Lid Wiper Epitheliopathy II

[jlg_uk]

Came across some articles about Lid Wiper Epitheliopathy, which appears to be a DES potential factor. Before posting this, I did a search and found this was raised over 2 years ago: http://www.dryeyezone.com/talk/showthread.php?t=1161

I thought it might be a good idea to talk about it again, and post some links to the articles I can find on it.

http://www.revoptom.com/archive/OP/o...5.htm#article2

Lid Wiper Epitheliopathy and Dry Eye Symptoms

The lid wiper is defined as that portion of the marginal conjunctiva of the upper eyelid that wipes over the ocular surface with blinking. The purpose of this study was to investigate whether lid wiper epitheliopathy occurred with patients who reported dry eye symptoms yet had normal fluorescein breakup time (FBUT), Schirmer test values and an absence of corneal fluorescein staining.

One hundred patients were divided into two groups based on the presence of dry eye symptoms as determined with the Standard Patient Evaluation of Eye Dryness questionnaire. After instillation of fluorescein and rose bengal dyes, the lid wipers of 50 asymptomatic and 50 symptomatic patients were graded for staining from grade 0 (absent) to grade 3 (severe). Of the symptomatic patients, 76 percent had staining of the lid wiper with 44 percent having Grade 1, 22 percent with Grade 2, and 10 percent with Grade 3. Of the asymptomatic patients, 12 percent had staining with 8 percent having Grade 1, 4 percent with Grade 2; and 0 percent with Grade 3. The prevalence of this lid wiper staining was found to be statistically significant.

Editor’s note: Don Korb's brilliant work on the lid wiper appears to be the missing link that explains the poor correlation between the signs commonly associated with dry eye, such as fluorescein staining and patient symptoms. A prior report from Korb and associates linked lid wiper damage and contact lens discomfort. Expect to see more on this important finding.

SOURCE: Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens 2005;31(1):2-8.

Hmm, this seems to be saying that the worse your DES is, the less likely LWE is to be a factor? Am I reading that right?

http://www.refractiveeyecare.com/Aug...20-%20Lemp.htm

“Lid-wiper” epitheliopathy

In dry eye disease the tear film loses some of its ability to lubricate, with the result that the eye’s system of regulated cell loss is disrupted. The exaggerated frictional force exerted by the upper lid leads to a premature loss of corneal cells and exposure of immature cells. These new cells are further compromised by direct mechanical damage from the lid.

Recently, attention has been called to the role of the interior edge of the upper lid in the pathogenesis of this effect. Several studies have identified the leading edge of the upper lid mucosa as acting like a “lid wiper.” As the tear film loses its ability to lubricate properly, friction from this lid region can damage the corneal surface.

Similar damage to the mucosal surface of the upper lid is also seen— rose bengal staining of this area is often found in dry eye disease patients. In fact, a study using a threepoint grading system for severity of staining in the lid-wiper region found staining to be present in 76% of eyes with dry eye disease symptoms vs 12% of asymptomatic eyes. This is not surprising: the two most sensitive areas of the ocular surface are the central cornea and the lid-wiper area of the upper lid.

This seems to be saying that the worse your tear film is, the more likely it is the lid wiper can get damaged (which could potentially damage the eyes more). Of course, the worse your tear film is, the more you blink - presumably making it even worse.

Commercial, but included as it's got a good picture:
http://www.systane.com/eyecare-profe...Eye-Relief.asp


All in all, I don't have any major conclusions - I do wonder though if this may be a factor for me, how I identify it myself (or rose bengall staining with a eye person who will listen I guess), and what everyone else thinks.

I wonder if you can tell from a picture (my left upper inner eyelid does have some redness in what I think is "the wiper") - remove /remove:

Prattstar - links to pictures removed at user's request

[jlg_uk]

Some other articles I'd missed (don't read all this unless of course you want to).

http://www.optometric.com/article.as...=100331#R15-17

The palpebral conjunctival surface and the eyelids

Lid architecture and contact relationship with the ocular surface and, more specifically, the tear film, play a vital role in tear-flow dynamics. Think of your lid as a windshield wiper. As the lid comes down, it “spreads” or “wipes” the tear film across the ocular surface. If a windshield wiper has any points of non-contact with the windshield, you get a smear. In the eye, that may lead to tear-film stagnation or alterations in the normal tear-film balance.

Improper apposition can lead to drainage issues, as well as lipid deposition problems. These appositional issues, whether local or more geographic, can lead to tear-film “spread” issues.

Donald R. Korb, O.D., of Boston, has published some interesting work recently that shows a high correlation between dry-eye symptomatic patients and a condition called lid wiper epitheliopathy.15 In this condition, the small area of squamous epithelium found on the palpebral conjunctiva at the lid margin acts as a “windshield wiper” to the ocular surface. More interesting is that many times, clinical findings are absent with this disease, although the patients are symptomatic for dry eye. This was especially true in patients who had lipid-based issues.

http://www.opticianonline.net/Articl...me+-+Part.html

Lid-wiper epitheliopathy testing

Symptoms due to DES sometimes occur in the absence of expected definitive ocular findings such as corneal staining and abnormal fluorescein break-up time (FBUT).73 A new clinical condition called lid-wiper epitheliopathy, recently described by Korb et al, has been demonstrated in patients with symptoms of dry eye but normal FBUT, Schirmer test values, and no fluorescein corneal staining.74

Lid-wiper epitheliopathy is a clinically observable alteration of the epithelium of the lid wiper, that portion of the marginal conjunctiva of the upper eyelid that wipes the ocular surface during blinking.73 The upper lid was everted and the lid wipers of subjects with DES symptoms but normal FBUT, Schirmer test values and an absence of corneal staining were graded for staining using the cobalt blue filter and X16 magnification, one minute after instillation of two drops of fluorescein separated by five minutes.

Fluorescein staining of the upper lid wiper is graded Grade 0 (absent) to Grade 3 (severe) for each of two characteristics, the linear area and the severity of the staining, with the final fluorescein grade being an average of the two.

Rose bengal dye is then instilled and the lid wiper viewed with white and red free light. Rose bengal staining is then graded in the same way as fluorescein staining and the final score is obtained by averaging the grades from each dye. Both dyes are required because the lid wiper involves conjunctival tissue and stratified squamous epithelium (analogous to the cornea).75

Final scores have been classified as 0.5 to 1.0 = Grade 1 (mild lid-wiper epitheliopathy); 1.25 to 2.0 = Grade 2 (moderate); 2.25 to 3.0 = Grade 3 (severe). Figure 7 shows a schematic of lid-wiper epitheliopathy grading.

Symptomatic contact lens wearers show a much higher percentage of lid wiper staining, 80 per cent opposed to only 13 per cent in an asymptomatic contact lens group.75

It has been speculated that in patients with DES the thickness of the tear film is insufficient to separate the corneal and lid wiper tissue surfaces and that the lid wiper is subjected to trauma during the entire lid movement, via the friction produced by the continual rubbing of the narrow surface area of lid wiper tissue against the corneal surface during a blink (3,000 to 15,000 blinks per day)76 and therefore it is the lid wiper and not the cornea, which exhibits the epitheliopathy.73

If artificial tears are recommended to treat DES when lid-wiper epitheliopathy is present, the product chosen should have a high lubricity so regular application will result in less friction and a smoother surface as the lid wiper moves across the ocular surface. This lessens the likelihood of mechanical damage to the lid wiper and the ocular surface while providing patient comfort. Plus, a lubricated coating and smooth surface produces less drag, thus helping to prevent further damage, allowing epithelial cells to heal.73

[jlg_uk]

In the interests of some balance:

http://www.revoptom.com/index.asp?page=2_1380.htm

“Korb and co-workers have once again contributed in a significant way to the body of information available on ocular surface disease,” says optometrist Joseph P. Shovlin, of Scranton, Pa. “Specifically, they have provided a useful test to help guide clinical assessment in patients who present with dry eye symptoms yet have a paucity or absence of routine clinical findings.”

However, optometrist Alan G. Kabat, of Nova Southeastern University College of Optometry, questions exactly how this condition relates to symptomology. “Korb does not describe any theory by which lid wiper epithliopathy is associated with the sensation of ocular dryness, burning, etc.,” Dr. Kabat says. “He does not discuss innervation of the tissue in any great degree, merely that the epitheliopathy is an associated finding with a high degree of correlation. So, I am left to ponder why the correlation exists.”

Furthermore, the study did not include patients with corneal compromise.

There's quite alot of of redness for me at this location. I'm wondering if this is a significant factor for me.

[acarol]

My upper lids are similar to yours.

[acarol]

Came across some articles about Lid Wiper Epitheliopathy, which appears to be a DES potential factor. Before posting this, I did a search and found this was raised over 2 years ago: http://www.dryeyezone.com/talk/showthread.php?t=1161

I thought it might be a good idea to talk about it again, and post some links to the articles I can find on it.

http://www.revoptom.com/archive/OP/o...5.htm#article2


Hmm, this seems to be saying that the worse your DES is, the less likely LWE is to be a factor? Am I reading that right?

http://www.refractiveeyecare.com/Aug...20-%20Lemp.htm


This seems to be saying that the worse your tear film is, the more likely it is the lid wiper can get damaged (which could potentially damage the eyes more). Of course, the worse your tear film is, the more you blink - presumably making it even worse.

Commercial, but included as it's got a good picture:
http://www.systane.com/eyecare-profe...Eye-Relief.asp


All in all, I don't have any major conclusions - I do wonder though if this may be a factor for me, how I identify it myself (or rose bengall staining with a eye person who will listen I guess), and what everyone else thinks.

I wonder if you can tell from a picture (my left upper inner eyelid does have some redness in what I think is "the wiper") - remove /remove:

Prattstar - links to pictures removed at user's request

Thats interesting about Systane as its one of the drops i've found the best