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Background: Although dupilumab has been associated with the development of conjunctivitis, little is known about other ocular surface disorders such as dry eye and how these side effects are managed., Objective: To evaluate the incidence and management of ocular surface disorders, including dry eye and conjunctivitis, among patients treated with dupilumab., Methods: Using US claims data, we evaluated the incidence of encounters for ocular surface disorders among patients treated with dupilumab. Secondary outcomes included ophthalmic medication use. A propensity score matched, active-comparator, new-user cohort design was used to compare the incidence of ocular surface disorders between those starting dupilumab versus methotrexate., Results: Among those with a history of atopic dermatitis, encounters for ocular surface disorders were more common in the 6 months after starting dupilumab than in the 6 months prior (11.7% versus 8.7%, P  < .001); 59.7% of those with a new ocular surface disorder diagnosis filled a prescription for an ophthalmic medication. The incidence of ocular surface disorders was higher among those treated with dupilumab than that in those treated with methotrexate (odds ratio 1.64; 95% confidence interval 1.17-2.30)., Limitations: Observational design., Conclusions: Dupilumab use for atopic dermatitis was associated with an increased risk of ocular surface disorders. Most patients who developed an ocular surface disorder received a prescription for an ophthalmic medication., Competing Interests: Dr Margolis was a member of joint Sanofi/Regeneron Data Safety and Monitoring Board for studies of dupilumab; he left the Data Safety and Monitoring Board about 2 years ago. He receives research funding to the Trustees of the University of Pennsylvania from the NIH-NIAMS and Valiant for unrelated studies of atopic dermatitis. He was on an advisory board sponsored by Leo, which disbanded about 2 years ago, and is currently a consultant for Leo both with respect to atopic dermatitis. Dr Bunya has served as a consultant for Verily and receives grant funding from 10.13039/100007489Bausch and Lomb for an unrelated study. Dr Massaro-Giordano has served as a consultant for Verily and was on advisory boards sponsored by Dompe and Lynthera. Author Barbieri has no conflicts of interest to declare. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication., (© 2021 by the American Academy of Dermatology, Inc. Published by Elsevier Inc.)

Purpose: To describe associations between symptoms and signs of dry eye disease (DED) and meibomian gland (MG) morphology., Methods: Cross-sectional study utilizing data from the Dry Eye Assessment and Management (DREAM) Study. Readers graded MG features in the middle third of upper and lower lids on infrared meibography images. Associations with signs and symptoms of DED were evaluated with adjustment for age and sex., Results: Among 268 patients, no MG features were associated with symptom scores (p > 0.08). Among 394 upper eyelids, better tear break-up times (<2, >2- <3.2and ≥ 3.2 s) were associated with more tortuous glands (mean (SD) 0.58(0.95), 0.83(1.2) and 1.14 (1.4), p = 0.01) and with higher scores on a composite score of MG features (21.90 (9.76), 23.29 (9.50), 26.26 (10.27); p = 0.02). Longer Schirmer test wetting lengths (0-5, >5-10, and >10 mm) were associated with increasing composite scores (22.02 (9.29), 23.80 (10.34), 24.96 (9.96), p = 0.03). Patients with Sjogren syndrome compared to other patients had fewer distorted MGs (mean 3.4 (2.3) vs 4.3 (2.3), p = 0.03) and fewer ghost glands (mean 0.33 (0.88) vs 0.89 (1.8), p = 0.006) in the upper lid., Conclusion: In the DREAM study, most MG morphologic features were not associated with the severity of DED symptoms or signs. Tortuous glands and a higher composite score for MG features were associated with longer tear break-up times and longer Schirmer test length in the upper eyelid only. Patients with Sjogren syndrome had fewer distorted and ghost glands., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: To describe and evaluate a comprehensive grading system for meibomian gland (MG) digital infrared images developed for the Dry Eye Assessment and Management (DREAM) Study., Methods: Cross-sectional study. Reading Center (RC) certified readers independently evaluated MG features of both lids from meibography images of dry eye disease subjects. Dropout areas were measured using planimetry software. Inter-reader and grade-regrade agreement and comparison of meiboscale scores (Meiboscale © ; Pult) from clinical centers to RC percent dropout and of MG features with clinical parameters were evaluated., Results: Among 551 eyes of 277 patients at baseline, 62 (11%) upper lid and 5 (1%) lower lid images were missing. Lid eversion was poor in 63 (13%) of upper lids compared to 15 (3%) of lower lids. Intraclass correlation for inter-reader and grade-regrade agreement was moderate to substantial for most MG features. MG features were more frequent in the upper lid (p < 0.001), except for dropout glands, gaps, fluffy gland areas and dropout areas. Clinic meiboscale score was associated with RC percent dropout (p < 0.001), a clinic score of 0% having a mean RC score of 19%, and a clinic score of >75% having a mean RC score of 66%. MG plugging was associated with ghost glands (p = 0.009), dropout glands (p < 0.001) and a composite severity score (p = 0.02); turbid and absent secretions were associated with ghost glands (p = 0.046)., Conclusion: RC readers identified MG features with good reproducibility. Upper lids had more MG features. RC dropout areas correlated well with clinic meiboscale scores. Ghost glands were associated with paste like and absent meibomian secretions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Current scales for assessment of bulbar conjunctival redness have limitations for evaluating digital images. We developed a scale suited for evaluating digital images and compared it to the Validated Bulbar Redness (VBR) scale., Methods: From a digital image database of 4889 color corrected bulbar conjunctival images, we identified 20 images with varied degrees of redness. These images, ten each of nasal and temporal views, constitute the Digital Bulbar Redness (DBR) scale. The chromaticity of these images was assessed with an established image processing algorithm. Using 100 unique, randomly selected images from the database, three trained, non-physician graders applied the DBR scale and printed VBR scale. Agreement was assessed with weighted Kappa statistics (K w )., Results: The DBR scale scores provide linear increments of 10 from 10-100 when redness is measured objectively with an established image processing algorithm. Exact agreement of all graders was 38% and agreement with no more than a difference of ten units between graders was 91%. K w for agreement between any two graders ranged from 0.57 to 0.73 for the DBR scale and from 0.38 to 0.66 for the VBR scale. The DBR scale allowed direct comparison of digital to digital images, could be used in dim lighting, had both temporal and nasal conjunctival reference images, and permitted viewing reference and test images at the same magnification., Conclusion: The novel DBR scale, with its objective linear chromatic steps, demonstrated improved reproducibility, fewer visualization artifacts and improved ease of use over the VBR scale for assessing conjunctival redness., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The subcommittee reviewed the prevalence, incidence, risk factors, natural history, morbidity and questionnaires reported in epidemiological studies of dry eye disease (DED). A meta-analysis of published prevalence data estimated the impact of age and sex. Global mapping of prevalence was undertaken. The prevalence of DED ranged from 5 to 50%. The prevalence of signs was higher and more variable than symptoms. There were limited prevalence studies in youth and in populations south of the equator. The meta-analysis confirmed that prevalence increases with age, however signs showed a greater increase per decade than symptoms. Women have a higher prevalence of DED than men, although differences become significant only with age. Risk factors were categorized as modifiable/non-modifiable, and as consistent, probable or inconclusive. Asian ethnicity was a mostly consistent risk factor. The economic burden and impact of DED on vision, quality of life, work productivity, psychological and physical impact of pain, are considerable, particularly costs due to reduced work productivity. Questionnaires used to evaluate DED vary in their utility. Future research should establish the prevalence of disease of varying severity, the incidence in different populations and potential risk factors such as youth and digital device usage. Geospatial mapping might elucidate the impact of climate, environment and socioeconomic factors. Given the limited study of the natural history of treated and untreated DED, this remains an important area for future research., (Copyright © 2017 Elsevier Inc. All rights reserved.)