Ocular Surface Abnormalities Research Articles

Effect of dry eye on Scheimpflug imaging of the cornea and elevation data

ObjectiveTo evaluate the effect of dry eye on Scheimpflug imaging of the cornea and elevation data. DesignProspective observational study. ParticipantsScheimpflug images of 50 patients with dry eye who were being tested for eligibility for corneal refractive surgery were screened. Twelve eyes of 12 patients with abnormal Belin/Ambrosio enhanced ectasia display (BAD) anterior elevation difference were included in the study. The patients had no history of contact lens wear or any other sign of ectasia. MethodsPeak central corneal densitometry value, corneal volume, pachymetry at the thinnest point, and BAD anterior elevation difference value at the centre of the 9 mm zone were recorded before and after 4 weeks of dry eye treatment. Measurements were compared with the Wilcoxon signed rank test. ResultsThe mean corneal peak densitometry and volume were similar before and after therapy (p = 0.465 and p = 0.441, respectively). The mean anterior elevation difference value at the centre of the 9 mm zone before treatment (6.67 ± 1.72 µm) was significantly higher than the mean post-treatment value (4.00 ± 1.48 µm) (p = 0.002). The mean pachymetry at the thinnest location after treatment (548 ± 11.0) was significantly higher than the pretreatment value (538 ± 8.5) (p = 0.027). ConclusionsBAD anterior elevation differences and pachymetric measurements may be affected by ocular surface or tear film abnormalities associated with dry eye disease. Repeated evaluations after treatment may reveal normal results.

Tear film and ocular surface dysfunction in diabetes mellitus in an Indian population.

Purpose:Ophthalmic complications in diabetes such as retinopathy, cataract, and infections have been extensively studied. Recently, attention has been drawn toward ocular surface changes in diabetes mellitus (DM). This study has been carried out to investigate the tear film and ocular surface abnormalities in type II DM patients.Materials and Methods:A total of 83 participants (130 eyes) were enrolled: 53 diabetics (80 eyes) and 30 healthy controls (50 eyes). Of the 53 diabetics, 24 patients (42 eyes) had some diabetic retinopathy. The tear film and ocular surface were evaluated using Schirmer test, tear film break-up time (TBUT), keratoepitheliopathy score (KES), Rose Bengal Staining (RBS) test, and conjunctival impression cytology.Results:When compared with the healthy controls, diabetics showed significantly reduced Schirmer, TBUT measurements and the higher grades of KES and RBS test (P < 0.001). Impression cytology analysis showed goblet cell loss and conjunctival squamous metaplasia in diabetics.Conclusion:Tear film abnormality is a significant feature of diabetic ocular surface diseases. These abnormalities are likely on account of poor quality and function of tears, combined with the subnormal ocular surface. Therefore, all diabetic patients especially those with evidence of retinopathy changes should undergo routine early examination and follow-up of tear function and ocular surface parameters.

The involvement of proline-rich protein Mus musculus predicted gene 4736 in ocular surface functions.

To research the two homologous predicted proline-rich protein genes, Mus musculus predicted gene 4736 (MP4) and proline-rich protein BstNI subfamily 1 (Prb1) which were significantly upregulated in cultured corneal organs when encountering fungal pathogen preparations. This study was to confirm the expression and potential functions of these two genes in ocular surface. A Pseudomonas aeruginosa keratitis model was established in Balb/c mice. One day post infection, mRNA level of MP4 was measured using real-time polymerase chain reaction (PCR), and MP4 protein detected by immunohistochemistry (IHC) or Western blot using a customized polyclonal anti-MP4 antibody preparation. Lacrimal glands from normal mice were also subjected to IHC staining for MP4. An online bioinformatics program, BioGPS, was utilized to screen public data to determine other potential locations of MP4. One day after keratitis induction, MP4 was upregulated in the corneas at both mRNA level as measured using real-time PCR and protein levels as measured using Western blot and IHC. BioGPS analysis of public data suggested that the MP4 gene was most abundantly expressed in the lacrimal glands, and IHC revealed that normal murine lacrimal glands were positive for MP4 staining. MP4 and Prb1 are closely related with the physiology and pathological processes of the ocular surface. Considering the significance of ocular surface abnormalities like dry eye, we propose that MP4 and Prb1 contribute to homeostasis of ocular surface, and deserve more extensive functional and disease correlation studies.

Potential Importance of Ozone in the Association Between Outdoor Air Pollution and Dry Eye Disease in South Korea.

Air pollution is an important public health concern and the ocular surface is continuously exposed to pollutants in outdoor air. Ocular surface abnormalities related to air pollution are thought to be a subtype of dry eye disease (DED). However, to date, there is no large-scale study evaluating an association between air pollution and DED that includes multiple air pollutants. To investigate associations between outdoor air pollution and DED in a Korean population. A population-based cross-sectional study using data on 16 824 participants in the fifth Korea National Health and Nutrition Examination Survey was conducted from January 1, 2010, to December 31, 2012. Data analysis was conducted from September 1 to 30, 2015. Dry eye disease was defined as previously diagnosed by an ophthalmologist or the presence of frequent ocular pain and discomfort. Outdoor air pollution measurements (mean annual humidity, particulate matter with aerodynamic diameter <10 µm [PM10], ozone, and nitrogen dioxide levels) were collected from 283 national monitoring stations in South Korea. Associations of multiple air pollutants with DED were assessed from multivariable logistic regression analyses. Sociodemographic factors and previously known factors associated with DED were applied as covariates (model 1 controlled for sociodemographic factors and model 2 controlled for sociodemographic, behavioral, and clinical factors). Among 16 824 participants (7104 men and 9720 women), higher ozone levels and lower humidity levels were significantly associated with symptoms and diagnosis of DED. In model 1, an increase in ozone levels of 0.003 ppm was significantly associated with symptoms and diagnosis of DED (symptoms: odds ratio [OR], 1.16; 95% CI, 1.02-1.30; P = .04; diagnosis: OR, 1.21; 95% CI, 1.05-1.40; P = .008), while a 5% increase in humidity levels was significantly associated with decreased symptoms and diagnoses of DED (symptoms: OR, 0.87; 95% CI, 0.77-0.98; P = .03; diagnosis: OR, 0.86; 95% CI, 0.76-0.97; P = .01). In model 2, an increase in ozone levels of 0.003 ppm was significantly associated with symptoms and diagnosis of DED (symptoms: OR, 1.17; 95% CI, 1.02-1.34; P = .03; diagnosis: OR, 1.27; 95 CI, 1.09-1.48; P = .002), while a 5% increase in humidity levels was significantly associated with decreased symptoms and diagnoses of DED (symptoms: OR, 0.88; 95% CI, 0.78-0.98; P = .045; diagnosis: OR, 0.86; 95% CI, 0.76-0.97; P = .02). In model 2, an increase in nitrogen dioxide of 0.003 ppm (OR, 1.12; 95% CI, 1.02-1.23 P = .02) was also associated with diagnosis of DED. Levels of sulfur dioxide and PM10 were not associated with symptoms or diagnosis of DED in model 1 or model 2 (P > .05 for each). Higher ozone levels and lower humidity levels were associated with DED in the Korean population, while PM10 level was not associated with DED.

Ocular toxicity assessment of chronic sildenafil therapy for pulmonary arterial hypertension.

The aim of this study was to investigate possible functional and structural ocular changes caused by chronic sildenafil therapy to treat pulmonary arterial hypertension (PAH). Case-control study included patients with pulmonary arterial hypertension: chronically using sildenafil and without sildenafil treatment. A comprehensive ophthalmologic exam including ectoscopy, extrinsic ocular motility, logMAR visual acuity measurement, contrast sensitivity test, color test, anterior segment biomicroscopy, Schirmer test 1, intraocular pressure, fundus exam under pupil dilation, fundus pictures, time domain and spectral domain optical coherence tomography, ocular Doppler ultrasound were performed. Full-field electroretinography (ERG) was tested for each eye in a subgroup of sildenafil-treated patients. Twenty patients from each group were tested. Bilateral severe keratitis was found in seven (35%) patients under sildenafil therapy. Lacrimal film break-up time (BUT) was significantly reduced (p = 0.006 respectively) and Doppler ultrasound showed a reduced resistance index of the central retinal artery in the group of sildenafil users (p = 0.019). No diffuse retinal functional abnormalities were found in ERG in treated patients. Visual acuity, contrast sensitivity and color discrimination were normal in both groups. No abnormalities were found in both time-domain and spectral-domain OCT for retinal parameters. One-third of the treated PAH group showed severe bilateral keratitis. This finding could be related to connective tissue abnormalities usually present in patients with this condition that might be exacerbated with the sildenafil usage. The resistance index of the central retinal artery was diminished in the chronic users group and it could be associated to the vasodilation caused by the medication in the choroidal vessels. An ophthalmic assessment for these patients is recommended to diagnose and treat possible ocular surface and choroidal blood flow abnormalities caused by sildenafil.

Current Perspectives of Prophylaxis and Management of Acute Infective Endophthalmitis.

Endophthalmitis is an intraocular inflammatory condition which may or may not be caused by infective agents. Noninfectious (sterile) endophthalmitis may be attributable to various causes including postoperative retained soft lens matter or toxicity following introduction of other agents into the eye. Infectious endophthalmitis is further subdivided into endogenous and exogenous. In endogenous endophthalmitis there is hematogenous spread of organisms from a distant source of infection whereas in exogenous endophthalmitis direct microbial inoculation may occur usually following ocular surgery or penetrating eye injury with or without intraocular foreign bodies. Acute infective endophthalmitis is usually exogenous induced by inoculation of pathogens following ocular surgery, open-globe injury and intravitreal injections. More infrequently the infective source is internal and septicemia spreads to the eye resulting in endogenous endophthalmitis. Several risk factors have been implicated including immunosuppression, ocular surface abnormalities, poor surgical wound construction, complicated cataract surgery with vitreous loss and certain types of intraocular lens. Comprehensive guidelines and recommendations on prophylaxis and monitoring of surgical cases have been proposed to minimize the risk of acute endophthalmitis. Early diagnosis and prompt management of infective endophthalmitis employing appropriately selected intravitreal antibiotics are essential to optimize visual outcome.

Deep phenotyping of 89 xeroderma pigmentosum patients reveals unexpected heterogeneity dependent on the precise molecular defect

Xeroderma pigmentosum (XP) is a rare DNA repair disorder characterized by increased susceptibility to UV radiation (UVR)-induced skin pigmentation, skin cancers, ocular surface disease, and, in some patients, sunburn and neurological degeneration. Genetically, it is assigned to eight complementation groups (XP-A to -G and variant). For the last 5 y, the UK national multidisciplinary XP service has provided follow-up for 89 XP patients, representing most of the XP patients in the United Kingdom. Causative mutations, DNA repair levels, and more than 60 clinical variables relating to dermatology, ophthalmology, and neurology have been measured, using scoring systems to categorize disease severity. This deep phenotyping has revealed unanticipated heterogeneity of clinical features, between and within complementation groups. Skin cancer is most common in XP-C, XP-E, and XP-V patients, previously considered to be the milder groups based on cellular analyses. These patients have normal sunburn reactions and are therefore diagnosed later and are less likely to adhere to UVR protection. XP-C patients are specifically hypersensitive to ocular damage, and XP-F and XP-G patients appear to be much less susceptible to skin cancer than other XP groups. Within XP groups, different mutations confer susceptibility or resistance to neurological damage. Our findings on this large cohort of XP patients under long-term follow-up reveal that XP is more heterogeneous than has previously been appreciated. Our data now enable provision of personalized prognostic information and management advice for each XP patient, as well as providing new insights into the functions of the XP proteins.

Goblet cell density and distribution in cats with clinically and histologically normal conjunctiva.

The aim of this study was to evaluate goblet cell density (GCD) and distribution in cats without clinical evidence of ocular surface disease and without histologic evidence of conjunctival disease. Fourteen Domestic Shorthair cats euthanized for reasons unrelated to this study. Before euthanasia, cats were verified using slit-lamp biomicroscopy and fluorescein staining to be free of eyelid or ocular surface abnormalities. Immediately after euthanasia, bilateral conjunctival specimens including third eyelid (TEL) were collected, routinely processed, and stained with periodic acid-Schiff and hematoxylin and eosin. Thirteen conjunctival regions were identified. For each region, GCD was expressed as the percentage of goblet cells/200 basal epithelial cells. Mean GCD ranged widely by region: anterior surface of the TEL = 48.8%, fornicial regions = 47.0%, palpebral regions = 38.5%, bulbar regions = 19.6%, and posterior surface of the TEL = 12.6%. The anterior surface of the TEL had significantly higher GCD than did the bulbar and the palpebral regions, but not the fornicial regions. Bulbar conjunctiva had significantly lower GCD than did all other conjunctival regions except the posterior surface of the TEL. No significant difference was noted between GCD of male versus female cats, dorsal versus ventral regions, or lateral versus medial regions. Although conjunctival GCD ranged widely by region, the anterior surface of the TEL appears to be an excellent location for assessing conjunctival goblet cells in cats because this area has high GCD and is more readily accessible than is the palpebral, fornicial, or bulbar conjunctiva.

Short break-up time type dry eye has potential ocular surface abnormalities

PurposeTo describe a case series in which corneal fluorescein staining (CFS) development occurred in short break-up time (s-BUT) dry eyes after a short period during prolonged opening of the eye. MethodsThe study was designed as a clinical case series. Ocular surface evaluations were performed on 13 individuals with s-BUT dry eye. Tear function examinations included Schirmer's test and BUT evaluation. ResultsIn all 13 cases, the BUT was short, but the tear quantity was not so bad. In all cases, CFS developed following a single eye opening, and the staining was observed at sites that showed as dark spots. In several cases, the CFS disappeared later. ConclusionIn this study, we demonstrated that CFS could develop following a single eye opening. Based on our findings, CFS is a dynamic phenomenon rather than a stable indicator of ocular surface abnormalities. Moreover, s-BUT dry eye has the potential to show ocular surface abnormalities.

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

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

Peripheral neuropathy and tear film dysfunction in type 1 diabetes mellitus.

Purpose. To compare tear film metrics in patients with type 1 diabetes mellitus (DM) and healthy controls and investigate the association between peripheral neuropathy and ocular surface quality. Methods. Dry eye symptoms were quantified in 53 patients with type 1 DM and 40 age-matched controls. Ocular examination included tear film lipid layer thickness grading, tear film stability and quantity measurement, and retinal photography. DM individuals additionally underwent a detailed neuropathy assessment. Results. Neither mean age nor dry eye symptom scores differed significantly between the DM and control groups (P = 0.12 and P = 0.33, resp.). Tear lipid thickness (P = 0.02), stability (P < 0.0001), and quantity (P = 0.01) were significantly lower in the DM group. Corneal sensitivity was also reduced in the DM group (P < 0.001) and tear film stability was inversely associated with total neuropathy score (r = −0.29, P = 0.03). Conclusion. The DM group exhibited significantly reduced tear film stability, secretion, and lipid layer quality relative to the age-matched control group. The negative correlation between tear film parameters and total neuropathy score suggests that ocular surface abnormalities occur in parallel with diabetic peripheral neuropathy.

Analysis of Graves’ ophthalmopathy patients’ tear protein spectrum

Background Graves’ ophthalmopathy/orbitopathy (GO) patients often suffer ocular surface damages and tear fluid proteins play a significant role in maintaining healthy ocular surfaces, while changes in tear protein components reflect the changes ocular surface abnormalities. In this study proteomics techniques were used to investigate tear protein compositions in GO patients. Methods We carried out a case-control study by comparing tear fluid contents of GO patients with that of healthy subjects. In the first step the tears were subjected to SDS-PAGE electrophoresis and then single protein bands were analyzed by to in-gel trypsin digestion and nano-flow liquid mass spectrometry (LC-MS/MS) using a MS software. Results In tear samples of GO subjects, the protein fractions of inflammation-related protein immunoglobulin kappa chain C region (IgKC) and serum albumin were essentially reduced, whereas a novel isoform of complement component 3 (C3), which we detected in control subjects, was completely absent in the GO patients’ tears. Conclusions Reduced protein concentrations of particularly IgKC and complement C3 as well as albumin in the tears of GO patients may contribute to changes in their ocular surfaces via diminished reactive oxygen species (ROS) depletion and adaptive immune responses. The completely absent of C3 in the GO patients’ tears, may imply that an important inflammatory signaling pathway is affected, which needs further investigation.

Hyperfluorescence of lysed cells using an in vitro model

Purpose: Whilst sodium fluorescein (‘fluorescein’) is widely used to investigate ocular surface abnormalities, the precise mechanisms of its action are not well understood. The aim of this study was to examine the levels of hyperfluorescence in cells that had been deliberately lysed using cytotoxic agents that are known to cause cell death.

Diurnal and Zonal Analysis of Corneal Surface Temperature in Young Healthy Adults

To determine diurnal changes and zonal differences of corneal surface temperature in young healthy adults following blinking. In this prospective, longitudinal, single-center study, 19 healthy left eyes of 19 healthy subjects (age 23.6 ± 2.2 years) were recruited. Corneal surface temperature (CST) was measured by the Ocular Surface Thermographer TG-1000 (Tomey, Germany) at 3 different time points: 8:00-10:00, 11:00-13:00, and 15:00-18:00. The CST was measured every second for 10 seconds immediately after blinking. We assessed the temperature at the corneal center and at 3 peripheral quadrants at 3 (temporal), 6 (inferior), and 9 (nasal) o'clock at the corneal limbus. Mean central/temporal/nasal/inferior corneal surface temperatures were, between 11:00 and 13:00, 34.1 ± 0.5°C/34.2 ± 0.6°C/34.4 ± 0.5°C/34.6 ± 0.5°C. During 10 seconds following eye opening and between time points 1, 2, and 3, the observed corneal surface temperature parameters did not change significantly (p>0.3 for all). However, there was a significant difference between temperatures at the nasal limbal area and the center of the cornea (p<0.03 at each time point). In addition, the temperature was warmer nasally than temporally until 6 seconds and 8-10 seconds after blinking (p<0.05 for seconds 0-6; 8-10 at time points 1, 2, and 3). In healthy subjects, corneal surface temperature does not change diurnally and is warmer nasally than centrally and temporally during the interblinking interval. Our study leads to the assumption that diurnal changes of corneal temperature indicate ocular surface abnormality or corneal pathology.

Ocular surface abnormalities related to type 2 diabetes are reversed by the opioid antagonist naltrexone

Ocular surface complications of type 2 diabetes are associated with reductions in tear production, increased corneal surface sensitivity, and delayed corneal re-epithelialization. This study examined the efficacy of topical application of the opioid antagonist naltrexone (NTX) in reversing these diabetic-related ocular surface complications in mice. The genetic db/db mouse model of type 2 diabetes, along with C57Bl/6 wild-type mice were investigated. Tear production was assessed by phenol red impregnated threads, and ocular surface sensitivity was measured using Von Frey filaments. Centrally located, circular corneal abrasions were created in mice and residual epithelial defects measured by fluorescein photography. Animals in each group received topical applications of drops of 10(-5) M NTX in sterile Vigamox (Vigamox, Alcon Laboratories, Fort Worth, Texas, USA) or sterile Vigamox alone, and tear production, corneal sensitivity, and reepithelialization were monitored. In comparison to diabetic mice receiving vehicle only, db/db mice treated with one drop of NTX demonstrated a marked reversal in dry eye and ocular surface hypersensitivity within 1 h of one drop of NTX. Reversal of the complications in db/db mice usually lasted for 48-90 h. Corneal epithelial repair in db/db mice was enhanced following a regimen of three drops of NTX daily such that by 72 h, residual wounds were one third the size in db/db mice receiving NTX relative to diabetic mice receiving vehicle. Application of Vigamox alone had no effect. No adverse effects of NTX administration were noted in the cornea. This is the first report of the efficacy of topical NTX in reversing corneal surface complications in type 2 diabetic mice.

Characteristics of ocular abnormalities in gout patients.

To characterize the clinical features of ocular surface in gout patients in coastal area of Shandong Province in China. A total of 380 consecutive gout patients were examined from January 2011 to May 2011. According to the course of gout, patients were divided into group A (<5 years), B (5-10 years) and C (>10 years). Group D (control group) was consist of 50 healthy subjects. Eyelids, lateral canthus, medial canthus, palpebral conjunctiva, sclera and cornea, anterior chamber, lens, anterior vitreous were examined by slit lamp to find whether there were deposition of uric acid crystals, ocular vascular tortuosity, redness and subconjunctival hemorrhage. The ophthalmic exams of visual acuity, intraocular pressure, fundus were used to assess any gout-related eye disease. Uric acid crystals were found in 3 patients and the positions of the deposite were in corneal stroma, corneal epithelium and superficial stroma, and sclera respectively. The incidence was 0.79%. Dilatated and tortuous blood vessels in conjunctiva and sclera surface were found in 38 (23.8%), 40 (44.0%), 58 (45.0%), 9 (18.0%) patients in groups A, B, C and D, respectively. The differences between group B and D, group C and D were statistically significant (P<0.01, P<0.01). Transparent vesicles with metal-like reflected light in subconjunctiva were seen in 26 (16.2 %), 29 (31.9%), 41 (31.8%), 2 (4.00%) patients in groups A, B, C and D, respectively. The differences between A and D, B and D, C and D were statistically significant (P<0.05, P<0.01, P<0.01). Subconjunctival hemorrhage was found in all groups, the difference among the four groups showed no statistically significance. Gout can cause ocular surface abnormalities, such as tophi deposition, subconjunctival transparent vesicles and hemorrhage, and vascular changes. These features have important clinical significance in early detection of the gout and prevention of eye injury.

New Approach for Conjunctivochalasis Using an Argon Green Laser

To evaluate the effectiveness of conjunctivoplasty using an argon green laser in symptomatic patients with conjunctivochalasis (CCh). Twenty-nine eyes of 18 patients with various grades of CCh were included in this study. All the patients, who were refractory to the conventional therapy, were treated using an argon green laser. The ocular symptoms and signs, including the CCh grade, the tear Ocular Surface Disease Index, the breakup time, the Schirmer test, and the abnormal ocular surface findings, were evaluated preoperatively and postoperatively. The mean age of the patients was 69.1 ± 8.4 years. The grade of CCh in 25 eyes (86%) decreased at 6 months after the laser conjunctivoplasty. When the grade reduction rates were calculated, the reduction rates of grades 1, 2, and 3 were 100%, 69%, and 48%, respectively. Most of the patients showed a significant symptomatic improvement, and the Ocular Surface Disease Index scores decreased from 0.41 to 0.22 (P < 0.001). The breakup time increased from 9.1 to 10.2 (P = 0.007), but the Schirmer test results did not show any differences after the surgery (P = 0.257). Conjunctivoplasty using an argon green laser is a simple and effective choice to treat symptomatic patients with CCh, especially in cases of mild-to-moderate grade CCh.

The Modified Cincinnati Procedure

To describe the technique and present the outcomes of combined conjunctival limbal autografts (CLAU) and keratolimbal allografts (KLAL) for the treatment of unilateral severe ocular surface failure. Interventional case series. Eleven eyes of 11 patients who sustained chemical burns (4 alkali and 2 acid) and combined chemical/thermal burns (5 eyes) from firework explosions had combined CLAU/KLAL surgery. Keratoplasty was performed subsequently for residual corneal stromal scarring limiting visual acuity. Inclusion criteria included eyes with severe unilateral total ocular surface failure, controlled glaucoma, and reasonable eyelid apposition with no exposure. Exclusion criteria included patients with any ocular surface abnormality in the fellow eye and those with contraindications to systemic immunosuppression (SI). Outcome measures included Snellen best-corrected visual acuity (BCVA), ocular surface stability, SI exposure, and complications. Preoperative BCVA was 20/400 or worse in all eyes. At the final follow-up (mean, 35.8 months; range, 12.1-105.9 months), 73% (8 of 11) eyes had BCVA of 20/80 or better (range, 20/25 to counting fingers), and ocular surface was stable in 82% (9 of 11). Ninety-one percent (10 of 11) had additional penetrating keratoplasty (PK) with a 60% (6 of 10 eyes) success rate. Three cases had subsequent Boston type 1 keratoprosthesis implantation after PK failure, and the fourth patient, at the time of his last follow-up visit, did not want further intervention for his edematous PK, which was a result of noncompliance-related corneal rejection. In eyes with more than 2 years of follow-up, SI was tapered at a mean of 16 months (range, 8-28 months). There were no intraoperative complications. No secondary tumors, cardiac events, or deaths occurred while patients were on SI. One patient developed secondary glaucoma refractory to medical management after subsequent PK, requiring cyclodiode laser. Combined CLAU/KLAL and staged keratoplasty is effective in improving vision and maintaining long-term ocular surface stability in patients with severe unilateral ocular surface disease and conjunctival deficiency.

Visual Improvement after Cultivated Oral Mucosal Epithelial Transplantation

To report the effectiveness, disease-specific outcomes, and safety of cultivated oral mucosal epithelial sheet transplantation (COMET), with the primary objective of visual improvement. Noncomparative, retrospective, interventional case series. This study involved 46 eyes in 40 patients with complete limbal stem cell deficiency (LSCD) who underwent COMET for visual improvement. These LSCD disorders fell into the following 4 categories: Stevens-Johnson syndrome (SJS; 21 eyes), ocular cicatricial pemphigoid (OCP; 10 eyes), thermal or chemical injury (7 eyes), or other diseases (8 eyes). Best-corrected visual acuity (BCVA) and ocular surface grading score were examined before surgery; at the 4th, 12th, and 24th postoperative week; and at the last follow-up. Data on COMET-related adverse events and postoperative management were collected. The outcomes in each disease category were evaluated separately. The primary outcome was the change in median logarithm of the minimum angle of resolution (logMAR) BCVA at the 24th postoperative week. The secondary outcome was the ocular surface grading score. Median logMAR BCVA at baseline was 2.40 (range, 1.10 to 3.00). In SJS, logMAR BCVA improved significantly during the 24 weeks after surgery. In contrast, the BCVA in OCP was improved significantly only at the 4th postoperative week. In 6 of the 7 thermal or chemical injury cases, logMAR BCVA improved after planned penetrating keratoplasty or deep lamellar keratoplasty. Grading scores of ocular surface abnormalities improved in all categories. Of 31 patients with vision loss (logMAR BCVA, >2) at baseline, COMET produced improvement (logMAR BCVA, ≤2) in 15 patients (48%). Visual improvement was maintained with long-term follow-up (median, 28.7 months). Multivariate stepwise logistic regression analysis showed that corneal neovascularization and symblepharon were correlated significantly with logMAR BCVA improvement at the 24th postoperative week (P=0.0023 and P=0.0173, respectively). Although postoperative persistent epithelial defects and slight to moderate corneal infection occurred in the eyes of 16 and 2 patients, respectively, all were treated successfully with no eye perforation. Long-term visual improvement was achievable in cases of complete LSCD. Cultivated oral mucosal epithelial sheet transplantation offered substantial visual improvement even for patients with end-stage severe ocular surface disorders accompanying severe tear deficiency. Patients with corneal blindness such as SJS benefited from critical improvement of visual acuity. The author(s) have no proprietary or commercial interest in anymaterials discussed in this article.

Evaluation of dry eye signs and symptoms in patients with systemic sclerosis

One of the most frequent ocular features of systemic sclerosis (SSc) is dry eye disease (DED), which has been identified to occur in 37-79% of patients. Although several studies have found weak or no correlations between symptoms and signs of dry eye, symptoms are often the motivation for seeking eye care, and are therefore a critical outcome measure when assessing treatment effect. The aim of this study is to evaluate the impact of symptoms of dry eye on vision-related quality of life in patients with systemic sclerosis, and to investigate the relation between clinical tests and symptoms of dry eye in these patients. In this cross-sectional study, 45 consecutive patients with SSc were enrolled. For evaluation of the symptoms the "Ocular Surface Disease Index (OSDI)" questionnaire was applied to all patients. After that, all individuals were submitted to a full ophthalmic examination, including the following tests: tear break-up time, Schirmer I, rose bengal staining. Patients were then grouped into dry eye and non-dry eye groups with regard to the diagnosis of dry eye. Mann-Whitney test was used to compare continuous variables, whereas the Fisher exact test was used to compare categorical data between groups. Spearman's correlation test was used to analyze the correlations between clinical tests and OSDI scores. P values <0.05 were considered significant. Dry eye disease was diagnosed in 22 patients (48.9%). Other ocular surface abnormalities found were: blepharitis (40% of the patients), pterygium (15.6%), pinguecula (82.2%), and superficial punctate keratitis (26.7%). Among the 45 patients, 29 patients (64.4%) had symptoms of ocular surface disease. The mean OSDI score was 26.8 ± 25.8 (SD). There were no statistically significant differences in OSDI scores between DED and non-DED patients. No substantive correlations were found between OSDI scores and TBUT, Schirmer I, or rose bengal staining score, and none of the observed correlations reached statistical significance. Symptoms of dry eye have a moderate impact on vision-related quality of life in patients with systemic sclerosis and do not correlate well with clinical findings.