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Purpose: The purpose of this study is to report the features of dry eye and ocular surface disease in an unusual case of ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome., Case Report: A single observational case report of a 22-year-old Japanese male with evaporative dry eye and corneal epithelial disease because of lipid layer abnormality resulting from meibomian gland agenesis was treated successfully with low dose lipid base ointment application., Discussion: The clinical features of the dry eye and ocular surface disease and management issues are discussed., Conclusion: Low dose lipid base ointment application may be a promising treatment modality for the ocular surface disease in ectrodactyly-ectodermal dysplasia (EEC)-clefting syndrome, which seems to help in alleviating the subjective complaints and in improving the objective clinical findings.

Purpose: To evaluate the efficacy of a new Orgahexa eye warmer mask for patients with simple meibomian gland dysfunction (MGD) in a prospective comparative study., Methods: Twenty right eyes of 20 patients with simple MGD, and 22 right eyes of 22 healthy controls were studied. Subjects were allocated to Orgahexa or conventional eye mask wear for 10 min (short-term study), and for 2 weeks (long-term study). Eyelid temperature measurements, slit lamp examination, tear film break-up time, Schirmer test, vital staining, tear film lipid layer interferometry, and dry eye symptomatology scoring with visual analog scales were performed., Results: The Orgahexa eye warmer improved both tear function and ocular surface status, and decreased symptoms significantly without any complications., Conclusions: The Orgahexa eye warmer is a simple, safe, and convenient method, which seems to improve the ocular surface status and tear functions in patients with simple MGD.

Purpose: To evaluate the safety and efficacy of an original warm moist air device on tear functions and ocular surface of patients with simple meibomian gland dysfunction (MGD)., Methods: Fifteen patients with simple MGD and 20 healthy volunteers were recruited in an initial prospective interventional clinical trial to evaluate the safety and short-term effects of the warm moist air device. The device was applied to the eyes of the subjects for 10 minutes. Temperatures of the eye lids and corneas were measured with an infrared thermometer. Symptoms of ocular fatigue were scored using visual analog scales (VASs). Schirmer test, tear film break-up time (BUT), DR-1 tear film lipid layer interferometry, fluorescein staining, and rose bengal staining were also performed before and after the application of the eye steamer. After the initial study, another 2-week prospective clinical trial was carried out in 10 patients with MGD who received the warm moist air treatment. Ten other patients were also recruited and received warm compress treatment with hot towels for 2 weeks to evaluate the long-term effects of the warm moist air device and the warm compresses on tear film lipid layer thickness and ocular surface health. The warm moist air device and the warm compresses were applied for 10 minutes twice a day. The changes in VAS scores for symptoms, BUT values, fluorescein, and rose bengal staining scores were examined before and after each treatment during the second trial., Results: VAS scores of ocular fatigue improved significantly with short- and long-term applications of the warm moist air device in both studies. The mean corneal surface and eye lid temperatures showed significant elevation within safe limits 10 minutes after the moist air application. The mean BUT prolonged significantly in the patients receiving warm moist air applications but did not change significantly in those treated with warm compresses. DR-1 tear film lipid layer interference showed evidence of lipid expression in the patients and controls, with thickening of the tear film lipid layer after 10 minutes of warm moist air device use. In the 2-week trial, tear film lipid layer thickness increased in both warm moist air device and warm compress groups, with a greater extent of increase in the warm moist air device group., Conclusion: Warm moist air device use provided symptomatic relief of ocular fatigue and improvement of tear stability in patients with MGD. The new warm moist air device seems to be a safe and promising alternative in the treatment of MGD.

A 45-year-old woman who underwent eyelid tattooing 20 years earlier presented with decreased left vision and eye discomfort. Her ocular history revealed an uneventful LASIK procedure 4 years previously with epithelial problems of the flap followed by S. aureus keratitis. Resultant corneal opacity necessitated a deep lamellar keratoplasty performed 9 months prior to admission followed by frequent epithelial problems. At the time of admission, her left eye had a corneal epithelial defect and both lower eyelid margins revealed subepidermal pigmentation and keratinization. Her initial examination revealed tear instability with increased ocular surface staining scores and advanced tear film lipid layer abnormality in both eyes. Meibography showed bilateral total meibomian gland dropout. Treatment with autologous serum eye drops resulted in full epithelialization. Meibomian gland disease-specific therapy did not result in any change in breakup time, vital staining scores, tear film lipid layer interferometry grades, or glandular dropout state.

Purpose: To review the literature on lipid supplementation therapy for dry eye and on image analysis using tear interference images from the specific tear lipid layer interference camera DR-1., Methods: Systematic literature review of lipid supplementation therapy for lipid tear deficiency dry eye, kinetic analysis of tear interference images using DR-1 camera, and computer-synthesized interference color chart for DR-1 camera., Conclusion: To establish lipid supplementation therapy, a quantification system of tear lipid layer is required. Tear lipid thickness could be quantified using a computer-synthesized interference color chart system.

Purpose: To describe the tear function and ocular surface disorders in a patient with ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome., Methods: Routine ophthalmic examinations were performed, including slit-lamp biomicroscopy, anterior segment photography including transillumination photos of the lids, Schirmer tests I and II, tear film break-up time (BUT) assessment, corneal fluorescein staining, DR-1 tear film lipid layer interferometry, and tear evaporation rate measurements., Results: Slit-lamp examination revealed conjunctival hyperemia, superficial punctate keratopathy, and corneal leucoma with neovascularization. Although the Schirmer test values were within normal limits, the BUT value was 0 s in both eyes. Transillumination of the lids showed the absence of meibomian glandular structures. DR-1 tear film lipid layer interferometry results were dry eye grade 5 with an irregular tear film, areas of corneal surface exposure, and several dry spots. The tear evaporation rate was elevated and was measured as 6.98 x 10(-7) g/cm2 per second (normal, 4.1 +/- 1.4 x 10(-7) g/cm2 per second)., Conclusion: The ocular surface disorder and shortened BUT in EEC syndrome were attributed to the absence of meibomian glands, leading to lipid layer deficiency in the tear film with a concomitant increase in tear evaporation., (Copyright Japanese Ophthalmological Society 2004)

Purpose: Kinetic analysis of sequential tear interference images was used to investigate how the precorneal lipid film spread and distributed in aqueous tear deficiency (ATD) dry eye., Methods: One eye of 17 patients with ATD was randomly selected for this noncomparative case series. Twelve patients also had noninflamed meibomian gland dysfunction (MGD). Sequential images were digitized and analyzed on computer. Data were further compared in 9 of the 17 cases before and after punctal occlusion (PO). Outcome measures included speed and pattern of lipid spread and resultant lipid layer thickness in the superior, central, and inferior cornea. Intensity and red/green/blue (RGB) color spectra of the tear interference image were compared before and after PO., Results: After lid blinking, it took a longer time (2.2 +/- 1.1 second) to reach a stable lipid film in all eyes with ATD compared with normal subjects (P < 0.0001). Because of this retarded spread, the thickest lipid film was located at the inferior cornea adjacent to the lid margin, with a gradient spreading toward the superior cornea (P = 0.01). As a result, the lipid film was thinner than normal on the superior cornea in 10 of 17 (59%) ATD eyes. Fifteen of 17 eyes (88%) showed vertical streaking, rather than a normal horizontal propagation pattern on the superior cornea. Such a lipid-deficient state and uneven distribution did not correlate with the presence or absence of MGD. The lipid spread time was shortened (P = 0.008), the distribution of the lipid film was more even, and the thickness approached normal in all nine eyes after PO., Conclusions: In this study, kinetic analysis of tear interference images provided evidence that retardation of lipid spread is, but MGD is not, the main reason for the increased thickness of precorneal lipid film in the inferior cornea of eyes with ATD. As a result, lipid film is deficient in the superior cornea and unevenly distributed, further destabilizing the tear film. The fact that PO significantly improves lipid spread, evenness, and thickness suggests that the performance of lipid film is also dictated by the amount of aqueous tear fluid. These findings provide new insight into the interaction between the lipid film and the aqueous tear fluid.

Purpose: To test a newly developed tear evaporimetry system that detects real-time changes in tear evaporation rates and shows the tear film stability in patients with obstructive meibomian gland dysfunction (MGD)., Methods: A ventilated chamber system with high-sensitivity microbalance sensor was used to evaluate tear evaporation. Tear evaporation rates and dynamic changes in them in response to blinking ("flip heights") were measured. Both were compared in 38 eyes of 22 normal subjects and 32 eyes of 21 patients with obstructive MGD, in a prospective case-control study. The relationship between tear evaporation rates and flip heights to meibomian gland orifice obstruction was also analyzed., Results: Changes in tear evaporation rates produced by blinking were detected. The tear evaporation rates in the patients' group were 5.8 +/- 2.7(10(-7)) g/cm(2) per second, significantly higher than in normal subjects (4.1 +/- 1.4[10(-7)] g/cm(2) per second; P = 0.0008). The flip heights in the obstructive MGD group were 0.58 +/- 0.33(10(-7)) g/cm(2) per second, significantly higher than in normal subjects (0.39 +/- 0.27[10(-7)] g/cm(2) per second, P = 0.02). The correlations between both tear evaporation rates and flip heights to the meibomian gland orifice obstruction score were statistically significant (P < 0.0001 and P = 0.004, respectively)., Conclusions: This new system was helpful in differentiating MGD patients from normal subjects. These significantly higher evaporation rates and higher flip heights reflect the unstable tear evaporation and may well indicate unstable tear film in patients with obstructive MGD with abnormal evaporative tear loss.

Objective: To use kinetic changes to characterize tear interference images in patients with lipid tear deficiency (LTD) dry eye., Methods: We used a DR-1 camera to digitize and analyze sequential images of tear interference on the central 8 mm of the cornea at the start of complete blinking in 11 healthy volunteers and 8 patients with LTD and noninflamed meibomian gland dysfunction., Main Outcome Measures: We studied tear lipid spread time and pattern, stability of the lipid after spread, and distribution of thickness in a prospective, case-control study., Results: On complete lid closure, the lipid spread was horizontal in healthy eyes but vertical in LTD (P<.001). Mean +/- SD lipid spread time was 0.36 +/- 0.22 seconds in healthy eyes but 3.54 +/- 1.86 seconds in LTD (P<.001). Conventional DR-1 grading could not distinguish these groups (P =.32). Mean +/- SD lipid film thickness in healthy eyes was 74.5 +/- 6.9 nm, thicker than the 43.8 +/- 10.6 nm in LTD (P<.001), and this result was confirmed by qualification with intensity histogram (P<.001)., Conclusions: Kinetic analysis of the tear interference revealed distinctive differences in the time and pattern of lipid spread and the distribution and stability of resultant lipid thickness between healthy subjects and patients with LTD. This method can be coupled with others for formulating effective therapies for patients with dry eye.

Aim: To test the short term efficacy and safety of an infrared warm compression device (IWCD, Eye Hot, Cept Co, Tokyo, Japan) as treatment for non-inflamed meibomian gland dysfunction (MGD)., Methods: 37 subjects with non-inflamed obstructive MGD, with and without aqueous tear deficiency (ATD) dry eye, participated in a prospective non-comparative interventional case series. Symptom scores, face scores, tear evaporation rates, fluorescein and rose bengal vital staining, tear break up time (BUT), Schirmer test, meibomian gland obstruction, and meibography were compared before and after 2 weeks of therapy., Results: In a total of 37 cases, total subjective symptom scores and subjective face scores improved significantly, from 12.3 (SD 5.9) to 8.4 (6.1), and from 7.0 (1.7) to 5.3 (2.0) (both p <0.0001). The results for tear evaporation rates during forced blinking (p = 0.002), fluorescein staining (p = 0.03), rose bengal staining (p = 0.03), BUT (p <0.0001), and meibomian gland orifice obstruction score (p <0.0001) had also improved significantly at the end of the 2 week period of infrared thermotherapy. No complaints and/or complications of the IWCD were reported., Conclusion: The IWCD was effective and safe for the treatment of MGD. Improved tear stability associated with release of meibum is a possible mechanism of this treatment.

Objective: We developed low-concentration homogenized castor oil eye drops for the treatment of patients with noninflamed obstructive meibomian gland dysfunction (MGD), a major cause of lipid-deficiency dry eye, and assessed the safety, stability, and efficacy of the eye drops., Design: Randomized, double-masked, placebo-controlled crossover clinical trial., Participants: Forty eyes of 20 patients with noninflamed MGD., Methods: After a preliminary study of eye drops containing castor oil, 2% castor oil and 5% polyoxyethylene castor oil (emulsifier) were mixed to formulate homogenized oil eye drops. The patients were assigned randomly to receive oil eye drops or placebo six times daily for 2 periods of 2 weeks each., Main Outcome Measures: At the end of each treatment period, we assessed symptoms, tear interference grade, tear evaporation, fluorescein and rose bengal scores, tear break-up time (BUT), and meibomian gland orifice obstruction. Safety and stability tests were also performed., Results: Symptom scores, tear interference grade, tear evaporation test results, rose bengal scores, tear BUT, and orifice obstruction scores after the oil eye drop period showed significant improvement compared with the results after the placebo period. No complications attributable to the eye drops were observed. The oil eye drops were stable when stored at 4 degrees C., Conclusions: The results indicate that castor oil eye drops are effective and safe in the treatment of MGD. The possible mechanisms of this treatment are improvement of tear stability as a result of lipid spreading, ease of meibum expression, prevention of tear evaporation, and the lubricating effect of the oil eye drops.

Objective: Changes in the ocular surface of patients with Sjögren syndrome (SS) often are more severe than those in patients with dry eye without SS. This study was conducted to investigate the possible involvement of meibomian gland dysfunction in SS-related ocular surface abnormalities., Design: A nonrandomized, prospective, clinical study., Participants: Twenty-seven eyes of 27 consecutive patients with SS (SS group) were studied. Twenty-nine eyes of age- and gender-matched non-SS patients with aqueous tear deficiency (non-SS group) were examined as control subjects., Intervention: Changes in the ocular surface, tear function, and meibomian gland were examined., Main Outcome Measures: Tear evaporation rate, meibomian gland expression, and meibography were measured., Results: Fluorescein and rose bengal staining scores were significantly higher in the SS group than in the non-SS group (P = 0.0001). Evaporation of tears was increased significantly in the SS group compared with the non-SS group. There were no significant differences in the rate of tear production between the SS and non-SS groups. Meibography showed that 11 (57.9%) of 19 eyes in the SS group had gland dropout (i.e., histologic destruction of meibomian glands) in more than half of the tarsus. The incidence was significantly higher than that in the non-SS group (5 [18.5%] of 27 eyes; P = 0.005)., Conclusions: The results of this study indicate that destruction of meibomian glands and an increase in tear evaporation often are associated with changes in the ocular surface in patients with SS. Severe ocular surface changes in patients with SS may be attributed, in part, to the meibomian gland dysfunction.