Tear Film and Meibomian Gland Characteristics in Adolescents Purpose: To establish normative values of ocular surface parameters in adolescents and explore factors associated with meibomian gland (MG) dropout. Methods: Subjects between 8 and 17 years of age were enrolled in this cross-sectional study. All subjects were given dry eye and lifestyle questionnaires. Tear film assessments and meibography were performed. Statistical tests included a one-way analysis of variance to test differences in ocular surface parameters between age groups and linear correlations between clinical findings and lifestyle factors. Results: Two hundred twenty-five subjects completed the study. Thirty-four subjects (15%) reported ocular discomfort, primarily itching. Tear meniscus height increased with age and was greatest in the oldest subjects (mean = 0.25 mm, P < 0.01). Across all subjects, meibography showed that 39% of the upper and 39% of the lower eyelids had MG dropout. The average MG dropout score was 0.50 ± 0.57 for the upper eyelids and was 0.67 ± 0.93 for the lower eyelids. There was no correlation between phone/tablet usage and MG dropout for either the upper (P = 0.39) or lower (P = 0.56) eyelids. Conclusions: The frequency of ocular symptoms in these adolescents was 15%. Because MG dropout is thought to increase with age, it was unexpected to observe that most subjects in this study had mild MG dropout in 1 or both eyelids. Although electronic device usage did not correlate with MG dropout in this study sample, it is still unclear what the effects of long-term digital device usage may have as the subjects age.

Short-Term Effects of Ground-Level Ozone in Patients With Dry Eye Disease: A Prospective Clinical Study Purpose: To investigate changes in the clinical features of patients with dry eye disease (DED) according to short-term outdoor ground-level ozone exposure. Methods: This prospective observational study included patients with DED who were treated with the same topical drugs (0.05% cyclosporine or 3% diquafosol) and visited the hospital twice at 2-month intervals. Patients who showed a short tear film breakup time and positive ocular surface staining were assigned to the diquafosol and cyclosporine groups, respectively. The ocular surface disease index (OSDI) score, tear secretion, tear film breakup time, and corneal fluorescein staining score were measured at each visit. The mean ground-level ozone concentration for 1 week before the ocular examinations was used as the ozone exposure level. Changes in dry eye parameters according to changes in ozone concentration were analyzed using univariate and multivariate linear analyses. Results: Thirty-three patients were included in the analysis. The mean age was 55.2 ± 10.5 years. Ozone concentrations were significantly associated with increased OSDI scores (R = 0.304, P = 0.0006) and a decreased tear secretion (R = −0.355, P = 0.0012) in univariate models. In multivariate models, the results were consistent; the OSDI score increased by 3.43 points (β = 3.43, P = 0.002), and tear secretion decreased by 1.43 mm (β = −1.43, P = 0.015) per 0.01 ppm increase in ozone concentrations over a 2-month interval. Notably, the cyclosporine group showed more prominent changes in the OSDI score and tear secretion with changes in the ozone concentration (P < 0.05). Conclusions: Short-term exposure to increased ground-level ozone concentration led to increased ocular discomfort and decreased tear secretion in patients with DED.

Evaluating Dry Eye and Meibomian Gland Dysfunction With Meibography in Patients With Stevens–Johnson Syndrome Purpose: To investigate ocular surface and meibomian gland characteristics using infrared meibography in patients with Stevens–Johnson syndrome (SJS). Methods: This is a single-center, prospective, noncontrolled, observational study. Thirty-two Thai patients (64 eyes) with SJS for 1 year or longer (1–44 years) were enrolled in the study. All participants underwent a comprehensive ophthalmic examination including slit-lamp biomicroscopy, tear meniscus height, fluorescein tear breakup time, ocular surface fluorescein staining, eyelid morphology, Schirmer 1 test, meibomian gland expressibility, and upper and lower eyelid meibography using a noncontact infrared meibograph mounted on a slit-lamp biomicroscope. Results: The mean age was 42.2 ± 17.7 years (range, 4–68 years). Twenty-nine patients (90.6%) had a history of severe ocular complications in the acute stage of the disease. Medications were the most common cause of SJS (93.8%). Meibum quality could not be assessed in 23 patients (71.9%) due to no glands expressible. Partial or complete loss of the meibomian glands in either the upper or lower eyelid was found in all patients. The degree of meibomian gland dropout significantly correlated with tear breakup time (P < 0.001), meibum quality (P < 0.001), meibum expressibility (P < 0.001), ocular surface staining (P < 0.001), and presence of long-term ocular sequelae including symblepharon (P = 0.027) and limbal stem cell deficiency (P = 0.003). Conclusions: SJS is associated with obstructive meibomian gland dysfunction. The severity of meibomian gland dropout has a relationship with abnormal dry eye tests, subjective meibomian gland evaluation, and other ocular sequelae of SJS.

Risk Factors for Dry Eye After Refractive Surgery Purpose: To determine the factors associated with clinically significant dry eye after keratorefractive surgery. Methods: This is a large database retrospective study that included consecutive cases of myopic laser in situ keratomileusis (LASIK) or photorefractive keratectomy performed between 2008 and 2016 at Care-Vision Laser Center, Israel. Patients were divided into 2 groups according to whether they developed clinically significant dry eye. Results: A total of 25,317 right eyes of 25,317 patients, with a mean age of 27.0 ± 8.3 years, were included. Postoperative dry eye developed in 1518 eyes (6.0%). The dry eye group was older (29.2 ± 9.0 vs. 27.6 ± 8.3 yrs, P < 0.001) and had a higher proportion of women (48.5% vs. 44.8%, P = 0.005), lower preoperative spherical equivalent (3.7 ± 2.0 vs. 4.0 ± 2.3D, P < 0.001), lower preoperative best-corrected visual acuity (0.019 ± 0.057 vs. 0.016 ± 0.064 Logarithm of the Minimum Angle of Resolution (LogMAR), P = 0.04), and lower proportion of preoperative soft contact lens wearers (40.6% vs. 45.5%, P < 0.001). In the postoperative dry eye group, a high proportion underwent LASIK (52.4% vs. 38.7%, P < 0.001) and were treated with a 7.0-mm (as opposed to 6.0 mm) optic zone (18.9% vs. 16.3%, P < 0.001). In multivariable analysis, older age [odds ratio (OR) 1.013, P < 0.001], female gender (OR 0.87, P = 0.009), lower preoperative refractive error (OR 1.05, P < 0.001), and LASIK (OR 0.67, P < 0.001) were associated with postoperative dry eye. Conclusions: Patients who are of older age, are of female gender, and have a lower preoperative refractive error and those undergoing LASIK are more likely to develop dry eye disease after keratorefractive surgery.

Prevalence of Novel Candidate Sjögren Syndrome Autoantibodies in the Penn Sjögren's International Collaborative Clinical Alliance Cohort Purpose: To evaluate the prevalence of novel candidate autoantibodies associated with Sjögren syndrome (SS) and their ability to identify those with SS among participants with dry eye enrolled in the Sjögren's International Collaborative Clinical Alliance (SICCA) study at the University of Pennsylvania (Penn). Methods: All participants previously underwent a full ocular and systemic evaluation for possible SS as part of the SICCA study. An enzyme-linked immunosorbent assay was used to detect IgG, IgA, and IgM autoantibodies to salivary protein 1 (SP-1), parotid secretory protein (PSP), and carbonic anhydrase 6 from previously banked baseline serum samples from SICCA study participants enrolled at Penn. The prevalence rate of each autoantibody, calculated by considering the presence of any isotype as antibody positive, was compared between participants with dry eye with SS (n = 81) or without SS (n = 129) using the Fisher exact test. Results: The prevalence of SP-1 IgM autoantibodies was higher in those with SS compared with those without SS (14% vs. 5%; P = 0.03). Similarly, the prevalence of PSP IgA autoantibodies was higher in those with SS compared with non-SS dry eye participants (21% vs. 11%; P = 0.048). There was no statistically significant difference in the prevalence of carbonic anhydrase 6 autoantibodies between those with or without SS (15% vs. 20%; P = 0.36). Conclusions: In the Penn SICCA cohort, SP-1 IgM and PSP IgA autoantibodies were more prevalent in the serum of SS-related dry eye participants compared with those without SS. Further longitudinal studies are needed to determine the clinical significance of these findings.

Meibomian Gland Morphology: The Influence of Structural Variations on Gland Function and Ocular Surface Parameters Purpose: To objectively and quantitatively characterize meibomian gland morphology and to investigate the influence of morphological variations on gland function and ocular surface and tear film parameters. Methods: One hundred fifty subjects were enrolled. The examinations included tear osmolarity, tear meniscus height, bulbar conjunctival hyperemia, noninvasive tear film breakup time, lid margin thickness, foam secretion, meibomian gland expressibility, count of functioning glands, corneal and conjunctival staining, fluorescein breakup time, lid wiper epitheliopathy, and Schirmer test. Patient symptoms were assessed using the Ocular Surface Disease Index questionnaire. Images from noncontact meibography were analyzed using an automated method that objectively estimates dropout area, number of glands, gland length and width, and gland irregularity. Results: Gland irregularity highly correlated with dropout area (r = −0.4, P < 0.001) and showed significant partial correlations with fluorescein breakup time (r = 0.162, P = 0.049) and the Ocular Surface Disease Index questionnaire (r = −0.250, P = 0.002) Subjects with dropout area <32% were divided into 2 groups: high and low irregularity. Gland expressibility was statistically significantly different between the 2 groups (U = 319.5, P = 0.006). In the high irregularity group, gland irregularity correlated with the Schirmer test (r = 0.530, P = 0.001) and corneal fluorescein staining (r = −0.377, P = 0.021). Conclusions: Automated morphological analysis of meibomian gland structure provides additional quantitative and objective information regarding gland morphology. The link between dropout area and gland function is not clear. Assessment of gland irregularity might better predict gland function and its effects on ocular surface and tear film parameters.

Permethrin Cream for the Treatment of Demodex Blepharitis Purpose: To evaluate the safety and efficacy of permethrin 5% cream for the treatment of Demodex blepharitis. Methods: Patients with confirmed Demodex blepharitis were prospectively recruited and treated with permethrin 5% cream for 6 months. Blepharitis symptoms, ocular examination findings, ocular surface disease index, and ex vivo eyelash Demodex counts were regularly assessed. Results: Twenty-three patients were recruited, of which 2 were lost to follow up and 21 entered the analysis. Mean patient age was 57.2 ± 16.8 years (range: 24–82 years), and 13 (62%) were women. Mean Demodex counts improved after treatment from 1.36 ± 1.233 to 0.48 ± 0.6 parasites per eyelash (P = 0.03), and the overall blepharitis symptoms score improved from 42.9 ± 22 to 32.7 ± 21 (P = 0.01). Improvement in disease symptoms (scored on a scale between 0 and 4) was noted including feeling of dry eye (2.85 ± 1.3–1.85 ± 1.7, P = 0.006), discharge (1.86 ± 1.7–1.00 ± 1.1, P = 0.040), and dandruff-like debris (1.69 ± 1.7–0.9 ± 1.6, P = 0.033), as well as clinical findings including a decrease in scaling (on a scale of 1–5; 1.43 ± 0.9–0.86 ± 0.7, P = 0.006) and corneal staining with fluorescein (on a scale of 1–4; 1.29 ± 0.4–1.05 ± 0.2, P = 0.040). No change in the ocular surface disease index score was noted (37.5 ± 24.1–41.63 ± 42.5, P = 0.913), and no adverse events were reported. Conclusions: Treatment of Demodex blepharitis with permethrin 5% cream resulted in a decrease in parasite burden and improvement in blepharitis signs and symptoms, with no reported adverse events. Permethrin might be a safe and effective alternative for the treatment of blepharitis associated with Demodex infection.

Pediatric Microbial Keratitis in Queensland, Australia (2005 to 2015) Purpose: To estimate the incidence and define the demographic and microbiological profile of pediatric microbial keratitis (MK) in Queensland, Australia. Methods: This is a retrospective study based on the multicenter database of all patients with positive corneal scrapes in Queensland, Australia, between 2005 and 2015. Pathology organizations in Queensland were identified by online and local directory search and were requested to provide digital records of the corneal scrapes, including patient demographics and culture and antibiotic sensitivity results. Patient demographics, yearly incidence (based on state population data), cultured organisms, and antibiotic sensitivities in MK in patients 16 years old or younger with keratitis were reported and compared with adults. Results: Pediatric cases comprised 125 cases of a total 3182 (3.9%) included in the database. The yearly incidence of MK in children was estimated to be 0.11 cases per 10,000 people 16 years old or younger (95% confidence interval, 0.086–0.134), which was significantly lower than the estimated incidence in people older than 16 years (0.82 per 10,000 people; 95% confidence interval, 0.72–0.92; P < 0.0001). The average age of pediatric patients was 9.2 years (SD 5.5). Culture results showed Gram-positive organisms were the most common causative organisms (84%; 67.2%), Pseudomonas aeruginosa was the most common single organism (24%; 19.2%), and fungal recovery was low (4%; 3.2%). Cultures positive for Streptococcus pneumoniae (17%; 13.6%; P < 0.001) and bacteria sensitive to all recorded antibiotics (96.8%; P < 0.001) were significantly more common in children. Conclusions: MK in pediatric patients is less common than in adults. Although Streptococcus pneumoniae was more common in children, P. aeruginosa was the most common isolate.

Keratoconus Could Be Associated With Psoriasis: Novel Findings From a Comparative Study Purpose: To explore the relationship between keratoconus (KC) and psoriasis. Methods: One hundred ten eyes of 55 patients with psoriasis (study group, SG) and 110 eyes of age–sex-matched 55 healthy volunteers (control group, CG) were included in the study. All cases underwent a detailed dermatological and ophthalmological examination including corneal topography. Moreover, Psoriasis Area and Severity Index (PASI) scoring of the patients was carried out in the SG. A thorough comparison of pachymetric, aberrometric, and topometric values between the groups was performed, and the results were interpreted. A χ2 test, Mann–Whitney U test, and Pearson correlation test were used for statistical assessment. Results: Although the average Kmax (44.6 in the SG; 44.5 in the CG; P = 0.613) and Belin/Ambrósio enhanced ectasia total deviation value (1.34 in SG; 1.20 in CG; P = 0.880) were similar between the groups, the mean index of vertical asymmetry value in the SG (0.14 mm) was significantly higher than that in the CG (0.11 mm) (P = 0.041). Moreover, 28 eyes from 16 patients with psoriasis were found to be associated with KC because 26 of those 28 eyes were KC suspects and 2 of them were definite KC. A positive correlation was found among topometric parameters, especially between duration of the disease and PASI score. A negative correlation was discovered between topometric parameters and the early beginning of psoriasis. Conclusions: Serious changes in topography maps may occur in psoriatic patients. The changes were found to be more evident in the presence of a higher PASI score and the early beginning and longer duration of the disease. The results hinted a potential relationship between psoriasis and KC.

Outcomes of Flap Lift Laser In Situ Keratomileusis Enhancements in a Large Patient Population: Does Application of a Bandage Contact Lens Affect Incidence of Epithelial Ingrowth? Purpose: To compare the incidence of corneal epithelial ingrowth (EIG) and the visual outcomes of enhancement with laser in situ keratomileusis (LASIK) by flap lift when a bandage soft contact lens (CL) was fitted after the procedure and when it was not. Methods: This is a multicenter, retrospective, interventional case series in which all patients who underwent LASIK enhancement from January 2005 to January 2015 were included consecutively. Patients were grouped depending on whether a bandage CL was fitted after re-treatment by flap lift (group 1) or not (group 2). Results: A total of 16,702 eyes from 12,485 patients were included. There were statistically significant differences between the groups regarding corrected distance visual acuity (better in group 1) and safety index (better in group 2) although these were not clinically relevant. The incidence of EIG was 0.58% in group 1 and 0.55% in group 2 although, again, the difference was not statistically different. Conclusions: We found no relevant differences in LASIK enhancement between patients who received a bandage CL and those who did not regarding the incidence of EIG and visual outcomes.