Sensitivity and
specificity of a screening
questionnaire for dry eye
19 questions
Women’s Health
Study questionnaire
(Schaumberg)
Prevalence of dry eye
syndrome among US
women
3 items from 14-item
original questionnaire
National Eye InstituteVisual Function
Questionnaire (NEI-VFQ
[Mangione])
Useful tool for grouplevel comparisons of
vision-targeted, healthrelated QoL in clinical
research; not influenced
by severity of underlying
eye disease.
25-item questionnaire:
2 ocular pain subscale
questions
Dry Eye Questionnaire
(DEQ, Begley et al)
Habitual patient-reported
symptoms and clinical
signs among patients
with dry eye of varying
severity
21 items on prevalence,
frequency, diurnal
severity
Contact Lens DEQ
(Begley et al)
Screening questionnaire
for dry eye symptoms in
contact lens wearers
13 questions
Melbourne Visual
Impairment Project
(McCarty)
Epidemiologic studies
Self-reported
symptoms elicited by
interviewer-administered
questionnaire
NEI-Refractive Error
questionnaire
QoL due to refractive
error
42-item questionnaire:
4 related questions
Sicca Symptoms
Inventory (Bowman)
Epidemiologic studies for
Sjögren Syndrome
Inventory of both
symptoms and signs of
Sjögren Syndrome
Bjerrum questionnaire
Screening questionnaire
3-part questionnaire
which includes an ocular
part with 14 questions
Japanese dry eye
awareness questionnaire
(Shimmura)
30 questions relating
to symptoms and
knowledge of dry eye
Population-based, selfdiagnosis study to assess
public awareness and
symptoms of dry eye
Dry eye clinic population
QoL: Quality of Life
Table 2: Summary of Dry Eye Questionnaires which met the criteria set by DEWS Report.1
EDITION TWO 2011
Eye Health
Advisor
symptoms of contact lens wearers,
who reported these complaints
significantly more frequently than
non-wearers of contact lenses.12
McMonnies’ questionnaire focuses
on risk factors for dry eye disease,
including age, sex, contact lens history,
dry eye symptoms, previous dry eye
treatments, secondary symptoms,
medical conditions associated with dry
eye symptoms, and medication use.
Nichols et al. reported about the
performance of the CLDEQ as
a screening survey. Based on the
sensitivity, specificity, and receiver
operator characteristic (ROC) curve
analyses the CLDEQ was capable of
discriminating contact lens related dry
eye in comparison with McMonnies’s
questionnaire. The accuracy of CLDEQ
was higher compared to McMonnies’
questionnaire as the highest predictive
efficiency for the CLDEQ was 1.44
(sensitivity/specificity: 87%/40%),
and for the McMonnies’ 1.20
(sensitivity/specificity: 34%/86%).12
CORRELATION BETWEEN
NON-INVASIVE TECHNIQUES
Veres et al. visualized the
morphological appearance of lidparallel conjunctival folds (LIPCOF)
using optical coherence tomography
(OCT) and related it to dry eye signs
and symptoms measured by Dry
Eye Questionnaire (DEQ). The OCT
grades, the height of the folds, and
the existence of tear film coverage
were in good accordance with the
severity of dry eye measured by
DEQ. The dry eye symptom scores
correlated with the height of the folds,
and the absence of tear film coverage
of the folds (r=0.574, P<0.001, and
r=-0.527, P<0.001, respectively). The
OCT LIPCOF grades correlated with
the DEQ scores (r=0.494, P<0.001
and r=0.310, P=0.029).13
The non-invasive tear film breakup time (NIBUT) can be measured
with Tearscope Plus® interferometer.
Since contact lens can induce dry
5
eye symptoms in otherwise asymptomatic subjects, it
is useful to have some idea, before fitting, which clinical
tests are able to discriminate between later symptomatic or
asymptomatic contact lens wearers. According to Pult et al.,
the LIPCOF, NIBUT and OSDI are significant discriminater
for contact lens related dry eye in new contact lens wearers:
the best combination is NIBUT and the sum of lid-parallel
conjunctival folds and OSDI score.14
IMPLICATION TO CLINICAL PRACTICE
Not all practitioners are enthusiastic about using
questionnaires. However, there are significant benefits of
using this non-invasive methodology. Firstly it saves qualified
time as the results of the questionnaire are calculated by
supporting staff and only analysed by practitioner. Secondly,
it provides instantaneous information without missing any
important points. Thirdly, it is a document that could be
used as a baseline over time in order to evaluate the effect
of therapeutic measures. Lastly it is a good modality to
entertain patients in the waiting room and demonstrate
them quality care. Chalmers and Begley in a very detailed
paper analysed the advantages of questionnaires. 16 Looking
at contact lens related dryness in particular the authors
highlighted the following points:
1. Use your ears for examination.
2. Patients with symptoms but not treatment are
representative for "unmet needs”.
3. Specific questions should be addressed to comfort
not only as quality but as quantity (length of
comfortable wear).
4. Special attention should be paid to the environment,
including computer work.
5. It is important to know how dryness change upon
removal of the lens.
Based on those points the authors developed a short
questionnaire, specially designed and tested for contact
lens practice. 16
It is important for the multilingual audience of Europe,
however, to know that regardless which questionnaire
has been selected it should be validated in the local
language in order to have the aforementioned power.
SUMMARY
In the recent decades even high speed videokeratoscopy,
wavefront sensing, lateral shearing inferometry have been
performed in natural and supressed blinking conditions to
describe and measure the dry eye conditions. Although
the capability of these methods to discriminate the dry
eye subjects from normal subjects is based on e.g. the
receiver operating curve or other statistical analysis the
detection performance is still not extraordinarly high.
6
The importance to include the patient’s perception and self
diagnosis of dry eye should be emphasized when evaluating
parameters of ocular surface imaging. Therefore, assessing
the subjective symptoms using different questionnaires is
the suggested initial step of dry eye patient care. Dry eye
questionnaires are a recommended part of the contact
lens practice, because of the greater disparity between
symptoms and signs. As already highlighted Contact Lens
Dry Eye Questionnaire has greater power in contact lens
cases and should be preferred, however, there is a choice
of different questionnaires that should be validated for every
practice. Questionnaires are simple, quick, not expensive
and non invasive method for instantaneous detection of dry
eye symptoms and their proper use will improve the eye
care and sucessful contact lens fitting.
References
1. International dry eye workshop: The definition and classification
of dry eye disease: report of definition and classification
subcommittee of international dry eye workshop (2007). Ocular
Surface 2007;5:75-92.
2. Murube J, Németh J, Höh H, Kaynak-Hekimhan P, HorwathWinter J, Agarwal A et al. The triple classification of dry eye for
practical clinical use. Eur J of Ophthalmology 2005;15:660-7.
3. Asbell PA, Lemp MA. Dry Eye Disease The clinician’s Guide
to Diagnosis and Treatment. In: Dry Eye and Contact Lenses.
Thieme Medical Publishers Inc. 2006;11:114-131.
4. Höh H, Schirra F, Kienecker C, Ruprecht KW. [Lid-parallel
conjunctival folds are a sure diagnostic sign of dry eye].
Ophthalmologe 1995;92:802–8.
5. Jean-Pierre Guillon, Andrew Godfrey: Tears and Contact Lenses
in: Contact lenses, Butterworth Heinemann Elsevier 2007
Chapter 5 111-127.
6. Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self-reported dry
eye disease across refractive modalities. IOVS 2005;46:1911-4.
7. Robert Monte´s-Mico: Role of the tear film in the optical quality
of the human eye J Cataract Refract Surg 2007; 33:1631–1635.
8. Németh J, Erdélyi B, Csákány B. Corneal topography changes
after a 15 second pause in blinking. J Cataract Refract Surg.
2001;27:589–592.
9. Németh J, Erdélyi B, Csákány B, Gáspár P, Soumelidis A,
Kahlesz F, Lang Zs High-Speed Videotopographic Measurement
of Tear Film Build-up Time Investigative Ophthalmology &
Visual Science, June 2002, Vol. 43, No. 6 1783-90.
10. Michael L Nordlund, Jay S. Pepose: Corneal responses to
infection p95-98. in Krachmer, Mannis, Holland CORNEA 2nd
edition, Mosby Elsevier.
11. Gulati A, Sullivan R, Buring JE, et al. Validation and repeatability
of a short questionnaire for dry eye syndrome. Am J
Ophthalmol 2006;142:125-31.
12. Jason J. Nichols, G. Lynn Mitchell, Kelly K. Nichols, Robin
Chalmers, Carolyne Begley: The Performance of the Contact
Lens Dry Eye Questionnaire as a Screening Survey for Contact
Lens-related Dry Eye Cornea 21(5): 469-475 2002.
13. Veres A, Tapasztó B, Kosina-Hagyó K, Somfai GM, Németh J:
Imaging lid-parallel conjunctival folds with OCT and comparing
its grading with the slit lamp classification in dry eye patients
and normal subjects. IOVS May 2011; 52:2945-2951.
14. Pult H, Murphy PJ, Purslow C: A novel method to predict the
dry eye symptoms in new contact lens wearers. Optom Vis Sci
2009;86:1042–50.
15. Petricek I.: Dry Eye. In: Berta A (ed): Red Eye. Differential
diagnosis and management. Int Ophthalmol 2008;28:Suppl
1,18-31.
16. Chalmers R, Begley C. Use your ears (not your eyes) to identify
CL-related dryness Optician, May 6, 2005; 229 (6000): 25-31
A magazine from Johnson & Johnson Vision Care
Current Diagnosis and Management
of Dry Eye
Igor Petricek+
INTRODUCTION
Of all conditions in eye care, dry eye is perhaps the
most elusive condition. Definitions vary, epidemiology
studies give widely differing figures, treatment options
advocate different approaches. Perhaps the main reason
why opinions differ so much is the fact that the crucial
question, where to draw a line between healthy and dry
eye, is still not decided upon. Perhaps it never will be,
since dry eye symptoms, and not signs, are the main
reason patients to see an eye doctor and symptoms
are deeply subjective. That is why there are different
attempts to develop a diagnostic algorithm which
will provide us with objective clinical measurements,
recordable and repeatable over time.
The most recent definition of dry eye was published in
Dry Eye WorkShop (DEWS) report (2007)1:
Dry eye is a multifactorial disease of the tears and ocular
surface that results in symptoms of discomfort, visual
disturbance, and tear film instability, with potential
damage to the ocular surface. It is accompanied by
increased osmolarity of the tear film and inflammation
of the ocular surface.
According to this definition, symptoms of discomfort
are given priority as compared to signs. A new element
is mentioning visual disturbance as a dry eye symptom.
This is particularly important for contact lens wearers.
Igor Petricek MD finished medical
school in Zagreb, Croatia, 1990 and after
residency in Ophthalmology he started
work at Zagreb University Hospital Eye
Department. From 2000 onwards he
is the head of Electrophysiology and
Ultrasound Laboratory at the same
department. Since 2004, he is an active member of Key
Faculty of the Southern European and Middle Eastern
External Eye Diseases Group. Since 2008 he actively
participated in various contactology meetings, mainly
regarding Pathophysiology of the ocular surface in
contact lens wear.
In summary, his current main interests and fields of
work in ophthalmology are electrophysiology of the eye,
ophthalmic ultrasound, color vision, dry eye, low vision
and contactology. This led to publication of 84 scientific
peer reviewed texts and presentation of 71 papers.
He is a member of Croatian Ophthalmology Society,
European Association for Vision and Eye Research
(EVER), The Association for Research in Vision and
Ophthalmology (ARVO), and Tear Film and Ocular
Surface Society (TFOS).
that all female contact lens wearers who were using
oral contraceptives experienced ocular dryness at
times, as opposed to 63% of females not using oral
contraceptives. Seventy six percent of male contact
lens wearers experienced dry eye symptoms.
A survey amongst ophthalmologists and general
medical practitioners from nine Eastern European and
Middle Eastern countries (Belarus, Bulgaria, Croatia,
Czech Republic, Poland, Russia, Ukraine, Turkey and
the United Arab Emirates) was conducted in 2004
to estimate the percentage of patients presenting
with symptoms of ocular irritation and to examine
differential diagnosis and treatment.2 Out of 23,569
patients screened, 25% had dry eye diagnosed as a
cause of such symptoms.
Contact lens wear may cause hyperosmotic shift of
the tear film.5,6 The causes for this may be reduced tear
stimulation caused by decreased corneal sensitivity,
thus reducing blink rate, increased lens-induced tear
hyperevaporation or accumulation of lens deposits in
the tear film. Therefore, if a person has a borderline or
moderate dry eye to start with, contact lens wear may
compromise tear function to the extent that it begins to
cause symptoms.
Studies consistently show that of all the symptoms
experienced by contact lens wearers, that of dryness is
most frequent.3,4 In a survey of 100 contact lens wearers,
only 25% of all patients said that they experienced
no dryness symptoms.2 The same survey showed
Most researchers agree today that dry eye could
be subdivided into hyposecretive and hyperevaporative
dry eye.7 Although most cases are of mixed ethiology,
hyposecretive dry eye is caused mainly by the aqueous
tear hyposecretion, and hyperevaporative dry eye by lipid
+ Zagreb University Hospital Eye department, Zagreb, Croatia
EDITION TWO 2011
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7
layer disfunction, what causes aqueous hyperevaporation.
Research presented at last TFOS meeting showed that out
of 180 subjects, 14 (8%) had hyposecretive dry eye, 100
(55%) had evaporative dry eye, and the remaining 66 (37%)
subjects had dry eye of mixed ethiology.6-8 Therefore, it is
evident that (hyper)evaporative dry eye is by far the most
frequent type of dry eye. Modern lifestyle, which invariably
includes working at computer, is perhaps the main culprit
for reduced blink rate.9 This is particularly important in
contactology, since this cause of hyperevaporative dry
eye is particularly frequent among contact lens wearers,
compounding the problem. Hyposecretive dry eye is
mainly found among the elderly and hyperevaporative
among younger population from which most contact lens
wearers are recruited.
Main symptom of hyperevaporative dry eye is tearing,
caused by the increased evaporation and condensation
of aqueous tears on palpebral margins, particularly in
cold weather. Hyposecretive dry eye mainly presents
with symptoms of burning, grittiness and foreign body
sensation.
DIAGNOSTIC MODES
Many standardized questionnaires are designed for
this purpose as well as dozens of tests, aiming at
detecting dry eye. However, it is universally known
that dry eye symptoms and signs usually present poor
correlations.10
The scope of this review does not permit us to get into
all the intricacies of dry eye diagnostics. Instead, we
will present the most frequently used diagnostic tests
as well as those that are currently being investigated as
promising.
TEAR BREAK-UP TIME TEST (TBUT)
Of all the tests, notwithstanding all its deficiencies,
TBUT test is still regarded as pivotal in dry eye
diagnostics. As mentioned in DEWS Report dry eye
definition, tear film instability is one of the main causes
of dry eye, and that is what TBUT test measures.
It is easy and quick to perform and is moderately
invasive. However, its interpretation depends heavily
on examiner's judgement. But, since currently we have
nothing better, TBUT remains as the most frequently
used test in dry eye diagnosis.
Apart from its dubious repeatability and unavoidable
examiner's influence, the other problem with TBUT test is
lack of consensus regarding cutoff value between normal
and pathologic values: older papers advocate 10 seconds,
while several newer ones reduce it to 5 seconds.
8
SCHIRMER TEST
Schirmer test was historically the first one used
in dry eye diagnosis. It still has a place in it, but with
strictly defined purpose: only to measure the quantity of
aqueous tear production. Any generalization of results to
the overall state of tear film is grossly wrong. Actually,
in hyperevaporative dry eye we often see tears dripping
from the test strip- interpreting this result as "normal tear
function" would mean missing the opportunity to properly
diagnose and treat patient's tear dysfunction. As a cutoff
value of Schirmer test, 10 milimeters of test strip wetted
with tears in 5 minutes is generally accepted.
LID PARALLEL CONJUNCTIVAL FOLDS
(LIPCOF)
A group of authors led by Prof. Hoeh in 1995 published the
paper Lid-parallel conjunctival folds are a sure diagnostic
sign of dry eye.11 The method described was named
Lidkantenparallelen Konjunktivalen Falten, or Lid Parallel
Conjunctival Folds (LIPCOF). It was presented as a very
useful and innovative way of diagnosing dry eye. However,
it was for a long time mentioned in relatively few published
papers, and is rarely used in everyday clinical practice,
especially outside Europe, where it is frequently termed
conjunctivochalasis and not associated with dry eye.
According to authors, the height and/or number of
bulbar conjunctival folds parallel to the temporal margin
of the lower eyelid are observed. Before assessment,
lower eyelid is briefly lifted from the eye surface- if folds
disappear, they indeed are what is described as LIPCOF.
Findings are ranked as follows:
s Grade 0: no folds- normal finding (not dry eye)
s Grade 1: one fold above the normal tear meniscus
height- mild dry eye
s Grade 2: multiple folds up to the height of normal tear
meniscus- moderately dry eye
s Grade 3: multiple folds above normal tear meniscus
height- severe dry eye (Figure 1)
Figure 1: Clinical picture demonstrating grade 3 LIPCOF
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Authors of this method claim that LIPCOF has 93%
positive predictive value.11 In other words, it detects
dry eye with 93% certainty. Its negative predictive
value is claimed to be 76%. Furthermore, LIPCOF is
not invasive, takes very short time to perform and has
no additional costs as it requires use of no test strips,
dyes etc. This may be particularly practical in dry eye
screening in contact lens wearers, especially regarding
soft contact lenses, since most ophthalmologists have at
their disposal only fluorescein dye that may stain the lens
or, if lens was removed to perform TBUT test, the lens
cannot be reinserted until dye disappears from the eye.12
Korb et al. explain appearance of staining on lid wiper
with decreased lubrication in dry eye, and consequently
increased friction. LWE has been graded in Prof Korb's
initial paper, and more precisely in his more recent
paper.15,16
However, the fact remains that LIPCOF is very rarely,
if ever, used outside the German-speaking area, the
language mentioned paper was written in. DEWS or
MGD (Meibomian Glands Disease) Workgroup reports
do not mention it at all.1,13 One recent study reafirms the
potential value of LIPCOF in dry eye screening, placing
cutoff value between grades 1 and 2.14
INTERBLINK INTERVAL VISUAL ACUITY
DECAY (IVAD)
Nevertheless, the main disadvantages of LIPCOF
remain the absence of definite reference parameter
(tear meniscus height is variable between people), the
subjectivity of the examiner, narrow range of grades
(0-3), and lack of understanding why folds actually
appear.
LID WIPER EPITHELIOPATHY (LWE)
Prof. Donald Korb with his coauthors has found
correlation between dry eye symptoms and the
appearance of inner upper eyelid lid wiper portion
staining.15 In symptomatic patients, 88% had LWE.16 Lid
wiper can be stained either with fluorescein or with
lissamine green (Figure 2).
Although not widely used in tear film diagnostics,
LWE is a promising concept. Its indisputable value is
in drawing attention to increased friction as one of the
main causes of dry eye symptoms, the fact that was
previously largely overlooked.
DEWS Report included visual disturbance among
most common dry eye symptoms.1 However, it does
not offer any practical diagnostic test that may
be used to detect and measure it. To date, it has
been difficult to quantify the decay of visual acuity
within the interblink interval. A new test, however,
has been specifically developed and validated
by the researchers at ORA Clinical Research and
Development ( North Andover, Mass., USA ) to
provide an accurate measure of visual function.17
The Interblink Interval Visual Acuity Decay ( IVAD )
test provides the necessary measurement of visual
function in real time. A computer-based paradigm
incorporates the presentation of Landolt’s C’s at
the patient’s best-corrected visual acuity. Patients
are instructed to track the orientation of the C by
pressing a button on a keypad. As the patient’s Best
Corrected Visual Acuity ( BCVA) declines during his
interblink interval, the size of the stimuli increases
accordingly. Visual acuity decay results are on the
order of milliseconds. In the study using IVAD,
there were 18 dry-eye patients and 17 age-matched
controls. The researchers found that dry-eye patients
could only maintain their BCVA for 8.75 ± 6.6 seconds
before it started to decay, while normal patients
maintained it for a statistically significant longer
period of time: 19.46 ±15.97 seconds. Acuity could
drop to as low as 20 / 80 in some patients.
Although promising, IVAD has
drawbacks. It is still too impractical for
use as it uses copyrighted software
and is primarily designed to be used
ophthalmic drugs.
Figure 2: Clinical picture demonstrating lid wiper, stained with Lissamine
Green
Lid wiper is part of the inner margin of the upper eyelid
that exerts most pressure on the eyeball during blinking.
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some serious
everyday clinical
and equipment,
in trials of new
As with LWE, its importance primarily lays in drawing
attention to another overlooked aspect of dry eyeimpaired vision due to uneven tear film distribution and
evaporation. That is particularly important in contact
lens wearers, who may experience compounded
symptoms due to contact lens desyccation.
9
LIPID LAYER THICKNESS (LLT)
As was already mentioned, lipid layer is fast becoming
the most investigated part of the tear film. Nowadays,
its dysfunction is acknowledged as the main cause
of majority of dry eye cases.8 Reduced blinking rate,
something seen so frequently among contact lens
wearers, also causes reduced lipid layer thickness.
However, how this can be visualized? It can be assessed
by using the interference phenomenon of lipid spread
over aqueous tear (Figure 3). The only commercially
available instruments to do this are Tearscope and
Figure 4: Meibomian gland expression
is with other signs of dry eye, staining correlates poorly
with symptoms: one may have pronounced dry eye
symptoms without any surface staining and vice versa.
In summary, the following diagnostic sequence is
recommended, which will not take too much time, and
does not require any additional equipment:
1.
2.
3.
4.
5.
6.
Case history
Slit lamp examination of lid margin for blepharitis
TBUT
LIPCOF
Meibomian Gland Expression
Ocular surface staining
Figure 3: Tearscopy based on interference phenomenon of lipid spread over
aqueous layer.
THERAPEUTIC APPROACH
Tearscope Plus ® (Keeler).19 They are not widely used due
to their price. Also, they are no longer produced. As with
visual disturbances, that leaves stressed importance of
the lipid layer on dry eye on the one hand, and lack of
tools to assess it in the other.
MEIBOMIAN GLAND EXPRESSION
One indirect way of assessing lipid layer function is
Meibomian gland expression. It was initially as well
as most recently described by Prof. Korb in 2008.20
By manually applying pressure on the lower eyelid for
10-15 seconds, we can assess quantity and appearance
of meibum (Figure 4). This method is again prone to
examiner's subjectivity. However, it is non-invasive,
requires no additional equipment and at least may give
us general idea about lipid layer secretion.
OCULAR SURFACE STAINING
Ocular surface staining marks a more serious form of
dry eye, one in which protective role of tear film has
been compromised. Typically, dry eye exhibits staining
in the palpebral aperture and at 6 o'clock. However, as it
10
What should be practitioners main goals in dry
eye therapy? Firstly, to alleviate symptoms, and thus
enhance patient's quality of life. Secondly, to prevent
development of possible complications of dry eye, such
as viral or bacterial infection or scarring. And last but not
least, not to minimise the side effects of the therapeutic
measures.
ARTIFICIAL TEARS
Artificial tears were and still are the mainstay of any
dry eye therapy. However, they have gone a long way
from just rewetting. Nowadays, their role in lubrication,
and, most recently, prevention of evaporation, are
increasingly gaining importance.
REWETTING
By volume, all artificial tears are 99% water. However,
what makes them different from 100% water are
demulcents that keep water on the eye long enough
to provide adequate rehydration. A demulcent (derived
from the Latin demulcere, "caress") is an agent that
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forms a soothing film over a mucous membrane,
relieving minor pain and inflammation of the membrane.
What is more important, it can swell to many times its
dry volume without losing its initial properties. After
absorbing water it can slowly release it, providing long
lasting rehydration.
LUBRICATION
Increased friction has been recognized as one of the
main causes of dry eye symptoms, as shown in Lid
Wiper Epitheliopathy concept. Compounds with proven
lubricating effect are nowadays available in rewetting
eyedrops. By reducing friction, dry eye symptoms such
as grittiness and foreign body sensation are reduced.
EVAPORATION PREVENTION
In case of diagnosed hyperevaporative dry eye
caused by lipid layer dysfunction, there was not much
available to the ophthalmologist to offer his patient.
However, recently there are formulations with lipid layer
substitutes, presenting perhaps the biggest change in
artificial tear therapy since introduction of Hydroxypropyl
methylcellulose (HPMC) as an active ingredient of
artificial tears in the early fifties.
PRESERVATIVES
As required by the Food and Drug Administration
(FDA), all multidose ophthalmic solutions must
contain some sort of preservative. However, not all
preservatives are the same. Benzalkonium chloride
(BAK) is still the most frequently used preservative. As
a cationic surfactant (detergent), it disrupts lipid layer
of the tear film and causes tear break-up. Therefore,
BAK-containing eyedrops may actually worsen the
symptoms of hyperevaporative dry eye by dissolving
lipid layer. Having this in mind, it is evident that either
monodose preservative-free artificial tears or those with
preservatives with less adverse effects, such as higher
molecular weight , are compounds of choice here.
OTHER THERAPEUTIC MEASURES
Change in environmental conditions (air convection and
humidity, monitor position). Air-conditioned environment
has low relative humidity. That is particularly evident
in passenger aircraft cabins, where dry eye symptoms
and contact lens intolerance may become particularly
bothersome. Regarding air-conditioning in houses or cars,
natural ventilation is therefore better option wherever
possible. Also, placing computer monitors below eye
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level will narrow the eye aperture and thus reduce ocular
area from which tears evaporate.
TREAT ANY EYELID DISEASE (BLEPHARITIS),
EYELID HYGIENE
Reduced blinking in contact lens wearers may cause
Meibomian gland orifices to clog, thus compromising
lipid layer function and increasing tear evaporation. This
is particularly evident in persons with oily facial skin. To
prevent this, eyelid hygiene (cleaning of gland orifices
with clean water of commercialy available lid scrubs) is
recommended on daily basis.
ASSESS CONTACT LENS CARE REGIMEN
Improper lens care (lens worn too long, use of
improper cleaning solution etc.) may also cause tear film
function to be excessively compromised.
CHANGE OF CONTACT LENS MATERIAL
In case none of the above can help, a change to siliconehydrogels (SiHs), may help. Eye care practitioners
should base lens selection initially on publications in
peer-reviewed journals and subsequently on their own
experience of product performance.
It has been claimed that ACUVUE ® OASYS ®
with HYDRACLEAR ® PLUS (senofilcon A) lens
has improved performance, especially for patients
in challenging environments who may have issues
with lens comfort and dryness. The enhanced
wettability and lubricity of the senofilcon A material
have been shown to increase levels of reported patient
comfort compared with habitual lenses, even in adverse
environments by reducing the disruption of the post lens
tear film and reduce lid sensation during blinking. 21
The material has been shown to allow an increase
in comfortable wearing time in a population of lens
wearers for whom comfortable wearing time had
previously been a problem. It has also been shown that
senofilcon A lenses can increase patient comfort in
specifically challenging situations such as computer use
and driving at night. 22
CHANGE OF LENS TYPE OR WEAR REGIMEN
If gas permeable contact lenses cause severe
discomfort due to ocular dryness, change to soft material
may be considered. In case of severe intolerance,
11
consider temporary or permanent reduction of wear
time or complete discontinuation of contact lens wear.
In contact lens practice diagnosis of dry eye is
compulsory and should include number of tests in order
to define the type of dry eye, as well the condition of
the ocular surface including potential damage such
as staining, lid wiper epithelopathy, LIPCOF. One
must combine most appropriate methods, but very
importantly this combinaation should be standardised
for better repeatability and improved diagnostic value
over time. As far as the problem is identified the eye
care pratitioner should decide on therapeutic measures.
Special attention should be payed on lens material and
its property, lens modality and if applicable contact lens
solutions. Careful contact lens selection and follow up
of each case will improve dry eye related symptoms and
ocular surface health.
15. Korb DR, Herman JP, Greiner JV, Scaffidi RC, Finnemore VM,
Exford JM, Blackie CA, Douglass T. Lid Wiper Epitheliopathy
and Dry Eye Symptoms. Eye and Contact Lens 2005; 31(1):
2-8.
16. Korb DR, OD, Herman JP, Blackie CA, et al. Prevalence of
Lid Wiper Epitheliopathy in Subjects With Dry Eye Signs and
Symptoms. Cornea 2010; 29:377–383.
17. Torkildsen G, The effects of lubricant eye drops on visual
function as measured by the Inter-blink interval Visual Acuity
Decay test. Clin Ophthalmol 2009; 3: 501-6.
18. Korb DR, Baron DF, Herman JP et al. Tear film lipid layer
thickness as a function of blinking. Cornea 1994; 13(4): 354359.
19. Tearscope. Tearscope Plus Clinical Handbook and Tearscope
Plus Instructions. Windsor, Keeler Ltd, Windsor, Berkshire;
Keeler Insts Inc., Broomall, PA, 1997.
20. Korb DR, Blackie CA. Meibomian gland diagnostic
expressibility: correlation with dry eye symptoms and gland
location. Cornea 2008;27(10):1142–1147.
21. Riley C, Young G, Chalmers R. Prevalence of ocular surface
symptoms, signs, and uncomfortable hours of wear in contact
lens wearers: the effect of refitting with dailywear silicone
hydrogel lenses (senofilcon a). Eye & Contact Lens, 2006;
32(6):281-6.
22. Young G, Riley CM, Chalmers RL, Hunt C. Hydrogel lens
comfort in challenging environments and the effect of refitting
with silicone hydrogel lenses. Optom Vis Sci, 2007; 84(4):302-8.
References
1. Definition and Classification of Dry Eye. Report of the Diagnosis
and Classification Subcommittee of the Dry Eye WorkShop
(DEWS). Ocul Surf 2007;5:75-92.
2. Petricek I, Prost M, Popova A. The differential Diagnosis of Red
Eye: A Survey of Medical Practitioners from Eastern Europe and
the Middle East. Ophthalmologica 2006; 220: 229-237.
3. McMonnies CW and Ho A. Marginal dry eye diagnosis: History
versus biomicroscopy. In: The Pre-ocular tear film in Health,
Disease, and Contact Lens Wear 1986; ed. Holly FJ: p. 32-40.
4. Brennan NA and Efron N. Symptomatology of HEMA contact
lens wear. Optom Vis Sci 1989; 66: 834-838.
5. Martin DK. Osmolality of the tear fluid in the contralateral
eye during monocular contact lens wear. Acta Ophthalmol
(Copenh.) 1987; 65: 551-555.
6. Farris RL, Stuchell RN and Mandel ID. Basal and reflex human
tear analysis. I. Physical measurements: Osmolarity, basal
volumes, and reflex flow rate. Ophthalmology 1981; 88: 852-857.
7. McCulley JP, Shine WE, Aronowicz J et al. Presumed
Hyposecretory/Hyperevaporative KCS: Tear Characteristics.
Trans Am Ophthalmol Soc 2003;Vol 101: 141-154.
8. TearLab presentation at TFOS, Florence, 2010.
9. Patel S, Henderson R, Bradley L, et al. Effect of visual display
unit use on blink rate and tear stability. Optom Vis Sci 1991;
68:888–892.
10. Nichols KK, Nichols JJ, Mitchell GL. The lack of association
between signs and symptoms in patients with dry eye disease.
Cornea 2004; 23(8): 762-770.
11. Hoeh H, Schirra F, Kienecker C, Ruprecht KW. Lid-parallel
conjunctival folds are a sure diagnostic sign of dry eye.
Ophthalmologe. 1995; 92(6):802-8.
12. W. Sickenberger, H. Pult, B. Sickenberger. LIPCOF and contact
lens wearers- a new tool to forecast subjective dryness and
degree of comfort of contact lens wearers. Contactologia 2000;
22: 74-79
13. The International Workshop on Meibomian Gland Dysfunction.
Investigative Ophthalmology & Visual Science, Special Issue
2011; Vol. 52, No. 4
14. Németh J, Fodor E, Berta A, Komár T, Petricek I, Higazy
M, Nemec P, Prost M, Semak G, Grupcheva H, Evren O,
Schollmayer P, Samaha A, Hlavackova K (2010) LIPCOF in
the Diagnosis of Dry Eye- Multicenter Study. TFOS Florence
(Poster).
12
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Meibomian gland dysfunction and contact
lenses… can we do better?
Christina N Grupcheva+
INTRODUCTION
Meibomian glans are of great interest to eye care
practitioners and researchers in the recent years, as
their secretion appears to be a very important factor for
tear film integrity and therefore optical quality and vision.
Furthermore, those glands are important for the health
of the ocular surface and the subjective appreciation of
comfort. Introduction of silicone-hydrogel lenses and
their hydrophobic material properties is another issue
that increases interest towards the quality and quantity
of the lipids in the tear film.
Detailed information about the meibomian glands related
research and publications can be found in the summary of
the Meibomian Glands Disease Workshop (MGD) at the
web page of the Tear Film Society - www.tearfilm.org.
NORMAL ANATOMY AND PHYSIOLOGY OF
THE MEIBOMIAN GLANDS
The sebaceous glands within the lids have been
described by Heinrich Meibom and named after him
– Meibomian glands. Meibomian glands, unlike other
Professor Christina N Grupcheva
MD, PhD, DSc, FEBO, FICO(Hon) Prof
CN Grupcheva is a National Professor
in Ophthalmology since 2010. Her
clinical and research interests and
expertise are related to cornea, anterior
segment, tear film, contact lenses and
complex anterior segment surgery. She
has published more than 100 scientific papers and
12 ophthalmology books. She regularly presents at
national and international meetings on subjects of her
expertise mainly as an invited lecturer. She is a member
of a number of Bulgarian, European and International
professional societies.
sebaceous glands, do not have direct contact with
hair follicles. Meibomian glands produce secretion via
holocrine mechanism. Each gland has multiple secretory
acini-containing meibocytes, lateral ductules, a central
duct, and a terminal excretory duct that opens at the
posterior lid margin (Figure 1). Meibum is delivered
to the lid margin by lid movement and muscular
contraction.It is assumed that orbicularis muscle and
for the lower medial part the Riolan’s muscle play a key
role. The secretion called maibum prevents evaporation
and maintains the surface tension of the tear film.1 It
also prevent contamination with skin lipids and prevents
tears to flow over lid margin. The lipid layer is distributed
by the lid margins and usually is 100 nm thick, however,
A
A
B
C
Figure 2: Clinical appearance (biomicroscopy) of the upper Meibomian
glands visualized from the conjunctival site (A) and lower lid with
excretory openings (B). Transillumination for visualization of the
lower meibomian glands (C) and lid margin keratinization and
neovascularisation (D).
+ Head of the Department of Ophthalmology and Visual Science, Medical University Varna
Figure 1: Schematic of the Meibomian gland anatomy and its adjacent
structures important for functional integrity - lateral ductules (A),
a central duct (B), and a terminal excretory duct (C) that opens at
the posterior lid margin.
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13
in case of glands dysfunction it may be as thin as 14
nm. 2 Thinner lipid layer is associated with decreased
break up time, which subjectively presents as low
quality of vision and discomfort. 3
There are mean of 30 Meibomian glands within the
upper lid tarsus and about 25 in the lower, according
to different morphometric studies. 4 The length of the
individual glands is reported approximately 5.5 mm in
the middle of the upper lid and approximately 2 mm in
the lower lid, and hence their calculated total volume
is also higher: approximately double in the upper lid
(26 µL) versus the lower lid (13 µL). 5 The Meibomian
glands in the lower lids tend to be wider than those in
the upper lids (Figure 2).
Not all glands function simultaneously, and the
details about functional characteristics still need to be
elucidated. Because of the larger, and more numerous
meibomian glands in the upper lids, researchers assume
that they also have a higher secretory capacity, however,
due to better accessibility of the lower lid margin the
latter appears to be of greater interest in the published
literature. There are many studies, but those performed
by Blackie and Korb are very detailed and certainly
seminal in regard to functional activity.6,7 These studies
concluded that not all glands deliver oil at the same time.
In addition, authors made a topographical evaluation of
the Meibomian glands proving that the number of active
glands in lower lids depends on their location along the
lid margin. It appears to be highest in the nasal third,
lower in the middle of the lid, and again a bit lower in
meibomian glands at the thetemporal third. It was also
observed that there is a correlation between the number
of actively delivering meibomian glands in the lower
eyelid and dry eye symptoms. 8
Functional regulation of the Meibomian gland is
complicated. In contrast to other sebaceous glands they
also have a distinct sympathetic and parasympathetic
innervation. Meibomian glands are regulated by sex
hormones and androgens have an up-regulating function,
whereas estrogens act antagonistically. Sufficient levels
of androgens are necessary in the production and
secretion of normal meibum. 9 There may be an increased
risk of MGD in cases of androgen insufficiency in: aging,
menopause, androgen-blocking medications, Sjögren’s
syndrome, and mutations within the androgen gene.
Increased age is associated with decreased meibum
production, along with changes in Meibomian gland
orifice appearance. Clinically older individuals frequently
have changes of the lid margins including keratinization,
neovascularization and clogged orificia of the Meibomian
glands. Histological evaluations of the meibomian glands
in older individuals have revealed increased atrophy. 9
Blackie and Korb,studied the Meibomian gland
14
function of young healthy individuals and found that if a
meibomian gland are active at 8 a.m., then, depending on
its location along the lower lid, there was a high likelihood
that it would continue to provide liquid secretion for 9
more hours.10 For example, 70% of the nasal glands, 30%
of the central glands, and 20% of the temporal glands
provided liquid secretion throughout 9-hour interval. If a
meibomian gland was non-functional at 8 a.m., it would
have sporadic activity during the day. These studies
highlight the important issue about the time dependent
characteristics of meibomian gland secretion.10 Each
gland might have a specified period of activity, and
finding the up-regulating factors in the future may help
treatment of Meibomian gland dysfunction.
MEIBOMIAN GLAND DYSFUNCTION
According to the MGD workshop the definition of this
condition is as follows: "Meibomian gland dysfunction
(MGD) is a chronic, diffuse abnormality of the meibomian
glands, commonly characterized by terminal duct
obstruction and/or qualitative/quantitative changes in
the glandular secretion. It may result in alteration of the
tear film, symptoms of eye irritation, clinically apparent
inflammation, and ocular surface disease.”
This dysfunction may result in alteration of the
tear film, and following symptoms: eye irritation,
clinically apparent inflammation, ocular surface
disease. Inflammation is not compulsory part of
general classification of the MGD, as the pathological
process may be result of the different conditions.11
The importance of MGD and its relationship to
other blepharitis as inflammatory disease is obviously
very important. There are number of publications
with regards to causative agents for MGD. A study
by Mathers et al.12 used meibography, volume of
meibomian gland lipid (expressed), tear osmolarity,
and Schirmer’s test to evaluate blepharitis patients.
Based on these criteria the authors separated the
patients into four groups: seborrheic with MGD
( 51%), obstructive MGD (21%), obstructive MGD
with sicca (12%), sicca alone (16%). In this study,
one of the most important highlights is that MGD
is present together with normal tear flow, increased
tear evaporation in itself is not sufficient to cause
dry eye. In contrast, if tear flow is low together with
increased tear evaporation, then dry eye is likely to
be present. In summary, the report supports a strong
involvement of Meibomian gland drop out and perhaps
hyperkeratinization in some types of blepharitis.12 It is
still unclear whether the keratinization and gland drop
out are primary or secondary phenomena.
In case of infective posterior blepharitis, bacterial
colonization by S. epidermidis, S. aureus, and P. acnes
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may lead to release of bacterial lipases and esterases
which modifies the lipids secreted from the meibomian
glands. Esterases produced by S. aureus hydrolyze
cholesterol esters into proinflammatory cholesterol
- isolated in chronic blepharitis cases. Unsaturated
fatty acids, which are fluid at body temperature,
are also a potential target of lipases and esterases.
Lipases are exotoxins produced by coagulase-negative
staphylococci, S. aureus, and P. acnes. Those enzimes
will result into break down of triglycerides into mono and
diglycerides (higher melting point) which are more solid
in nature. This can plug the Meibomian gland and reduce
the delivery of normal meibum onto the tear film, thus
negatively affecting the integrity of the tear film.
For clinical purposes MGD can be categorized 2 into
four subtypes, as follows:
1. MGD alone
s Asymptomatic – no symptoms and subtle signs,
but altered Meibomian gland expression test.
s Symptomatic (noncicatricial, cicatricial) – symptoms typical of evaporative dry eye combined
with lid marginal changes and Meibomian glands
drop out.
2. MGD with associated with ocular surface
damage – most commonly conjunctival and
corneal staining.
3. MGD-related evaporative dry eye
4. MGD associated with other ocular disorders.
Figure 3: In vivo confocal microscopy (HRT II Rostock corneal module)
demonstrating acinar structures of normal lid and lid (A),
clinically proven MGD with neovascularization (B), inflammation
around a acinar structures (C) and atrophic changes (D).
and wider research applications.13
Recently HRT II Rostock corneal module allowed in vivo
confocal microscopy of the Meibomian glands. This quick
and non-invasive technology allows judgment of the acinar
structure and adjacent tissues and dynamic follow up over
time (Figure 3).
Another indirect method as aforementioned is lipid
pattern assessed by Tearscope. Due to expense and
limited clinical availability this test is not widely used
except for research projects. Furthermore, the pattern of
lipids is not standardized and requires free interpretation
which is associated with low repeatability.
Using in vivo confocal microscopy, Ibrahim et al. made
classification of the Meibomian gland presentation in 3
stages14 :
1. Typical acinar unit: the mean acinar unit density was
139±8 glands/mm2, the mean longest and shortest
acinar unit diameters were 45.3±15.0 and 24.9±7.3
µm, respectively, the mean inflammatory cell density
(ICD) was 13±1 cells/mm2;
2. Meibomian gland dysfunction (MGD): the MG
dropout grade 2, and the MG expressibility grade
2, atrophy in the glands with extensive periglandular
inflammatory cells, the mean acinar unit density was
26±3 glands/mm2, the mean longest and shortest
acinar unit diameters were 67.3±27.4 and 37.9±7.1
µm, respectively, the mean ICD was 1167±10 cells/
mm2;
3. MGD (enlargement of acinar unit): the MG dropout
grade was 2 and expressibility grade was 3, the
mean acinar unit density was 40±5 glands/mm2,
the mean longest and shortest acinar unit diameters
were 133.5±62.3 and 75.0±8.1 µm, respectively, the
mean ICD was 232±9 cells/mm2.14
Direct method allows visualization of the Meibomian
glands by microscopy, or by meibography via
transillumination through the tarsus. Meiboscopy is the
quantification of meibomian gland dropout by using lid
transillumination, while meibography is the same technique,
but using photodocumentation, usually infrared camera, and
long term record. Both methods, still have limited clinical
The function of the Meibomian glands may also be
judged on the basis of Meibomian gland expression. It has
been introduced as a clinical method by D Korb, and it is
common to express the glands by applying digital pressure
through the substance of the lids.8 For research, however,
standardized methods with different devices has been
developed. On the basis of meibum expression, meibomian
CLINICAL EVALUATION OF THE MEIBOMIAN
GLANDS
Meibomian glands function is judged on the basis of
indirect and direct methods. The principle indirect method
is tear break up time (TBUT), however, lipid layer is best
judged by the Tearscope patterns. In the clinical practice
TBUT is the most popular and widely used. In case of
MGD the value of the TBUT is lower than 10 seconds.
However, the quality of the tear film break up such as
zones, extent and pattern must also be analyzed.
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gland orifice obstruction has been classified as:
– grade 1: cloudy meibum expressed with mild
pressure;
– grade 2: cloudy meibum expressed with more than
moderate pressure;
– grade 3: meibum cannot be expressed even with
strong pressure.
Meibomian gland expression is also used to obtain
meibomian samples for lipid analysis.
When the lids are normal, light expression may be
expected to expel secretion contained in the ducts, and
also is possible to force presecretory lipids from the acini.
In MGD much heavy expression is required.
In MGD, the qualitative analysis of expressed oil may
highlight:
– clear fluid,
– cloudy fluid,
– viscous fluid containing particulate matter,
– densely opaque, toothpaste-like material.
To improve clinical judgment several grading scales
have been developed. The scales also try to combine
quantitative analysis, based on number of glands prone to
expressivity:
– all glands expressible,
– 3–4 glands expressible,
– 1–2 glands expressible,
– no glands expressible.
It is still debatable which tests are appropriate for
asymptomatic patients, however, as a rule the more
severe is the MGD the examination should include the
whole range of available tests.
MANAGEMENT OF THE MEIBOMIAN
GLANDS DYSFUNCTION
Although, there are variety of treatments they may
be divided into two principal groups: lid hygiene and
hot procedures with expressive massage. The first
may be performed with baby shampoo or over the
counter (OTC) products. Warm compresses or special
devices may help Meibomian glands expression and
functional improvement. In case of dry eye it should
be managed appropriately. Most importantly in case
of infection antimicrobials should be used, and in case
of inflammation short term corticosteroids might be
considered on short term basis.
s adjunctive use of lubricants/artificial tears in cases of
additional dry eye disease,
s topical antibiotic ointments for moderate to severe
cases,and
s systemic tetracycline derivatives (e.g., tetracycline
250 mg four times per day or doxycycline 100 mg two
times perday) for 6 weeks to several months in recurrent cases, and/or
s to consider topical steroids in severe cases for a shortterm and incision and curettage with optional steroid
injection in chalazion.
Considering antibiotic treatment, it should be mentioned
that macrolide antibiotics present immunomodulatory and
anti-inflammatory effects which are separate from direct
antibacterial actions.17 Furthermore tetracycline and its
derivatives applied systemically present antiinflammatory
and lipid-regulating properties, rather than antimicrobial
effects. Tetracyclines (and in even lower dose doxacycline)
inhibit lipase activity and therefore decrease free fatty
acids, which destabilize the preocular tear film and
promote inflammation. Excessive lipase activity and
alterations of lipid composition directly influence tear
stability, and may also play a role in keratinization of the
lid margin and plugging of meibomian gland.17
Surgical treatments of MGD (including probing) are
not widely used and manage the complications of the
disease, than the disease itself.
MGD AND CONTACT LENSES
Contact lens problems such as deposits or transient
visual disturbances and discomfort are common in
patients with MGD. Proper management of existing
symptomatic or asymptomatic disease is required for
successful contact lens wear. Contact lenses on the
other hand may be associated with decreased number of
Meibomian glands or MGD, as a result of chronic trauma.
It is debatable which material and which design is more
traumatic to the lids. However, published literature
The Moorfields Manual of Ophthalmology and The Wills
Eye Manual recommend15, 16 :
s warm compresses and lid massage up to four times
per day for 15 minutes,
Figure 4: Clinical picture of Meibomian glands expression with minimal (A),
moderate (B) and heavy (C) pressure and the excessive meibum in
the tear film (D).
16
A magazine from Johnson & Johnson Vision Care
is not convincing about "traumatic effect” of contact
lenses over Meibomian gland. Ong and Larke18 reported
that 30% of contact lens wearers developed MGD
after 6 months, compared with only 20% of the non–
lens-wearing population. This difference appear to be
statistically significant, however, neither lens type (hard,
gas permeable, or soft) nor sex was significant factor.
Much larger study by Hom et al.,19 demonstrated a small
excess of MGD in the contact lens wear (41%) versus
non-contact lens wear (38%) group, but results were not
statistically significant or likely to be relevant clinically.
Despite that published literature did not highlight the role
of lens characteristics and modality for development and
severity of the MGD, careful contact lens selection and
follow up is essential to minimize possible complications.
Contact lens is a part of the anterior ocular surface
and has a significant interactive effect over it, especially
considering the tear film. The so-called pre-contact lens
tear film consists of water and lipid layers. The latter is a
product of the Meibomian glands It has been proven that
patients with giant papillary conjunctivitis are more likely
to have Meibomian gland dysfunction with gland dropout
than patients without GPC.20 Additionally, the viscosity
of meibomian gland excreta is greater in lids with GPC.
More recent studies have shown that contact lens wear
(regardless soft lenses or gas permeable) is associated with
a decrease in the number of functional Meimbonian glands.
This decrease is proportional to the duration of contact
lens wear. This may be correlated to literature reports for
incidence of dry eye in up to 50% of contact lens wearers.
Although there are no studies in the literature looking at
MGD and different materials and designs one may speculate
that less trauma caused by lenses with higher lubricity and
lower modulus would be beneficial. Again theoretically
corneo-scleral soft lenses should have less traumatic effect
than gas permeable lenses. Moreover from the same
point of view edge design should play a role in MGD and
especially clogging of the excretory duct by epithelial cells,
as initially suggested by Henriquez et al.21 Of course, material
properties should be considered in case of MGD. As lipid
layer is affected, hydrophobic lenses, theoretically should be
contaminated easily with lipids and lipid deposition would
be associated with poor wettability. In order to prevent this,
eye care practitioner should consider lenses with wettable
surface, and definitely frequent replacement regimen would
be beneficial. In most difficult cases daily disposable lenses
should be the first choice.
CONCLUSIONS
Meibomian gland disease is a serious clinical problem
with increasing incidence and prevalence. The reasons
for this increased frequency are improved diagnostics
and clinical awareness, as well the greater demand for
EDITION TWO 2011
Eye
Eye Health
Health
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comfort from patients. Contact lens practice is certainly
the most affected specialized eye care division by the
consequences of this condition. The eye care practitioner
must properly diagnose and manage the problem and
also select the proper material and design in order to
manage, not only treat Meibomian Gland Dysfunction.
References
1. Mathers WD, Lane JA. Meibomian gland lipids, evaporation,
and tear film stability. Adv Exp Med Biol. 1998;438:349–360.
2. Foulks GN, Bron AJ. Meibomian gland dysfunction: a clinical
scheme for description, diagnosis, classification, and grading.
OculSurf. 2003;1:107–126.
3. Bron AJ, Tiffany JM. The contribution of meibomian disease to
dry eye. Ocul Surf. 2004;2:149 –164.
4. Jester JV, Nicolaides N, Smith RE. Meibomian gland studies:
histologic and ultrastructural investigations. Invest Ophthalmol
Vis Sci. 1981;20:537–547.
5. Greiner JV, Glonek T, Korb DR, et al. Volume of the human and
rabbit meibomian gland system. Adv Exp Med Biol. 1998;438:
339–343.
6. Blackie CA, Korb DR. Recovery time of an optimally secreting
meibomian gland. Cornea. 2009;28:293–297.
7. Blackie CA, Korb DR. The diurnal secretory characteristics of
individual meibomian glands. Cornea. 2010;29:34 –38.
8. Korb DR, Blackie CA. Meibomian gland diagnostic
expressibility: correlation with dry eye symptoms and gland
location. Cornea. 2008;27:1142–1147.
9. Nien CJ, Paugh JR, Massei S, Wahlert AJ, Kao WW, Jester
JV.Age-related changes in the meibomian gland. Exp Eye Res.
2009; 89:1021–1027.
10. Blackie CA, Korb DR, Knop E, Bedi R, Knop N, Holland
EJ.Nonobvious obstructive meibomian gland dysfunction.
Cornea. 2010;29:1333–1345.
11. Arita R, Itoh K, Maeda S, et al. Proposed diagnostic criteria
for obstructive meibomian gland dysfunction. Ophthalmology.
2009; 116:2058–2063.
12. Mathers WD, Shields WJ, Sachdev MS, Petroll WM, Jester
JV. Meibomiangland dysfunction in chronic blepharitis. Cornea
1991;10: 277–85.
13. Foulks G, Bron AJ. A clinical description of meibomian gland
dysfunction. Ocul Surf. 2003;1:107–126.
14. Ibrahim OM. Matsumoto Y. Dogru M. Adan ES. Wakamatsu TH.
Goto T. Negishi K. Tsubota K. Ophthalmology. 117(4):665-72,
2010 Apr.
15. Smith GT, Dart J. External eye disease. In: Jackson TL, ed.
MoorfieldsManual of Ophthalmology. Philadelphia: Mosby
Elsevier;Chap 4:2008.
16. Ehler J, Shah ChP. Wills Eye Manual. Philadelphia: Lippincott
Williams & Wilkins; 2008.
17. Bertino JS. Impact of antibiotic resistance in the management
ofocular infections: the role of current and future antibiotics.
Clin Ophthalmol. 2009;3:507–521.
18. Ong BL, Larke JR. Meibomian gland dysfunction: some clinical,
biochemical and physical observations. Ophthalmic Physiol
Opt.1990;10:144–148.
19. Hom MM, Martinson JR, Knapp LL, Paugh JR. Prevalence of
meibomian gland dysfunction. Optom Vis Sci. 1990;67:710–
712.
20. Mathers WD, Billborough M. Meibomian gland function and
giant papillary conjunctivitis. Am J Ophthalmol. 1992;114:188–
192.
21. Henriquez AS, Korb DR. Meibomian glands and contact lens
wear. Br J Ophthalmol. 1981;65:108–111.
17
Top 10 Questions on Dry Eye Symptoms
Answered by Eye Care Professionals
1
WHAT IS THE MOST COMMON
CAUSE OF DRY EYE SYMPTOMS
IN YOUR PRACTICE?
Dr. Anna Maria Ambroziak,
Warsaw - Poland
Based on the published literature, every fifth patient
approaching an eye care practitioner presents one or more
symptoms of dry eye. My own, long term experience
demonstrates that the problem affects a large group of
patients, but most of those patients have been previously
underdiagnosed, perhaps because the applied diagnostic
criteria are not straightforward. Dry eye has significant
implications and requires a careful approach, particularly
within the group of contact lens users.
The most common cause of the disorder of tear film
integrity and stability, in my experience, definitely is the
meibomian glands dysfunction, usually associated with
unsettled regulation of oestrogen-related secretion.
Therefore, dry eye caused by the disorder of the lipid
layer and excessive tear film evaporation affects mostly
women, both young taking contraceptives, and older ones,
particularly, during the menopausal period, whether they are
subjected to hormonal therapy or not. The most common
causes, however, are qualitative and quantitative blinking
disorders due to computer work, reading or watching TV. Dry
eye symptoms among children and teenagers are reasonably
frequent, though unnoticed ailment significantly associated
with occurring, and not always treated dermatological issues.
For instance, currently common practice of treating acne with
oral Accutane (isotretinoin), on a certain length and dosage,
leads to dry eye symptoms in all patients.
In the era of modern materials and the possibility of fitting
daily disposable silicone-hydrogel contact lenses it should be
highlighted that disorders of the eye surface are not, in any
way, contraindications of safe contact lens wearing.
2
DO YOU USE QUESTIONNAIRES
TO IDENTIFY YOUR DRY EYE
PATIENTS AND HOW DO THEY
WORK?
Dr. Tomas Vido, Prague - Czech Republic
Although I am familiar with several dry eye
questionnaires that have been developed in order
18
to assist us, as clinicians, in discovering our dry eye
patients, I have never really used them extensively
in my practice since now. There are many reasons,
but the most important one is that in my very busy
practice, questionnaires would fit with some difficulty.
My patients prefer to communicate in person with me
or with the supporting staff, and they really do not enjoy
"working” on filling in papers, while being in the waiting
room.
However, when I am taking history I always use
questions related to dry eye symptoms. The questions
are modified and customized for each particular
patient, but the three main areas are: symptoms of
dry eye such as discomfort, irritation and transient
visual disturbances, symptoms’ alterations influenced by
different environments and impact on dry eye symptoms
on patient quality of life. I usually take notes on those
and then I use similar kind of questions at the follow up
visits. I do believe that in direct communication the eye
care professional can achieve better objectivity, leading
the patients and helping them for retrospective self
evaluation of their dry eye symptoms. However, I believe
that in some communities, dry eye questionnaires might
work best and they are definitely invaluable for research
studies but also for day-to-day practice.
3
WHAT IS THE DIAGNOSTIC DRY
EYE TEST OF YOUR CHOICE?
Dr. Rosella Fonte, Verona - Italy
In my clinical practice I prefer to adopt a
procedure, rather than a single test that helps me in making
a differential diagnosis of the dry eye condition, and it is as
follows: first I use the phenol red test, to rule out a problem
of quantity of the tear film (or, in alternative the evaluation
of the tear prism and his height and width). If with this
result, I can exclude a tear volume problem, (and after
looking at the picture of the tear film interference), then I
need to determine whether the problem is secondary to a
lack of the mucin or lipid components of the tear film. So
I use the lissamine green test, also seeking the presence
of lid wiper epitheliopathy and highlighting features related
to the mucin component. Finally, through the use of the
fluorescein and the observation of the Meibomian glands, I
can determine the problems related to the lipid component.
It' s a three-stage procedure, fast, accurate and valid,
A magazine from Johnson & Johnson Vision Care
which in my hands allows, in a reasonable time, and during
the routine contact lens exam, not to miss any of the
components of the tear film. Therefore identifying the true
nature of the problem, I can plan a strategy to improve the
visual comfort of the patient.
4
WHAT IS THE MOST COMMON
REASON FOR DRY EYE
SYMPTOMS IN CONTACT LENS
WEARERS?
Dr. Deniz Oral, Istanbul - Turkey
Almost half of the contact lens wearers report dryness
to some degree, and these symptoms are caused by a
combination of different factors. While no single reason
stands out as the most common, the more frequently
encountered causes of dryness in contact lens wearers
are decreased tear volume and tear instability.
Studies showed that contact lens wearers with dryness
symptoms have lower tear meniscus volumes. Although
decrease in corneal sensitivity is proposed as a cause of
reduced tear production, it is still not clear if long term
contact lens wear decreases tear production. Decreased
tear meniscus volume and increased tear film osmolarity
has been linked to increased evaporation rather than
decreased tear production in contact lens users with
dryness.
Tear instability results from dysfunction of the meibomian
glands and presents with decreased pre-lens lipid layer
thickness and rapid tear film break-up. Meibomian
dysfunction may be the skin property of an individual, may
result from contact lens wear, or combination of both.
While meibomian gland loss is normally an age related
change in the eyelids, chronic irritation from contact lenses
seems to accelerate this process especially in the upper
eyelid. The extent of meibomian gland loss is reportedly
related to the duration of contact lens wear. Along with
meibomian gland dysfunction, true blepharitis also causes
tear film instability. Suppressed blink reflex which is
most notably caused by computer use, and results in
prolongation of blink intervals, that further exacerbates the
dryness symptoms caused by tear film instability.
same: there are different causes beneath the condition
as well as different related symptoms. If one lens works
well for a particular patient, this doesn’t necessary
mean it will work for other patients as well. Considering
it’s hard to judge which kind of lens will work better on
a particular patient with dry eye symptoms, it could be
important I experimentally fit one lens after another,
recording carefully objective and subjective responses.
In patients with dry eye symptoms I consider mostly
three characteristics of soft contact lenses (CLs):
nature of materials including presence of wetting agent,
CLs parameters, and frequency of replacement. These
characteristics could improve tolerance in patients with
dry eye symptoms for different reasons: slower lens
water dehydration rate, better stability of pre-lens tear
film, reduction of deposits on lens surface.
If we consider the first characteristic, there are a lot
of specific aspects of soft CLs materials that could be
managed in order to improve comfort in patients with dry
eye symptoms: water content, dehydration properties
(linked to free water and bound water content), ionic
charge, wettability, thickness. In particular Silicone
Hydrogels materials have been demonstrated helpful
in those patients due to their excellent dehydration
stability. Also the availability of a wetting agent into the
lens provides better wettability, decreases the friction
between the lid and lens surface and is believed to
improve comfort. This is of particular benefit for daily
disposable lenses.
Lens parameters are important for the vulnerable
anterior ocular surface of the dry eye patient and
it is compulsory to pay attention to the lens–lid
interaction, lens movement and perhaps the corneal
staining characteristics. Lastly useful characteristic
is the possibility to discharge the lens after use. This
opportunity, given by daily disposable, eliminates every
problem that is due to the build up of surface deposits.
6
DO YOU FIT WITH CONTACT
LENSES PATIENTS WHO ARE
DIAGNOSED WITH MEIBOMIAN
GLAND DYSFUNCTION?
Dr. Heiko Pult, Weinheim - Germany
5
WHICH LENS CHARACTERISTICS
YOU CONSIDER MOSTLY
IN PATIENTS WITH DRY EYE
SYMPTOMS?
Dr. Fabrizio Zeri, Rome - Italy
First of all my clinical approach to this topic is quite
empirical. Patients with dry eye symptoms are not all the
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Eye Health
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Meibomian gland dysfunction ( MGD) is one of the
most common causes of an lipid-layer abnormality
and a sufficient lipid-layer is fundamental to stabilize
the tear film especially in contact lens wear. In fact,
daily lid hygiene is useful to reduce dry eye symptoms
and improve tear film. In more pronounced MGD the
use of warm and moist compresses plus lid hygiene
is effective in improving contact lens comfort. This
works very well when former happy experienced
lens wearers -no suffering from MGD - are claiming
19
dry eye symptoms. We educate naive MGD lens
wearers in MGD treatment before fitting. Those who
agree are mostly able to wear lenses with sufficient
comfort. Therefore MGD is not an exclusion criterion
of contact lenses with proper management there is a
high chance to succeed.
To improve compliance we apply digital imaging of
the ocular surface including infra-red non-contact
meibography. Photographs allow monitoring MGD
status. Meibography is a technique to visualize the
meibomian glands' morphology. It is one of the most
important tools in MGD diagnose. We are using a
self-built meibograph, but an alternative option is
using the built in infra-red cameras of topographers
or Scheimpflug cameras. To facilitate comfortable
eversion of the patients' eyelids and better images,
slight optical and software modifications are vital.
However updated devices plus appropriate software
are just coming on the market.
Even though untreated MGD is one of the most
common causes of dry eye, proper treatment can
help the patient wearing contact lenses successfully.
Good education and continuous monitoring including
meibography is fundamental.
7
WHAT IS YOUR OPINION ON
COMBINATION CONTACT
LENSES, MAKE UP AND
DRYNESS?
Dr. Arleta Waszczykowska Łód , Poland
Make-up around eyes may intensify symptoms of dry
eye and become the source of infection. Every single
use of cosmetics poses the risk of growth of air-borne
bacteria or pathogens located on the skin. Preservatives
enclosed in cosmetic products minimize the risk of
microorganisms growth but simultaneously may irritate
the skin in sensitive individuals provoking allergic or
even toxic reaction. There are many people allergic to
aromatic compounds or other substances present in
cosmetics like rosin, nickel or lanolin.
To limit the source of additional inflammatory conditions
of eye globe surface, make-up should be put on the skin
after lens insertion, and removed just after lens removal.
One should avoid oily cosmetics, put mascara only on
the eyelashes endings, and underline the lower eyelid
below the line of eyelashes. Application of make up on
the lower lid margin is often associated with chronic
meibomian gland disease. It is not recommended to use
metallic eye shadows thickening and prolonging eyelashes
mascaras with brocade or silk, because they may act like
foreign bodies when located in conjunctival sac. There are
contradictory opinions about waterproof make-up used
20
by contact lens wearers. On the one hand waterproof
make-up minimizes the risk of cosmetics smearing during
administration of moisturizing drops but on the other
hand removal of waterproof make-up requires more oily
and skin irritating cosmetics. Make-up removal should be
performed very gently and in the direction of eyelashes to
reduce the risk of corneal erosion.
8
DO YOU SEE ANY BENEFITS
OF DAILY DISPOSABLE LENSES
IN PATIENTS WITH DRY EYE
SYMPTOMS?
Dr. Bassima Aldelaigan, Riyadh Kingdom of Saudi Arabia
Hot dry climate, air conditions and windy weather, all
can contribute in causing dry eyes. Many patients drop
out of contact lens wear, because of poor tolerance
to wearing contact lens more than few hours a day. In
our practices, every day we face patients who suffer
from dry eyes, and drop out of contact lens (CL) wear
because of extreme discomfort and intolerance.
Symptoms like dryness, grittiness, redness and
discomfort are common problems during contact lens
wear. It is practitioner’s role to investigate the cause of
the discomfort, and effectively manage these patients,
to prevent contact lens drop outs. I have found that,
switching patients to daily disposable contact lens has
alleviated many of their symptoms, like foreign body
sensation, grittiness and red eyes.
Daily disposable lenses are proven to be the most
convenient, healthier choice especially for patients in
challenging environments and those who are suffering
from dry eyes and other ocular problems. Now when
daily disposable lenses comes in a silicone hydrogel
(SiH) material, we can get the benefit of having a fresh
clean pair with the advantage of the increased oxygen
transmissibility provided by SiH lenses. Studies have
shown that patients wearing SiH lenses report higher
level of comfort comparing to patients wearing hydrogel
lenses.
9
WHAT IS YOUR THERAPEUTIC
APPROACH IN CONTACT LENS
WEARERS WITH MEIBOMIAN
GLAND DYSFUNCTION?
Dr. Zeynep Ozbek, Izmir - Turkey
Meibomian glands are modified sebaceous glands
located in the posterior portion of the lid margin. They
secrete the outer lipid layer of the precorneal tear
A magazine from Johnson & Johnson Vision Care
film, render the lubricant action during blinking as well
as minimize evaporation and construct the appropriate
surface tension of the tear film between blinks.
Therefore they have an important contribution to both
the comfort and visual quality in daily life. Meibomian
gland dysfunction can manifest itself by simple dry
eye symptoms such as photophobia, burning, stinging,
foreign body sensation since decreased lipid secretion
to the tear film will cause reduced break-up time.
These symptoms may be even worse in a contact lens
wearer. Surprisingly the situation is easily overlooked
although not uncommon.
Usually, upon hearing complaints of dry eyes,
the eye care practitioner will focus on the cornea
and bulbar conjunctiva looking for clues of reduced
wetting. However, the real clue in meibomian gland
dysfunction lies in the lid margin. Usually the gland
orifices will be capped by small oil globules, the
tear film appears oily and foamy, sometimes froth
accumulates on the lid margin. In longstanding cases,
clogging of the orifices causes inflammation due to
staphylococcal exotoxins and this leads to hyperemia,
thickening and telengectesias. I prefer to start with lid
hygiene and warm compresses after the lenses are
out. If there are signs of inflammation I may prefer
refrainment from contacts for a couple of weeks, antistaphyloccal therapy such as fucidic acid and some
weak steroids additionally. If I see frequent flare-ups I
do not hesitate to start oral doxycycline and go on at
least for 6 weeks.
10
The second step is to switch our patients to
silicone-hydrogel lenses giving preference to frequent
replacement. In our practice 45% of patients with
dry eye symptoms use silicone-hydrogel planned
replacement lenses and 37% use one-day lenses.
The third step aimed to maintain the volume of tear
fluid on the ocular surface. To relieve symptoms and
improve the comfort, we recommend moisturizing eye
drops before insertion and after removal of the lenses.
They can also be used if needed during the day. We
recommend the use of moisturizing drops without
preservatives, or drops containing biodegradable
preservatives. In case of persistent dry eye symptoms,
regardless of rewetting drops, we consider lacrimal
plugs. Sometimes, gas-permeable lenses can be an
option.
The fourth step is to modify the wearing time and
modality. We do not recommend extended wear lenses
for dry eye patients and sometimes our patients get
the advice to reduce wearing time during specific tasks
such as working on a computer. Management of dry
eye disease today is a challenge due to lack of universal
therapy. Therefore the eye care practitioner must find
the best approach for every single case.
WHAT IS YOUR THERAPEUTIC
APPROACH IN CONTACT LENS
WEARERS WITH DRY EYE
SYMPTOMS?
Dr. Olga Lobanova, Samara - Russia
The therapeutic approach to the management of
patients with dry eye syndrome include: normalization
of the evaporation of tears, proper choice of contact
lens and care system, suitable contact lens wearing
time, use of moisturizing drops and if indicated antiinflammatory therapy. We follow a phased approach to
the treatment of dry eye disease, paying attention to the
severity of the disease and the response to the therapy.
The first step is aimed at stabilizing the tear film
and decrease evaporation of tears by normalization of
the lipid layer. In our practice, we recommend warm
compresses, followed by a massage and lid hygiene.
In case of indications, local anti-inflammatory therapy
is also added. The course of treatment is usually 10-15
days. For control we are also using ocular protection
index (OPI), ocular surface disease index (OSDI) and
staining of the ocular surface.
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