CLINICAL SCIENCE
Evaluation of Dry Eye and Meibomian Gland Dysfunction With Meibography in Patients With Rosacea Melis Palamar, MD, Cumali Degirmenci, MD, Ilgen Ertam, MD, and Ayse Yagci, MD
Purpose: To evaluate the dry eye tests and meibography of patients with ocular rosacea.
Methods: Thirty-six eyes of 18 patients with ocular rosacea (group 1) and 38 eyes of 19 healthy individuals (group 2) were enrolled. Besides full-eye examination, corneal and conjunctival fluorescein staining and Oxford scoring, tear film break-up time, Schirmer 1 test, ocular surface disease index score assessment, and evaluation of upper and lower eyelid meibomian glands using infrared captures of an optical coherence tomography (OCT) (Spectralis HRA+OCT; Heidelberg Engineering) device were performed (grade 0: no loss of meibomian glands, grade 1: gland dropout area ,1/3 of the total meibomian glands, grade 2: gland dropout area 1/3 to 2/3 of the total meibomian glands, grade 3: gland dropout .2/3 of the total meibomian glands). Results: The mean ages of group 1 and group 2 were 50.2 6 9.5
(range, 32–65), and 46.3 6 14.1 years (range, 25–70), respectively (P = 0.225). No significant difference in best-corrected visual acuity and meiboscores of upper eyelids were detected in between groups. Schirmer 1 and tear film break-up time in group 1 were significantly lower than in group 2 (P = 0.005, P , 0.001, respectively). Ocular surface disease index and Oxford scale scores and meiboscores of lower and total (upper + lower) eyelids were significantly higher in group 1 than in group 2 (P = 0.04, P = 0.018, P , 0.001, P = 0.03, respectively).
Conclusions: Ocular rosacea causes dry eye and significant meibomian gland loss that can objectively be demonstrated with meibography. The infrared camera of OCT—that is widely found in many ophthalmology departments—might be used to evaluate meibomian gland dysfunction in these individuals. Key Words: dry eye, ocular surface, meibomian gland dysfunction, meibography, ocular rosacea (Cornea 2015;34:497–499)
R
osacea is a chronic cutaneous disorder characterized by persistent erythema, telangiectasias, papules, and pustules, primarily of the convexities of the central face (cheeks, chin, Received for publication November 11, 2014; revision received December 30, 2014; accepted January 7, 2015. Published online ahead of print March 2, 2015. From the Department of Ophthalmology (MP, CD, AY) and Department of Dermatology (IE), Ege University Faculty of Medicine, Izmir, Turkey. The authors have no funding or conflicts of interest to disclose. Reprints: Melis Palamar, MD, Ege Universitesi Tip Fakultesi Hastanesi, Goz Hastaliklari AD, Bornova 35040, Izmir, Turkey (e-mail: melispalamar@ hotmail.com). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cornea Volume 34, Number 5, May 2015
nose, and central forehead).1 Four subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) and 1 variant (granulomatous) are described for rosacea, depending on which primary and secondary features are more prominent.1 Patients may have clinical features consistent with more than 1 subtype. More than half of all patients with rosacea have ocular disease.2 Ocular symptoms include blepharitis, meibomitis, recurrent chalazia, episcleritis, iritis, and corneal ulcers, vascularization, and scarring.2–5 Meibomian glands are specialized sebaceous glands, which are localized at the tarsal plates of the eyelids. These glands are responsible for lipid secretion, which plays a significant role to build the surface tension and stability of the tear film and prevents evaporation.6–8 Meibomian gland dysfunction (MGD) is a chronic disease, which results in ocular irritation and ocular surface disorders because of lipid layer abnormalities.9 Meibography is a relatively new technique for evaluating MGD. Infrared imaging of meibomian glands and scoring systems for meibomian gland loss are the leading research subjects on MGD recently.10,11 To the best of our knowledge, no study to date has evaluated the meibomian glands of patients with ocular rosacea with meibography. For this purpose, we evaluated the dry eye tests and performed meibography of patients with ocular rosacea as measured with optical coherence tomography (OCT) and compared these results with healthy individuals.
MATERIALS AND METHODS In this cross-sectional observational study, 36 eyes of 18 patients with ocular rosacea (group 1) and 38 eyes of 19 healthy volunteers (group 2) were evaluated. All patients with ocular rosacea included in the study were already diagnosed as rosacea by a specialized dermatologist (I.E.). Ocular rosacea diagnosis—which can be very challenging—was made with the detection of dry eye, blepharitis, MGD, and ocular irritation among these already diagnosed patients by a specialized ophthalmologist (M.P.).6–8 Patients with corneal involvement (ulcers, vascularization, and scarring) or episcleral/scleral involvement, cataract, glaucoma, contact lens use, previous ophthalmic surgery, smoking history, and patients using any medications were excluded. Both eyes of each subject were evaluated for the study, and the mean values of both eyes were assessed for data analysis. All cases underwent a detailed ophthalmological examination and the following tests were performed: corneal and conjunctival fluorescein staining and Oxford scoring, tear film www.corneajrnl.com |
497
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 5, May 2015
Palamar et al
break-up time (T-BUT), Schirmer 1, ocular surface disease index score assessment, and evaluation of the meibomian glands after everting both upper and lower eyelids to reveal infrared captures using the OCT device (Spectralis HRA +OCT; Heidelberg Engineering, Heidelberg, Germany). Partial or complete loss of the meibomian glands were scored for each eyelid as grade 0 (no loss of meibomian glands), grade 1 (the area characterized by gland dropout was ,1/3 of the total meibomian glands), grade 2 (the area characterized by gland dropout was 1/3-2/3 of the total meibomian glands), and grade 3 (the area characterized by gland dropout was .2/3 of the total meibomian glands).10 Meiboscore assessment was performed masked by the same researcher (A.Y.). The meiboscores for the upper and lower eyelids and total (upper + lower) eyelids were summed for each eye. This study was approved by the institutional review board of the Ege University Hospital and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from each subject. The Statistical Package for the Social Sciences version 11.5.0 was used for statistical analysis.
RESULTS
The mean age of group 1 and group 2 were 50.2 6 9.5 (range, 32–65) and 46.3 6 14.1 years (range, 25–70), respectively (P = 0.225) (Table 1). Best-corrected visual acuity of group 1 and group 2 were 1.0 (range, 1.0–1.0) and (range, 1.0–1.0), respectively (P = 0.2). Schirmer 1 measurements of group 1 and group 2 were 16.8 6 10.1 (range, 0–35) and 23.4 6 9.0 (range, 5–35) mm, respectively (P = 0.005). T-BUT measurements of group 1 and group 2 were 10.2 6 5.5 (range, 2–20) and 20.2 6 7.9 (range, 7–39) seconds, respectively (P , 0.001). Dry eye was detected in 3 patients in group 1 and none in group 2 according to Schirmer 1 and T-BUT values. The mean superficial punctate staining according to the Oxford scale in group 1 and group 2 were 1.1 6 0.8 (range, 0–2) and 0.02 6 0.1 (range, 0–1), respectively (P = 0.018). The mean ocular surface disease index scores in group 1 and group 2 were 30.0 6 23.2 (range, 2.1–75) and 18.2 6 16.0 (range, 2.1–62.5), respectively (P = 0.04). The average upper eyelid, lower eyelid, and total (upper eyelid plus lower eyelid) eyelid meiboscores in group 1 were
TABLE 1. Demographics, Dry Eye Tests, and Meiboscores of the Groups Group 1
Group 2
P
Age, yrs 50.2 6 9.5 (32–65) 46.3 6 14.1 (25–70) 0.225 Schirmer-1, mm 16.8 6 10.1 (0–35) 23.4 6 9.0 (5–35) 0.005 T-BUT, s 10.2 6 5.5 (2–20) 20.2 6 7.9 (7–39) ,0.001 Oxford scale 1.0 6 0.8 (0–2) 0.02 6 0.1 (0–1) 0.018 OSDI score 30 6 23.2 (2.1–75) 18.2 6 16 (2.1–62.5) 0.04 Upper meiboscore 1.0 6 0.8 (0–2) 1.0 6 1.0 (0–3) 0.48 Lower 2.0 6 0.9 (0–3) 0.6 6 0.6 (0–2) ,0.001 meiboscore Total meiboscore 1.5 6 0.6 (0–2.5) 1.0 6 0.7 (0–2.5) 0.03 OSDI, ocular surface disease index.
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1.1 6 0.8 (range, 0–2), 2.1 6 0.9 (range, 0–3), and 1.6 6 0.7 (range, 0–2.5), respectively. The average upper eyelid, lower eyelid, and total eyelid meiboscores in group 2 were 1.02 6 1.0 (range, 0–3), 0.6 6 0.6 (range, 0–2), and 1.1 6 0.7 (range, 0–2.5), respectively. The difference between meiboscores of the groups for lower eyelids and total eyelids were statistically significant (P , 0.001, P = 0.03, respectively).
DISCUSSION The diagnosis of ocular rosacea is particularly challenging in the subgroup of patients who lack the typical facial skin findings. Up to 90% of patients with ocular rosacea may have neither obvious roseatic skin changes nor a previous diagnosis of rosacea, and 8% to 20% may have no skin manifestations at all.3,4 In patients with signs and symptoms consistent with ocular rosacea, but without cutaneous features, the diagnosis of ocular rosacea should be considered in the clinical differential diagnosis. Nevertheless, considering the lack of specificity of the ocular signs and symptoms, the term ocular rosacea should probably not be applied to those patients in scientific reports and trials, unless typical skin findings are also detected. Herein, all patients with ocular rosacea included in the study were already diagnosed with rosacea by a specialized dermatologist and diagnosed as ocular rosacea by a specialized ophthalmologist. Ocular rosacea may cause visual impairment by causing severe dry eye, corneal ulcers and scarring, and even corneal perforation.3,4 Because we excluded all patients with corneal involvement, none of our patients had any visual disability. Dry eye and related symptoms with accompanying decreased T-BUT and tear production may occur in patients with ocular rosacea.3–5 In 16.6% of our patients with ocular rosacea, dry eye was positive, and Schirmer 1 and T-BUT measurements were significantly lower than in normal individuals. Because the dry eye disease in these individuals was mild with no adjunctive corneal epitheliopathy, no decrease in bestcorrected visual acuity was detected. Meibomian glands play an important role in structuring the lipid layer of the tear film.12 MGD, which is present in up to of 92% of patients with rosacea, consequently causes dry eye, mainly of the evaporative type.3,4 There are several ways to evaluate meibomian gland function: slit-lamp biomicroscopy for meibomian gland orifice appearance and to assess the quality of meibum, T-BUT measurement, ocular surface staining, and analyzing meibum expressed from the glands and meibography—a relatively newly described technique that warrants MGD diagnosis.4 A number of strategies are available to perform meibography, including transilluminating meibography, noncontact meibography, infrared photography, and confocal microscopy.13 Although the transillumination method seems to be the simplest, it requires technical experience to perform and is associated with patient discomfort. By contrast, noncontact methods, which are available now, offer a more patient-friendly strategy for meibomian gland imaging.10,11,13 Herein, the infrared camera of OCT—which is commonly found in many clinics—was used for meibography, which provides visualization of the meibomian gland structure using an infrared filter. Lower Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 5, May 2015
eyelid and total eyelid meiboscores of patients with ocular rosacea were significantly higher than in normal individuals. In patients with ocular rosacea, elevated concentrations of proinflammatory cytokine interleukin-1a and promatrix metalloproteinase 9—a degrading enzyme—within the tears are reported.12–14 The reason for significant lower eyelid meibomian gland loss in these patients might be the further exposure of lower eyelids to the tears as reported by Eom et al.15 Furthermore, meibomian glands are anatomically different between upper and lower eyelids and may differ functionally given that upper eyelids move more prominently than do the lower eyelids during blinking.16 Therefore, meibum is more easily and continuously secreted in the upper eyelids than in the lower eyelids. This may prevent obstruction and hyperkeratinization within the upper eyelids. Besides, in the upper eyelids, the direction of meibum delivery follows the direction of gravity.16 However, in lower eyelids, meibum delivery occurs in the opposite direction.16 Therefore, the meibum of the lower meibomian glands is more likely to stagnate in the ducts and orifices, resulting in duct dilation, acinar atrophy, and ultimately meibomian gland loss.15,16 It is also known that aging causes a significant decrease in meibomian gland acini even in healthy individuals. However, the mean age of both groups was similar to exclude this hypothesis as a cause of the difference between groups.10,17,18 As a result, ocular rosacea causes dry eye and MGD, which can easily and objectively be demonstrated with meibography. The infrared camera of OCT might be used to evaluate MGD and meibomian gland loss in these patients. Even if these patients do not have any complaints, eyelid hygiene, warm compress, and if possible, preservative-free ocular lubrication agents should be advised to prevent potential complications. REFERENCES 1. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: report of the NNational Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol. 2002;46:584–587.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Dry Eye and Meibography in Patients With Rosacea
2. Ghanem VC, Mehra N, Wong S, et al. The prevalence of ocular signs in acne rosacea: comparing patients from ophthalmology and dermatology clinics. Cornea. 2003;22:230–233. 3. Akpek EK, Merchant A, Pinar V, et al. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. 1997;104:1863–1867. 4. Alvarenga LS, Mannis MJ. Ocular rosacea. Ocul Surf. 2005;3:41–58. 5. Kocak-Altintas AG, Kocak-Midillioglu I, Gul U, et al. Impression cytology and ocular characteristics in ocular rosacea. Eur J Ophthalmol. 2003;13:351–359. 6. Knop N, Knop E. Meibomian glands. Part I. Anatomy, embryology and histology of the Meibomian glands. Ophthalmologe. 2009;106: 872–883. 7. Nagyova B, Tiffany JM. Components responsible for the surface tension of human tears. Curr Eye Res. 1999;19:4–11. 8. Craig JP, Tomlinson A. Importance of the lipid layer in human tear film stability and evaporation. Optom Vis Sci. 1997;74:8–13. 9. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52:1930–1937. 10. Arita R, Itoh K, Inoue K, et al. Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population. Ophthalmology. 2008;115:911–915. 11. Pult H, Riede-Pult BH. Non-contact meibography: keep it simple but effective. Cont Lens Anterior Eye. 2012;35:77–80. 12. Dursun D, Piniella AM, Pflugfelder SC. Pseudokeratoconus caused by rosacea. Cornea. 2001;20:668–669. 13. Pult H, Nichols JJ. A review of meibography. Optom Vis Sci. 2012;89: E760–E769. 14. Stone D, Chodosh J. Oral tetracyclines for ocular rocasea: an evidencebased review of the literature. Cornea. 2004;23:106–109. 15. Afonso AA, Sobrin L, Monroy DC, et al. Tear fluid gelatinase B activity correlates with IL-1alpha concentration and fluorescein clearance in ocular rosacea. Invest Ophthalmol Vis Sci. 1999;40:2506–2512. 16. Eom Y, Choi KE, Kang SY, et al. Comparison of Meibomian gland loss and expressed meibum grade between the upper and lower eyelids in patients with obstructive meibomian gland dysfunction. Cornea. 2014; 33:448–452. 17. Knop E, Knop N, Millar T, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 2011;52:1938–1978. 18. Matsumoto Y, Sato E, Ibrahim O, et al. The application of in vivo laser confocal microscopy to the diagnosis and evaluation of meibomian gland dysfunction. Mol Vis. 2008;14:1263–1271.
www.corneajrnl.com |
499
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Evaluation of Dry Eye and Meibomian Gland Dysfunction With Meibography in Patients With Rosacea Melis Palamar, MD, Cumali Degirmenci, MD, Ilgen Ertam, MD, and Ayse Yagci, MD
Purpose: To evaluate the dry eye tests and meibography of patients with ocular rosacea.
Methods: Thirty-six eyes of 18 patients with ocular rosacea (group 1) and 38 eyes of 19 healthy individuals (group 2) were enrolled. Besides full-eye examination, corneal and conjunctival fluorescein staining and Oxford scoring, tear film break-up time, Schirmer 1 test, ocular surface disease index score assessment, and evaluation of upper and lower eyelid meibomian glands using infrared captures of an optical coherence tomography (OCT) (Spectralis HRA+OCT; Heidelberg Engineering) device were performed (grade 0: no loss of meibomian glands, grade 1: gland dropout area ,1/3 of the total meibomian glands, grade 2: gland dropout area 1/3 to 2/3 of the total meibomian glands, grade 3: gland dropout .2/3 of the total meibomian glands). Results: The mean ages of group 1 and group 2 were 50.2 6 9.5
(range, 32–65), and 46.3 6 14.1 years (range, 25–70), respectively (P = 0.225). No significant difference in best-corrected visual acuity and meiboscores of upper eyelids were detected in between groups. Schirmer 1 and tear film break-up time in group 1 were significantly lower than in group 2 (P = 0.005, P , 0.001, respectively). Ocular surface disease index and Oxford scale scores and meiboscores of lower and total (upper + lower) eyelids were significantly higher in group 1 than in group 2 (P = 0.04, P = 0.018, P , 0.001, P = 0.03, respectively).
Conclusions: Ocular rosacea causes dry eye and significant meibomian gland loss that can objectively be demonstrated with meibography. The infrared camera of OCT—that is widely found in many ophthalmology departments—might be used to evaluate meibomian gland dysfunction in these individuals. Key Words: dry eye, ocular surface, meibomian gland dysfunction, meibography, ocular rosacea (Cornea 2015;34:497–499)
R
osacea is a chronic cutaneous disorder characterized by persistent erythema, telangiectasias, papules, and pustules, primarily of the convexities of the central face (cheeks, chin, Received for publication November 11, 2014; revision received December 30, 2014; accepted January 7, 2015. Published online ahead of print March 2, 2015. From the Department of Ophthalmology (MP, CD, AY) and Department of Dermatology (IE), Ege University Faculty of Medicine, Izmir, Turkey. The authors have no funding or conflicts of interest to disclose. Reprints: Melis Palamar, MD, Ege Universitesi Tip Fakultesi Hastanesi, Goz Hastaliklari AD, Bornova 35040, Izmir, Turkey (e-mail: melispalamar@ hotmail.com). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cornea Volume 34, Number 5, May 2015
nose, and central forehead).1 Four subtypes (erythematotelangiectatic, papulopustular, phymatous, and ocular) and 1 variant (granulomatous) are described for rosacea, depending on which primary and secondary features are more prominent.1 Patients may have clinical features consistent with more than 1 subtype. More than half of all patients with rosacea have ocular disease.2 Ocular symptoms include blepharitis, meibomitis, recurrent chalazia, episcleritis, iritis, and corneal ulcers, vascularization, and scarring.2–5 Meibomian glands are specialized sebaceous glands, which are localized at the tarsal plates of the eyelids. These glands are responsible for lipid secretion, which plays a significant role to build the surface tension and stability of the tear film and prevents evaporation.6–8 Meibomian gland dysfunction (MGD) is a chronic disease, which results in ocular irritation and ocular surface disorders because of lipid layer abnormalities.9 Meibography is a relatively new technique for evaluating MGD. Infrared imaging of meibomian glands and scoring systems for meibomian gland loss are the leading research subjects on MGD recently.10,11 To the best of our knowledge, no study to date has evaluated the meibomian glands of patients with ocular rosacea with meibography. For this purpose, we evaluated the dry eye tests and performed meibography of patients with ocular rosacea as measured with optical coherence tomography (OCT) and compared these results with healthy individuals.
MATERIALS AND METHODS In this cross-sectional observational study, 36 eyes of 18 patients with ocular rosacea (group 1) and 38 eyes of 19 healthy volunteers (group 2) were evaluated. All patients with ocular rosacea included in the study were already diagnosed as rosacea by a specialized dermatologist (I.E.). Ocular rosacea diagnosis—which can be very challenging—was made with the detection of dry eye, blepharitis, MGD, and ocular irritation among these already diagnosed patients by a specialized ophthalmologist (M.P.).6–8 Patients with corneal involvement (ulcers, vascularization, and scarring) or episcleral/scleral involvement, cataract, glaucoma, contact lens use, previous ophthalmic surgery, smoking history, and patients using any medications were excluded. Both eyes of each subject were evaluated for the study, and the mean values of both eyes were assessed for data analysis. All cases underwent a detailed ophthalmological examination and the following tests were performed: corneal and conjunctival fluorescein staining and Oxford scoring, tear film www.corneajrnl.com |
497
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 5, May 2015
Palamar et al
break-up time (T-BUT), Schirmer 1, ocular surface disease index score assessment, and evaluation of the meibomian glands after everting both upper and lower eyelids to reveal infrared captures using the OCT device (Spectralis HRA +OCT; Heidelberg Engineering, Heidelberg, Germany). Partial or complete loss of the meibomian glands were scored for each eyelid as grade 0 (no loss of meibomian glands), grade 1 (the area characterized by gland dropout was ,1/3 of the total meibomian glands), grade 2 (the area characterized by gland dropout was 1/3-2/3 of the total meibomian glands), and grade 3 (the area characterized by gland dropout was .2/3 of the total meibomian glands).10 Meiboscore assessment was performed masked by the same researcher (A.Y.). The meiboscores for the upper and lower eyelids and total (upper + lower) eyelids were summed for each eye. This study was approved by the institutional review board of the Ege University Hospital and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from each subject. The Statistical Package for the Social Sciences version 11.5.0 was used for statistical analysis.
RESULTS
The mean age of group 1 and group 2 were 50.2 6 9.5 (range, 32–65) and 46.3 6 14.1 years (range, 25–70), respectively (P = 0.225) (Table 1). Best-corrected visual acuity of group 1 and group 2 were 1.0 (range, 1.0–1.0) and (range, 1.0–1.0), respectively (P = 0.2). Schirmer 1 measurements of group 1 and group 2 were 16.8 6 10.1 (range, 0–35) and 23.4 6 9.0 (range, 5–35) mm, respectively (P = 0.005). T-BUT measurements of group 1 and group 2 were 10.2 6 5.5 (range, 2–20) and 20.2 6 7.9 (range, 7–39) seconds, respectively (P , 0.001). Dry eye was detected in 3 patients in group 1 and none in group 2 according to Schirmer 1 and T-BUT values. The mean superficial punctate staining according to the Oxford scale in group 1 and group 2 were 1.1 6 0.8 (range, 0–2) and 0.02 6 0.1 (range, 0–1), respectively (P = 0.018). The mean ocular surface disease index scores in group 1 and group 2 were 30.0 6 23.2 (range, 2.1–75) and 18.2 6 16.0 (range, 2.1–62.5), respectively (P = 0.04). The average upper eyelid, lower eyelid, and total (upper eyelid plus lower eyelid) eyelid meiboscores in group 1 were
TABLE 1. Demographics, Dry Eye Tests, and Meiboscores of the Groups Group 1
Group 2
P
Age, yrs 50.2 6 9.5 (32–65) 46.3 6 14.1 (25–70) 0.225 Schirmer-1, mm 16.8 6 10.1 (0–35) 23.4 6 9.0 (5–35) 0.005 T-BUT, s 10.2 6 5.5 (2–20) 20.2 6 7.9 (7–39) ,0.001 Oxford scale 1.0 6 0.8 (0–2) 0.02 6 0.1 (0–1) 0.018 OSDI score 30 6 23.2 (2.1–75) 18.2 6 16 (2.1–62.5) 0.04 Upper meiboscore 1.0 6 0.8 (0–2) 1.0 6 1.0 (0–3) 0.48 Lower 2.0 6 0.9 (0–3) 0.6 6 0.6 (0–2) ,0.001 meiboscore Total meiboscore 1.5 6 0.6 (0–2.5) 1.0 6 0.7 (0–2.5) 0.03 OSDI, ocular surface disease index.
498
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1.1 6 0.8 (range, 0–2), 2.1 6 0.9 (range, 0–3), and 1.6 6 0.7 (range, 0–2.5), respectively. The average upper eyelid, lower eyelid, and total eyelid meiboscores in group 2 were 1.02 6 1.0 (range, 0–3), 0.6 6 0.6 (range, 0–2), and 1.1 6 0.7 (range, 0–2.5), respectively. The difference between meiboscores of the groups for lower eyelids and total eyelids were statistically significant (P , 0.001, P = 0.03, respectively).
DISCUSSION The diagnosis of ocular rosacea is particularly challenging in the subgroup of patients who lack the typical facial skin findings. Up to 90% of patients with ocular rosacea may have neither obvious roseatic skin changes nor a previous diagnosis of rosacea, and 8% to 20% may have no skin manifestations at all.3,4 In patients with signs and symptoms consistent with ocular rosacea, but without cutaneous features, the diagnosis of ocular rosacea should be considered in the clinical differential diagnosis. Nevertheless, considering the lack of specificity of the ocular signs and symptoms, the term ocular rosacea should probably not be applied to those patients in scientific reports and trials, unless typical skin findings are also detected. Herein, all patients with ocular rosacea included in the study were already diagnosed with rosacea by a specialized dermatologist and diagnosed as ocular rosacea by a specialized ophthalmologist. Ocular rosacea may cause visual impairment by causing severe dry eye, corneal ulcers and scarring, and even corneal perforation.3,4 Because we excluded all patients with corneal involvement, none of our patients had any visual disability. Dry eye and related symptoms with accompanying decreased T-BUT and tear production may occur in patients with ocular rosacea.3–5 In 16.6% of our patients with ocular rosacea, dry eye was positive, and Schirmer 1 and T-BUT measurements were significantly lower than in normal individuals. Because the dry eye disease in these individuals was mild with no adjunctive corneal epitheliopathy, no decrease in bestcorrected visual acuity was detected. Meibomian glands play an important role in structuring the lipid layer of the tear film.12 MGD, which is present in up to of 92% of patients with rosacea, consequently causes dry eye, mainly of the evaporative type.3,4 There are several ways to evaluate meibomian gland function: slit-lamp biomicroscopy for meibomian gland orifice appearance and to assess the quality of meibum, T-BUT measurement, ocular surface staining, and analyzing meibum expressed from the glands and meibography—a relatively newly described technique that warrants MGD diagnosis.4 A number of strategies are available to perform meibography, including transilluminating meibography, noncontact meibography, infrared photography, and confocal microscopy.13 Although the transillumination method seems to be the simplest, it requires technical experience to perform and is associated with patient discomfort. By contrast, noncontact methods, which are available now, offer a more patient-friendly strategy for meibomian gland imaging.10,11,13 Herein, the infrared camera of OCT—which is commonly found in many clinics—was used for meibography, which provides visualization of the meibomian gland structure using an infrared filter. Lower Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Cornea Volume 34, Number 5, May 2015
eyelid and total eyelid meiboscores of patients with ocular rosacea were significantly higher than in normal individuals. In patients with ocular rosacea, elevated concentrations of proinflammatory cytokine interleukin-1a and promatrix metalloproteinase 9—a degrading enzyme—within the tears are reported.12–14 The reason for significant lower eyelid meibomian gland loss in these patients might be the further exposure of lower eyelids to the tears as reported by Eom et al.15 Furthermore, meibomian glands are anatomically different between upper and lower eyelids and may differ functionally given that upper eyelids move more prominently than do the lower eyelids during blinking.16 Therefore, meibum is more easily and continuously secreted in the upper eyelids than in the lower eyelids. This may prevent obstruction and hyperkeratinization within the upper eyelids. Besides, in the upper eyelids, the direction of meibum delivery follows the direction of gravity.16 However, in lower eyelids, meibum delivery occurs in the opposite direction.16 Therefore, the meibum of the lower meibomian glands is more likely to stagnate in the ducts and orifices, resulting in duct dilation, acinar atrophy, and ultimately meibomian gland loss.15,16 It is also known that aging causes a significant decrease in meibomian gland acini even in healthy individuals. However, the mean age of both groups was similar to exclude this hypothesis as a cause of the difference between groups.10,17,18 As a result, ocular rosacea causes dry eye and MGD, which can easily and objectively be demonstrated with meibography. The infrared camera of OCT might be used to evaluate MGD and meibomian gland loss in these patients. Even if these patients do not have any complaints, eyelid hygiene, warm compress, and if possible, preservative-free ocular lubrication agents should be advised to prevent potential complications. REFERENCES 1. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: report of the NNational Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol. 2002;46:584–587.
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Dry Eye and Meibography in Patients With Rosacea
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