Search

Purpose: Hyperkeratinization of meibomian gland (MG) ducts is currently recognized as the primary pathologic mechanism of meibomian gland dysfunction (MGD). This research figured out a method to isolate the MG ducts and established a novel system to culture the human meibomian gland ductal cells (HMGDCs) for investigating the process of MGD., Methods: The MG ducts were obtained from the eyelids of recently deceased donors and subjected to enzymatic digestion. The acini were then removed to isolate independent ducts. These MG ducts were subsequently cultivated on Matrigel-coated wells and covered with a glass plate to obtain HMGDCs. The HMGDCs were further cultivated until passage 2, and when they reached 60% confluence, they were treated with IL-1β and rosiglitazone for a duration of 48 hours. Immunofluorescence staining and Western blot techniques were employed to identify ductal cells and analyze the effects of IL-1β on HMGDCs in an in vitro setting., Results: Ophthalmic micro-forceps and insulin needles can be employed for the purpose of isolating ducts. Within this particular culture system, the rapid expansion of HMGDCs occurred in close proximity to the duct tissue. MG ducts specifically expressed keratin 6 (Krt6) and hardly synthesized lipids. Furthermore, the expression of Krt6 was significantly higher (P < 0.0001) in HMGDCs compared to human meibomian gland cells. Upon treatment with IL-1β, HMGDCs exhibited an overexpression of keratin 1, which was effectively blocked by the administration of rosiglitazone., Conclusions: The present study successfully isolated human MG ducts and cultured HMGDCs, providing a valuable in vitro model for investigating the mechanism of MGD. Additionally, the potential therapeutic efficacy of rosiglitazone in treating hyperkeratinization of ducts in patients with MGD was identified.

Meibomian gland dysfunction (MGD) is a highly prevalent condition and the most common cause of evaporative dry eye disease. Studying the proteome of MGD can result in important advances in the management of the condition. Here, we collected tear film samples from treatment naïve patients with MGD (n = 10) and age-matched controls (n = 11) with Schirmer filtration paper. The samples were analyzed with label-free quantification nano liquid chromatography-tandem mass spectrometry. The proteins were considered differentially expressed if p < 0.05. A total of 88 proteins were significantly regulated. The largest change was observed in cystatin-SN, which was downregulated in MGD and correlated negatively with tear meniscus height. The downregulation of cystatin-SN was confirmed with targeted mass spectrometry by single reaction monitoring (SRM). Eighteen immunoglobulin components involved in B cell activation, phagocytosis, and complement activation were downregulated in MGD including Ig alpha-1 chain C region, immunoglobulin J chain, immunoglobulin heavy variable 3-15, and Ig mu chain C region. The changes in cystatin-SN and immunoglobulin chains are likely to result from the inflammatory changes related to tear film evaporation, and future studies may assess their association with the meibum quality.

Background: This study aimed to explore the associations between Demodex infestation and the ocular surface characteristics of meibomian gland dysfunction (MGD) in different age groups, to further understand the effect of Demodex on MGD., Methods: A total of 202 consecutive MGD patients aged 18 to 70 years were randomly recruited. All patients were divided into two groups based on their age: young patients (18-40 years) and elderly patients (41-70 years). The main observations were the different relationship between Demodex infestation and ocular surface and meibomian gland (MG) parameters in two age groups. We also compared ocular surface and MG parameters between the young and the elderly groups. Demodex infestation was diagnosed based on expert consensus in China., Results: Our results indicated significant differences among young Demodex-positive, suspicious-positive, and negative patients in MG dropout (P = 0.000), plugging of MG orifices (P = 0.000), lid margin abnormality (P = 0.000), and meibum quality (P = 0.000). In elderly patients, there were significant differences among the Demodex-positive, suspicious-positive, and negative groups in terms of ocular surface disease index (OSDI) (P = 0.037), fluorescein tear film break-up time (FBUT) (P = 0.002), corneal fluorescein staining (CFS) (P = 0.036), MG dropout (P = 0.000), plugging of MG orifices (P = 0.008), lid margin abnormality (P = 0.000), and MG expression (P = 0.037). The mean number of mites in elderly Demodex-positive patients (10.64 ± 7.50) was greater than that of in young patients (7.60 ± 4.71) (P = 0.014). MG dropout (P = 0.000), plugging of MG orifices (P = 0.006), lid margin abnormality (P = 0.000), MG expression(P = 0.001), and meibum quality (P = 0.032) were more severe in elderly Demodex-positive patients. Additionally, FBUT (P = 0.005) was lower and tear film lipid layer thickness (LLT) (P = 0.001) was higher in the elderly., Conclusion: The effect of Demodex infestation on the ocular surface and MG parameters of MGD was different in patients of different ages. It is necessary to pay more attention to the diagnosis and treatment of Demodex infestation in MGD., (© 2022. The Author(s).)

Background: To investigate the association of long-term androgen deprivation therapy (ADT) with ocular surface characteristics in prostate cancer patients., Methods: A total of 30 male prostate cancer patients who received ADT were selected. All candidates were scored using the Ocular Surface Disease Index (OSDI) and subsequently divided into two groups containing 9 symptomatic patients (scores >12) and 21 asymptomatic patients (scores ≤ 12). Another 20 healthy age-matched males were selected as the control group. Each candidate was assessed with respect to eyelid margin abnormality, tear film break-up time (NI-BUT), tear meniscus height (TMH), meiboscore, meibum expressibility, and demodex infection., Results: The NI-BUT in the ADT group was significantly shorter than that in the control group. The scores for OSDI, eyelid margin abnormality, meibum expressibility, and meiboscores were significantly higher in the ADT group ( P < 0.05). Moreover, the NI-BUT in the symptomatic ADT group was significantly shorter than that in the asymptomatic ADT group ( P < 0.05). The meiboscores and meibum expressibility score in the symptomatic ADT group were significantly higher than those in the asymptomatic ADT group ( P < 0.05). The presence of demodex in the symptomatic ADT group was also higher than that in the asymptomatic ADT group ( P < 0.05).The length of time that patients had been taking ADT was positively correlated with meiboscores and negatively correlated with NI-BUT., Conclusion: Androgen levels were associated with significant changes in relative meibomian gland function. Subjective symptoms, such as dryness and foreign body sensation, were more obvious in prostate cancer patients receiving ADT, which may be caused by MGD and demodex infection. It's recommended that more attention be paid to the ocular surface in prostate cancer patients taking ADT by performing examination of NI-BUT and meibomian gland morphology and function with a view to providing more comprehensive prevention and treatment protocols., Competing Interests: The authors declare that there is no potential conflict of interest relevant to the publication of this article., (Copyright © 2021 Weina Li et al.)

Previous our study reported that three-dimension (3D) cultures of human orbital fibroblasts (HOFs) replicated the etiology of deepening of the upper eyelid sulcus (DUES) caused by prostaglandin F2α analogues (PGF2α-ags). To examine this further, the effects of PGF2α-ags on HOFs were characterized by (1) lipid staining (2D; two-dimension, 3D), (2) comparison of the 3D organoid sizes of preadipocytes (DIF-) or adipocytes (DIF+) that had been treated with various concentrations of several PGF2α-ags, (3) physical stiffness (3D), and (4) the mRNA expression of adipogenic related genes, extracellular matrix (ECM), tissue inhibitors of metalloproteinases (TIMPs) and matrix metalloproteinases (MMPs) (3D). PGF2α-ags caused a dramatic down-sizing of the 3D DIF+ organoids and this reduction was concentration dependent. The effects caused by PGF2α-ags were also observed in 3D preadipocytes. Micro-squeezer analysis clearly indicated that PGF2α-ags induced an increase in their physical solidity. The size of each organoid under several conditions was inversely correlated with the mRNA expression profile of collagen1 (COL1), TIMP2, and MMP2 and 9. These findings indicate that PGF2α-ags affect the expression of COL1, TIMP2, and MMP2 and 9 which, in turn, modulate the 3D ECM network within the organoids, thus resulting in their downsizing.

Meibum-a lipid secretion that is produced by Meibomian glands (MG) in a process termed meibogenesis-plays a critical role in ocular surface physiology. Abnormalities in the chemical composition of meibum were linked to widespread ocular pathologies-dry eye syndrome (DES) and MG dysfunction (MGD). Importantly, in epidemiologic studies the Asian population was shown to be prone to these pathologies more than the Caucasian one, which was tied to differences in their meibomian lipids. However, biochemical data to support these observations and conclusions are limited. To determine if non-DES/non-MGD Asian meibum was significantly different from that of Caucasians, individual samples of meibum collected from ethnic Asian population living in Japan were compared with those of Caucasians living in the USA. These experiments revealed that composition of major lipid classes, such as wax esters (WE), cholesteryl esters (CE), triacylglycerols, (O)-acylated ω-hydroxy fatty acids (OAHFA), cholesteryl sulfate, cholesteryl esters of OAHFA, and diacylated α,ω-dihydroxy fatty alcohols remained invariable in both races, barring a minor (< 10%; p < 0.01) increase in the Asian CE/WE ratio. Considering the natural variability range for most meibomian lipids (app. ± 15% of the Mean), these differences in meibogenesis were deemed to be minimal and unlikely to have a measurable physiological impact.

Background: Floppy eyelid syndrome is a disorder in which the tarsal plate is easily distensible and is currently treated with conservative or surgical measures. Human tarsal plate contains type I collagen, which is crosslinked in corneal tissue as a treatment for keratoconus. We hypothesized that collagen crosslinking would similarly stiffen tarsal plate tissue and investigated this in porcine and human tarsal plate specimens., Methods: Riboflavin-sensitized porcine and human tarsus samples were irradiated with ultraviolet-A light. Porcine experiments were analyzed with gross photographs, anterior segment optical computed tomography (AS-OCT) imaging, and tensile testing. A prospective study of human tarsus was performed on samples from patients undergoing wedge resection for floppy eyelid syndrome and was analyzed with AS-OCT and tensile testing., Results: 73 porcine adnexa and 9 patients (16 eyelids) who underwent wedge excision were included in the study. Grossly, greater stiffness was observed in crosslinked porcine tissue. AS-OCT imaging in porcine tissue showed a distinct hyperreflective band in crosslinked specimens whose area and intensity increased with longer treatment time (P = 0.003); this band was also visible in crosslinked human specimens. Tensile testing was performed, but results were not statistically significant., Conclusions: AS-OCT imaging, which has not been previously described for tarsal plate, showed a characteristic change in crosslinked porcine and human specimens. Tissue stiffness was increased grossly, but changes in tensile properties were not statistically significant. Further study is warranted to determine relevance as a potential treatment for floppy eyelid syndrome.

Purpose: We sought to evaluate the distribution and characteristics of meibomian gland dysfunction (MGD) and the treatment patterns for symptomatic MGD patients in South Korea., Methods: One hundred ninety-six right eyes of 196 MGD patients were enrolled. For each patient, meibum expressibility in the central eight glands in both the upper and lower eyelids was examined. Each upper and lower eyelid was separately classified into one of the following three subtypes: nonobvious obstructive (low-delivery without lid margin abnormality), obvious obstructive (low-delivery with lid margin abnormality), and hypersecretory (high-delivery with lid margin abnormality). All treatment plans were also recorded., Results: The mean number of expressible glands of the central eight glands in the upper eyelids (3.9 ± 2.6) was significantly higher than that in the lower eyelids (2.2 ± 2.4, p < 0.001). Obvious obstructive MGD was the most common subtype, followed by the hypersecretory and nonobvious obstructive subtypes in both the upper and lower eyelids. Of the 196 subjects, 38 (19.4%) had upper and lower eyelids that were assigned to different categories. Eyelid hygiene was the most prescribed treatment (74.5%), followed by lubricant eye drop usage (71.5%). Physicians tended to determine treatment plans based on the subtype of the upper eyelid rather than that of the lower eyelid., Conclusions: The majority of subjects were classified as having the obvious obstructive subtype of MGD, and 19.4% had upper and lower eyelids that were different subtypes. Eyelid hygiene was the most prescribed treatment for MGD patients, and treatment patterns were mostly determined based on the subtype of the upper eyelids., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2019 The Korean Ophthalmological Society.)

Purpose: To propose and to evaluate a quantitative measuring method of meibomian gland (MG) vagueness., Methods: A total of 47 patients (32 female and 15 male, 39.21 ± 11.07 years) with meibomian gland dysfunction (MGD) were recruited to the MGD group, and 47 healthy volunteers were recruited to the control group matched in age and gender. The clinical examinations included ocular surface evaluation, MG function indexes and MG morphological indexes (including MG vagueness value). Reliability and efficacy of MG vagueness value, correlation between vagueness value and relevant variables, and diagnostic efficacy of combining vagueness value with efficacious indexes were all evaluated., Results: The MG vagueness value of the MGD group (19.78 ± 13.17) was significantly lower than that of the control group (31.90 ± 13.15). The vagueness value possessed good between-reader reliability (intraclass correlation coefficient = 0.928 > 0.9), and was correlated with age (r = -0.356), most clinical indexes and the acinar shortest diameter (r = -0.278). The area under the curve (AUC) in the receiver operating characteristic (ROC) curve of vagueness value was 0.766 [95% confidence interval (CI): 0.668-0.864] with sufficient diagnostic efficacy, and the cutoff value was <21. The AUC improved to 0.956 (95% CI: 0.938-0.999), after efficacious indexes (vagueness value, meiboscore and tear breakup time) were combined., Conclusion: Meibomian gland (MG) vagueness is quantifiable. The MG vagueness value proposed in this study has good reliability, a close relationship with MGD clinical features and sufficient diagnostic efficacy. Combining this new index with other indexes commonly used offers an exciting prospect in MGD diagnosis., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To evaluate spontaneous and evoked ocular sensory responses in rats after denervation of the lacrimal gland, as well as protein changes in tears that may mediate functional changes., Methods: Sprague-Dawley rats served as subjects. The left lacrimal gland was partially denervated with saporin toxin conjugated to p75. Unilateral and bilateral eye closures (winks and blinks) and grooming behaviors were measured weekly. Nociceptive responses were evoked by ocular application of menthol; tear production was assessed using the phenol thread test. Relative changes in tear protein abundances were measured using a Tandem Mass Tagging approach., Results: Denervation of the lacrimal gland reduced eye closure behavior, particularly in the ipsilateral eye, and eye wipe responses to noxious menthol were also reduced. Tear volume did not change, but tear protein composition was altered. Proteins implicated in the structural integrity of epithelial cells and in protective functions were reduced by lacrimal denervation, including keratins, serotransferrin, and beta-defensin. Other proteins that may modulate TRPM8 channels and alter sensory neuronal function were reduced, including arachidonate 15-lipoxygenase B. A low-abundance protein that responds to oxidative stress and injury, proteasome subunit beta type 10, was upregulated in denervated rats., Conclusions: Denervation of the lacrimal gland causes long-lasting hypoalgesia, impairs the blink response, and alters tear proteins. Tear proteins were altered without changing tear volume. We speculate that impaired TRPM8 function in corneal sensory nerves may contribute to ocular hypoalgesia, supporting growing evidence that this transduction molecule is important for both nociceptive and spontaneous blinking behaviors.

Purpose: The purpose of this study was to assess the prevalence of meibomian gland dysfunction (MGD) and its association with tear film and ocular surface parameters in an Austrian clinical population of dry eye patients., Methods: The records of 1372 consecutive patients from a dry eye unit were analysed retrospectively. Symptoms and objective tear film and ocular surface parameters were evaluated. Patients were classified into pure MGD, pure aqueous tear deficiency (ATD), MGD combined with ATD, pure anterior blepharitis (AB), Sjogren's syndrome (SS) without MGD and SS together with MGD., Results: Nine-hundred and sixty-five patients, that is 70.3% of the investigated population, mean age 55.4 ± 16.6 years, had signs of MGD. Of these, 684 (70.9%) were female. The intensity of symptoms did not differ between subgroups. Four hundred and ninety (50.8%) MGD patients had Schirmer test values ≤10 mm/5 min. The fluorescein break-up time and Schirmer test values were significantly higher in the pure AB and MGD group. The pure MGD group showed a significantly lower fluorescein staining of the cornea compared to the other groups, except for pure AB. Lissamine green staining of the ocular surface was present in all groups, but was at least pronounced in the pure MGD and AB group., Conclusion: Meibomian gland dysfunction is a major cause of ocular discomfort and could often be found in combination with a reduced aqueous tear secretion. Although the intensity of subjective complaints was similar to all other subgroups, pure MGD exhibited the lowest severity of signs of ocular surface damage and also affected younger people., (© 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Meibomian Gland Dysfunction (MGD) is a leading cause of evaporative Dry Eye Disease (DED). This makes non-invasive meibography an important procedure in the clinical evaluation of DED patients. Our purpose was to conduct a lead-off investigation focused on the practicality of performing meibography in a developing country, with limited access to complex ophthalmic imaging systems, using a custom meibographer, as a step to future comparative studies on meibomian glands and DED in Africa., Methods: Meibomian glands(MG) in 76 upper eyelids (UL) and 49 lower eyelids (LL) in 1 eye each of 125 patients randomly selected from a patient population presenting with subjective DED symptoms at a clinic were photographed using a custom meibographer. Single frames were captured, and the MG area determined by intensity threshold segmentation and area calculation using Image J software. MG loss (MGL) was quantified by outlining its area and expressing it as a percentage of the total MG per Pult's grading scheme. Dry eye measures included Tear Film Break Up - Time (TUBT), Schirmer's test and Ocular Surface Staining (OSS). Symptoms were evaluated using the SPEED II questionnaire. Correlations between MGL and age, ocular signs and symptoms were analyzed by Pearson's. Differences between comparable groups were analyzed by Mann - Whitney test; p < 0.05 was considered significant., Results: Overall mean MGL was 32.10% ± 25.0% (26.25% ± 22.40% for UL and 40.33% ± 26.70% for LL). MGL correlated significantly with age [r = 0.91, p = 0.001], SPEED scores [r = 0.90, p = 0.001], OSS [r = 0.75, p = 0.001] and TBUT [r = - 0.81, p = 0.001]. MGL scores were significantly higher in the UL than LL [U = 1293.5 p = 0.004]., Conclusion: This study for the first time presents data on the status of Meibomian glands in Africa. It furthermore suggests that it is feasible to examine Meibomian glands using a custom meibographer in developing countries with limited access to complex imaging systems. It also demonstrates the benefit and cost-effectiveness of a simple device by the observed significant relations between meibomian gland loss and DED in these patients.

Purpose: To investigate the efficacy of a novel treatment - intra-meibomian gland (MG) injection of the anti-VEGF agent bevacizumab - for MG dysfunction (MGD) with eyelid-margin vascularity., Methods: A total of 26 eyes from 13 patients diagnosed with MGD and eyelid-margin vascularity were included in our study. Patients received intra-meibomian gland injections of bevacizumab (150 μL, 2.5 mg/0.1 mL) at multiple sites with a 29 G needle where telangiectasia was severe. The Ocular Surface Disease Index (OSDI), tear film, tear-breakup time (TBUT), eyelid-margin features, MG features, conjunctiva, and corneal staining were assessed at 1 day before injection and 1 week, 1 month, and 3 months after injection. Blood pressure, best-corrected visual acuity, intraocular pressure, and slit lamp examinations were performed to assure the safety of patients at 1 day before and 1 day, 1 week, 1 month, and 3 months after injection., Results: Lid-margin vascularity, conjunctival injection, expressed secretion quality, expressivity of the MG, TBUT, corneal staining, and OSDI were significantly improved 1 week, 1 month, and 3 months after injection compared to baseline values. Lid-margin vascularity, conjunctival injection, meibomian gland expressivity, TBUT, and OSDI continued to improve; the greatest improvements were observed at 1 month and sustained for 3 months. Spearman's correlation analysis indicated that age and sex significantly influenced TBUT improvement. Females and older patients tended to have shorter baseline TBUT that followed a different trend from that of males and younger patients during postinjection visits, revealed by subgroup analysis. No local or systemic side effects were observed at follow-up visits., Conclusion: This study is the first to explore a novel therapy for MGD - intra-MG injection of the anti-VEGF agent bevacizumab - and it demonstrates that the treatment is effective and safe in eliminating eyelid-margin vascularity, improving MG function and relieving clinical signs and symptoms of MGD., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: To investigate the tear cytokine profile in congenital aniridia, and correlate cytokine levels with ophthalmologic findings., Methods: We examined 35 patients with aniridia and 21 healthy controls. Tear fluid was collected with Schirmer I test and capillary tubes from each eye, and the concentration of 27 inflammatory cytokines determined using multiplex bead assay. Eyes of all participants were examined with tests for dry eye disease, including evaluation of meibomian glands (meibography). Differences in cytokine levels between the two groups were analyzed, and correlations between cytokine concentrations and ophthalmologic findings in the aniridia group investigated., Results: The concentrations of six tear cytokines were significantly higher in aniridia patients than controls in both eyes, and included interleukin 1β (IL-1β), IL-9, IL-17A; eotaxin; basic fibroblast growth factor (bFGF/FGF2); and macrophage inflammatory protein 1α (MIP-1α/CCL3). The ratio between the anti-inflammatory IL-1RA and the proinflammatory IL-1β was significantly lower in patients than controls in both eyes (P = 0.005 right eye and P = 0.001 left eye). Increasing concentration of IL-1β, IL-9, IL-17A, FGF2, and MIP-1α correlated with parameters for meibomian gland dysfunction (MGD) in the aniridia group, including increasing atrophy of meibomian glands, and shorter break-up time of the tear film., Conclusions: A number of pro-inflammatory cytokines are significantly elevated in tear fluid from aniridia patients, and correlate with parameters for MGD in aniridia. Increased inflammation of the ocular surface may be a factor in the development of MGD in aniridia patients, and explain the high prevalence of MGD and dry eye disease in these patients.

PurposeTo assess tear cytokine levels and clinical outcomes in meibomian gland dysfunction (MGD) in the blind eye of patients wearing an ocular prosthesis after 2 months of treatment with topical loteprednol etabonate and eyelid scrubs with warm compresses.Patients and methodsThis study included patients with MGD wearing a unilateral ocular prosthesis for more than 1 year. All patients topically received 0.5% loteprednol etabonate and were instructed to scrub their eyelids with warm compresses on the prosthetic eye for 2 months. We evaluated tear cytokine levels using Multiplex Bead Immunoassays, performed biomicroscopic examination of the lid margins and meibomian gland, conducted meibography imaging, and assessed MGD-related ocular symptoms using a questionnaire for the prosthetic eye before and 2 months after treatment.ResultsThirty consecutive patients were included. There were significant reductions in the levels of interleukin (IL)-6, interferon-γ, monocyte chemotactic protein-1, IL-8, tumor necrosis factor-α, and IL-1β (P<0.001 for each cytokine). Moreover, there were improvements in ocular symptoms (P=0.001), lid margin abnormalities (P<0.001), meibomian gland expressibility (P<0.001) and meibography findings (P=0.037).ConclusionTopical loteprednol etabonate in conjunction with eyelid scrubs and warm compresses were effective in treating MGD in prosthetic eye wearers. Furthermore, tear cytokine measurements may serve as an additional approach for evaluating the efficacy of anti-inflammatory treatment for MGD in prosthetic eye wearers.

We analyzed the tear film proteome of patients with dry eye (DE), meibomian gland dysfunction (MGD), and normal volunteers (CT). Tear samples were collected from 70 individuals. Of these, 37 samples were analyzed using spectral-counting-based LC-MS/MS label-free quantitation, and 33 samples were evaluated in the validation of candidate biomarkers employing customized antibody microarray assays. Comparative analysis of tear protein profiles revealed differences in the expression levels of 26 proteins, including protein S100A6, annexin A1, cystatin-S, thioredoxin, phospholipase A2, antileukoproteinase, and lactoperoxidase. Antibody microarray validation of CST4, S100A6, and MMP9 confirmed the accuracy of previously reported ELISA assays, with an area under ROC curve (AUC) of 87.5%. Clinical endpoint analysis showed a good correlation between biomarker concentrations and clinical parameters. In conclusion, different sets of proteins differentiate between the groups. Apolipoprotein D, S100A6, S100A8, and ceruloplasmin discriminate best between the DE and CT groups. The differences between antileukoproteinase, phospholipase A2, and lactoperoxidase levels allow the distinction between MGD and DE, and the changes in the levels of annexin A1, clusterin, and alpha-1-acid glycoprotein 1, between MGD and CT groups. The functional network analysis revealed the main biological processes that should be examined to identify new candidate biomarkers and therapeutic targets.

The EDA gene encodes ectodysplasin A (Eda), which if mutated causes X-linked hypohidrotic ectodermal dysplasia (XLHED) disease in humans. Ocular surface changes occur in XLHED patients whereas its underlying mechanism remains elusive. In this study, we found Eda was highly expressed in meibomian glands, and it was detected in human tears but not serum. Corneal epithelial integrity was defective and the thickness was reduced in the early postnatal stage of Eda mutant Tabby mice. Corneal epithelial cell proliferation decreased and the epithelial wound healing was delayed in Tabby mice, whereas it was restored by exogenous Eda. Eda exposure promoted mouse corneal epithelial wound healing during organ culture, whereas scratch wound assay showed that it did not affect human corneal epithelial cell line migration. Epidermal growth factor receptor (EGFR), phosphorylated EGFR (p-EGFR), and phosphorylated ERK1/2 (p-ERK) were down-regulated in Tabby mice corneal epithelium. Eda treatment up-regulated the expression of Ki67, EGFR, p- EGFR, and p- ERK in human corneal epithelial cells in a dose-dependent manner. In conclusion, Eda protein can be secreted from meibomian glands and promotes corneal epithelial cell proliferation through regulation of the EGFR signaling pathway. Eda release into the tears plays an essential role in the maintenance of corneal epithelial homeostasis., (© 2017 by The American Society for Biochemistry and Molecular Biology, Inc.)

Managing cardiovascular disease (CVD) risk factors is the key to prevent CVD. This study aimed to prevent CVD by introducing asymptomatic meibomian gland dysfunction (MGD), a condition associated with various CVD risk factors, as an early indicator for CVD in middle-aged population. Participants with and without asymptomatic MGD underwent standardized questionnaires, physical examinations, and laboratory investigations. One ophthalmologist completed the identification and grading of MGD by using slit-lamp biomicroscopy examination on the eyelid margins, meibomian gland orifices, and meibomian gland secretions. Standardized techniques were used to measure the CVD risk factor parameters. After adjusted for age and gender, CVD risk factors including elevated uric acid (P = 0.01), total cholesterol (Total-C, P < 0.001), low-density lipoprotein cholesterol (LDL-C, P < 0.001), fasting triglyceride (Fasting TG, P < 0.001), decreased high-density lipoprotein cholesterol (HDL-C, P = 0.04), and presence of hepatic steatosis (P = 0.008) were significantly associated with asymptomatic MGD. Stepwise logistic regression analysis revealed that LDL-C (OR: 1.03, 95% CI: 1.02-1.04) and Fasting TG (OR: 1.01; 95% CI: 1.00-1.01) levels were risk factors for having asymptomatic MGD (P < 0.001). Together, the results suggest that asymptomatic MGD may serve as an indicator for CVD.

Purpose: To estimate the prevalence of meibomian gland dysfunction (MGD) in the Japanese population., Methods: We undertook a clinical study on the prevalence of MGD in Japan using the same diagnostic criteria as a previous population-based study conducted in Spanish Caucasians. The participants were consecutive patients scheduled for cataract surgery at Inouye Eye Hospital. All participants were aged 50 years or older. Patients completed a symptoms questionnaire and underwent a comprehensive slit-lamp examination. Meibomian gland dysfunction was diagnosed when one or more of the following was present in at least in one eye: absent, viscous, or waxy white secretion upon digital expression; presence of two or more lid margin telangiectases; and/or plugging of two or more gland orifices., Results: The study included 510 patients (205 men and 305 women). Mean participant age was 71.1 ± 8.5 years (range, 50-93 years). The prevalences of symptomatic and total MGD (symptomatic MGD + asymptomatic MGD) were 11.2% and 74.5%, respectively. The prevalence of total MGD increased significantly as participant age increased (P < 0.0001). The ratio of males to females and the prevalence of any systemic disease did not differ between patients who were positive or negative for MGD. For the total MGD group, all slit-lamp findings were more frequent, fluorescein score was higher, tear film breakup time was shorter, and meibo-score was larger, compared to non-MGD patients., Conclusions: Based on the present diagnostic criteria, prevalence of MGD is higher in Tokyo, compared to the Spanish population.

Purpose: A novel meibomian gland dysfunction (MGD) model was developed to facilitate understanding of the pathophysiology of MGD and to evaluate treatment with azithromycin ophthalmic solution (azithromycin). MGD was induced in HR-1 hairless mice by feeding them a special diet with limited lipid content (HR-AD)., Methods: Male HR-1 hairless mice were fed an HR-AD diet for 16 weeks. Development of MGD was assessed by histopathology at 4-week intervals. The lid margin was observed by slit-lamp examination. After cessation of the HR-AD diet, the mice were fed a normal diet to restore normal eye conditions. Expression of cytokeratin 6 was determined by immunostaining. We evaluated the effects of topically applied azithromycin on the plugged orifice in this model., Results: After mice were fed the HR-AD diet, histopathology analysis showed hyperkeratinization of the ductal epithelium in the meibomian gland. Ductal hyperkeratinization resulted in the loss of acini, followed by atrophy of the gland. Slit-lamp examination revealed a markedly plugged orifice, telangiectasia, and a toothpaste-like meibum compared with that of a normal eyelid. Cessation of feeding with HR-AD ameliorated both the MGD signs and the expression of cytokeratin 6, restoring the tissue to a histologically normal state. Azithromycin treatment significantly decreased the number of plugged orifices and ameliorated atrophy, as revealed by histopathologic analysis., Conclusions: We developed a novel model that mimics human MGD signs in HR-1 hairless mice fed an HR-AD diet. Azithromycin treatment led to therapeutic improvement in this model. This MGD model could be useful for the evaluation of drug candidates for MGD.

Purpose: Notch1 was previously shown to play a critical role in murine meibomian gland function and maintenance. In this study, we have examined the expression and activation of Notch pathway in human meibomian gland epithelial cells in vitro., Methods: An immortalized human meibomian gland epithelial cell (HMGEC) line was cultured under proliferative and differentiative conditions. Expression of Notch receptors and ligands were evaluated by quantitative PCR and Western blot. The effect of Notch inhibition and induction on oil production was also assessed., Results: Human meibomian gland epithelial cell expressed Notch1, Notch2, Notch3, Jagged1, Jagged2, Delta-like 1, and Delta-like 3. The level of cleaved (activated) Notch1 strongly increased with differentiation. The expression of Notch3 was inversely correlated with proliferation. Induction and inhibition of Notch1 led to an increase and decrease in the amount of oil production, respectively., Conclusions: Notch signaling appears to play an important role in human meibomian gland epithelial differentiation and oil production. This may provide a potential therapeutic pathway for treating meibomian gland dysfunction.

Purpose: Intratarsal keratinous cysts (IKCs) have been frequently misdiagnosed as chalazia or epidermal cysts. We reviewed a series of cases of IKCs to identify clinical features that distinguish IKCs from other eyelid diseases., Methods: We retrospectively reviewed the medical records of 17 suspected IKC patients between January 2004 and September 2014., Results: Seventeen patients who were clinically suspected to have IKC were enrolled. All patients presented with non-inflamed eyelid nodules fixed to the tarsus. Among them, 12 biopsy specimens were available and 11 patients (91.7%) were diagnosed with IKC, with a pathological finding of stratified squamous cell lining with keratin material. The mean patient age was 55.1 years (31-71). Six patients had a surgical history of incision or incomplete excision of the lesion, followed by recurrence. On eyelid eversion, five patients showed a white-yellow nodule, and three patients had a bluish cystic lesion. The diameter of the nodules ranged from 4 to 10 mm. The intracystic material was a milky white fluid. Ten patients underwent a complete surgical excision including partial tarsectomy and there was no recurrence., Conclusions: IKC can be distinguished from other intratarsal lesions by a characteristic tarsal nodule fixed to the tarsus. To prevent recurrence, complete excision with partial tarsectomy is needed.

Purpose: We measured the components of meibum in patients with meibomian gland dysfunction (MGD) and control subjects and then examined the relation between meibum composition and clinical parameters., Methods: Thirty-eight patients with MGD (13 men and 25 women; mean age ± SD, 66.9 ± 15.0 years) and 20 control subjects (8 men and 12 women; 64.5 ± 6.7 years) were enrolled. Ocular symptom score, keratoconjunctival staining score, tear film breakup time, and Schirmer's test value were determined. Lid margin abnormalities and meibomian gland morphology were assessed for upper and lower eyelids, and meibum properties were evaluated at temporal, central, and nasal sites of each lid. Free fatty acid (FFA) composition of meibum was analyzed by liquid chromatography-Fourier transform mass spectrometry., Results: Upper meibum color score was significantly correlated with epiphora and sticky sensation in MGD patients. Meibum grade, color, or viscosity did not differ significantly among the sites evaluated. A total of 103 species of FFA--including very long chain (such as C36 and C37) and odd-numbered chain (such as C17, C19, and C21) FFAs--were detected in meibum. Free fatty acid composition differed between clear and colored (cloudy or yellow) meibum, with unsaturated FFAs tending to be more abundant in colored meibum., Conclusions: Free fatty acid composition of human meibum correlates with meibum color as determined with a slit-lamp microscope. This finding may provide insight into the pathogenesis of MGD.

Purpose: We evaluated inter-examiner reliability in grading of clinical variables associated with meibomian gland dysfunction (MGD) in real-time examination versus a graded digital image., Methods: Meibography grading of meibomian gland atrophy and acini appearance, and slit-lamp grading of lid debris and telangiectasias were conducted on 410 post-menopausal women. Meibography and slit-lamp photos were captured digitally and saved for analysis by a masked examiner. Gland atrophy was graded as a proportion of partial glands in the lower lid, and acini appearance by the presence/absence of grape-like clusters. Lid debris and telangiectasias were graded based on severity and quantity from the same image, respectively. Observed agreement and weighted kappas (κ(w)) with 95% confidence intervals (CI) determined the degree of inter-examiner reliability between grading of these clinical variables in real-time examination and digital photographs using a multiple-point categorical scale., Results: Observed agreement was determined for telangiectasias (40.6%), lid debris (50.9%), gland dropout (42.8%), and acini appearance (54.5%). Inter-examiner reliability for the four clinical outcomes ranged from fair agreement for acini appearance (κ(w) = 0.23, 95% CI = 0.14-0.32) and lid debris (κ(w) = 0.24, 0.16-0.32) to moderate agreement for gland dropout (κ(w) = 0.50, 0.40-0.59) and telangiectasias (κ(w) = 0.47, 0.39-0.55). Conclusions. Gland dropout and potentially lid telangiectasia grading from a photograph are more representative of grading in a real-time examination compared to acini appearance and lid debris. Alternative grading scales and/or clinical variables associated with MGD should be addressed in future studies.

Purpose: Nuclear magnetic resonance (NMR) spectroscopy has been used to quantify lipid wax, cholesterol ester terpenoid and glyceride composition, saturation, oxidation, and CH₂ and CH₃ moiety distribution. This tool was used to measure changes in human meibum composition with meibomian gland dysfunction (MGD)., Methods: (1)H-NMR spectra of meibum from 39 donors with meibomian gland dysfunction (Md) were compared to meibum from 33 normal donors (Mn)., Results: Principal component analysis (PCA) was applied to the CH₂/CH₃ regions of a set of training NMR spectra of human meibum. PCA discriminated between Mn and Md with an accuracy of 86%. There was a bias toward more accurately predicting normal samples (92%) compared with predicting MGD samples (78%). When the NMR spectra of Md were compared with those of Mn, three statistically significant decreases were observed in the relative amounts of CH₃ moieties at 1.26 ppm, the products of lipid oxidation above 7 ppm, and the =CH moieties at 5.2 ppm associated with terpenoids., Conclusions: Loss of the terpenoids could be deleterious to meibum since they exhibit a plethora of mostly positive biological functions and could account for the lower level of cholesterol esters observed in Md compared with Mn. All three changes could account for the higher degree of lipid order of Md compared with age-matched Mn. In addition to the power of NMR spectroscopy to detect differences in the composition of meibum, it is promising that NMR can be used as a diagnostic tool.

Purpose: This study represents a first step toward the evaluation of possible compositional differences in meibum from normal donors (Mn) and donors with meibomian gland dysfunction (Md) by (1)H-NMR spectroscopy. The results highlight the applicability of (1)H-NMR spectroscopy for the quantitative analysis of waxes, cholesteryl esters, and glycerides in meibum lipid (ML)., Methods: Meibum was obtained from 41 normal donors and 51 donors with meibomian gland dysfunction (MGD). (1)H-NMR spectroscopy was used to quantify the amount of waxes, glycerides, and cholesteryl esters in human meibum., Results: The relative amount of cholesteryl esters in Mn increased with age and was 40% (P < 0.05) lower in Md. Interestingly, the relative levels of cholesteryl esters in infant meibum were comparable to those in Md. The relative amounts of glycerides were not affected significantly by age or MGD., Conclusions: The changes in cholesteryl ester could be used as a molecular marker for MGD and could potentially be applied to follow the efficacy of drug therapy in the treatment of MGD. The similarity of the levels of cholesteryl esters in infant meibum and Md suggests that the relative amounts of these meibum components alone are unlikely to be responsible for the increased stability of the infant tear film and decreased stability of the tear film with MGD. This study reveals the complexity of human MLs and the changes that occur with age and disease. Understanding the factors that lead to such variations is of utmost relevance in the design of effective therapies.

Recently, the association of Th-17 cells or IL-17 with ocular inflammatory diseases such as uveitis, scleritis and dry eye syndrome was discovered. We assessed whether interleukin (IL)-17 was present in the tears of various ocular surface inflammatory diseases and the tear IL-17 concentrations were clinically correlated with various ocular surface inflammatory diseases. We measured concentrations of IL-17 in tears of normal subjects (n = 28) and patients (n = 141) with meibomian gland dysfunction (MGD), dry eye syndrome (DES), Sjögren syndrome (SS), Stevens-Johnson syndrome (SJS), graft-versus-host disease (GVHD), filamentary keratitis, and autoimmune keratitis associated with rheumatoid arthritis or systemic lupus erythematosus. Clinical epitheliopathy scores were based on the surface area of corneal and conjunctival fluorescein staining. The mean concentrations of IL-17 in tears of patients with filamentary keratitis, GVHD, autoimmune keratitis, SS, DES, MGD, SJS were significantly higher in order than that in normal subjects. Tear IL-17 concentration was significantly correlated with clinical epitheilopathy scores in the patients with systemic inflammatory disease, while tear IL-17 was not correlated with clinical severity of the cornea and conjunctiva in the dry eye patients without any systemic inflammatory disease. Tear IL-17 is likely to correlate clinically with corneal disease severity only in the patients with systemic inflammatory disease.

Purpose: Instability of the tear film with rapid tear break-up time is a common feature of aqueous-deficient and evaporative dry eye diseases, suggesting that there may be a shared structural abnormality of the tear film that is responsible for the instability. It may be that a change in the normal meibum lipid composition and conformation causes this abnormality. Principle component analyses of infrared spectra of human meibum indicate that human meibum collected from normal donors (Mn) is less ordered than meibum from donors with meibomian gland dysfunction (Md). In this study the conformation of Md was quantified to test this finding., Methods: Changes in lipid conformation with temperature were measured by infrared spectroscopy. There were two phases to our study. In phase 1, the phase transitions of human samples, Mn and Md, were measured. In phase 2, the phase transitions of model lipid standards composed of different waxes and cholesterol esters were measured., Results: The phase-transition temperature was significantly higher (4°C) for the Md compared with the Mn of age-matched donors with no history of dry-eye symptoms. Most (82%) of the phase-transition temperatures measured for Md were above the values for Mn. The small change in the transition temperature was amplified in the average lipid order (stiffness) at 33.4°C. The average lipid order at 33.4°C for Md was significantly higher (30%, P = 0.004) than for Mn. The strength of lipid-lipid interactions was 72% higher for Md than for Mn. The ability of one lipid to influence the melting of adjacent lipids is termed cooperativity. There were no significant differences between Mn and Md in phase-transition cooperativity, nor was there a difference between Mn and Md in the minimum order or maximum order that Mn and Md achieved at very low and very high temperatures, respectively. The model wax studies showed that the phase transition of complex mixtures of natural lipids was set by the level of unsaturation. A double bond decreased the phase-transition temperature by approximately 40°C. The addition of a second CH CH moiety decreased the phase-transition temperature by approximately 19°C. Unsaturated waxes were miscible with saturated waxes. When a saturated wax was mixed with an unsaturated one, the saturated wax disproportionately increased the phase transition of the mixture by approximately 30°C compared with the saturated wax alone. Cholesterol ester had little effect on the phase-transition temperature of the waxes. Model studies indicated that changes in the amount of lipid saturation, rather than the amount of cholesterol esters, could be a factor in the observed conformational changes., Conclusions: Meibum lipid compositional changes with meibomian gland dysfunction reflect changes in hydrocarbon chain conformation and lipid-lipid interaction strength. Spectroscopic techniques are useful in studying the lipid-lipid interactions and conformation of lipid from individual patients. (ClinicalTrials.gov number, NCT00803452.).

Purpose: The basis of fluorescein-associated superficial punctate staining in dry eyes is controversial. Prior explanations include fluorescein pooling in surface erosive defects, intercellular trapping of fluorescein, and intracellular staining in dead cells. In this study, the hypothesis that punctate erosions are individual cells with enhanced fluorescence was tested., Methods: Ten impression cytology membrane materials were compared, to optimize cellular yield in buccal mucosa and cornea. Clinicocytologic correlation of punctate fluorescent spots was performed in four dry eye patients. Individual punctate spots were localized by fiducial marks in photographs, before and after removal with impression membranes, and were traced in fluorescence microscopy and cytologic staining. Two-way contingency table analysis was used to determine the correlation of punctate spots with cells removed by the membrane. Clinicopathologic correlation of punctate spots was performed in 10 corneas removed in dry eye patients by transplantation for concurrent diseases. Punctate fluorescence was tracked in specimens by fiducial marks and epifluorescence. The distribution of fluorescent spots in specific cell layers of the cornea was determined by confocal microscopy., Results: Cellular yield was greatest with impressions from polytetrafluoroethylene (PTFE [Teflon]; BioPore; Millipore, Billerica, MA) membrane compared with its closest rival (P = 0.019). Punctate fluorescent spots, most of which disappeared after impression cytology (71%), correlated with cells on the membranes (P = 0.009). The punctate spots were more frequent in the superficial cell layers of the cornea (80%) compared with the deepest two layers (0%) (P < 0.00049)., Conclusions: Punctate epithelial erosions correspond to enhanced fluorescence in epithelial cells predominantly in superficial layers of the cornea and would be more aptly named fluorescent epithelial cells (FLECs).

Purpose: To evaluate tear film stability in patients with tear dysfunction and an asymptomatic control group by using the novel, noninvasive Tear Stability Analysis System (TSAS)., Methods: In this prospective case-control study, 45 patients with dysfunctional tear syndrome (DTS) were stratified into three groups (1, 2, and 3/4) based on clinical severity, with higher scores indicating more severe symptoms; 25 asymptomatic control subjects were evaluated. TSAS measurements were performed with the RT-7000 Auto Refractor-Keratometer (Tomey Corporation, Nagoya, Japan). Images of ring mires projected onto the cornea every second for 6 seconds were captured and analyzed. Focal changes in brightness were calculated as numerical ring breakup (RBU) values, and the elapsed time when the cumulative values (RBU sum) exceeded a threshold was defined as the ring breakup time (RBUT)., Results: RBUTs in the DTS groups were all significantly lower than those in the control subjects, with the lowest values found in DTS 3/4. RBUT was significantly shorter in DTS 3/4 than in DTS 1 (P<0.001). The change in RBU sum over a 6-second period in the DTS groups combined or between the individual groups was statistically significant (P<0.001), as was the difference between the 1- and 6-second values. For distinguishing between asymptomatic controls and DTS, the sensitivity and specificity of a 5.0-second RBUT cutoff were 82.0% and 60.0%, respectively., Conclusions: The TSAS may be a useful, noninvasive instrument for evaluating tear stability and for classifying DTS severity.

Purpose: Floppy eyelid syndrome (FES) is an acquired hyperelasticity disorder affecting the upper eyelid. The tarsal plate becomes hyperelastic with a loss of intrinsic rigidity. As a result, the eyelid is subjected to cyclic mechanical stress. This condition was used as a model to investigate changes in dynamic fibroblast contractility in the context of chronic cyclic mechanical stress., Methods: Contractile efficiency was investigated in a free-floating, three-dimensional collagen matrix model. Intrinsic cellular force measurements and responses to changes in gel tension were explored using a tensioning culture force monitor (t-CFM). Gene expression differences between cell lines exhibiting differences in contractile phenotype were explored with a genome level microarray platform and RT-PCR., Results: FES tarsal plate fibroblasts (TFs) showed an increased contractile efficiency compared with the control, and t-CFM measurements confirmed a higher intrinsic cellular force at plateau levels. Cyclic stretch/relaxation experiments determined that TFs in FES maintained a functional tensional homeostasis response but with an altered sensitivity, operating around a higher mechanostat set point. Gene expression array and RT-PCR analysis identified V-CAM1 and PPP1R3C as being upregulated in FES TFs., Conclusions: These changes may represent an adaptive response that allows tensional homeostasis to be maintained at the high levels of tissue stress experienced in FES. Gene expression studies point to a role for V-CAM1 and PPP1R3C in mediating changes in the dynamic range of mechanosensitivity of TFs. This work identifies FES as a useful model for the study of adaptive physiological responses to mechanical stress.

PURPOSE. To study screening methods and associated factors of Meibomian gland disease and dry eye subtypes in a specialized eye clinic in Singapore. METHODS. This cross-sectional study involved 200 patients in a dry eye clinic. The outcome measures evaluated were dysfunctional tear syndrome (DTS) level, meibomian gland disease grade, Schirmer test (ST) result, fluorescein tear break-up time (TBUT), corneal fluorescein staining grade, and irritative eye symptoms. RESULTS. The meibomian gland screening grade was associated with TBUT (P = 0.007), especially in the upper eyelid and correlated with reading difficulty (P = 0.007) and reversibility of symptomatic blurring with lubricants (P = 0.006). An abnormal ST result was associated with early morning discomfort (P = 0.001), and reduced TBUT was linked to discomfort in windy conditions (P < 0.001). In all patients examined, evaporative dry eye (58%) was the most common type, followed by the mixed evaporative and aqueous tear deficiency (30.5%) types. Fluorescein staining in the central and inferior cornea was most severe in the mixed type. CONCLUSIONS. In dry eye patients, screening for meibomian gland disease based on anteriorization of Marx's line may predict a decrease in TBUT and difficulty in performing certain visual-function-related activities. These findings facilitate better understanding of the meibomian gland's contribution to multifactorial dry eye syndrome, apart from routine conventional tests performed in clinics.

Purpose: To compare tear epidermal growth factor (EGF) concentration in dry eye (DE) conditions and determine correlations between EGF levels and severity of symptoms and ocular surface signs., Methods: In this prospective case-control study, 35 patients with DE, including subgroups with meibomian gland disease (MGD), Sjögren's syndrome (SS) aqueous tear deficiency, or neurotrophic keratopathy (NK), and 17 asymptomatic control subjects were evaluated. Symptoms, Schirmer test, fluorescein clearance test (FCT), EGF concentration, dye staining, and the presence of corneal subepithelial fibrosis and meibomian gland (MG) orifice metaplasia were recorded. Tear EGF and the severity of irritation and ocular surface signs were correlated., Results: Tear EGF was higher in MGD than in the control (P = 0.03) and was lower in SS than in the control (P < 0.0001; MGD (P < 0.05) and NK (P < 0.01) groups. The DE subgroup with results in the FCT > 3 and Schirmer 1 >or= 8 had higher EGF levels than the group with FCT > 3 and Schirmer 1 < 8 and both groups with good tear clearance (P < 0.01). Tear EGF levels correlated inversely with conjunctival (r = -0.49, P = 0.0032) and corneal (r = -0.39, P = 0.022) dye staining and positively with MG orifice metaplasia (r = 0.36, P = 0.03) and corneal subepithelial fibrosis (r = 0.5, P = 0.0006)., Conclusions: Tear EGF concentration was increased in eyes with MGD, corneal subepithelial fibrosis, and MG orifice metaplasia. Elevated tear EGF may promote development of corneal subepithelial fibrosis and lid margin changes.

This article provides an overview of the pathologic features of adult orbital xanthogranulomatous disease, a rare heterogeneous group of disorders that includes 4 clinical syndromes: adult-onset xanthogranuloma, necrobiotic xanthogranuloma, adult-onset asthma and periocular xanthogranuloma, and Erdheim-Chester disease. The diagnosis is made by biopsy of the lesion, demonstrating tissue infiltration by the hallmarks of xanthoma cells and Touton giant cells. The differential diagnosis is broad, including syndromes within the adult xanthogranulomatous disease category as well as other entities involving the eyelid and the orbital tissues. Because of its rarity and sometimes close similarity to other disease entities, it is often misdiagnosed initially. This article focuses on the morphology and immunohistochemical patterns in diagnosis of adult orbital xanthogranulomatous disease with emphasis on adult-onset asthma and periocular xanthogranuloma in particular, its clinical features and associated systemic manifestations in differential diagnosis, as well as the current management strategy.

Hemangiopericytoma (HP) is a well-recognized neoplasm arising from vascular pericytes that has been reported only in the dog and man. In this study, we describe a 14-year-old female Arabian horse that was presented for surgical excision of a 2-cm-diameter expansile subcuticular mass in the right lower eyelid. Histologically, the mass consisted of loosely arranged interlacing streams and storiform bundles of spindle cells that often formed distinct whorls around a central capillary and bundles of collagen (Antoni A-like pattern). Immunohistochemical analysis revealed strong diffuse cytoplasmic immunoreactivity for vimentin and focal immunoreactivity for smooth muscle actin, whereas neoplastic cells did not stain for Factor VIII-related antigen, Glial fibrillary acidic protein (GFAP), or S100. On the basis of histomorphology and immunohistochemical reactivity, the present tumor was diagnosed as HP. To our knowledge, this is the first report describing a HP in a horse.

Purpose: Type V collagen forms heterotypic fibrils with type I collagen and accounts for 10% to 20% of corneal collagen. The purpose of this study was to define the ocular phenotype resulting from mutations in the type V collagen genes COL5A1 and COL5A2 and to study the pathogenesis of anomalies in a Col5a1-deficient mouse., Methods: Seven patients with classic Ehlers-Danlos syndrome (EDS) due to COL5A1 haploinsufficiency and one with an exon-skipping mutation in COL5A2 underwent an ocular examination, corneal topography, pachymetry, and specular microscopy. A Col5a1-haploinsufficient mouse model of classic EDS was used for biochemical and immunochemical analyses of corneas. Light and electron microscopy were used to quantify stromal thickness, fibril density, fibril structure, and diameter., Results: Five males and three females (mean age, 26 +/- 13.57 years; range, 11-52) were studied. All patients had "floppy eyelids." The corneas of all eyes were thinner (mean corneal thickness: 435.75 +/- 12.51 microm) when compared with control corneas (568.89 +/- 28.46 microm; P < 0.0001). In the Col5a1+/- mouse cornea, type V collagen content was reduced by approximately 49%, and stromal thickness was reduced by approximately 26%. Total collagen deposition in Col5a1(+/-) corneas also was reduced. Collagen fibril diameters were increased, but fibril density was decreased throughout the stroma at all developmental stages., Conclusions: In the eye, COL5A1 and COL5A2 mutations manifest as abnormally thin and steep corneas with floppy eyelids. Mechanisms involved in producing the latter anomalies probably involve altered regulation of collagen fibrillogenesis due to abnormalities in heterotypic type I/V collagen interactions similar to those observed in the Col5a1+/- mouse cornea.

Purpose: To determine the impact of evaporation on preocular aqueous tear (AT) loss in normal subjects (controls) and patients with keratoconjunctivitis sicca (KCS)., Methods: Eighteen patients (32 eyes) with KCS with or without associated meibomian gland dysfunction (MGD) and 11 sex-matched controls had AT evaporation determined between relative humidity (RH) of 20% and 45% using an evaporometer. AT volume, flow, and turnover were determined with a fluorophotometer., Results: Evaporative rates increased significantly when the RH was changed from 40%-45% to 20%-25% (P < .001). This change was similar in all groups and on average accounted for a 99.43% increase. There were no statistically significant differences in evaporative rate between controls, the KCS alone group, and the KCS/MGD group. Dry eye patients exhibited a decreased tear turnover when compared to controls. Evaporative contribution to tear loss at 40%-45% RH was 23.47% for controls, 30.99% for "classic" KCS patients, and 25.44% for KCS/MGD patients. At 20%-25% RH, the evaporative contribution was 41.66% for controls, 57.67% for classic KCS patients, and 50.28% for KCS/MGD patients., Conclusions: RH significantly impacts evaporation regardless of the presence of dry eye disease and probably accounts for the increased dry eye symptoms in people (controls and dry eye patients) in conditions of low RH (eg, deserts, airplane cabins, cold dry seasons). Contribution of evaporation to tear loss tends to be higher than previously described. The percent contribution is dependent on environmental conditions such as RH. There was a trend toward increased contribution to AT loss in dry eye patients vs controls, but statistical significance was not reached.

Purpose: The aim was to investigate the effect of low dose doxycycline (20 mg) therapy in patients with chronic meibomian gland dysfunction that were refractory to conventional therapy., Methods: The randomized prospective study enrolled 150 patients (300 eyes) who have chronic meibomian gland dysfunction and who didn't respond to lid hygiene and topical therapy for more than 2 months. All topical therapy was stopped for at least 2 weeks prior to beginning the study. After conducting the tear break up time test (TBUT) and Schirmer test, the authors randomly divided the patients into three groups a high dose group (doxycycline, 200 mg, twice a day), a low dose group (doxycycline, 20 mg, twice a day) and a control group (placebo). After one month, the author repeated the TBUT and Schirmer tests, and analyzed the degree of symptomatic improvement., Results: Compared to the control group, both the high and low dose group showed statistically significant differences after treatment in TBUT, Schirmer test, the number of symptoms reported and the degree of improvement of subjective symptoms. However, there was no statistically significant difference between the high and low dose group after treatment in TBUT (9.42 +/- 2.87 sec, 9.54 +/- 1.58 sec, p=0.726), Schirmer test (19.98 +/- 4.05 mm, 19.65 +/- 5.02 mm, p=0.624), the number of symptoms reported (1.45 +/- 0.62, 1.53 +/- 0.52, p=0.304), as well as the degree of improvement of subjective symptoms (p=0.288). The high dose group (18 patients, 39.13%) reported side effects more frequently than did the low dose group (8 patients, 17.39%) (P=0.002)., Conclusions: Low dose doxycycline (20 mg twice a day) therapy was effective in patients with chronic meibomian gland dysfunction that were refractory to conventional therapy.

Background/aim: Recent studies have demonstrated that tear lipocalin (TL) and phospholipids have a crucial role in maintaining tear film stability. The level of TL in patients with meibomian gland dysfunction (MGD) was examined and these data were correlated with the severity of their clinical disorder., Methods: 12 patients with obstructive MGD, 12 patients with seborrhoeic MGD, and 12 age matched normal control subjects participated in this study. 3 mul of unstimulated tears were collected with a micropipette from the inferior tear meniscus in the right eye of all subjects. Tear samples were fractionated by high performance liquid chromatography, and TL concentrations were assayed with a bicinchoninic acid technique., Results: The mean concentration of TL in patients with obstructive and seborrhoeic MGD was significantly lower than in normal controls. TL concentration correlated positively with tear film break up time and negatively with fluorescein staining scores., Conclusion: These results suggest that TL deficiency may be a predisposing factor for the manifestation of symptoms in MGD.

Aim: To elucidate the pathogenic mechanism of amyloid formation in corneal amyloidosis with trichiasis., Methods: Ophthalmological examination was performed in nine patients to determine secondary corneal amyloidosis with trichiasis. Congo red staining and immunohistochemistry using anti-human lactoferrin antibody were used for biopsied corneal samples. For genetic analyses, single strand conformation polymorphism (SSCP), direct DNA sequence analysis, and polymerase chain reaction (PCR) induced mutation restriction analysis (IMRA) were employed to detect lactoferrin gene polymorphism., Results: All patients had had trichiasis at least for 1 year, and all amyloid-like deposits were found in one eye with trichiasis. Ophthalmological examination revealed that eight patients showed gelatinous type of amyloid deposition and one showed lattice type of amyloid deposition. Studies of biopsied corneal samples with Congo red stain revealed positive staining just under the corneal epithelial cells. Immunoreactivity of anti-human lactoferrin antibodies was recognised in all tissues with positive Congo red staining. Lactoferrin gene analysis revealed that seven patients were heterozygotic and two were homozygotic for lactoferrin Glu561Asp. The frequency of the polymorphism in the patients was significantly different from that in 56 healthy control subjects., Conclusion: Lactoferrin Glu561Asp is a key polymorphism related to facilitating amyloid formation in corneal amyloidosis with trichiasis.

Purpose: Floppy eyelid syndrome (FES) presents nonspecific ocular surface irritation. The hypothesis for the current study was that one contributing factor is the abnormality in tear film dynamics., Methods: Sixteen patients with FES were consecutively examined. Tear film dynamics were evaluated by kinetic tear interference images, infrared thermometry, water evaporation rate, tear break-up time, and fluorescein clearance test. Data showing evaporation rate and thermometry were compared with those of 10 normal subjects., Results: There was a high correlation between the eye with the worse symptoms and the eyes with the more severe floppy lids (P < 0.01) and with ocular surface evaporation rate (P = 0.02). Except for one patient, all others showed abnormal tear film, with an average tear break-up time of 2.9 +/- 3.7 seconds. Kinetic analysis of tear interference images revealed that lipid spread in a vertical or mixed pattern in 18 eyes (75%) with a delayed spread time (P = 0.0007), indicating that most of the patients had lipid tear deficiency. The ocular skin temperature and water evaporation rate were higher in the FES group (P = 0.0003 and 0.026, respectively). Nearly all patients with FES showed eyelid hyperpigmentation. The ocular surface evaporation rate in the FES group was also higher than that of the normal subjects (P < 0.0001). Multiple regression analysis showed that a vertical pattern of lipid spread had a significant influence on ocular surface evaporation rate (P = 0.003)., Conclusions: Tear film abnormality is prevalent in patients with FES and is characterized by lipid tear deficiency, leading to rapid tear evaporation. The FES lid skin is also characterized by high temperature, high water evaporation rate, and hyperpigmentation. Studies directed to investigating the linkage of lid changes and meibomian gland dysfunction may shed new lights on the pathogenesis of FES.

Purpose: To report a case of congenital phakomatous choristoma (PC) of the eyelid, a rare tumor of lenticular anlage in the subcutaneous tissue and dermis., Case: A boy had a mass in the right lower eyelid near the inner canthus at birth. At age 10 months, the tumor was excised., Results: The tumor cells showed intense immunoreactivity positive for S-100 protein, vimentin, and periodic acid-Schiff. Keratin markers, epithelial membrane antigen, glial fibrillary acidic protein, muscle specific actin, and epithelial membrane antigen were negative. The histopathologic features were consistent with those of a PC., Conclusions: This histopathologic and immunoreactivity study supports the proposal that PC is a rare entity of lenticular anlage origin. Only 18 such cases have been described previously.

Purpose: Kinetic analysis of sequential tear interference images was used to investigate how the precorneal lipid film spread and distributed in aqueous tear deficiency (ATD) dry eye., Methods: One eye of 17 patients with ATD was randomly selected for this noncomparative case series. Twelve patients also had noninflamed meibomian gland dysfunction (MGD). Sequential images were digitized and analyzed on computer. Data were further compared in 9 of the 17 cases before and after punctal occlusion (PO). Outcome measures included speed and pattern of lipid spread and resultant lipid layer thickness in the superior, central, and inferior cornea. Intensity and red/green/blue (RGB) color spectra of the tear interference image were compared before and after PO., Results: After lid blinking, it took a longer time (2.2 +/- 1.1 second) to reach a stable lipid film in all eyes with ATD compared with normal subjects (P < 0.0001). Because of this retarded spread, the thickest lipid film was located at the inferior cornea adjacent to the lid margin, with a gradient spreading toward the superior cornea (P = 0.01). As a result, the lipid film was thinner than normal on the superior cornea in 10 of 17 (59%) ATD eyes. Fifteen of 17 eyes (88%) showed vertical streaking, rather than a normal horizontal propagation pattern on the superior cornea. Such a lipid-deficient state and uneven distribution did not correlate with the presence or absence of MGD. The lipid spread time was shortened (P = 0.008), the distribution of the lipid film was more even, and the thickness approached normal in all nine eyes after PO., Conclusions: In this study, kinetic analysis of tear interference images provided evidence that retardation of lipid spread is, but MGD is not, the main reason for the increased thickness of precorneal lipid film in the inferior cornea of eyes with ATD. As a result, lipid film is deficient in the superior cornea and unevenly distributed, further destabilizing the tear film. The fact that PO significantly improves lipid spread, evenness, and thickness suggests that the performance of lipid film is also dictated by the amount of aqueous tear fluid. These findings provide new insight into the interaction between the lipid film and the aqueous tear fluid.

Purpose: To test a newly developed tear evaporimetry system that detects real-time changes in tear evaporation rates and shows the tear film stability in patients with obstructive meibomian gland dysfunction (MGD)., Methods: A ventilated chamber system with high-sensitivity microbalance sensor was used to evaluate tear evaporation. Tear evaporation rates and dynamic changes in them in response to blinking ("flip heights") were measured. Both were compared in 38 eyes of 22 normal subjects and 32 eyes of 21 patients with obstructive MGD, in a prospective case-control study. The relationship between tear evaporation rates and flip heights to meibomian gland orifice obstruction was also analyzed., Results: Changes in tear evaporation rates produced by blinking were detected. The tear evaporation rates in the patients' group were 5.8 +/- 2.7(10(-7)) g/cm(2) per second, significantly higher than in normal subjects (4.1 +/- 1.4[10(-7)] g/cm(2) per second; P = 0.0008). The flip heights in the obstructive MGD group were 0.58 +/- 0.33(10(-7)) g/cm(2) per second, significantly higher than in normal subjects (0.39 +/- 0.27[10(-7)] g/cm(2) per second, P = 0.02). The correlations between both tear evaporation rates and flip heights to the meibomian gland orifice obstruction score were statistically significant (P < 0.0001 and P = 0.004, respectively)., Conclusions: This new system was helpful in differentiating MGD patients from normal subjects. These significantly higher evaporation rates and higher flip heights reflect the unstable tear evaporation and may well indicate unstable tear film in patients with obstructive MGD with abnormal evaporative tear loss.

We report a novel localized amyloidosis associated with lactoferrin. To elucidate the precursor protein of corneal amyloidosis associated with trichiasis, we analyzed amyloid deposits from three patients by histopathology and biochemistry. Amyloid deposits showed immunoreactivity, confirmed by electron microscopy, for only anti-human lactoferrin antibody. Electrophoresis of amyloid fibrils revealed lactoferrin with and without sugar chains; N-terminal sequence analysis revealed full-length lactoferrin and a truncated tripeptide of N-terminal amino acids, Gly-Arg-Arg. Carboxymethylated wild-type lactoferrin formed amyloid fibrils in vitro. Lactoferrin gene analysis in the three patients revealed a Glu561Asp mutation in all of the patients and a compound heterozygote of Ala11Thr and Glu561Asp mutations in one patient. A heterozygotic Glu561Asp mutation appeared in 44.8% of healthy Japanese volunteers, suggesting that the mutation may not be an essential mutation for amyloid formation (p = 0.104). Results thus suggest that lactoferrin is this precursor protein.

This article describes the first report of phakomatous choristoma of the eyelid in Korea. A six-month-old boy underwent excision of a congenital inferonasal orbital mass arising from the left lower lid. A dermoid cyst was suspected, however a diagnosis of phakomatous choristoma was made following conventional histology. An immunohistochemical study of this rare benign congenital tumor was conducted. The cuboidal epithelial cells comprising this choristoma showed strongly positive cytoplasmic staining with S-100 protein and vimentin. They also showed focally positive staining with a neuron-specific enolase, while they showed no immunoreactivity to cytokeratin or epithelial membrane antigen. The results of the immunohistochemical study support the conclusion that this tumor is of lenticular anlage origin.

Purpose: Phakomatous choristoma is a rare congenital tumour of lenticular origin. The exact location at clinical presentation is controversial, but herein we provide evidence that phakomatous choristoma may be located in the lower eyelid or orbit or both., Methods: Case report of an infant presenting with a mass in the lower eyelid at birth, a systematic review of previous cases of phakomatous choristoma and an outline of the histopathological features in normal mid-facial embryonic development at different gestational ages., Results: The histopathological features of the present case were consistent with those of a phakomatous choristoma. The preoperative imaging studies and clinical findings at surgery suggested that the tumour occupied parts of both the lower eyelid and anterior orbit. Histopathological sections of a normal human embryo showed that at the 26-mm stage of development the embryonic lens is formed but the bony walls defining the orbit are not yet present., Conclusion: Phakomatous choristoma arises in a setting of undifferentiated mesenchymal tissue which later may develop into the lower eyelid or orbit depending on the choristomatous elements being deposited superficial or deep to the embryonic surface.

Aims: To assess the integrity of the ocular surface epithelium in patients with atopic dermatitis from the viewpoint of its barrier function., Methods: 49 patients with atopic dermatitis with blepharoconjunctivitis (ABC group), 27 age matched patients with seasonal or perennial allergic conjunctivitis (AC group), and 20 volunteers with normal healthy eyes (NH group) were assigned to this study. Ocular surface epithelium barrier function was evaluated by the fluorophotometric method using a slit lamp fluorophotometer. 3 microliters of 0.5% sodium fluorescein was instilled into the conjunctival sac of the right eye and fluorescein uptake (ng/ml) 30 minutes later (20 minutes after eye washing) was measured in the central cornea and the temporal bulbar conjunctiva. Fluorophoto metric measurements performed were analysed in each group and compared between the groups., Results: The ABC group showed significantly higher fluorescein uptake (mean 28.2 (SEM 3.3) ng/ml) in the cornea than the AC (11.4 (2.2), p = 0.001) and NH groups (9.3 (2.1), p = 0.001). There was no significant difference between the AC and NH groups (p = 0.930). The ABC group also showed significantly higher fluorescein uptake in the bulbar conjunctiva (393.4 (54.0)) than the AC (182.9 (24.6), p = 0.011) and NH groups (169.3 (29.1), p = 0.012). There was also no significant difference in fluorescein uptake between the AC group and the NH group (p = 0.987)., Conclusion: This study suggested that ocular surface epithelium barrier function is impaired in patients with atopic dermatitis with blepharoconjunctivitis.