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Kenneth Sall,1 Gary N Foulks,2 Andrew D Pucker,1 Karen L Ice,1 Richard C Zink,1 George Magrath1 1Lexitas Pharma Services, Inc, Durham, NC, USA; 2University of Louisville (Retired), Louisville, KY, USACorrespondence: Kenneth Sall, Lexitas Pharma Services, Inc, 313 Foster St, Durham, NC, 27701, USA, Tel +1 919 205-0012, Email drsall@sallresearch.comPurpose: Validation of the novel Lexitas modified NEI scale for use in assessment of corneal fluorescein staining.Patients and Methods: A series of 18 illustrations and 14 clinical photographs depicting varying severity levels of corneal fluorescein staining were assessed by 3 independent examiners. Regions of the cornea were graded for staining severity based on 3 different grading scales: the original NEI staining scale (density-based scoring; 0– 3 scale), a structured version of the NEI scale (dot-count scoring; 0– 3 scale), and the Lexitas modified NEI staining scale (0– 4 scale with half-point increments). Kappa statistics (simple and weighted) were computed to determine intra-examiner image grading repeatability for each examiner over 2 separate assessments. Inter-examiner assessment reliability utilized the scores from the first read of each examiner, and pairs of examiners to compute kappa statistics.Results: Data was analyzed from the scores provided by the examiners from each gradable corneal region on 32 images (18 illustrations and 14 photographs) for a total of 154 corneal regions across the 3 grading scales for each validation run. The mean intra-examiner simple/weighted kappa values using the NEI density, NEI dot count, and the Lexitas modified NEI staining scales were 0.67/0.72, 0.91/0.94, 0.80/0.92 for the graded illustrations, and 0.83/0.88, 0.76/0.85, 0.77/0.88 for the graded photographs, respectively. The mean inter-examiner simple/weighted kappa values using the NEI density, NEI dot count, and the Lexitas modified NEI staining scales were 0.59/0.65, 0.86/0.90, and 0.78/0.91 for the graded illustrations, and 0.80/0.88, 0.84/0.89, 0.69/0.88 for the graded photographs, respectively.Conclusion: The expanded scale of the Lexitas modified NEI staining scale demonstrated a high degree of reliability and repeatability of grading assessments within and across individual examiners, comparing favorably with the original NEI staining scale. A future investigation into the in-office utility of the Lexitas modified NEI staining scale is warranted.Keywords: clinical trials, corneal sodium fluorescein staining, dry eye disease, repeatability, validation

ObjectivesTo evaluate efficacy and safety of abatacept in adults with active primary Sjögren’s syndrome (pSS) in a phase III, randomised, double-blind, placebo-controlled trial.MethodsEligible patients (moderate-to-severe pSS [2016 ACR/European League Against Rheumatism (EULAR) criteria], EULAR Sjögren’s Syndrome Disease Activity Index [ESSDAI] ≥5, anti-SS-related antigen A/anti-Ro antibody positive) received weekly subcutaneous abatacept 125 mg or placebo for 169 days followed by an open-label extension to day 365. Primary endpoint was mean change from baseline in ESSDAI at day 169. Key secondary endpoints were mean change from baseline in EULAR Sjögren’s Syndrome Patient Reported Index (ESSPRI) and stimulated whole salivary flow (SWSF) at day 169. Other secondary clinical endpoints included glandular functions and patient-reported outcomes. Selected biomarkers and immune cell phenotypes were examined. Safety was monitored.ResultsOf 187 patients randomised, 168 completed double-blind period and 165 continued into open-label period. Mean (SD) baseline ESSDAI and ESSPRI total scores were 9.4 (4.3) and 6.5 (2.0), respectively. Statistical significance was not reached for primary (ESSDAI −3.2 abatacept vs −3.7 placebo, p=0.442) or key secondary endpoints (ESSPRI, p=0.337; SWSF, p=0.584). No clinical benefit of abatacept over placebo at day 169 was seen with other clinical and PRO endpoints. Relative to baseline, abatacept was associated with significant differences vs placebo in some disease-relevant biomarkers (including IgG, IgA, IgM-rheumatoid factor) and pathogenic cell subpopulations (post hoc analyses). No new safety signals were identified.ConclusionsAbatacept treatment did not result in significant clinical efficacy compared with placebo in patients with moderate-to-severe pSS, despite evidence of biological activity.

Dry eye is one of the most common and bothersome complaints reported by patients with Sjögren’s disease. Dry eye represents the failure of tears to protect the eye and to provide a smooth corneal surface. It is a consequence of aberrant interactions between the proteins and the lipids in the aqueous layer of the tear film. Dry eye is diagnosed with the use of clinical examination, tear function testing, and laboratory analysis of tears. Before the diagnosis is made, other common conditions such as allergies or blepharitis must be ruled out, along with the use of any medications that have drying as a side effect.

Purpose The safety of KPI-121 0.25%, an ophthalmic nanoparticle suspension of loteprednol etabonate, was evaluated in subjects with dry eye disease (DED) in one phase 2 and three phase 3 randomized trials of similar design. Methods Adults with DED received KPI-121 0.25% or vehicle drops 4 times daily (QID) for ≥2 weeks; 1430 subjects received KPI-121 0.25% and 1438 subjects received vehicle drops. Main safety assessments were adverse events (AEs) and intraocular pressure (IOP). As a common side effect associated with the use of ocular corticosteroids is elevated IOP, subjects with a history of or current diagnosis of glaucoma were excluded. Results Instillation site pain was the most common AE, reported by 5.2% of subjects in the KPI-121 0.25% group and 4.4% of subjects in the vehicle group; other AEs were reported by ≤0.8% of subjects in the KPI-121 group. IOP elevations, a side effect associated with the use of ophthalmic corticosteroids, were observed with low incidence: 0.6% and 0.2% of subjects in the KPI-121 and vehicle groups, respectively. An IOP elevation was defined as an increase from baseline of >5 mm Hg that resulted in an IOP of ≥21 mm Hg in either eye during use of the study product. Conclusions KPI-121 ophthalmic suspension 0.25% seemed to be safe and well tolerated when dosed QID for 2 to 4 weeks in those DED subjects included in the 4 trials.

Clinical trials in dry eye disease provide major challenges due to characteristics of the disease that require design parameters to control for variability in an unstable tear film and lack of correspondence between symptoms and signs of the disease. Lessons learned from previous randomized clinical trials are that precise selection of inclusion and exclusion criteria is essential for obtaining a positive outcome and that proper standardization of clinical procedures across multiple investigative sites is required. The relative lack of regulatory approval of pharmaceutical treatments for dry eye disease appears to be improving with better avoidance of the pitfalls of clinical trial design and an evolving regulatory environment, but ongoing challenges demand rigorous attention to detail in planning and execution of future prospective, randomized, vehicle-controlled, double-masked, parallel group clinical trials.

One of the most common disorders of the ocular surface is dry eye disease (DED). A historical perspective of our understanding of DED can be captured in seven thematic areas. Structure and function of the components of the tear film and ocular surface and the lacrimal functional unit provide the basic information. The hallmarks of DED are tear instability and hyperosmolarity. The role of inflammation in DED and the neurobiological aspects of the ocular surface are important to understanding the vicious cycle of the disease. Recent advances in the diagnosis and treatment of DED provide novel appreciation of DED.

Purpose To identify factors contributing to the inadequacies of systematic reviews and meta-analyses (SRMAs) published in the ophthalmology literature. Design Perspective Methods Review and synthesis of selective literature, with interpretation and perspective. Results While recommendations for the design, conduct, and assessment of quality and risk of bias of systematic reviews have been widely available, some recent publications illustrate a serious potential failing in this domain: inclusion of refuted science, lack of citation of post publication correspondence and failure to utilize ≥1 alternative search strategy. Conclusions Examples of inadequacies of peer review in medical literature and their perpetuation of erroneous science by unfiltered inclusion in subsequent systematic reviews have been identified and the problem can be traced to authors, peer reviewers, and editors of journals. This perspective identifies and analyzes several possible causes of the problem and recommends some specific corrective actions to improve the quality and accuracy of such reviews.

Sjögren's disease is associated with a high burden of illness, diminished quality of life, and increased health care costs. The Sjögren's Syndrome Foundation developed the first US clinical practice guidelines for management of the oral, ocular, and rheumatologic or systemic manifestations. Guideline recommendations were reviewed by a consensus expert panel using a modified Delphi process. This initiative should improve the quality and consistency of care for Sjögren's disease in the United States, guide insurance reimbursement, and define areas for future study. Guidelines will be periodically reviewed and revised as new information becomes available.

The development of novel therapies for Dry Eye Disease (DED) is formidable, and relatively few treatments evaluated have been approved for marketing. In this report, the Subcommittee reviewed challenges in designing and conducting quality trials, with special reference to issues in trials in patients with DED and present the regulatory perspective on DED therapies. The Subcommittee reviewed the literature and while there are some observations about the possible reasons why so many trials have failed, there is no obvious single reason other than the lack of correlation between signs and symptoms in DED. Therefore the report advocates for conducting good quality studies, as described, going forward. A key recommendation for future studies is conduct consistent with Good Clinical Practice (GCP), including use of Good Manufacturing Practice (GMP) quality clinical trial material. The report also recommends that the design, treatments, and sample size be consistent with the investigational treatment, the objectives of the study, and the phase of development. Other recommendations for pivotal studies are a priori selection of the outcome measure, and an appropriate sample size.

Purpose To describe new options for diagnosis and severity grading of dry eye disease. Design Perspective on technological advancements to identify tear dysfunction and their value in diagnosing and grading dry eye disease. Methods Evidence is presented on new and evolving technologies to measure tear stability, composition, and meniscus height and their role in dry eye diagnosis and therapeutic efficacy grading is assessed. Results Evolving concepts regarding pathogenesis and new technologies to evaluate the tears and ocular surface have improved the ability to diagnose, classify, and grade the severity of dry eye disease. New technologies include noninvasive imaging of tear stability and tear meniscus height as a measure of tear volume and tear composition (osmolarity, lacrimal factors, inflammatory mediators, growth and differentiation factors). Approved tests, such as tear osmolarity and tear imaging, are being integrated into clinical practice and may eventually supplant certain traditional tests that have greater variability and less sensitivity. Other tests, such as molecular assays of tears and conjunctival cells, are currently being used in studies investigating pathogenesis and therapeutic mechanism of action. They may eventually translate to routine clinical practice. Conclusions New technologies have emerged that can noninvasively evaluate the tears and measure disease-associated compositional changes. These tests are being integrated into clinical practice and therapeutic trials for diagnosis, classification, and severity grading of dry eye disease.

Purpose Relationships between tear film lipid (TFL) layer composition, structure, and function could provide insight into the etiology of dry eye. The molar ratio of cholesteryl ester (CE)/wax ester (WE) was measured in meibum from normal donors (Mn) and compared with meibum from donors with meibomian gland dysfunction (MMGD). Methods CE/WE was measured using nuclear magnetic resonance spectroscopy. Results CE/WE was distributed into two populations with 81% distributed near 0.55 and 19% near 0.3. CE/WE were higher in donors 13 to 19 years old compared with donors 1 to 12 years old and 20 to 88 years old. CE/WE for MMGD was 30% lower, 0.34 ± 0.04, compared with Mn, 0.49 ± 0.04. There were no sex differences in CE/WE. There were no significant racial differences between the CE/WE ratios for Asians and Caucasians. The CE/WE ratio was higher for blacks and lower for Hispanics compared to Caucasians. Due to the small number sampled, confirmation of the later racial results is needed. The packing of CE and WE in the TFL layer was proposed. Conclusions Although MMGD contains much less CE than Mn, factors other than the CE content, such as the levels of saturation and/or proteins, may be responsible for the higher order of MMGD. In addition to saturation, CE could contribute to the increase in order of Mn between 0 and 20 years of age. Observed changes in the meibum content of CE alone is not likely to influence tear film stability.

PURPOSE We have previously reported that mouse kallikrein (KLK) 22 in the lacrimal and salivary glands is an autoantigen that can induce primary Sjogren syndrome (SS) in rats. In this study, we determine whether the production of antibodies against tissue KLK is specific for SS and whether the antibody can be used as a biomarker for the diagnosis in humans. METHODS Sera from 11 patients diagnosed with SS, 8 patients with dry eye disease (DED), and 8 normal age/sex-matched controls (NL) were collected for detecting antibodies against tissue KLK1, KLK11, KLK12, and KLK13 by capture enzyme-linked immunosorbent assay. RESULTS Anti-KLK11 antibody was significantly higher in the SS than in the DED (P = 0.05) and NL (P < 0.01) groups, with no difference in the level of this antibody between the DED and NL groups. In addition, receiver operating characteristic analysis revealed that, at or above an optical density cutoff point of 0.2695, anti-KLK11 antibody has a sensitivity of 82% and a specificity of 94% to distinguish the SS group from the other groups. CONCLUSIONS Our results suggest that anti-KLK11 might be a novel biomarker for SS in humans. Further investigation is required to confirm this finding and to establish the exact role of KLK11 in the pathogenesis of SS.

Purpose: Meibomian gland dysfunction (MGD) is a common clinical problem that is often associated with evaporative dry eye disease. Alterations of the lipids of the meibomian glands have been identified in several studies of MGD. This prospective, observational, open-label clinical trial documents the improvement in both clinical signs and symptoms of disease as well as spectroscopic characteristics of the meibomian gland lipids after therapy with topical azithromycin ophthalmic solution and oral doxycycline treatment. Methods: Subjects with symptomatic MGD were recruited. Signs of MGD were evaluated with a slit lamp. Symptoms of MGD were measured by the response of subjects to a questionnaire. Meibum lipid–lipid interaction strength, conformation, and phase transition parameters, and meibum protein content were measured using Fourier transform infrared spectroscopy and principal component analysis. Terpenoids, short-chain CH3 moieties, lipid oxidation, wax, cholesterylesters and glycerides were measured with a proton nuclear magnetic resonance ( 1 H-NMR) spectrometer. Results: Topical therapy with azithromycin and oral therapy with doxycycline relieved signs and symptoms and restored the lipid properties of the meibomian gland secretion toward normal. Compared with 4 weeks of azithromycin treatment reported in our previous study, oral doxycycline treatment was slightly less effective in improving foreign body sensation and the signs of plugging and secretion. In subjects with clinical evidence of MGD, changes in ordering of the lipids and phase transition temperature were brought closer to normal with azithromycin treatment than doxycycline treatment. Treatment with doxycycline but not azithromycin restored the Fourier transform infrared spectroscopy–principal component analysis scores and relative area of the 1 H-NMR resonance at 1.26 ppm. Both doxycycline and azithromycin treatment restored the levels of the relative areas of the 1 H-NMR resonance at 5.2 and 7.9 ppm to normal levels. The levels of meibum protein and meibum lipid oxidation were not influenced by azithromycin or doxycycline treatment. Conclusions: The mechanism of action of doxycycline may be different from that of azithromycin in therapy of MGD. It is notable that when carotenoids in meibum are low, as in MGD, the tear film is unstable and patients have the signs and symptoms of dry eyes. When carotenoids are restored with azithromycin and doxycycline treatment, tear film stability is restored and patients no longer have the signs and symptoms of dry eyes.

Kamran Hosseini,1 Richard L Lindstrom,2,3 Gary Foulks,4 Kelly K Nichols5 1InSite Vision, Alameda, CA, 2Minnesota Eye Consultants, 3Department of Ophthalmology and Visual Neurosciences, University of Minnesota Medical School, Minneapolis, MN, 4Department of Ophthalmology and Vision Science, School of Medicine, University of Louisville, Louisville, KY, 5School of Optometry, University of Alabama at Birmingham, Birmingham, AL, USA Purpose: To evaluate the clinical efficacy and safety of a 1% azithromycin–0.1% dexamethasone combination in DuraSite (“combination”) compared to 0.1% dexamethasone in DuraSite, 1% azithromycin in DuraSite, and vehicle in the treatment of subjects with blepharitis.Materials and methods: This was a Phase III, double-masked, vehicle-controlled, four-arm study in which 907 subjects with blepharitis were randomized to combination (n=305), 0.1% dexamethasone (n=298), 1% azithromycin (n=155), or vehicle (n=149). Ten study visits were scheduled: screening visit, days 1 and 4 (dosing phase) and 15, and months 1–6 (follow-up phase). On day 1, subjects applied one drop of the study drug to the eyelid of the inflamed eye(s) twice daily, and continued with twice-daily dosing for 14 days. After completing 14 days of dosing, subjects were followed for 6 months for efficacy and safety.Results: A total of 57 subjects (6.3%) had complete clinical resolution at day 15: 25 (8.2%), 17 (5.7%), 8 (5.2%), and 7 (4.7%) subjects in the combination-, 0.1% dexamethasone-, 1% azithromycin-, and vehicle-treatment groups, respectively. The combination was superior to 1% azithromycin and vehicle alone, but not to 0.1% dexamethasone alone. Mean composite (total) clinical sign and symptom scores improved in all four treatment groups during the posttreatment evaluation phase for the intent-to-treat population, but outcomes were superior when a drop containing 0.1% dexamethasone was utilized. Clinical response was noted as early as day 4, and persisted as long as 6 months. Most adverse events were considered mild in severity and not related to the study drug.Conclusion: A higher percentage of subjects in the combination group achieved complete clinical resolution of the signs and symptoms of blepharitis at day 15 than with 1% azithromycin and vehicle, but outcomes were similar to treatment with 0.1% dexamethasone alone. The combination was well tolerated. Keywords: blepharitis, dexamethasone, azithromycin, eyelid inflammation

Accelerated evaporation of tears may contribute to dry eye symptoms. It is not clear whether contact lenses decrease or increase the rate of evaporation of tears. In this study, the rates of evaporation through contact lenses (ERTCL) were measured in vitro to gain insight to this question. Contact lenses were equilibrated with various solutions to determine if they influenced ERTCL in vitro. ERTCL was measured gravimetrically. ERTCL measured in vitro for used contact lenses was about 20% faster than for buffer alone suggesting that natural tear components bound to the lenses changed the ERTCL. One natural tear component that binds to contact lenses is waxes. Equilibration of contact lenses with wax increased the ERTCL by about 30% suggesting that waxes might potentially increase ERTCL in vivo. Squalene, found in sebum and possibly meibum was infused into the contact lenses as a step toward decreasing the ERTCL. Squalene decreased ERTCL by over 60% in vitro. Soaking a contact lens in DuraSite(®) with benzalkonium chloride (BAK) did not alter the ERTCL. ERTCL were about 40% higher than the evaporation rate of DuraSite(®) alone or without BAK. In addition to lowering the ERTCL, the squalene in contact lenses could be a source of terpenoids to replace the terpenoids deficient in patients with MGD. If the ERTCL could be minimized in vivo, contact lenses could potentially be used to relieve dry eye symptoms in patients with evaporative dry eye.

Ocular surface disorder--and dry eye, in particular--is a leading reason for visits to eye care professionals. It has been generally accepted that meibomian gland dysfunction (MGD) is a leading cause of evaporative dry eye, as well as being associated with aqueous-deficient dry eye. Yet, researchers and clinicians have lacked a global consensus on the definition of MGD, its epidemiology, pathophysiology, and management. Various systemic diseases and medications have been associated with the progression of both dry eye and MGD, as have several ocular disorders beyond those directly affecting the surface. It is in the best interest of patients for clinicians to be able to better identify and diagnose MGD, differentiating it from other ocular surface disorders, and to recognize the effects of MGD on the ocular surface, and thus initiate appropriate therapy. This CME activity provides expert insight into the Tear Film and Ocular Surface Society's International Workshop on MGD consensus report, offering practical application of its findings to better manage MGD patient care, particularly for those patients facing or undergoing ocular surgery.

Objective To evaluate safety and efficacy of topical ophthalmic tofacitinib (CP-690,550), a novel Janus kinase inhibitor, in treating dry eye disease (DED). Design A phase 1/2 prospective, randomized, double-masked, multicenter, vehicle- and comparator-controlled trial (NCT00784719). Participants Patients (n = 327) 18 years of age and older with a DED diagnosis for 6 months or more. Methods Tofacitinib (0.0003% twice daily, n = 46; 0.001% in both eyes twice daily, n = 47; 0.003% twice daily, n = 48; 0.005% twice daily, n = 48; 0.005% once daily, n = 44) results were compared with those of groups receiving active treatment cyclosporine ophthalmic emulsion 0.05% twice daily (n = 47) and vehicle twice daily (n = 47). Safety and efficacy evaluations were performed at baseline and throughout the 8-week study. Main outcome measures Schirmer wetting, corneal staining, tear film break-up time, conjunctival staining, Ocular Comfort Index (OCI), and Ocular Surface Disease Index (OSDI). Results All tofacitinib doses were well tolerated, exhibiting better patient-reported ocular tolerability than cyclosporine. For the proportion of patients achieving 10 mm or more Schirmer wetting (without anesthesia) at week 8 (primary end point), greater response rates were observed in the tofacitinib 0.001% twice daily (27.3%), 0.005% twice daily (25.5%), and 0.005% once daily (26.1%) groups versus vehicle (20.0%); however, the differences were not statistically significant. Mean increase in Schirmer wetting (without anesthesia) from baseline was statistically significant (P Conclusions This phase 1/2 study of tofacitinib demonstrated a trend for improving both signs and symptoms of dry eye. All doses of tofacitinib exhibited a reasonable safety profile and were well tolerated by patients with DED.

Protein-meibum and terpenoids-meibum lipid interactions could be important in the etiology of meibomian gland dysfunction (MGD) and dry eye symptoms. In the current model studies, attenuated total reflectance (ATR) infrared (IR) spectroscopy was used to determine if the terpenoid β-carotene and the major proteins in tears and meibum affect the hydrocarbon chain conformation and carbonyl environment of wax, an abundant component of meibum. The main finding of these studies is that mucin binding to wax disordered slightly the conformation of the hydrocarbon chains of wax and caused the wax carbonyls to become hydrogen bonded or experience a more hydrophilic environment. Lysozyme and lactoglobulin, two proteins shown to bind to monolayers of meibum, did not have such an effect. Keratin and β-carotene did not affect the fluidity (viscosity) or environment of the carbonyl moieties of wax. Based on these results, tetraterpenoids are not likely to influence the structure of meibum in the meibomian glands. In addition, these findings suggest that it is unlikely that keratin blocks meibomian glands by causing the meibum to become more viscous. Among the tear fluid proteins studied, mucin is the most likely to influence the conformation and carbonyl environment of meibum at the tear film surface.

Objective To recount the historic evaluation of meibomian gland dysfunction (MGD) and describe new techniques to monitor disease and therapy. Methods A review of the literature regarding the description of MGD and the role of abnormalities of meibomian gland secretion in health and disease. Results Meibomian gland dysfunction is a common clinical condition and is a major cause of evaporative dry eye with associated discomfort, visual disturbance, and contact lens intolerance. Despite the early description of the anatomy and physiology of the meibomian gland, recognition of the importance of the MGD and particularly therapeutic options to treat it has been limited. Conclusions Improved methods of spectroscopic and chemical analysis of the meibomian gland secretion in health and disease are providing a better understanding of the physical and chemical abnormalities of the meibomian gland secretions and are allowing better evaluation of medical therapies.

Changes in the phase transition temperatures and conformation of human meibum lipid with age and meibomian gland dysfunction have been quantified but with analysis of less than 1% of the infrared spectral range. The remaining 99% of the spectral range was analyzed with principal component analysis (PCA) and confirms our previous studies and reveal further insights into changes that occur in meibum with age and disease. Infrared spectra of meibum from 41 patients diagnosed with meibomian gland dysfunction (Md) and 32 normal donors (Mn) were measured. Principal component analysis (PCA) was used to quantify the variance among the spectra and meibum protein was quantified using the infrared carbonyl and amide I and II bands. A training set of spectra was used to discriminate between Mn and Md with an accuracy of 93%. This shows that certain spectral regions (eigenvectors) contain compositional and structural information about the changes that occur with the principal component (variable), meibomian gland dysfunction. The spectral features of the major eigenvector indicate that Md contains more protein and relatively less CH(3) and cis = CH band intensity compared to Mn. The amount of protein was confirmed from relative infrared band intensities. Our study supports the idea that compositional differences result in meibum that is less fluid and more viscous with meibomian gland dysfunction so that less lipid flows out of the meibomian gland orifice as observed clinically. This study also demonstrates the power of the combination of infrared spectroscopy and PCA as a diagnostic tool that discriminates between Mn and Md.

Both lipids and mucins contribute to the stability of the tear film and lipids may inhibit tears from evaporating. Younger people have lower lipid viscosity, higher lipid volume, and a lower rate of tear evaporation. Since age-related changes in human meibum composition and conformation have never been investigated, as a basis for the study of lipid-associated changes with meibomian gland dysfunction, we used the power of infrared spectroscopy to characterize hydrocarbon chain conformation and packing in meibum from humans without dry eye symptoms in relation to age and sex. Meibum from normal human donors ranging in age from 3 to 88 years was studied. Meibum phase transitions were quantified by fitting them to a 4-parameter 2-state sigmoidal equation. Human meibum order and phase transition temperatures decrease with age and this trend may be attributed to lipid compositional changes. If meibum has the same thermodynamic properties on the surface of the tears as it does on the lid margin, a decrease in lipid-lipid interaction strength with increasing age could decrease the stability of tears since lipid-lipid interactions on the tear surface must be broken for the tear film to break up. This study also serves as a foundation to examine meibum conformational differences in meibum from people with meibomian gland dysfunction.

Raman spectroscopy could potentially be used as a diagnostic tool for the detection of meibomian gland dysfunction by measuring the composition, conformation, and amount of meibum lipid on the lid margin. Toward this goal and to test our studies of meibum lipid using infrared spectroscopy, we measured the Raman spectra of samples from human donors with and without meibomian gland dysfunction.Human meibum was expressed from the eyelids and collected on a spatula. Meibum was placed onto an AgCl window for analysis using a Raman spectrometer.Raman spectra of human meibum closely resembled that of wax. The Raman band intensity ratio, 1303/1267 cm(-1), was used to calculate a saturation level CH(2)/=CH of 12 for meibum from normal donors and 11.8 for meibum from donors with meibomian gland dysfunction. Human meibum was found to fit well in the linear relationships between lipid saturation and lipid order at physiological temperature and between lipid saturation and the lipid phase transition temperature. The CH stretching band region predominates the Raman spectra of human meibum. If sample temperature could be controlled, the CH stretching bands could be used to calculate the lipid structural order in terms of trans and gauche rotomer levels. Raman spectra indicate that carotenoid-like bands decrease from the equivalent of about 90 microg carotenoid per gram of meibum wax at 19 years of age to about 0 at 80 years of age in samples from patients with meibomian gland dysfunction. The carotenoids may serve as antioxidants.Principal component analysis shows that a component containing carotenoid-like bands may be a promising spectral feature that could be used to distinguish differences between the Raman spectra of donors from normal and those with meibomian gland dysfunction. This study demonstrates the wealth of structural and compositional information that Raman spectra of human meibum provide.

Dry eye syndrome is a collection of common disorders of multifactorial etiology. Although the epidemiology of dry eye has been well studied, reports of genetic patterns that might influence susceptibility to dry eye are few. We reported that the frequency of non-Sjögren's aqueous-deficient dry eye patients expressing only the MUC1/A splice variant of the mucin MUC1 may be lower than that of a normal control group [Imbert, Y., Darling, D.S., Jumblatt, M.M., Foulks, G.N., Couzin, E.G., Steele, P.S., Young, W.W., Jr., 2006. MUC1 splice variants in human ocular surface tissues: possible differences between dry eye patients and normal controls. Exp. Eye Res. 83, 493-501]. Also, He et al. [He, Y., Li, X., Bao, Y., Sun, J., Liu, J., 2006. The correlation of polymorphism of estrogen receptor gene to dry eye syndrome in postmenopausal women. Yan. Ke. Xue. Bao. 22, 233-236] reported a difference between Chinese dry eye and control groups in the frequency of a polymorphism in estrogen receptor alpha (ERalpha). In the present study we determined the statistical significance and generality of these observations and tested if the MUC1 splice variant difference between subject groups reflected a difference in the MUC1 variable number of tandem repeat (VNTR) size class. There was a perfect correlation between the MUC1/A or MUC1/B splice variant pattern and the SNP genotype frequency of the SNP (rs4072037) controlling that splicing event. In contrast, western and Southern blotting indicated that MUC1 VNTR size class corresponded to the MUC1 SNP genotype in only 80% of cases. We determined the status of the MUC1 SNP in normal and dry eye populations all of whom were female Caucasians. The MUC1 SNP genotype frequency of the normal control group was statistically different from both the non-Sjögren's aqueous-deficient dry eye group with ocular surface staining (P=0.017) and the evaporative dry eye group (P=0.015). We also tested SNP rs2234693 to analyze the polymorphism in the ERalpha gene and found no significant difference in the SNP genotype frequency between the control group and either of the dry eye subtypes. Thus, among Caucasians there is no evidence for an association of the ERalpha gene polymorphism with dry eye syndrome as previously described in a Chinese population. In conclusion, the etiologies of evaporative dry eye and non-Sjögren's aqueous-deficient dry eye are known to be different. However, our results suggest that both of these subtypes of dry eye disease may share a common mechanism or factor related to MUC1 genotypic differences that affects susceptibility to ocular surface damage. This altered susceptibility may not be related to the MUC1 VNTR size class. Therefore, mechanisms influencing protection of the ocular surface against inflammation and damage in different types of dry eye disease warrant further investigation particularly in relation to MUC1 genotype.

Physicians caring for patients who have Sjögren's syndrome often face a particularly difficult task in managing the dry eye that occurs with this disease. The discomfort produced by the condition and the fluctuation of vision attendant to tear film instability are often the most annoying of the clinical symptoms. The understanding of dry eye disease in both its clinical expression and underlying etiopathology has expanded over the past 10 years with implications for management and therapy. The array of potential treatments both topical and systemic has evolved to provide a much more targeted and effective arsenal from which the clinician may choose.

Infrared and fluorescence spectroscopies were applied to characterize the molecular conformational/structure and dynamics of human meibum (ML) and tear lipids (SSL). ML lipids contained more C C and CH3 moieties than SSL. SSL contained OH groups that were not apparent in the spectra of ML. The C O stretching band observed in the infrared spectra of SSL and ML revealed that the C O groups are not involved in hydrogen bonds. Bands due to the polar moieties C O and PO2− did not change significantly with increasing temperature, suggesting that they may not play an appreciable thermodynamic role in the lipid hydrocarbon chain phase transition. Components in tears bind to SSL and exclude water at the water–lipid boundary where the polar headgroups of phospholipids are located. If similar interactions occur in vivo at the tear film lipid–aqueous interface, they would reduce the rate of evaporation. The results provide a foundation for future studies to assess possible differences with age and sex in tears from normal and dry eye subjects.

Purpose: Mucins are highly glycosylated proteins that act as lubricants, protectants, and mediators of signal transduction. The UDP-GalNAc:polypeptide N-acetylgalactosaminyltransferase (ppGaNTase) family members initiate mucin-type O-glycosylation. Because O-glycosylation provides mucins with the viscoelastic properties required for proper mucin function, ppGaNTase expression is vital to the maintenance of healthy epithelial surfaces including the ocular surface. Differences of expression of ppGaNTase isoforms might be factors influencing susceptibility to dry eye disease. Therefore, we determined the expression of the ppGaNTase isoforms in normal human ocular surface tissues and the conjunctival epithelium from patients with aqueous-deficient dry eye. Methods: Expression of ppGaNTase isoforms was quantitated by real-time reverse transcriptase polymerase chain rection (RT-PCR). Results: Conjunctiva and cornea expressed multiple ppGaNTase isoforms, with isoforms T12 and T4 being the most strongly expressed in conjunctiva and T12 and T3 in the cornea. In contrast, lacrimal gland expressed fewer isoforms and had lower total ppGaNTase expression. Brush cytology was found to be superior to impression cytology for harvesting conjunctival epithelium in terms of ease of use, safety, and reproducibility of results. Similar to whole conjunctiva, the strongest isoforms in conjunctival epithelial cells were T12 and T4, followed by T3, Tl, T5, and T2. No significant differences of ppGaNTase expression were found between the conjunctival epithelium of dry eye and normal control groups. Conclusion: Human ocular surface tissues express multiple ppGaNTase isoforms, suggesting a requirement for glycosylating diverse mucin-type substrates. However, there is no evidence to date to suggest that differences of ppGaNTase expression levels might contribute to susceptibility to dry eye disease.

Mucins are highly glycosylated proteins that are vital to the maintenance of healthy epithelial surfaces including the ocular surface. Mucins act as lubricants, protectants, and mediators of signal transduction. The majority of the O-glycosylation sites on the transmembrane mucin MUC1 are found in a highly polymorphic core region containing a variable number of tandem repeats (VNTR). MUC1 alleles can be divided into size classes that contain small (30-45) or large (60-90) numbers of repeats. Although at least 12 splice variants of MUC1 have been found in other tissues, no splice variants have been reported in human ocular surface tissues. We have used RT-PCR to identify MUC1 splice variants that were then confirmed by sequencing. We here report the presence in some samples of human cornea, conjunctiva, and lacrimal gland of MUC1/B which features canonical splicing between exons 1 and 2 and MUC1/A, a transcript that retains 27bp from the 3' end of intron 1 and is predicted to add 9 amino acids to the MUC1 sequence upstream of the tandem repeat region. Cornea and conjunctiva both contain the MUC1/SEC splice variant that lacks the transmembrane domain and, therefore, results in a soluble, secreted form of MUC1. Cornea and conjunctiva also contain MUC1/Y and MUC1/Z(X) variants that lack the tandem repeat region. Cornea, conjunctiva, and lacrimal gland also contain a previously undescribed MUC1 variant transcript, termed MUC1/YI, that retains 99bp from the 5' end and 27bp from the 3' end of the first intron, resulting in a frame shift and premature stop codon. This transcript is predicted to produce a novel 27 amino acid peptide after signal peptidase cleavage. Analysis of brush cytology samples revealed that the percentage of dry eye patients expressing the MUC1/A variant in the conjunctival epithelium is lower than in normal control donors. Western blotting confirmed that MUC1/A is associated with alleles containing the large size class of tandem repeats. Therefore, we propose that one factor in susceptibility to dry eye disease may be the lengths of the MUC1 VNTR in conjunctival epithelium based on the rationale that longer VNTR provide better lubrication and greater protection of the ocular surface against inflammation.

Purpose: Gene delivery at high efficiency is crucial for cornea endothelial cell gene therapy. This study investigated the efficiency of gene transfer by recombinant adeno-associated virus (rAAV) in an organ culture system.Methods: Human cornea tissue was exposed to rAAV delivering green fluorescent protein (ss-rAAV2-CMV-GFP) for one hour and then cultured at 31ˆC for 2 weeks in a medium supplemented with growth factors. Endothelial cells expressing GFP gene were then identified.Results: High-efficiency gene transfer was found in over 90% of endothelial cells. Gene expression could be detected within 24 hours and remained stable up to 2 weeks in the organ culture system.Conclusions: The high-delivery efficiency and rapid induction of gene expression indicate that rAAV is a promising vector for cornea endothelial cell gene therapy for ocular diseases. Organ culture at 31ˆC using culture medium supplemented with growth factors significantly facilitates gene transfer into human corneal endothelium.

Currently, the armamentarium of contact lenses that can be used for therapeutic effect provides a wider selection of lenses than ever before. If the therapeutic goal is protection and healing of the corneal epithelium, epithelial or stromal edema is best avoided, and the selection of a high-Dk silicone hydrogel (balafilcon A, lotrafilcon A) lens or a very thin membrane-type lens (crofilcon) is the best choice. If the goal is surface protection as well as stimulation of stromal wound vascularization, selection of a low-water content, thick, hydrophilic lens is the better option. If the patient is prone to lens loss or requires frequent replacement of the therapeutic lens, a prudent economic decision is to select a daily disposable moderate-water content lens. Specific circumstances may mandate the selection of a specific therapeutic lens. Patients with a prior history of active giant papillary conjunctivitis may be better served by the use of a crofilcon glyceryl methacrylate lens, which has a lower incidence of this complication. Patients who have dry eye may benefit from a higher-water content lens if adequate unpreserved tear supplementation is provided with or without punctal occlusion. The options when selecting a therapeutic contact lens are wider than ever before. Although the new generation of high-Dk lenses promises fewer limiting problems of vascularization and infection, one can use the older traditional therapeutic lenses when induced vascularization of the cornea is needed or when an economic necessity exists. Not all of the available lenses are FDA approved for therapeutic use, and such wear is an off-label use. The patient should be informed of the goal of therapy as well as the benefits and risks of therapeutic contact lenses.

Purpose. To define dry eye disease and describe the evolution of our understanding of the clinical expression and pathophysiology of dry eye. To relate tear function to contact lens wear and review the problems dry eye causes with contact lens tolerance and performance. Methods. Review of literature. Results. The rudimentary definition of dry eye as a lack of tears is expanded through an increased understanding of the clinical presentations of dry eye. The classification of dry eye is historically reviewed. The pathophysiology is related to the evolution of therapy for dry eye disorders. The function of the tear film is related to contact lens wear and the problems induced by dry eye correlated with contact lens intolerance. Conclusion. The tear film is critical to successful contact lens wear. Disturbances of the quantity or quality of the tear film, whether because of aqueous deficiency or evaporative tear problems, results in intolerance of contact lens wear and damage to the ocular surface.

Objective To evaluate the safety and efficacy of the removal of INTACS. Design Subgroup analysis from a nonrandomized comparative interventional trial. Participants Four hundred fifty-two patients with best spectacle-corrected visual acuity of 20/20 or better and myopia (1.0–3.5 diopters [D]) were enrolled in the U.S. Food and Drug Administration clinical trials of INTACS. Forty-six eyes among a total of 684 underwent INTACS removal. Intervention INTACS removal. Methods Safety and efficacy of INTACS removal was assessed by comparison of results from preoperative and 3-month postremoval visits. Safety was assessed by maintenance of preoperative best spectacle-corrected acuity and induction of astigmatism (measured by manifest refraction). Efficacy was assessed by comparison of mean spherical equivalent measured by both manifest and cycloplegic refraction, as well as percentage of eyes within ± 0.5 D and ± 1.0 D of baseline values. A subset of 27 patients completed a prospective questionnaire assessing the frequency of six visual symptoms (glare, halos, double vision, photophobia, night vision difficulties, and fluctuating vision). Main outcomes measures Best spectacle-corrected visual acuity, manifest refraction, and cycloplegic refraction. Results Forty-one of 46 patients’ eyes that had undergone INTACS removal had reached the 3-month postremoval visit. Of these eyes, 73% (30 of 41) had returned to within ± 0.5 D and 97% (40 of 41) to within ± 1.0 D of baseline spherical equivalent as measured by manifest refraction. With respect to astigmatism, 88% (36 of 41) had returned to within ± 0.5 D and 100% (41 of 41) to within ± 1.0 D of preoperative value. No patient had a loss of best spectacle-corrected acuity of more than 2 lines, with equal numbers of eyes having a loss or gain of 1 line (nine eyes) and 2 lines (one eye). For most eyes, INTACS removal was associated with a substantial reduction in the six types of visual symptoms; however, in some eyes (up to 15%) symptoms that had not been detected preoperatively were noted after INTACS removal. Conclusions INTACS removal was not associated with a loss (> 2 lines) of best spectacle-corrected visual acuity or induction (> 1 D) of astigmatism or myopia. INTACS removal was associated with a reversal to preoperative values in most cases.

Objective To report a new surgical technique to manage severe acute toxic epidermal necrolysis. Design Two interventional case reports. Participants Two patients. Case 1: A 6-year-old boy had severe toxic epidermal necrolysis develop after being treated with trimethoprim and sulfamethoxazole for chronic otitis media. Both eyes and eyelids were affected. He underwent bilateral lysis of symblepharon and all adhesions and bilateral amniotic membrane transplantation to the entire ocular surface except the cornea. Loss of eyelid skin required transplantation of amniotic membrane to all four eyelids and strips of amniotic membrane at the eyelid margins. Case 2: An 8-year-old girl with severe toxic epidermal necrolysis associated with mycoplasma pneumonia had bilateral, diffuse keratoconjunctivitis, diffuse corneal epithelial defects, and bilateral symblepharon. Amniotic membrane transplantation was performed bilaterally, using a symblepharon ring in the left eye. Intervention Amniotic membrane transplantation. Main outcome measures Preservation of normal ocular and eyelid surfaces and prevention of blindness. Results Case 1: Thirty-six months after bilateral ocular surgery, there is no symblepharon, good ocular surface wetting, and an uncorrected bilateral vision of 20/20. Case 2: Amniotic membrane transplantation protected both ocular surfaces and prevented conjunctival contracture without adhesion of the eyelids to the ocular surface. The central vision was preserved. There was minimal peripheral corneal vascularization and mild conjunctival scarring of the tarsal conjunctival surface 34 months postoperatively. Conclusions These are the first cases of acute toxic epidermal necrolysis treated with amniotic membrane transplantation and the first use of the procedure on external eyelid surfaces with good healing of the eyelids. This new treatment for acute toxic epidermal necrolysis preserves normal ocular and eyelid surfaces and may prevent blindness.

Purpose To provide a consensus clinical guideline for management of dry eye disease associated with Sjogren disease by evaluating published treatments and recommending management options. Design Consensus panel evaluation of reported treatments for dry eye disease. Methods Using the 2007 Report of the International Workshop on Dry Eye (DEWS) as a starting point, a panel of eye care providers and consultants evaluated peer-reviewed publications and developed recommendations for evaluation and management of dry eye disease associated with Sjogren disease. Publications were graded according to the American Academy of Ophthalmology Preferred Practice Pattern guidelines for level of evidence. Strength of recommendation was according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Results The recommendations of the panel are briefly summarized herein. Evaluation should include symptoms of both discomfort and visual disturbance as well as determination of the relative contribution of aqueous production deficiency and evaporative loss of tear volume. Objective parameters of tear film stability, tear osmolarity, degree of lid margin disease, and ocular surface damage should be used to stage severity of dry eye disease to assist in selecting appropriate treatment options. Patient education with regard to the nature of the problem, aggravating factors, and goals of treatment is critical to successful management. Tear supplementation and stabilization, control of inflammation of the lacrimal glands and ocular surface, and possible stimulation of tear production are treatment options that are used according to the character and severity of dry eye disease. Summary Management guidelines for dry eye associated with Sjogren's disease are presented.

Publication of the DEWS report in 2007 established the state of the science of dry eye disease (DED). Since that time, new evidence suggests that a rethinking of traditional concepts of dry eye disease is in order. Specifically, new evidence on the epidemiology of the disease, as well as strategies for diagnosis, have changed the understanding of DED, which is a heterogeneous disease associated with considerable variability in presentation. These advances, along with implications for clinical care, are summarized herein. The most widely used signs of DED are poorly correlated with each other and with symptoms. While symptoms are thought to be characteristic of DED, recent studies have shown that less than 60% of subjects with other objective evidence of DED are symptomatic. Thus the use of symptoms alone in diagnosis will likely result in missing a significant percentage of DED patients, particularly with early/mild disease. This could have considerable impact in patients undergoing cataract or refractive surgery as patients with DED have less than optimal visual results. The most widely used objective signs for diagnosing DED all show greater variability between eyes and in the same eye over time compared with normal subjects. This variability is thought to be a manifestation of tear film instability which results in rapid breakup of the tearfilm between blinks and is an identifier of patients with DED. This feature emphasizes the bilateral nature of the disease in most subjects not suffering from unilateral lid or other unilateral destabilizing surface disorders. Instability of the composition of the tears also occurs in dry eye disease and shows the same variance between eyes. Finally, elevated tear osmolarity has been reported to be a global marker (present in both subtypes of the disease- aqueous-deficient dry eye and evaporative dry eye). Clinically, osmolarity has been shown to be the best single metric for diagnosis of DED and is directly related to increasing severity of disease. Clinical examination and other assessments differentiate which subtype of disease is present. With effective treatment, the tear osmolarity returns to normal, and its variability between eyes and with time disappears. Other promising markers include objective measures of visual deficits, proinflammatory molecular markers and other molecular markers, specific to each disease subtype, and panels of tear proteins. As yet, however, no single protein or panel of markers has been shown to discriminate between the major forms of DED. With the advent of new tests and technology, improved endpoints for clinical trials may be established, which in turn may allow new therapeutic agents to emerge in the foreseeable future. Accurate recognition of disease is now possible and successful management of DED appears to be within our grasp, for a majority of our patients.

Treatment regimens used for infectious ocular diseases by community-based and academic ophthalmologists were compared. A mail survey asked about antimicrobial choices for serious keratitis, conjunctivitis, and blepharitis; presurgical and postsurgical prophylaxis; use of antibiotics and steroids for treatment of acute adenovirus conjunctivitis; and use of chloramphenicol. Responses were returned by 177 community-based and 84 academic ophthalmologists. Community ophthalmologists generally paralleled academic ophthalmologists in their treatment choices.

We describe a case of focal argyrosis of the conjunctiva clinically simulating a melanoma. An 82-year-old woman was referred for an asymptomatic pigmented conjunctival lesion. Her only significant past ocular history was strabismus surgery 76 years earlier. Biopsy of the conjunctiva and lateral rectus muscle revealed the discoloration was pigment granules. Energy-dispersive x-ray microanalysis revealed the pigmentation to be silver deposits. The patient had strabismus surgery probably using a silver clip. Argyrosis should be considered in the differential diagnosis of focal pigmented conjunctival lesions. [Ophthalmic Surg Lasers 2000;31:495-498]

The occurrence of Acanthamoeba keratitis is increasing in the United States because of an expanding population at risk of infection and sporadic outbreaks of infection. Such outbreaks are the result of lapses in contact lens wear and care and of alterations in water quality and water treatment procedures. Although improved techniques in diagnosis are available, better identification of infection alone does not explain an increase in the observed occurrence of the disease. Likewise, there does not appear to be an increase in the virulence or infectivity of the amoebae. Strategies for prevention, including patient education, improved decontaminating agents, maintenance of water treatment standards, and possible immunization of subjects at risk, are needed.

At the Kentucky Lions Eye Center at the University of Louisville School of Medicine, an ocular surface research center has coalesced, primarily from elements already present at the University.

The goal of this report is to review previously published clinical trials addressing contact lens discomfort (CLD) to identify appropriate trial design and outcome parameters to guide future clinical research that will characterize and investigate possible causes of CLD. A further goal is to identify possible confounding features of clinical trial design and performance in order to reduce bias in conduct of future trials or analysis of data from those trials.

Christine W Sindt,1 Gary N Foulks2 1Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, IA, 2Kentucky Lions Eye Center, Department of Ophthalmology and Visual Science, University of Louisville, Louisville, KY, USA Objectives: The aim of the study reported here was to assess the efficacy of an artificial tear emulsion for the treatment of dry eye associated with meibomian gland dysfunction (MGD). Methods: At five clinics, patients completed a 1-week treatment with their habitual topical therapy and then a 4-week treatment with open-label study medication: Systane® Balance Lubricant Eye Drops (Alcon, Alcon Inc, Fort Worth, TX, USA). Subjective assessments included a preference survey, the Impact of Dry Eye in Everyday Life questionnaire, and the Work Productivity and Activity Impairment questionnaire. Objective assessments by unmasked investigators included visual acuity, meibomian gland expression and dropout, tear film breakup time, corneal staining, and dosing frequency. Results: At baseline, the 49 patients had mean meibomian gland expression grades and gland dropout that indicated mild to moderate MGD. Patients administered their habitual therapy 2.5 ± 1.3 times per day. After 4 weeks of study medication, the Impact of Dry Eye in Everyday Life questionnaire results indicated statistically and clinically significant improvements. Fewer than half of the participants were employed, limiting the usefulness of the Work Productivity and Activity Impairment questionnaire. Visual acuity remained statistically similar, while corneal staining and tear film breakup time improved significantly (P < 0.05) but modestly. The outcomes were achieved with 1.9 ± 1.1 doses per day of study medication, a significantly lower frequency than the habitual frequency (P < 0.001). The most common medication-related adverse event was blurred vision (3/49 patients, 6.1%). At study conclusion, 27/44 (61.4%) survey respondents preferred the study medication to their habitual therapy. Conclusion: The artificial tear emulsion was effective for treating the signs and symptoms of dry eye in MGD patients. Keywords: ophthalmic solutions, Work Productivity and Activity Impairment, Impact on Dry Eye in Everyday Life, MGD, tear film breakup time, corneal staining

Purpose: To evaluate the relationship between signs and symptoms of dry eye disease (DED) in a clinic-based population. Methods: In a retrospective analysis, clinical signs and symptoms were evaluated for 344 subjects (n = 82, normal; n = 263, dry eye), across 11 sites from the EU and United States. Pearson correlations between signs and symptoms (r2) and an independent components analysis (ICA) mixing matrix were derived from the data set. Similar analysis was performed on an independent data set from 200 subjects in a previous study in Munich, Germany. Results: No correlations above r2 = 0.17 were found between any signs and symptoms, except for corneal and conjunctival staining, which reported an r2 = 0.36. In the multisite study, the average r2 for osmolarity (0.07), tear breakup time (0.12), Schirmer test (0.09), corneal (0.16) and conjunctival staining (0.17), meibomian grading (0.11) and Ocular Surface Disease Index® (0.11) were consistently low. Among patients who showed evidence of DED by consensus of clinical signs, only 57% reported symptoms consistent with a diagnosis of DED. Similar results were observed in the Munich-based study data set. Each component of the ICA mixing matrix exhibited minimal residual information. Conclusions: No consistent relationship was found between common signs and symptoms of DED. Each type of measurement provides distinct information about the condition of the ocular surface. These results also demonstrate that symptoms alone are insufficient for the diagnosis and management of DED and argue for a consensus of clinical signs that better reflect all aspects of the disease.

The Collaborative Corneal Transplantation Studies are a pair of multicenter prospective clinical trials evaluating the effectiveness of histocompatibility matching in high risk keratoplasty patients. The antigen matching study (AMS) evaluated HLA matching in patients without circulating lymphocytotoxic antibody to HLA antigens and the cross-match study (CS) evaluated the effect of using cross-match-negative donors in patients with identified circulating lymphocytotoxic antibodies to HLA antigens. Sera from 510 patients considered for enrollment in the studies were screened preoperatively for the presence of anti-class I lymphocytotoxic antibodies (LA). The 42 patients (8%) found to have detectable LA entered the CS. The 468 patients found not to have detectable LA preoperatively entered the AMS. Fifteen of the 37 transplanted CS patients were found to have donor-specific anti-class I antibody (before or after surgery). These patients were also screened for anti-class II LA and 25 had anti-class II panel reactive antibody > or = 5%. Forty-nine of the 419 transplanted AMS patients (12%) were found to have produced anti-class I LA after surgery, and in 19 patients, antibody specificities were those of donor HLA antigens. There was a significant association between the number of mismatched class I antigens and the number of donor-specific LA produced. The production of LA by AMS patients was significantly associated with reaction episodes; eighty-two percent of patients (40 of 49) with LA had reaction, compared with 63% of patients (230 of 365) without LA (P = 0.02). Likewise, production of donor-specific LA was significantly associated with immune-mediated graft failure (P = 0.025). For CS patients, there was no correlation between the production of donor-specific anti-class I or nonspecific anti-class II antibodies and graft outcome. However, the CS patients had poorer graft survival than did AMS patients at 3 years (57% vs. 66%, P = 0.01). These data demonstrate that LA, especially directed against donor class I HLA antigens following corneal transplantation in high risk patients, are associated with immune graft rejection and can be an indicator of allograft rejection.