Swati Singh, MBBS, MS, Dilip Kumar Mishra, MD, Swapna Shanbhag, MBBS, MS, Geeta Vemuganti, MD, Vivek Singh, PhD, Mohammad Javed Ali, MBBS, MD, Sayan Basu, MBBS, MS
The lacrimal gland, a major contributor to the aqueous component of the tear film, delivers its secretions via ducts opening onto the superotemporal forniceal conjunctiva. Diseases that affect the structure or function of the lacrimal gland result in aqueous tear deficiency. One of the causes of severe aqueous deficiency is Stevens-Johnson syndrome (SJS), an acute self-limiting mucocutaneous blistering disease that often results in chronic ocular sequelae. However, the pathobiological features of aqueous tear deficiency in SJS are not understood fully. A previous report by Singh et al suggests that the aqueous deficiency in SJS could be secondary to fibrosis in the periductal conjunctiva and not the result of primary inflammatory damage to the lacrimal gland itself. Further exploration and confirmation of these initial observations may have significant translational implications because therapeutic approaches can be developed to address the periductal fibrosis, instead of attempting to rejuvenate the entire lacrimal gland.
In Chang Cho, MD, PhD, Beom-Jun Kim, MD, Hi-Jin You, MD, PhD, Woo Hyun Tark, MD
Upper eyelid ectropion occurs as a post-blepharoplasty complication or involution change, and it causes dry eye symptoms that cannot be resolved with conservative management.
The aim of this study is to describe the authors’ surgical technique of anatomical correction of upper eyelid ectropion, including tarsal scoring incision.
The technique involves the following 4 steps: (1) adhesiolysis at the preaponeurotic layer; (2) undermining and redraping of the pretarsal flap in a pretarsal plane; (3) optional, partial thickness tarsal scoring incision over the central two-thirds; and (4) downward repositioning of the pretarsal flap and lower fixation to the tarsus. Outcomes were assessed based on the position of eyelid margin and the improvement of the dry eye symptoms.
A retrospective review of 54 cases of patients who underwent ectropion correction, including tarsal scoring incision, was performed. The eyelid margin was well positioned in 51 patients (94.4%). Of the 32 patients involved in the study assessed with the 7-point Patient Global Impression of Improvement, 29 (90.6%) reported the resolution of dry eye symptoms. Furthermore, in the 22 patients assessed with the Ocular Surface Disease Index, the mean score significantly decreased from 43.2 ± 24.1 before surgery to 29.8 ± 23.3 (P = 0.006) after surgery.
The combination of partial-thickness tarsal plate scoring and lower flap redraping surgical techniques resolved the upper eyelid ectropion, reducing the dry eye symptoms.
Allen M Putterman, MD
The authors present a technique to treat upper eyelid ectropion, in which they compare their patients’ abnormal eyelids to lower eyelid ectropions.1 However, the definition of an eyelid ectropion is: “The eyelid turns or sags outward away from the eye, exposing the surface of the inner eyelid.” 2 This did not occur in the patients whom the authors are presenting. Instead, they include 48 postblepharoplasty and 6 “senile” patients who had eversion of the upper eyelid margin. These patients did not have eyelids that turned outward away from the eye, or exposure of the inner aspect of the eyelid. Instead, they had eversion of the eyelid margin with the inner margin still in contact with the eye. (When the…….
Shani Golan, Filippos Vingopoulos, Luke C. Olson, Hency H. Patel, Shulamit Pinchover, Cynthia M. Magro, Benjamin Levine & Gary J. Lelli
Purpose: Fasanella-Servat operation (FSO) was previously reported to be associated with post-operative dry eyes due to accessory lacrimal gland resection during the surgery.
We performed a retrospective, cohort study to determine the frequency of lacrimal tissue resection during FSO and its correlation with post-operative eye dryness and keratopathy.
Methods: Review of all patients who underwent FSO at New York-Presbyterian Weill Cornell Hospital over a two-year period (2013–2015). Patients were included only if they had adequate histopathological specimens of the resected tissue obtained during surgery. Outcomes included the study of the pathological specimen for the presence of lacrimal tissue; Post-operative dry eye symptoms and pre- and post-operative corneal epitheliopathy.
Results: 46 patients with a total of 58 eyelid resections were studied.
Eight eyelids (13.7%) were found to have lacrimal tissue present in the pathology specimens.
Postoperatively, nine patients reported some symptoms of dry eye and new-onset keratopathy was noted in four eyes (6.8%), only one of which had lacrimal tissue present in histopathology specimen obtained from surgery.
Discussion: Previous studies found lacrimal tissue present in up to 43% of specimens resected during FSO. Our data found a lower rate of lacrimal tissue resection during FSO, and did not find an association between lacrimal tissue resection and post-operative dryness or epitheliopathy.
Conclusion: Our study is one of few to examine histopathological resections from the FSO.
We found that lacrimal tissue is not frequently resected during FSO, and when it is resected, there is no increased incidence of post-operative dryness or keratopathy.
Ofira Zloto, Adham Matani, Daphna Prat, Ari Leshno, Guy Ben Simon
To examine the effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty on dry eye syndrome.
Prospective, comparative clinical study.
This is prospective, comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients with dermatochalasis and the ptosis group consisted of adult patients with dermatochalasis and ptosis that showed significant improvement after phenylephrine 10% instillation. The following parameters were compared for all patients before the procedure (baseline) and on postoperative day 90: MRD1, Ocular-Surface-Disease-Index (OSDI), Schirmer test 2, tear break-up time (TBUT), fluorescein staining, Lissamine-green staining (LG).
Fifty-four patients participated in this study (blepharoplasty group: 23 patients, ptosis group 31 patients). There were significant increases in the postoperative LG scores and in fluorescein staining post ptosis surgery compared with the preoperative values (paired t test, P = .05 and P = .02, respectively). The postoperative OSDI score was significantly higher post ptosis surgery compared with the preoperative score (25.38 vs 17.24, respectively, paired t test, P < .01). There were no significant differences, in the blepharoplasty group, between the postoperative and preoperative objective and subjective dry eye tests.
MMCR surgery causes an increase in the subjective feeling of dry eye as well as an increase of signs of dry eye. This increase was not noticed after blepharoplasty surgery. Physicians should be aware of the risk of dry eye after ptosis surgery and discuss dry eye as a complication of MMCR surgery with their patients before surgery. Those patients should be examined carefully and treated for dry eye during follow-up.
Jinhwan Park, Sehyun Baek
To compare the structure and function of the Meibomian gland and eyelid blinking patterns between thyroid eye disease (TED) patients with dry eye and nonthyroidal dry eye (DE) patients.
This was a prospective, cross‐sectional and observational study. Clinical measurements were performed as follows: (1) external examination, (2) Lipiview® Interferometer (lipid layer thickness, incomplete blinking rate and meibography) and (3) slit‐lamp biomicroscopy (corneal staining, tear break‐up time (TBUT), meibum expression).
The TED and DE groups included 98 and 62 patients, respectively. The meiboscores of the upper eyelid in TED and DE groups were significantly different (1.21 ± 0.76 and 0.94 ± 0.71, respectively, p = 0.046). The rate of incomplete blinking was 53.3 ± 34.5 and 34.6 ± 36.3%, respectively, and was significantly higher in the TED group (p = 0.006).
In the TED group, CAS was the only variable affecting the meiboscore of the upper and lower eyelids (p = 0.031, 0.039, respectively). Significantly, active TED patients had more decreased basal tear secretion than inactive TED patients (7.4 ± 2.1 mm versus 8.5 ± 1.5 mm, p = 0.024). Moreover, active TED patients had decreased meibum expression in both upper and lower eyelids compared with inactive TED patients (2.20 ± 0.88 versus 1.08 ± 0.84, p = 0.002 in upper eyelid, 2.10 ± 0.88 versus 1.18 ± 0.88, p = 0.007 in lower eyelid, respectively).
In TED patients, incomplete blinking and loss of Meibomian gland structure in the upper eyelid were more prominent than in DE patients. CAS was a factor affecting the structural loss of Meibomian glands in TED individuals.
Jinhwan Park, Joohyun Kim & Sehyun Baek
To evaluate the clinical features and treatment outcomes of patients complaining of tearing after receiving chemotherapy.
The clinical records of patients who complained of tearing between August 2014 and February 2016, and underwent or were undergoing chemotherapy were retrospectively reviewed. Clinical measurements were as follows: LipiView® interferometer (lipid layer thickness and meibography), lacrimal drainage examinations (syringing), and outcomes at 6 months after treatment.
This study included 34 eyes of 17 patients with a mean age of 62.4 ± 14.82 years. The mean follow-up period was 9.6 months. On syringing, 10 eyes (29.4%) showed total regurgitation, 19 eyes (55.9%) showed partial regurgitation, and 5 eyes (14.7%) showed no regurgitation. On LipiView®, mean lipid layer thickness was 34.5 nm (range, 20–89 nm). Mean meiboscore was 2.15 ± 0.86 in upper eyelid and 2.53 ± 0.79 in lower eyelid. Patients were treated with silicon tube intubation (STI) (10 eyes, 29.4%), dacryocystorhinostomy (DCR) (4 eyes, 17.6%), conjunctivodacryocystorhinostomy (CDCR) (8 eyes, 11.8%), DCR combined with CDCR (1 eyes, 8.8%), and conservative care (11 eyes, 32.4%). Mean time interval from onset of tearing to first clinic visit was 1.4 months in the conservative care group, 2.9 months in the STI and DCR groups, and 6.0 months in the CDCR group.
Because of the high incidence of accompanying meibomian gland loss in cases of lacrimal drainage system (LDS) obstruction, reflex tearing by mebibomian gland dysfunction should also be considered for proper management of tearing. Early recognition and management of LDS stenosis could result in patients undergoing surgery with a lower burden.
Min Gyu Choi, Joon Hyung Yeo, Jeong Woo Kang, Yeoun Sook ChunJeong Kyu LeeJae Chan Kim
To determine the effects of botulinum toxin type A (BTX-A) injection on dry eye signs, symptoms, and tear cytokine levels in patients with intractable dry eye disease (DED).
In this prospective study, patients with intractable DED were randomized to a BTX-A (group A) or control group (group B). Patients were injected with BTX-A or normal saline in the medial part of the upper and lower eyelids. Before and at 2 weeks, 1 month, 2 months, and 4 months after injection, dry eye signs; tear film break-up time (TBUT), Schirmer I test, corneal fluorescein staining (CFS), and symptoms; ocular surface disease index (OSDI); and frequency of lubricants were assessed. The tear levels of matrix metalloproteinase (MMP)-9 and serotonin were measured before and at 1 month after injection.
Fifty-two eyes from 26 patients (mean age, 57.7 years) were included. The TBUT was higher at 2 weeks and at 1 month in group A. The Schirmer I test and OSDI scores were also better in group A for up to 2 months. The CFS grades in group A were significantly lower until 4 months. Repeated measures analysis of variance (RMANOVA) demonstrated significant differences between the two groups over time for the Schirmer I test (p = 0.002), CFS (p = 0.025), OSDI (p = 0.020), and frequency of lubricants (p = 0.029). The MMP-9 conversion rate of group A (76.92%) was significantly higher than that of group B (38.46%, p = 0.005). The tear serotonin level in group A was reduced from 2.76 ± 0.34 to 1.73 ± 0.14 ng/mL (p < 0.001). No complications were observed during the study.
BTX-A injection into the medial part of eyelid improves dry eye signs and symptoms and reduces tear cytokine levels. BTX-A is thus a potential treatment option for patients with intractable DED.
Bautista, Sana Ali; Wladis, Edward J.; Schultze, Robert L.
Purpose: Müller’s muscle-conjunctival resection (MMCR) is a highly effective technique to correct upper eyelid ptosis. However, several authorities have raised concerns about the possibility of postoperative ocular surface dryness. This study was performed to assess the impact of MMCR on clinically meaningful parameters of the ocular surface.
Methods: In adult patients, tear break-up time, lipid layer thickness, and osmolarity were measured via direct observation, interferometry, and impedance measurements before surgery and 3 months after surgery in patients who underwent MMCR. Statistical analysis was performed via a dedicated software package.
Results: Fifteen eyes of 14 patients were included in the study. Mean pre- and postoperative tear break-up times were 12.71 ± 2.20 and 12.43 ± 2.41 seconds, respectively (p = 0.1648). Preoperatively, the mean lipid layer thickness measurement was 91.00 ± 7.02 nm, whereas the mean postoperative value was 88.86 ± 21.36 nm (p = 0.6613). The mean preoperative tear osmolarity measured 291.4 ± 8.86 mOsm/l, and the mean postoperative measurement was 289.86 ± 9.74 mOsm/l (p = 0.2652).
Conclusions: MMCR does not appear to change clinically meaningful ocular surface disease parameters, and postoperative dryness did not result from this procedure. In appropriately selected patients, MMCR can be safely performed without increased concerns regarding postoperative dry eye disease.
Jinhwan Park, MD, Joohyun Kim, MD, Hwa Lee, MD, PhD, Minsoo Park, MD, PhD, Sehyun Baek, MD, PhD
The purpose of this study was to evaluate the structure and function of the meibomian gland and the incomplete blinking rate to understand the pathophysiology of dry eye in thyroid eye disease (TED) patients.
Patients who were diagnosed with TED were enrolled between October 2015 and February 2016. Clinical measurements were performed in the following order: (i) external examination (Hertel exophthalmometer and palpebral fissure height), (ii) LipiView interferometer (lipid layer thickness [LLT], incomplete blinking rate, and meibography), (iii) slit-lamp biomicroscopy (corneal surface staining, tear breakup time, meibum expression, Marx line).
Thirty eyes of 30 TED patients (male = 8; female = 22) were included in this study. The TED patient population had a mean age of 42.9 ± 11.8 years and a mean clinical activity score (CAS) of 2.33 ± 1.60. The meiboscore was 1.17 ± 0.90 in the upper eyelid and 0.70 ± 0.65 in the lower eyelid; scores were significantly higher in the upper eyelid (p < 0.001). The mean LLT was 82.43 ± 24.52 nm, and the mean incomplete blinking rate was 51.04 ± 33.62% (0–100%). CAS was the only variable that correlated with the meiboscore. There was no significant correlation between incomplete blinking and a degree of palpebral fissure height or proptosis.
Tear film instability due to increased incomplete blinking can cause dry eye in TED. In addition to the increase in CAS, meibomian gland dysfunction may also be a cause of dry eye in TED. However, further comparative studies are needed to confirm these results.
Alicia Galindo-Ferreiro, Mohammed Dufaileej, Alberto Galvez-Ruiz, Rajiv Khandekar & Silvana A. Schellini
Purpose: To report indications and success rates of dacryocystectomy (DCT) in a tertiary hospital. Methods: A retrospective chart review was performed of all patients who underwent DCT at the King Khaled Eye Specialist Hospital, Saudi Arabia, from 2008 to 2015. Data included patient demographics, symptoms before and after surgery, and complications. Univariate analysis using parametric and non-parametric methods was performed. Results: Forty-seven DCT surgeries were performed over the study period. The median age of patients was 58.2 ± 2 years old, 63.8% were female, 60% of surgeries were performed on the left side, and 8% of patients underwent bilateral simultaneous DCT. Chronic dacryocystitis was the surgical indication for DCT for all of the patients and 23.5% of them had dry eye preoperatively. Successful treatment was observed in 80.8% of patients and 8.5% complained of tearing after DCT. Conclusion: The main indication for DCT in our hospital was chronic dacryocystitis with good outcomes for elderly patients with dry eyes.