Abstract
Purpose
The utility of in vivo confocal microscopy (IVCM) in the investigation of palpebral conjunctival and corneal inflammation in patients with meibomian gland dysfunction (MGD)-associated refractory dry eye symptoms following gland expression, despite objective clinical improvement.
Methods
A retrospective, observational pilot study was conducted evaluating five patients with MGD-associated refractory dry eye symptoms and three control groups: symptomatic untreated MGD patients (n=3), treatment-responsive MGD patients with improved symptoms (n=3) and asymptomatic healthy normals (n=11). Ocular surface disease index (OSDI) scores, tear break-up time (TBUT), the number of meibomian glands yielding liquid secretion (MGYLS), palpebral conjunctival epithelial and substantia propria immune cell (EIC, SIC), and corneal dendritic cell (DC) densities were measured.
Results
Despite clinical improvement (TBUT: 6.4±1.2 s to 10.1±2.1 s, P=0.03; MGYLS: 3.5±0.8 glands to 7.0±1.1 glands, P=0.13) and a normal clinical examination post treatment, MGD patients remained symptomatic. IVCM revealed increased immune cells in the palpebral conjunctiva (refractory MGD EIC=592.6±110.1 cells/mm2; untreated MGD EIC=522.6±104.7 cells/mm2, P=0.69; responsive MGD EIC=194.9±119.4 cells/mm2, P<0.01; normals EIC=123.7±19.2 cells/mm2, P< 0.001), but not the cornea (refractory MGD DC=60.9±28.3 cells/mm2; normals DC=25.9±6.3 cells/mm2; P=0.43). EIC did not correlate with TBUT (Rs=−0.26, P=0.33). OSDI scores correlated with both EIC (Rs=0.76, P<0.001) and TBUT (Rs=−0.69, P<0.01) but not SIC. Intraglandular immune cells were also seen.
Conclusion
MGD-associated refractory symptoms and the symptom-sign disparity may be explained by clinically non-apparent, active inflammation of the palpebral conjunctiva as detected by IVCM. These patients may benefit from anti-inflammatory therapy.
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Acknowledgements
The work presented in this article was supported by NIH K08-EY020575 (PH), NIH L30-EY021919 (PH), Falk Medical Research Foundation (PH), and Research to Prevent Blindness Career Development Award (PH). The funding organizations had no role in the design or conduct of this research.
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Drs Hamrah and Qazi are inventors on a patent application regarding the utility of the diagnostic procedure and findings described in this report. The remaining authors declare no conflict of interest.
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This work was presented in part at the Association for Research in Vision and Ophthalmology in Ft. Lauderdale, Florida, May 2012; at the American Academy of Optometry in Boston, Massachusetts, October 2011; and at the 27th Biennial Cornea Conference in Boston, Massachusetts, September 2011.
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Qazi, Y., Kheirkhah, A., Blackie, C. et al. In vivo detection of clinically non-apparent ocular surface inflammation in patients with meibomian gland dysfunction-associated refractory dry eye symptoms: a pilot study. Eye 29, 1099–1110 (2015). https://doi.org/10.1038/eye.2015.103
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DOI: https://doi.org/10.1038/eye.2015.103
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