Topical glaucoma medications:Clinical implications for the ocular surface

Glaucoma is a leading cause of irreversible blindness. The use of topical eye drops to reduce intraocular pressure remains the mainstay treatment. These eye drops frequently contain preservatives designed to ensure sterility of the compound. A growing number of clinical and experimental studies report the detrimental effects of not only these preservatives but also the active pharmaceutical compounds on the ocular surface, with resultant tear film instability and dry eye disease. Herein, we critically appraise the published literature exploring the effects of preservatives and pharmaceutical compounds on the ocular surface

Morphological changes in the meibomian glands of patients with phlyctenular keratitis: a multicenter cross-sectional study

Summary of 13 patients with phlyctenular keratitis. (XLSX 11 kb

Increased Tear Fluid Production as a Compensatory Response to Meibomian Gland Loss A Multicenter Cross-sectional Study

PurposeTo compare tear film parameters as well as meibomian gland morphologic features and function among patients with meibomian gland dysfunction (MGD), those with non–Sjögren syndrome aqueous-deficient dry eye (non-SS ADDE), those with non-SS ADDE and MGD, and normal subjects.DesignMulticenter, cross-sectional, observational case series.ParticipantsForty-one eyes of 41 patients (all women; mean age ± standard deviation, 62.1±9.9 years) with non-SS ADDE, 70 eyes of 70 patients (all women; 66.0±8.7 years) with MGD, 17 eyes of 17 patients (all women; 72.4±7.8 years) with non-SS ADDE and MGD, and 70 eyes of 70 normal control subjects (all women; 65.0±7.1 years).MethodsOcular symptoms were scored from 0 to 14 and lid margin abnormalities from 0 to 4 according to their respective number. Meibomian gland changes were scored from 0 to 6 (meiboscore) on the basis of noncontact meibography findings, and meibum was graded from 0 to 3 depending on its volume and quality. Conjunctival and corneal epithelial damage were scored from 0 to 9 (fluorescein score). Tear film break-up time (TBUT) was measured as an index of tear film stability, and tear fluid production was evaluated with Schirmer's test.Main Outcome MeasuresOcular symptom score, lid margin abnormality score, meiboscore, meibum grade, fluorescein score, TBUT, and Schirmer's test value.ResultsThe ocular symptom score did not differ significantly between the MGD and non-SS ADDE groups (P = 0.762). The lid margin abnormality score, meiboscore, and meibum grade were significantly higher in the MGD group than in the non-SS ADDE group (P = 0.0012, P < 0.0001, and P < 0.0001, respectively). The fluorescein score, TBUT, and Schirmer's test value were significantly worse in the non-SS ADDE group than in the MGD group (P < 0.0001, P = 0.0061, and P < 0.0001, respectively). The meiboscore correlated significantly with Schirmer's test value only in the MGD group (ρ = 0.508, P = 8.3×10−6).ConclusionsAn increase in tear fluid production likely compensates for loss of meibomian glands in individuals with MGD

Structure of MSPL–inhibitor complex

Infection of certain influenza viruses is triggered when its HA is cleaved by host cell proteases such as proprotein convertases and type II transmembrane serine proteases (TTSP). HA with a monobasic motif is cleaved by trypsin-like proteases, including TMPRSS2 and HAT, whereas the multibasic motif found in high pathogenicity avian influenza HA is cleaved by furin, PC5/6, or MSPL. MSPL belongs to the TMPRSS family and preferentially cleaves [R/K]-K-K-R↓ sequences. Here, we solved the crystal structure of the extracellular region of human MSPL in complex with an irreversible substrate-analog inhibitor. The structure revealed three domains clustered around the C-terminal α-helix of the SPD. The inhibitor structure and its putative model show that the P1-Arg inserts into the S1 pocket, whereas the P2-Lys and P4-Arg interacts with the Asp/Glu-rich 99-loop that is unique to MSPL. Based on the structure of MSPL, we also constructed a homology model of TMPRSS2, which is essential for the activation of the SARS-CoV-2 spike protein and infection. The model may provide the structural insight for the drug development for COVID-19

Therapeutic Efficacy and Safety of Intense Pulsed Light for Refractive Multiple Recurrent Chalazia

To evaluate the efficacy and safety of intense pulsed light (IPL) combined with meibomian gland expression (MGX) for the treatment of refractory multiple and recurrent chalazia without surgery or curettage. This was a retrospective controlled study. Patients with multiple and recurrent chalazia, who had performed the conventional treatment at least 2 months without any surgery or curettage, were enrolled in this study. Twenty-nine consecutive multiple recurrent chalazia (12 patients) were assigned to receive either the combination of IPL and MGX or MGX alone as a control. Each eye underwent one to four treatment sessions with 2-week intervals. Parameters were evaluated before and 1 month after the final treatment session. Clinical assessments included symptom, size of each chalazion, lid margin abnormalities, corneal and conjunctival fluorescein staining, meibum grade, the number of Demodex mites, the Schirmer value and meiboscore. All parameters except meiboscore and the Schirmer value were significantly improved with IPL-MGX therapy, whereas only meibum grade was significantly improved with MGX alone. There were no adverse events which occurred in either group. IPL-MGX was safe and effective for multiple and recurrent chalazia without surgery or curettage by reducing the size of chalazion and improving lid margin abnormalities and meibum grade

Proposed Algorithm for Management of Meibomian Gland Dysfunction Based on Noninvasive Meibography

Although the pathophysiology of meibomian gland dysfunction (MGD) remains incompletely understood, many treatment options have recently become available. According to an international workshop report, treatment selection for MGD should be based on a comprehensive stage classification dependent on ocular symptoms, lid margin abnormalities, meibum grade, and ocular surface staining. However, it is often difficult to evaluate all parameters required for such classification in routine clinical practice. We have now retrospectively evaluated therapeutic efficacy in MGD patients who received five types of treatment in the clinic setting: (1) meibocare (application of a warm compress and practice of lid hygiene), (2) meibum expression plus meibocare, (3) azithromycin eyedrops plus meibocare, (4) thermal pulsation therapy plus meibocare, or (5) intense pulsed light (IPL) therapy plus meibocare. Patients in each treatment group were classified into three subsets according to the meiboscore determined by noncontact meibography at baseline. Eyes in the IPL group showed improvement even if the meiboscore was high (5 or 6), whereas meibocare tended to be effective only if the meiboscore was low (1 or 2). The meiboscore may thus serve to guide selection of the most appropriate treatment in MGD patients. Prospective studies are warranted to confirm these outcomes

Meibum Color and Free Fatty Acid Composition in Patients With Meibomian Gland Dysfunction

Citation: Arita R, Mori N, Shirakawa R, et al. Meibum color and free fatty acid composition in patients with meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015;56:4403-4412. DOI:10.1167/iovs.14-16254 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 6 SD, 66.9 6 15.0 years) and 20 control subjects (8 men and 12 women; 64.5 6 6.7 years) were enrolled. Ocular symptom score, keratoconjunctival staining score, tear film breakup time, and Schirmer&apos;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 C 36 and C 37 ) and odd-numbered chain (such as C 17 , C 19 , and C 21 ) 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. Keywords: meibomian gland, meibum, meibography, fatty acid P osterior blepharitis, an inflammatory condition of the posterior lid margin, is encountered relatively often in ophthalmic clinics. It is associated with allergic conjunctivitis, infectious conjunctivitis, and, in particular, meibomian gland dysfunction (MGD). 1 Given that 86% of patients with dry eye have been found to manifest MGD, 2 posterior blepharitis is also associated with dry eye. In normal individuals, meibomian gland secretion (meibum) is a clear oily liquid that spreads readily to become the outermost surface of the tear film. It is a complex mixture of lipids of various classes including wax esters, cholesteryl esters, (O-acyl)-x-hydroxy fatty acids (OAHFAs) and their esters, acylglycerols, diacylated diols, free fatty acids (FFAs), cholesterol, and, in smaller amounts, other polar and nonpolar lipids. Although the volume of meibum is small, its components and the changes in these components have been examined as possible disease biomarkers. METHODS Study Design This cross-sectional observational study was conducted at The University of Tokyo Hospital, Itoh Clinic (Saitama City, Saitama), and Maeda Ophthalmic Clinic (Aizuwakamatsu City, Fukushima). Subjects were enrolled from December 2012 to December 2013. The study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board of Tokyo University School of Medicine. All subjects provided written informed consent before entry into the study. Subjects The MGD group included 38 patients (13 men and 25 women; mean age 6 SD, 66.9 6 15.0 years) who were diagnosed with MGD on the basis of Japanese diagnostic criteria (age of ‡20 years; at least one symptom such as an uncomfortable sensation in the target eye; and at least one abnormal lid finding). The control group included 20 individuals (8 men and 12 women; 64.5 6 6.7 years) who had never been diagnosed with blepharitis or MGD, were aged ‡20 years, and had no history of contact lens wear or eye surgery. Subjects with severe systemic illness or with squamous cell debris (collarette) around the base of the eyelashes were excluded. Protocol One eye was selected as the target eye in each subject. Complications, history of contact lens wear or eye surgery, presence of ocular allergy, and concomitant medications were noted as background information. The subjects were also questioned with regard to their experience of 15 subjective symptoms: ocular fatigue, discharge, foreign body sensation, dryness, uncomfortable sensation, sticky sensation, pain, epiphora, itching, redness, heavy sensation, glare, excessive blinking, burning sensation, and ocular discomfort on arising. Each symptom was assessed on a scale of 0 to 3: Lid margin findings were assessed for the upper and lower eyelids with the use of a slit-lamp microscope (TOPCON, Tokyo, Japan). Telangiectasia was assessed on a scale from 0 to 3: 0 ¼ no findings; 1 ¼ mild telangiectasia; 2 ¼ moderate telangiectasia or redness; 3 ¼ severe telangiectasia or redness. Mucocutaneous junction was assessed on a scale of 0 to 3: 0 ¼ Marx&apos;s line (ML) courses on the skin side of the meibomian orifice (MO) line and does not touch the MO at all; 1 ¼ parts of ML touch the MO; 2 ¼ ML courses through the MO; 3 ¼ ML courses along the eyelid margin side of the MO. 10 Irregularity, plugging, foaming, and thickness were assessed on a scale from 0 to 2: 0 ¼ no findings; 1 ¼ mild findings; 2 ¼ severe findings. Corneal and conjunctival staining were scored 0 to 9. 11 The fluorescein tear film breakup time (BUT) was measured three times consecutively after the instillation of fluorescein, and the mean value was adopted. Tear fluid production was evaluated by Schirmer&apos;s test without anesthesia. Meibomian glands were evaluated for the upper and lower lids with the use of a noncontact meibography system (TOPCON) attached to a slit-lamp microscope. Partial or complete loss of meibomian glands was scored on a scale of 0 to 3 (meiboscore), and meibomian gland distortion was graded on a scale of 0 to 2, as described previously. Meibum was collected at six sites for each target eye: three sites in the upper lid (temporal, central, and nasal) and three sites in the lower lid (nasal, central, and temporal). Powderfree gloves were worn by the collector to avoid contamination. The eyelids were carefully cleaned with a cotton swab dipped in saline before expression of meibum. Meibum was extruded with the use of the Arita Meibomian Gland Compressor (Katena Products, Denville, NJ, USA), and it was collected with a separate stainless steel spatula at each site. Collected meibum was immediately transferred to dry ice for storage. The degree of ease with which meibum was expressed was evaluated semiquantitatively for each of the six collection sites on a scale of 0 to 3: 0 ¼ clear meibum readily expressed; 1 ¼ cloudy meibum expressed with mild pressure; 2 ¼ cloudy meibum expressed with more than moderate pressure; 3 ¼ meibum could not be expressed even with strong pressure. 14 Meibum color was assessed for each site according to three categories (clear, cloudy, yellow) and a scale of 0 or 1: 0 ¼ clear; 1 ¼ colored (cloudy or yellow). Meibum viscosity was also assessed for each site on the basis of three categories (oily, creamy, toothpaste-like) and a scale of 0 or 1: 0 ¼ oily; 1 ¼ nonoily (creamy or toothpaste-like). Lipid Analysis Meibum collection and FFA composition analysis were performed as previously described. 9 Meibum was dissolved in chloroform:methanol (1:1, vol/vol; Wako, Osaka, Japan) and analyzed by liquid chromatography-Fourier transform mass spectrometry (LC-FTMS). Water containing 0.1% ammonium acetate (Sigma-Aldrich Corp., St. Louis, MO, USA) and methanol containing 0.1% ammonium acetate (Sigma-Aldrich Corp.) were used as the mobile phase. We performed a high mass accuracy full scan (m/z of 180-550) with a Q Exactive mass spectrometer (Thermo Scientific, Waltham, MA, USA) to identify individual lipid molecular species. Given that the amount of collected meibum sample was too small to weigh, we corrected for weight differences among samples by normalizing the FFA data by the total peak area before statistical analysis. The percentage peak area was calculated with the following equation: percentage peak area of FFA X ¼ (peak area value of FFA X in sample Y)/(total peak area value of all FFAs in sample Y). The percentage peak area was used as a measure of the content of each FFA among total FFAs in meibum. Statistical Analysis Data are presented as means 6 SD unless indicated otherwise. The frequency of each ocular symptom was compared between the MGD and control groups with Fisher&apos;s exact test. Means of parameters were compared between the MGD and control groups or between upper and lower eyelids with Student&apos;s t-test. Meibum color and viscosity were compared between the MGD group and the control group, between the upper and lower eyelids, or among temporal, central, and nasal sites with Fisher&apos;s exact test. Meibum grade was compared among temporal, central, and nasal sites of each eyelid in the MGD group with one-way analysis of variance. The relations between clinical signs were evaluated with Spearman&apos;s correlation analysis. A P value of &lt;0.05 was considered statistically significant. Principal component analysis (PCA) was performed with the use of AI output software 15 (developed at Osaka University) in order to explore the relation between FFA composition of meibum and clinical signs. Principal component analysis is a primary multivariate technique that has been widely adopted in lipidomics, metabolomics, and proteomics. RESULTS Clinical Signs and Meibum Properties Patients were diagnosed with MGD according to the Japanese diagnostic criteria. The distribution of meibum color and viscosity differed significantly between the MGD and control groups at each of the six sites examined. There were no significant differences in meibum color or viscosity among the temporal, central, and nasal sites of the upper or lower eyelids of the MGD group or the control group, or between the upper and lower eyelids at each site in the MGD group Lipid Analysis Liquid chromatography-FTMS was applied to quantify FFAs in meibum and to determine whether their amounts might change in association with ocular symptoms. The highresolution negative electrospray ionization (ESI) mode was adopted to analyze the FFAs in all six meibum samples from each of the 38 MGD patients and 20 control subjects. We detected 103 FFA species with carbon chains of C 12 to C 37 in meibum We also generated a volcano plot comparing FFA species between the clear meibum group and the colored (cloudy or yellow) meibum grou