Wednesday, March 27, 2013

Abstract: Herpes zoster and corneal nerve alteration

Unilateral herpes zoster ophthalmicus results in bilateralcorneal nerve alteration: an in vivo confocal microscopy study.

Herpes zoster ophthalmicus (HZO), thought to be a unilateral disease, results in loss of corneal sensation, leading to neurotrophic keratopathy. This study aimed to analyze bilateral corneal nerve changes in patients with HZO by in vivo confocal microscopy (IVCM) and their correlation with corneal sensation as a measure of nerve function.
Prospective, cross-sectional, controlled, single-center study.
Twenty-seven eyes with the diagnosis of HZO and their contralateral clinically unaffected eyes were studied and compared with normal controls (n = 15).
In vivo confocal microscopy (Confoscan 4; Nidek Technologies, Gamagori, Japan) and corneal esthesiometry (Cochet-Bonnet; Luneau Ophthalmologie, Chartres, France) of the central cornea were performed bilaterally in all patients and controls. Patients were grouped into normal ( > 5.5 cm), mild ( > 2.5-5.5 cm), and severe ( < 2.5 cm) loss of sensation.
Changes in corneal nerve density, total nerve number, main nerve trunks, branching, and tortuosity were evaluated after IVCM and were correlated to corneal sensation, disease duration, and number of recurrences.
Eyes with herpes zoster ophthalmicus had a significant (P < 0.001) decrease in total nerve length (595.8±358.1 vs. 2258.4±989.0 μm/frame), total number of nerves (5.4±2.8 vs. 13.1±3.8), number of main nerve trunks (2.3±1.1 vs. 4.7±1.2), and number of nerve branches (3.2±2.3 vs. 8.4±3.7) as compared with controls. In the contralateral clinically unaffected eyes, total nerve length (1053.1±441.4 μm/frame), total number of nerves (8.3±2.9), and main nerve trunks (3.1±1.0) also were decreased significantly as compared with controls (P < 0.01). Reduced nerve density, total nerve count, main trunks, and tortuosity was correlated significantly with corneal sensation across all subgroups (P < 0.001).
Patients with unilateral HZO demonstrated a profound and significant bilateral loss of the corneal nerve plexus as compared with controls, demonstrating bilateral changes in a clinically unilateral disease. Loss of corneal sensation strongly correlated with subbasal nerve plexus alterations as shown by IVCM.
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Ophthalmology. 2013 Jan;120(1):40-7. doi: 10.1016/j.ophtha.2012.07.036. Epub 2012 Sep 19.
Hamrah P, Cruzat A, Dastjerdi MH, Prüss H, Zheng L, Shahatit BM, Bayhan HA, Dana R, Pavan-Langston D.
Ocular Surface Imaging Center and Cornea & Refractive Surgery Service, Massachusetts Eye & Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts 02114, USA.

Abstract: Restasis & MGD

To compare the efficacy of topical cyclosporine [0.05% cyclosporine A (CsA)] and preservative-free artificial tears in the treatment of meibomian gland dysfunction (MGD).
A 3-month prospective, randomized, double-masked, parallel-group controlled trial enrolled 70 patients with symptomatic MGD and unstable tear film [tear breakup time (TBUT) < 8 seconds]. Patients were randomized to topical CsA (0.05%; group A) and 0.5% carboxymethylcellulose (control; group B) instilled twice daily for 3 months. Ocular Surface Disease Index (OSDI), lid margin inflammation, meibomian gland expression, conjunctival injection, corneal and interpalpebral dye staining, noninvasive tear breakup time (NIBUT) using the Tearscope Plus and invasive fluorescein tear breakup time (FBUT), and Schirmer I test were performed.
At the 3-month evaluation, mean OSDI, NIBUT and FBUT, lid margin inflammation, meibomian gland expressibility, and tarsal injection showed significant improvement from baseline in group A (P < 0.01, P < 0.01, P < 0.001, P < 0.05, and P < 0.001, respectively). In group B, only the OSDI improved significantly from baseline at 3 months (P = 0.003). TBUTs (NIBUT and FBUT) were significantly longer in group A at all visits, and the mean change of TBUTs from baseline was also significantly greater in group A at 3 months (P < 0.001).
Topical CsA 0.05% twice daily may be helpful in the treatment of MGD mainly by improving tear film stability.

Cornea. 2012 Dec;31(12):1386-93. doi: 10.1097/ICO.0b013e31823cc098.
Prabhasawat P, Tesavibul N, Mahawong W.
Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Abstract: Radioiodine treatment for hyperthyroidism & tear function

Radioiodine (RAI) is used in the treatment of hyperthyroidism and differentiated thyroid cancer. Radioiodine therapy is associated with dry eyes and some side effects are seen especially due to beta rays. In this study, the functional and cytological status of lacrimal glands after RAI therapy was evaluated.
Twenty-five patients with a mean age of 55.16 years with planned low-dose RAI therapy were evaluated. Just before and 6 months after the treatment, the lacrimal glands were evaluated with tear break-up time (BUT), Schirmer's test, impression cytology and "Ocular Surface Disease Index (OSDI)" questionnaire.
The mean value of Schirmer's test was 16.20 ± 3.61 pre-treatment and 11.28 ± 4.39 post-treatment for the right eye, and 15.76 ± 3.27 and 10.60 ± 4.42 for the left eye, respectively. The mean value of Schirmer's test decreased significantly post-treatment in both eyes (p = 0.0001). The BUT score also decreased significantly post-treatment (p = 0.001). The mean value of OSDI score was 27.5 ± 8.02 pre-treatment and 46.36 ± 10.27 post-treatment. The mean value of OSDI score increased post-treatment (p = 0.0001). The impression scores also increased post-treatment in both eyes (p = 0.0001).
Even low-dose (≤30 mci) RAI treatment affects lacrimal gland functions. Low-dose RAI causes a decrease in the value of Schirmer's test and the BUT test, and an increase in the value of OSDI score and impression scores.

Ann Nucl Med. 2013 Feb 27. [Epub ahead of print]
Koca G, Acar U, Atilgan HI, Ergintürk Acar D, Altiparmak UE, Demirel K, Yalniz-Akkaya Z, Ustun H, Korkmaz M, Ornek F.
Department of Nuclear Medicine, Ministry of Health, Ankara Training and Research Hospital, Ulucanlar Street, 06560, Ankara, Turkey,

Abstract: "Extended blinks" and interblink intervals in DES

Investigation of extended blinks and interblink intervals insubjects with and without dry eye.
(Link is to full text of study)
The purpose of this study was to investigate the occurrence and duration of extended blinks ≥ 70 msec and their associated interblink intervals in normal subjects and in subjects with mild to moderate dry eye.
This single-center, prospective, double-blind study included 11 subjects with dry eye and eight subjects with normal eyes. Extended blinks were defined as lid closure in at least two successive video frames (≥70 msec). Digital video imaging of each subject's eyes was recorded while the subject viewed a 10-minute documentary. The subjects did not know that blink was the outcome being measured. Following capture, the videos were manually analyzed in a masked fashion for the occurrence of extended blinks. The length of the interblink interval (ie, time between blinks) before and after these extended blinks (the interblink interval ratio) was calculated, as well as differences in lid contact times.
The dry eye group had a median extended blink duration which was 2.53 times longer than that of the normal group. For subjects with dry eye, interblink intervals post-extended blink were significantly longer than interblink intervals pre-extended blink (P < 0.001). Interblink intervals did not lengthen significantly in normal subjects. In both groups, the duration of the extended blink was significantly (P = 0.001) and positively correlated with interblink interval ratio (post-extended to pre-extended blink interblink interval), such that for each doubling of extended blink duration, the interblink interval ratio increased by 10%. Blinks longer than one second in duration occurred almost exclusively in subjects with dry eye.
THIS STUDY REPORTS THREE CENTRAL FINDINGS: blink duration tended to be longer in subjects with dry eye; a lengthening of the interblink interval after an extended blink occurred in subjects with dry eye but not in those without dry eye; and a longer blink duration was associated with a significantly increased interblink interval ratio in all subjects.

Clin Ophthalmol. 2013;7:337-42. doi: 10.2147/OPTH.S39356. Epub 2013 Feb 14.
Rodriguez JD, Ousler GW 3rd, Johnston PR, Lane K, Abelson MB.

Ora, Inc, Andover, MA.

Abstract: Tear production & drainage after Botox for blepharospasm

Tear production and drainage after botulinum toxin Ainjection in patients with essential blepharospasm.

Purpose:To evaluate the clinical manifestations of tear production, distribution and drainage in the essential blepharospasm patients, and to analyse the changes after botulinum toxin A injection in these patients.
 Methods:This prospective study was performed in 23 patients with essential blepharospasm treated with Botulinum neurotoxin A (BoNT-A; Dysport, Ipsen Biopharm, UK) from November 2010 to February 2011. Ocular examinations, including frequency and severity of blepharospasm, tear break up time (BUT), Schirmer's test, lower lid tear meniscus height (TMH) measured by optical coherence tomography (OCT, rtvue software version 3.5; Optovue Inc., Fremont, CA, USA), and dacryoscintigraphy using 99m technetium pertechnetate, were performed before and 2 weeks after BoNT-A injection. We asked all patients about changes in the dry eye symptom score, before and after treatment. Results were analysed with independent t-test using spss software version 12.0 for Windows XP, (SPSS Inc., Chicago, IL, USA).
 Results:Botulinum neurotoxin A treatment relieved blepharospasm in all patients. Mean injection dose was 38±5.6 units. After injection, mean tear BUT was significantly increased from 4.7±4.9 to 6.6±1.6seconds (p=0.001) Lower TMH increased in all three points and most notably at the lateral point (p=0.05). On dacryoscintigraphy, tear drainage velocity was not affected by BoNT-A treatment. But Tc-99m 50% clearance time in interpalpebral fissure significantly increased from 1564 to 2220seconds on the time activity curve (p=0.027). Subjective dry eye symptoms also improved in 16 patients (70%) after injection.
 Conclusion:Tear film stability and TMH increased, but tear drainage velocity was not affected by BoNT-A treatment. Overall Tc-99m 50% clearance time in interpalpebral fissure significantly increased, and tear storage from mild lateral lower eyelid laxity increased after BoNT-A injection. Botulinum neurotoxin A injection was also effective for combined dry eye symptom in the essential blepharospasm patients.
Acta Ophthalmol. 2013 Mar;91(2):e108-12. doi: 10.1111/aos.12002.
Park DI, Shin HM, Lee SY, Lew H.
Department of Ophthalmology, CHA University, Bundang CHA Medical Center, Sungnam, Korea Department of Ophthalmology, Yonsei University, Severance Hospital, Seoul, Korea.

Abstract: LASIK and tear film (in)stability

Conscientiously refraining from any snarky remarks.

The study was conducted to evaluate tear film stability and tear secretion before and after laser in situ keratomileusis.
It was a prospective, longitudinal and non-comparative analysis of clinical data of 20 consecutive myopic patients (40 eyes) collected before and after laser in situ keratomileusis. Assessments included tear secretion (Schirmer I and II), fluorescein tear break up time and ocular surface staining. Statistics: The statistical package for social science (SPSS 10.0) was used for data analysis. The parameters of tear secretion and tear stability were analyzed using the paired and unpaired Student t-tests.
Schirmer II was reduced at seven days (9.5 ± 4.30 mm) and one month (10.3 ± 3.06 mm, p = 0.001) after operation from the pre-operative value of 16.12 ± 3.90 mm. Tear film stability significantly decreased at seven days (6.79 ± 3.05 sec, p Less than 0.001) and one month (8.03 ± 2.81secs, p less than 0.001) from its pre-operative value (12.68 ± 2.69 secs). 87.5% had tear film instability (FBUT less than 10secs) seven days after surgery; it was reduced to 75 % at one month and 27.5 % at three months. It was 7.5 % before surgery. Corneal staining score was increased significantly at seven days (1.42 ± 1. 58, p less than 0.01) and one month (0.95 ± 1.41, p = 0.02), from the pre-operative score of 0.17 ± 0.44.
Laser in situ keratomileusis significantly alters the tear film stability, Schirmer values and corneal staining at least for three months.
Nepal J Ophthalmol. 2011 Jul-Dec;3(2):140-5. doi:
Shrestha GS, Wagh S, Darak A.
Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal.

Abstract: Yup, airplanes are bad for dry eye

No surprises here. We have had how many hundreds of threads on DryEyeTalk over the years talking about how to cope in the air. - In one of the very earliest, Phyllis aka Lucy summed it all up:

Drink up. 
Lube up. 
Cover up.

To evaluate symptoms, signs and the levels of 16 tears inflammatory mediators of dry eye (DE) patients exposed to an environment simulating an in-flight air cabin in an environmental chamber.
Twenty DE patients were exposed to controlled environment simulating an in-flight airplane cabin [Simulated in-flight condition (SIC)] of 23ºC, 5% relative humidity, localized air flow, and 750 millibars (mb) of barometric pressure. As controls, 15 DE patients were subjected to a simulated standard condition (SSC) of 23ºC, 45% relative humidity, and 930 mb. A DE-symptoms questionnaire, diagnostic tests, and determination of 16 tear molecules by multiplex bead array were performed before and 2 hr after exposure.
After SIC exposure, DE patients became more symptomatic, suffered a significant (p≤0.05) decrease in tear stability (tear break-up time) (from 2.18±0.28 to 1.53±0.20), and tear production (Phenol red thread test), and a significant (p≤0.05) increase in corneal staining, both globally (0.50±0.14 before and 1.25 ± 0.19 after) and in each area (Baylor scale). After SSC, DE patients only showed a mild but significant (p≤0.05) increase in central and inferior corneal staining. Consistently, tear levels of IL-6 and MMP-9 significantly increased and tear EGF significantly decreased (p≤0.05) only after SIC.
The controlled adverse environment conditions in this environmental chamber can simulate the conditions in which DE patients might be exposed during flight. As this clearly impaired their lacrimal functional unit, it would be advisable that DE patients use therapeutic strategies capable of ameliorating these adverse episodes.

Invest Ophthalmol Vis Sci. 2013 Feb 14. pii: iovs.12-11361v1. doi: 10.1167/iovs.12-11361. [Epub ahead of print]
Teson M, Gonzalez-Garcia MJ, Lopez-Miguel A, Enriquez-de-Salamanca A, Martin-Montanez V, Benito MJ, Mateo ME, Stern ME, Calonge M.
IOBA, University of Valladolid, Valladolid, Spain.

Abstract: Tear osmolarity in Sjogrens Syndrome

PURPOSE:: The Schirmer test is one of the 2 ocular surface tests included in the current classification criteria for Sjögren syndrome (SS). Tear osmolarity may also be a useful test for the diagnosis of dry eye disease. The purpose of this study was to examine the relationship between tear osmolarity, the Schirmer test I, and dry eye symptoms in SS.
 METHODS:: Patients with a diagnosis of SS were assessed for tear osmolarity with the TearLab Osmolarity System, tear production with Schirmer testing, symptoms with the Ocular Surface Disease Index (OSDI), and discomfort associated with each test.
 RESULTS:: Forty-nine patients with a mean age of 53.7 years and a female (92%) predominance were enrolled. The majority of patients (86%) were receiving systemic therapy for severe SS. Higher tear osmolarity was moderately associated with lower scores on the Schirmer test I (ρ = -0.39, P < 0.01) and OSDI (ρ = -0.45, P < 0.01). Schirmer test I results and lower OSDI scores were not correlated significantly (ρ = 0.20, P = 0.17). Tear osmolarity testing was significantly less painful than Schirmer testing (P < 0.01).
 CONCLUSIONS:: Signs and symptoms of dry eye in SS patients were not strongly correlated. An unexpected finding was that higher tear osmolarity was associated with lower symptom severity. Tear osmolarity testing in the clinical setting was feasible and was associated with significantly less discomfort than Schirmer testing in patients with severe SS.

Cornea. 2013 Feb 12. [Epub ahead of print]
Bunya VY, Langelier N, Chen S, Pistilli M, Vivino FB, Massaro-Giordano G.
*Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA †Penn Sjogren's Syndrome Center, Department of Rheumatology, University of Pennsylvania, Philadelphia, PA.

Abstract: Bipolar, lithium carbonate, sodium valproate & dry eye

Ocular dryness is a well-recognized adverse side effect of many topical and systemic medications. In psychiatry, patients who have consumed such drugs as lithium carbonate and sodium valproate frequently experience dry eye symptoms. The purpose of this study was to compare tear film stability between patients who use these drugs with those patients who are not on medication.
After obtaining informed consent, the tear film break up time (TBUT) test was performed in 96 eyes of 48 subjects. The subjects were placed in to three groups. Participants included two groups of euthymic bipolar disorder patients (16 cases each) with history of pharmacotherapy for more than two years. Patients in each group were taking only one type of mood stabilizer (lithium carbonate or sodium valproate). In addition,16 age-matched bipolar patients who did not take any topical or systemic medications were included in a control group. Values of TBUT were compared between the three groups using the student's t-test.
The mean tear film break up time (TBUT) in test groups were 4.88 seconds± 0.34(lithium group), 4.81 seconds ± 1.60 (valproate group) and 15seconds± 2.0(control group), respectively. No statistically significant differences were observed between the first and the second groups in TBUT values, but significant differences were found between the two groups and the control group (P< 0.0001).
The results of this study show that lithium carbonate and sodium valproate contribute to decrease of tear film break up time, resulting from dryness of the eyes.

Iran J Psychiatry. 2012 Fall;7(4):191-3.
Dibajnia P, Mohammadinia M, Moghadasin M, Amiri MA.
Shahid Beheshti University of Medical Sciences, Faculty of Rehabilitation Sciences,Tehran, Iran.