Current Eye Research

ISSN: 0271-3683 (Print) 1460-2202 (Online) Journal homepage: http://www.tandfonline.com/loi/icey20

Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment Seung Hoon Oh, Byul Lyu, Hye Bin Yim & Na Young Lee To cite this article: Seung Hoon Oh, Byul Lyu, Hye Bin Yim & Na Young Lee (2015): Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment, Current Eye Research To link to this article: http://dx.doi.org/10.3109/02713683.2015.1015142

Published online: 24 Mar 2015.

Submit your article to this journal

Article views: 44

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=icey20 Download by: [Monash University Library]

Date: 13 November 2015, At: 10:05

Current Eye Research, Early Online, 1–6, 2015 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2015.1015142

RESEARCH REPORT

Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment

Downloaded by [Monash University Library] at 10:05 13 November 2015

Seung Hoon Oh, Byul Lyu, Hye Bin Yim and Na Young Lee Department of Ophthalmology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

ABSTRACT Purpose: To compare the responses to dry eye treatment of patients sorted by the degree of lower lid laxity. Methods: Sixty patients were grouped into three groups according to the degree of lower lid laxity. Tear break-up time (TBUT), Schirmer test (ST) scores, ocular surface disease index (OSDI) scores, and changes in OSDI score in each group were compared, before and at 3 months after treatment. Results: TBUT, ST, and OSDI scores were not different among the three groups at baseline. TBUT improved in each group at 3 months after treatment, and no differences between groups were found. ST scores were not increased after treatment, while OSDI were improved to 22.57 ± 5.243, 31.16 ± 11.353, and 37.85 ± 13.342 in the no, moderate, and high laxity groups, respectively; these improvements were statistically significant (p = 0.003, 50.001, 50.001, respectively). Patients with greater than moderate lower lid laxity saw the smallest improvement in response to dry eye treatment, as assessed by change in OSDI score (p = 0.005 versus moderate laxity group, p = 0.005 versus no laxity group). Conclusions: Lower lid laxity is one of the factors contributing to the responses to dry eye treatment assessed by change in OSDI score, independent of TBUT and ST scores. Keywords: Dry eye syndrome, lower lid laxity, OSDI, Schirmer test, snap back test

INTRODUCTION

eye syndrome emphases on the correction of these underlying causes; supplementation with artificial tears, stimulation of lacrimal secretion, anti-inflammatory treatments, adjustment of tear osmolarity, or stimulation of mucin secretion from goblet cells. It is however difficult in practice to achieve complete remission of symptoms and patients often complain of inadequate symptom control despite improvements in clinical parameters.3,4 The eyelid plays an important role in dry eye by influencing the meibomian gland secretion, the frequency of lid blinking, and the quality of interactions between the ocular surface and eyelid. Reports of dry eye caused by post-surgical deformation of the eyelid emphasize its importance in protecting the ocular surface.5 Additionally, the fact that evaporative type is the most common within the dry eye spectrum

According to the definition of dry eye syndrome proposed by the 2007 International Dry Eye Workshop (DEWS), it is a multi-factorial disease of tears and of the ocular surface. It promotes various degrees of ocular discomfort, damaging the ocular surface with hyperosmolar tears and inflammation.1 The diagnosis and treatment guidelines of the DEWS report classify dry eye syndrome grossly into tear-deficient and evaporative types. The deficient type is caused by primary or secondary failure of the lacrimal glands while the evaporative type is caused by the meibomian gland dysfunction (MGD) and/or by decreased number of goblet cells which can be damaged by preservatives in eye drops and ocular surface diseases such as allergic conjunctivitis.1,2 The treatment of dry

Received 9 October 2014; revised 26 January 2015; accepted 30 January 2015; published online 17 March 2015 Correspondence: Na Young Lee, MD, PhD, Department of Ophthalmology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-ku, Seoul 137-701, Korea. Tel: (8232) 280-5112. Fax: (8232) 280-5118. E-mail: [email protected]

1

2

S. H. Oh et al.

Downloaded by [Monash University Library] at 10:05 13 November 2015

emphasized the role of eyelid in dry eye syndrome.6,7 However, as indicated in the DEWS report, the effect of eyelid features on dry eye lacks sufficient formal investigation.1,5,8 The Ocular Surface Disease Index (OSDI) is a 12-item questionnaire designed to provide a rapid assessment of the symptoms of ocular irritation consistent with dry eye disease and their impact on vision-related functioning.9,10 The OSDI allows clinicians to collect comprehensive subjective data in addition to a clinical history, and it can be used as a tool for measuring the effectiveness of a specific dry eye disease treatment.11 In this study, responses to dry eye treatment were compared among three groups of different lower lid laxity to evaluate its influence.

MATERIALS AND METHODS Study Population and Method The study population consisted of 60 dry eye patients who visited Incheon Saint Mary’s Hospital between August 2013 and November of the same year. The project was approved by the ethics committees and the Institutional Review Board of Incheon Saint Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea and the work was carried out in accordance with the Declaration of Helsinki. Individual medical histories were evaluated, including information on the use of contact lenses and on previous and current use of eye drops. The degree of subjective dry eye symptoms was quantified using the OSDI, with a maximum score of 100 points. The OSDI scores indicate the severity of subjective symptoms and range from 0 to 100. Visual acuity, intraocular pressure, slit lamp examination, tear break-up time (TBUT), and Schirmer test (ST) scores were evaluated for each patient. The degree of lower lid laxity was evaluated through a snap-back test, and the patients were classified into groups according to the time taken for the lower lid to come back to its original position. Upon releasing, if the recoil is not immediate before the next blink, the snap-back test is documented in seconds.12 Patients whose lids showed immediate recovery in one second to the original position were designated group I. Group II showed spontaneous recovery without blinking, but the lower lid returns back to the globe in 2 to 4 s. Group III included patients who required blinking of the eyelids for recovery, and group IV patients did not show recovery, despite blinking actions of the eyelids. In this study, group IV was excluded, as those patients showed overt eyelid ectropion. MGD was evaluated according the guidelines of the Japanese MGD Working Group and the International Workshop on MGD with modification.13,14 Meibum

quality is assessed in the lower lid on a scale of 0 to 3 for each gland: 0, clear; 1, cloudy; 2, cloudy with debris (granular); and 3, thick, like toothpaste. Expressibility is assessed on a scale of 0 to 3 in five glands in the lower lid, according to the number of glands expressible: 0, all glands; 1, three to four glands; 2, one to two glands; and 3, no glands. Finally, MGD grade is subdivided according to the sum of expressibility and secretion quality (0); 0, minimally altered expressibility and secretion quality (1–2); 1, mildly altered expressibility and secretion quality (3–4); 2, moderately altered expressibility and secretion quality (5–6); 3 severely altered expressibility and secretion quality.14 Patients with contact lenses or punctal plugs, progressive ocular surface disease other than dry eye, a previous history of ocular surgery or facial palsy, entropion, ectropion, lagophthalmos, or previously diagnosed dry eye and on-going treatment were excluded from the study population. Patients with skin diseases were also excluded. TBUT was measured after the application of 1 mL of 1% sodium fluorescein solution by micropipette, followed by blinking of the eye. Measurements were performed three times, and the average time elapsed prior to the breaking up of the tear film was recorded. For ST, a standard filter paper strip (Eagle Vision, Memphis, TN) was inserted at the temporal one third of the lower conjunctival sac, without topical anesthesia, and millimeters of tear wetting of the strip after 5 min was recorded. Patients were prescribed a preservative-free 0.1% hyaluronate artificial tear solution (Tearin FreeTM 0.1%, DHP Korea Inc., Seoul, Korea), and were instructed to apply the eye drops at least four times per day; no upper limit of application was set. Patients with frequent conjunctival injection and conjunctival folliculosis were prescribed a preservative-free 0.1% fluorometholone eye drop (FumeronTM 0.1%, Hanlim Pharm. Co., Seoul, Korea), to be applied four times per day, with reducing the dose by half per every week. Cyclosporine eye drops (RestasisTM, Allergan Inc., Irvine, CA) were used twice per day by patients whose ST measurements were less than 5 mm, indicating teardeficient dry eye. They were instructed to stop the eye drops if they showed symptoms of intolerance, such as ocular stinging. Patients demonstrating MGD above grade III were instructed to perform warm lid massage, to clean eyelid margins with commercial lid cleanser (BlephasolTM, Laboratoires Thea Inc., ClermontFerrand, France), and to apply tetracycline ointment (TeramycinTM, Pfizer Inc., New York, NY) to the lid margins once or twice per day.

Statistical Analysis The study population was divided into three groups according to the degree of lower lid laxity. To Current Eye Research

Effects of Lower Lid Laxity to OSDI 3 minimize the effect of age, each subject in a group was matched with subjects in the other groups who differed in age by less than 5 years. To evaluate the response to treatment, the TBUTs, ST scores, and OSDI scores of the groups were measured and compared at the beginning of the study and after 3 months of treatment. Results were evaluated using SPSS v19 (SPSS, Inc., Chicago, IL) to perform Wilcoxon signedrank tests, Mann–Whitney tests, Fisher’s exact tests and linear regression analysis. Values for p50.05 were considered to indicate statistical significance.

Downloaded by [Monash University Library] at 10:05 13 November 2015

RESULTS The average ages of the age-matched study populations in each group were 56.42 ± 5.551 years in group I, 56.04 ± 7.416 years in group II, and 57.60 ± 6.261 years in group III (Table 1). There were no significant differences in age among the groups. Sex ratios were: 2 males and 10 females in group I, 3 males and 21 females in group II, and 6 males and 18 females in group III, showing an overall female predominance, but no statistically significant difference in gender ratio among the groups. Preservative-free 0.1% hyaluronate artificial tears were used in treating dry eyes in all patients. Preservative-free 0.1% fluorometholone was used by 50.0% of patients in group I and by 58.3% in groups II and III. Cyclosporine eye

drops were used by 16.7% of patients in group I, 20.8% in group II, and 25.0% in group III. Tetracycline ointment and BlephasolTM lid cleanser were used by 16.7% in group I, 25.0% in group II, and 37.5% in group III; these differences were not significant. The average grade of MGD at the time of diagnosis was 1.33 ± 0.492 in group I, 1.79 ± 0.584 in group II, and 2.00 ± 0.417 in group III, showing a positive correlation with the degree of lower lid laxity. Before treatment, average TBUTs were 4.00 ± 0.853 s in group I, 3.92 ± 1.349 s in group II, and 4.08 ± 1.100 s in group III. After treatment, they increased to 5.83 ± 1.337 s in group I, 5.67 ± 1.761 s in group II, and 5.42 ± 1.060 s in group III. TBUTs were not significantly different among the groups before or after treatment. However, the increase after 3 months of treatment was significant in all groups (Figure 1). Although it was not statistically significant, the increase in TBUT was inversely correlated with the severity of lid laxity. ST scores were not significantly different among the groups before or after treatment, and no significant improvement was observed, despite treatment (Figure 2). OSDI scores before treatment did not differ among the groups, and showed improvement of symptoms in all three groups after 3 months of treatment (p = 0.003,50.001, and 50.001, respectively, Figure 3). A severe degree of lower lid laxity was correlated with greater residual symptoms after 3 months of treatment

TABLE 1 Demographics and changes in tear break-up time (TBUT), Schirmer test (ST) and ocular surface diseases index (OSDI) scores before and at 3 months after the treatment in eyes grouped by the degree of lower lid laxity. p Valueb

Groups Parameters Age Gender Treatments (%) 0.1% Fluorometholon 0.05% Cyclosporine A Tetracyclin oint + BlephasolTM MGD TBUT (s) pre 3m p value DTBUT ST (mm) pre 3m p value DST OSDI pre 3m p value DOSDI

I (n = 12)

II (n = 24)

III (n = 24)

I & II

II & III

I &III

56.42 ± 5.551 M:F = 2:10

56.04 ± 7.416 M:F = 3:21

57.60 ± 6.261 M:F = 6:18

0.906 1.000

0.358 0.461

0.497 0.691

50.0 16.7 16.7 1.33 ± 0.492

58.3 20.8 25.0 1.79 ± 0.584

58.3 25 37.5 2.00 ± 0.417

0.729 1.000 0.691 0.028b

1.000 1.000 0.534 0.145

0.729 0.691 0.268 0.002b

4.00 ± 0.853 5.83 ± 1.337 0.003a 1.83 ± 1.115

3.92 ± 1.349 5.67 ± 1.761 50.001 a 1.75 ± 1.482

4.08 ± 1.100 5.42 ± 1.060 50.001 a 1.33 ± 0.917

0.722 0.768

0.685 0.431

0.664 0.325

0.861

0.300

0.225

8.17 ± 2.480 8.17 ± 2.406 0.794 0.00 ± 2.000

8.00 ± 4.587 8.29 ± 4.805 0.634 0.29 ± 2.053

9.17 ± 4.229 9.50 ± 4.587 0.505 0.33 ± 1.880

0.266 0.305

0.105 0.114

0.704 0.655

0.917

0.777

1.000

50.52 ± 15.844 22.57 ± 5.243 0.003a 27.95 ± 11.800

57.99 ± 16.308 31.16 ± 11.353 50.001a 26.82 ± 9.563

57.81 ± 16.487 37.85 ± 13.342 50.001a 19.97 ± 6.643

0.363 0.020b

0.765 0.048b

0.212 50.001b

0.381

0.005b

0.005b

For the comparison of gender and treatments among three groups, Fisher’s exact test was used (significance level is p50.05). a Wilcoxon signed rank test (significance level is p50.05). b For the comparison of age, MGD, TBUT, ST and OSDI among three groups, Mann–Whitney test was used (significance level is p50.05). !

2015 Informa Healthcare USA, Inc.

Downloaded by [Monash University Library] at 10:05 13 November 2015

4

S. H. Oh et al.

FIGURE 1 Changes in tear break-up time (TBUT) before and at 3 months after the treatment in eyes grouped by the degree of lower lid laxity.

FIGURE 3 Changes in ocular surface disease index (OSDI) scores before and at 3 months after the treatment in eyes grouped by the degree of lower lid laxity. *Indicates statistical significance (p50.05).

FIGURE 2 Changes in Schirmer test (ST) before and at 3 months after the treatment in eyes grouped by the degree of lower lid laxity.

create tear deficiency and rapid evaporation of tears, leading to hyperosmolarity and the secretion of inflammatory mediators. In turn, these conditions promote further damage to the involved structures, creating a vicious cycle aggravating dry eye.15,16 Dry eye itself rarely causes permanent visual loss, but it is, nevertheless, a major ocular disease, in which frequent blurred vision and ocular discomfort can lead to decreased effective visual acuity and decreased quality of life for patients.17,18 With the release of the DEWS guidelines in 2007, the importance of anti-inflammatory actions in the aspects of histopathological mechanism in dry eye syndrome has been highlighted. Since that time, treatment approaches have concentrated on suppressing inflammation of the ocular surface and lacrimal glands, as well as on supplementation with artificial tears. Adjunctive measures employed include punctal plugging, therapeutic contact lenses, and warm massage of the eyelid. However, treatment attempts that following recommendations in the guideline often show inadequate clinical responses. This suggests that more variables, in addition to tear supplementation and control of ocular surface inflammation, need to be taken into consideration in treating dry eye. Studies of a relationship between lid laxity and dry eye have mainly examined the floppy eye lid syndrome of upper lid. However, they have failed to accurately identify either the prevalence or pathogenic mechanism for the disease. Soft and flexible upper eyelids often accompany MGD, and it is understood that symptoms of dry eye are triggered by papillary conjunctivitis, conjunctival epithelialization, and irregular wetting of the ocular surface, which are caused by the disruption of the lid/ocular surface interaction.19

(p = 0.020, 0.048, and 5 0.001, for groups I, II, and III, respectively). By univariate and multivariate regression analysis, lower lid laxity was a statistical significant factor to the difference of OSDI scores before and at 3 months after the treatment (p = 0.007 and 0.020, respectively) independently (Table 2).

DISCUSSION Dry eye is a multi-factorial disease involving several structures, including the epithelium of the cornea, goblet cells of the conjunctiva, meibomian glands of the eyelids, and lacrimal glands of the orbit. Complex interactions of the various structures of ocular surface

Current Eye Research

Effects of Lower Lid Laxity to OSDI 5 TABLE 2 Various parameters associated with ocular surface diseases index (OSDI) scores before and at 3 months after the treatment by univariate and multivariate regression analysis. Univariate analysis Parameters Age (year) MGD TBUT ST Lid laxity

b 0.122 2.444 1.683 0.138 4.402

Multivariate analysis

SE

p Value

0.191 2.243 1.071 0.308 1.563

0.527 0.280 0.122 0.656 0.007a

a

b 0.119 0.711 1.714 0.130 4.291

SE

p Valuea

0.218 2.779 1.088 0.300 1.786

0.587 0.799 0.121 0.666 0.020a

Downloaded by [Monash University Library] at 10:05 13 November 2015

SE, standard error; MGD, meibomian gland dysfunction; TBUT, tear break-up time; ST, Schirmer test. a Indicates statistical significance (p50.05).

In this study, patients with definite defects and anatomical changes, such as lagophthalmos, entropion, and ectropion, were excluded. Those without such defects were divided into three groups according to the degree of lower lid laxity. They underwent standard dry eye treatments, and treatment results and clinical outcomes were compared among the groups. Age, TBUT, ST score, and OSDI score did not differ among the groups at the beginning of the treatment, but the degree of MGD was positively correlated with the degree of lower lid laxity (r = 0.429, p = 0.000). This phenomenon is equally common in the cases of the floppy eye lid syndrome, and is thought to arise from the weakened pumping action of orbicularis oculi muscles, decreased clearance of meibomian gland orifices by the friction between upper and lower lid during blinking, and from cystic changes, atrophy, and epithelial metaplasia of the glands themselves.19–21 To confirm the effect of lower lid laxity to the OSDI scores after treatment, we performed univariate and multivariate regression analysis. As a result, lower lid laxity was a statistical significant factor to the difference of OSDI scores before and at 3 months after the treatment independently. Interestingly, the degree of MGD was not a statistical significant factor of the treatment effect in regression analysis. Recently, Wu et al. studied morphological characteristics and function of meibomian glands evaluating abnormalities of lid margins, expression of meibum, and gland dropout degree visualized by meibography.22,23 They reported that the scores of lid margin abnormality was the only variable that was significantly correlated with OSDI among these MGD parameters. They did not investigate the lid laxity, and lid margin abnormality could be an indicator of morphological characteristics of lid among MGD parameters. Their result is consistent with ours that morphological characteristics of lid are important factor to OSDI scores. According to studies performed in Japan and Korea, the majority of the dry eye syndromes occurring in East Asia are of the short TBUT type.24,25 Patients in this study also showed TBUTs of less than 5 s, and there were no initial differences in the TBUTs of patients with different degrees of lid !

2015 Informa Healthcare USA, Inc.

laxity. TBUT increased in all three groups after the 3-month treatment period, and, although it was not statistically significant, the increase in TBUT was inversely correlated with the severity of lid laxity. The amount of tear secretion measured by ST did not show a definite improvement after 3 months of treatment, and there were no differences among the groups. The OSDI scores were not significantly different among the groups at the beginning of the study, and all groups showed improvements after 3 months of treatment. However, compared to the members of group I, who had normal lid laxity, those in groups II and III had significant high OSDI scores, and group III showed significantly less improvement in OSDI score than did group I and II (p = 0.005 and 0.005, respectively). Based on their OSDI scores, patients can be categorized as having a normal ocular surface (0–12 points) or as having mild (13–22 points), moderate (23–32 points), or severe (33–100 points) ocular surface disease.11 In this study, the average OSDI score was categorized as severe ocular surface disease in all three groups before treatment. After treatment, the average OSDI score of group I was categorized as moderate, while those of group II and III were categorized as severe. This simple categorization also confirms the effect of lid laxity to the OSDI before and after treatment. However, potential limitations of our study should be mentioned. First, this study is limited by the small number of cases in each group with different treatment regimes, although the difference was not statistically significant. Furthermore, lid laxity above grade III usually occurs in the elderly, whereas grade I laxity predominantly occurs in the fifth and sixth decades of life. To minimize the effect of age, the patients were selected by individual age matching, and those whose ages were at the lower or upper end of the range were excluded from the study. Second, the degree of lower lid laxity was evaluated only through a snap-back test. Laxity is best assessed with the snap, distraction, and elevation tests. A medial distraction test is performed by displacing the MCT laterally. The lateral distraction test is performed in a similar fashion. A lower lid

Downloaded by [Monash University Library] at 10:05 13 November 2015

6

S. H. Oh et al.

elevation test is performed by displacing the lower lid above the inferior limbus.26 Previous studies reported the association of OSDI and MGD; however, few studied the association of OSDI and lid laxity. However, we verified that lower lid laxity was the only statistical significant factor to the difference of OSDI scores before and at 3 months after the treatment by univariate and multivariate regression analysis. Additional evaluation of lid distraction test, elevation test and the anatomy of lid configuration including horizontal and vertical lid width and height would distinguish three groups of lid laxity definitely and would have enhanced the result of the present study. In conclusion, the results of this study suggest that lower lid laxity is one of the factors contributing to the responses to dry eye treatment assessed by change in OSDI score, independent of TBUT and ST scores. Additionally, the conventional treatment of dry eye may be insufficient for patients with lower lid laxity above a moderate degree. Further study is needed to determine whether early surgical correction of lower lid laxity may aid in alleviating the symptoms of dry eye.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

REFERENCES 1. Report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop: the definition and classification of dry eye disease. Ocul Surf 2007;5:75–92. 2. Shimazaki-Den S, Iseda H, Dogru M, Shimazaki J. Effects of diquafosol sodium eye drops on tear film stability in short BUT type of dry eye. Cornea 2013;32: 1120–1125. 3. Cho BJ, Lee JH, Shim OJ. The relation between clinical manifestations of dry eye patients and their BUTs. J Korean Ophthalmol Soc 1992;33:297–302. 4. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea 2004;23:762–770. 5. Mastrota KM. Impact of floppy eyelid syndrome in ocular surface and dry eye disease. Optom Vis Sci 2008;85: 814–816. 6. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop. Ocul Surf 2007;5:93–107. 7. Cuevas M, Gonza´lez-Garcı´a MJ, Castellanos E, Quispaya R, Parra P de L, Ferna´ndez I, et al. Correlations among symptoms, signs, and clinical tests in evaporativetype dry eye disease caused by Meibomian gland dysfunction (MGD). Curr Eye Res 2012;37:855–863.

8. Rees TD, Jelks GW. Blepharoplasty and the dry eye syndrome: guidelines for surgery? Plast Reconstr Surg. 1981;68:249–252. 9. Walt J. Ocular Surface Disease Index (OSDI) administration and scoring manual. Irvine (CA): Allergan, Inc.; 2004. 10. Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol 2000; 118:615–621. 11. Miller KL, Walt JG, Mink DR, Satram-Hoang S, Wilson SE, Perry HD, et al. Minimal clinically important difference for the ocular surface disease index. Arch Ophthalmol 2010; 128:94–101. 12. Ozgur OK, Murariu D, Parsa AA, Parsa FD. Dry eye syndrome due to botulinum toxin type-A injection: guideline for prevention. Hawaii J Med Public Health 2012;71: 120–123. 13. Amano S, MGD Working Group. Definition and diagnostic criteria for meibomian gland dysfunction. J Eye (Atarashii Ganka) 2010;27:627–631. 14. Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O’Brien T, et al. The International Workshop on Meibomian Gland Dysfunction: report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci 2011;52: 2050–2064. 15. Dana MR, Hamrah P. Role of immunity and inflammation in corneal and ocular surface disease associated with dry eye. Adv Exp Med Biol 2002;506:729–738. 16. Stern ME, Gao J, Siemasko KF, Beuerman RW, Pflugfelder SC. The role of the lacrimal functional unit in the pathophysiology of dry eye. Exp Eye Res 2004;78: 409–416. 17. Le Q, Ge L, Li M, Wu L, Xu J, Hong J, Gong L. Comparison on the vision-related quality of life between outpatients and general population with dry eye syndrome. Acta Ophthalmol 2014;92:124–132. 18. Li M, Gong L, Chapin WJ, Zhu M. Assessment of visionrelated quality of life in dry eye patients. Invest Ophthalmol Vis Sci 2012;53:5722–5727. 19. Gonnering RS, Sonneland PR. Meibomian gland dysfunction in floppy eyelid syndrome. Ophthal Plast Reconstr Surg 1987;3:99–103. 20. Bron AJ, Tiffany JM, Gouveia SM, Yokoi N, Voon LW. Functional aspects of the tear film lipid layer. Exp Eye Res 2004;78:347–360. 21. Liu DT, Di Pascuale MA, Sawai J, Gao YY, Tseng SC. Tear film dynamics in floppy eyelid syndrome. Invest Ophthalmol Vis Sci 2005;46:1188–1194. 22. Wu H, Wang Y, Dong N, Yang F, Lin Z, Shang X, et al. Meibomian gland dysfunction determines the severity of the dry eye conditions in visual display terminal workers. PLoS One 2014;21;9:e105575. 23. Arita R, Itoh K, Inoue K, Amano S. Noncontact infrared meibography todocument age-related changes of the meibomian glands in a normal population. Ophthalmology 2008;115:911–915. 24. Jeong HS, Lim JS, Oh DK, Chi MJ, Paik HJ, Shyn KH, et al. Prevalence and risk factors of Dry Eye Syndrome in the Incheon area. J Korean Ophthalmol Soc 2011;52: 1135–1141. 25. Toda I, Fujishima H, Tsubota K. Ocular fatigue is the major symptom of dry eye. Acta Ophthalmol (Copenh) 1993;71: 347–352. 26. Bergeron CM, Moe KS. The evaluation and treatment of lower eyelid paralysis. Facial Plast Surg 2008;24: 231–241.

Current Eye Research

Lower Lid Laxity is Negatively Correlated with Improvement of the Ocular Surface Disease Index in Dry Eye Treatment.

To compare the responses to dry eye treatment of patients sorted by the degree of lower lid laxity...
481KB Sizes 0 Downloads 13 Views