Morphologic Evaluation of Meibomian Glands Morphologic Evaluation of Meibomian Glands

Using Noncontact Infrared MeibographyUsing Noncontact Infrared Meibography

　　　　 Yumiko BanYumiko Ban,,1,2,3)1,2,3) Seika Den,Seika Den,2)2) Jun Shimazaki, Jun Shimazaki,2,3)2,3)

1)1) Department of Ophthalmology, Hino Municipal Hospital, Department of Ophthalmology, Hino Municipal Hospital, 　　　　 Tokyo, Japan Tokyo, Japan 2) Department of Ophthalmology,2) Department of Ophthalmology, Tokyo Dental College,Tokyo Dental College, School of Dental Medicine, Chiba, JapanSchool of Dental Medicine, Chiba, Japan3) Department of Ophthalmology, School of Medicine, 3) Department of Ophthalmology, School of Medicine, Keio University, Tokyo, JapanKeio University, Tokyo, Japan

Authors have no financial interest.

World Cornea Congress Boston, Massachusetts, April 7-9, 2010Ⅵ

BackgroundBackground ・・ Recently, noncontact infrared meibography (NIM) has been developedRecently, noncontact infrared meibography (NIM) has been developed1-31-3, which allows easy , which allows easy

observation of the meibomian glands (MG) structure over a wide area encompassing both the observation of the meibomian glands (MG) structure over a wide area encompassing both the upper and lower eyelids. upper and lower eyelids.

・　・　　　 To date, only semi-quantitative criteria of gland destruction To date, only semi-quantitative criteria of gland destruction (gland drop-out) have been used to evaluate the MG. (gland drop-out) have been used to evaluate the MG.

・・　　　　　　 To evaluate the morphologic assessment of the MG using NIM To evaluate the morphologic assessment of the MG using NIM and investigate the quantitative evaluationand investigate the quantitative evaluation

・・　　　　　　 To investigate the relationship between MG morphology andTo investigate the relationship between MG morphology and the condition of the tear film and the condition of the tear film and ocular surface epitheliaocular surface epithelia

Purpose

1, Arita R, et al. Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population. 　 Ophthalmology. 2008 ;115:911-52, Arita R, et al. Contact lens wear is associated with decrease of meibomian glands. Ophthalmology. 2009 ;116:379-84. 3, Arita R, et al. Proposed diagnostic criteria for obstructive meibomian gland dysfunction. Ophthalmology. 2009 ;116:2058-63

Study DesignStudy Design

Subjects recruited in this studySubjects recruited in this study ・・　　　　　　 37 eyes of 37 subjects 37 eyes of 37 subjects (The data used in this study were obtained from the right eye(The data used in this study were obtained from the right eye in each subject.)in each subject.) ・・　　　　　　 males: 23 cases, females: 14 casesmales: 23 cases, females: 14 cases ・・　　　　　　 Mean age 46.5 ±15.4 years (range 19Mean age 46.5 ±15.4 years (range 19 ～～ 75 years75 years ））

Exclusion criteriaExclusion criteria ・・　　　　　　 Obvious eyelid or ocular surface disorders, contact lens wear, Obvious eyelid or ocular surface disorders, contact lens wear, history of ocular surgery, and dry eye according to history of ocular surgery, and dry eye according to the 2007 International Dry Eye Workshop Report the 2007 International Dry Eye Workshop Report

MethodsMethods MeibographyMeibography The meibography apparatus comprised a slit lamp (RO 5000, Rodenstock) The meibography apparatus comprised a slit lamp (RO 5000, Rodenstock) with a magnifying power of 12 and an infrared charge-coupled device videowith a magnifying power of 12 and an infrared charge-coupled device video camera (XC-EI50, Sony). camera (XC-EI50, Sony). The digital images obtained by meibography were recorded and analyzed using image J (free software).Morphometric indices which we conducted morphologic assessment of the MGMorphometric indices which we conducted morphologic assessment of the MG ・ ・ Length of MG ductLength of MG duct ・ ・ Percent area of MG acini Percent area of MG acini ・ ・ Number of gland drop-outsNumber of gland drop-outsTear functionTear function Schirmer test Schirmer test ⅠⅠ Break-up time of tear film (BUT)Break-up time of tear film (BUT)

Tear film lipid layer interferometry (TFLLI) (Yokoi’s grading system)Tear film lipid layer interferometry (TFLLI) (Yokoi’s grading system) 4 4

Evaluation of ocular surfaceEvaluation of ocular surfaceFluorescein staining score (FS)Fluorescein staining score (FS)Expression of meibum (Shimazaki’s grading system)Expression of meibum (Shimazaki’s grading system) 5 5

4, Yokoi N , et al. Correlation of tear lipid layer interference patterns with the diagnosis and severity of dry eye. Am J Ophthalmol. 1996 ;122:818-245, Shimazaki J, et al. Meibomian gland dysfunction in patients with Sjögren syndrome Ophthalmology. 1998 ;105:1485-8

13mm13mm

10mm

5mm

4mm

Upper eyelid We measured and calculated the mean value for the length of the 5 selected central MG ducts. The white lesion was considered to be the lipid of MG. It seemed to be the MG acini.

We defined a rectangle measuring 5x4 mm in the central upper eyelid. We measured the percent area of MG acini contained within the selected rectangle. ( In the lower eyelid, a square measuring 4x4 mm along the central lid margin was defined.)

The number of gland drop-outs contained in the image was counted.The white lesion was reversed to the black

lesion. We calculated the black area, and found the percent area of MG acini.

Statistical analysis ・　　　 The unpaired t test was used to compare the upper and lower eyelid. ・　　　 The Pearson and Spearman rank sum tests were performed to determine correlations between MG morphologic values and tear film or ocular surface.

Success rate for evaluation and morphometric values of MG in upper and lower eyelids

Upper eyelid Lower eyelid

Length of MG ducts (mm) 5.53 ± 1.27 * 2.97 ± 0.90

Number of eyes with successful 35 (94.6%) 36 (97.3%)

evaluation (%)

Percent area of MG acini (%) 41.6 ± 12.4 41.0 ± 15.1

Number of eyes with successful 20 (54.1%) 31 (83.8%)

evaluation (%)

Number of gland drop-outs

0 27 22

1 2 2

2 0 4

3≥ 6 9

Uncountable 2 0

* = p < 0.05

　　 Data on tear function/ocular surface Data on tear function/ocular surface

Schirmer

(mm)

BUT

(seconds)

FS

(points)

TFLLI

(grade)

Meibum

(grade)(grade)

11.4±9.21 6.00±2.87 0.41±0.76 2.16±1.26 1.14±1.03

BUT = Break-up time of tear filmFS = Fluorescein staining scoreTFLLI = Tear film lipid layer interferometry

Correlation between morphometric values of MGand tear film or ocular surface epithelia

The number in the table represents the r value.*p < 0.05, **p < 0.001, Pearson r#p < 0.05, Spearman r

age Schirmer BUT FS TFLLI Meibum

Length of MG Upper -0.485* 0.087 0.246 -0.223 -0.116 -0.345#

duct Lower -0.533** -0.080 0.211 -0.438# -0.241 -0.312

Percent area of Upper -0.600** 0.048 0.549* -0.367 -0.601# -0.641#

MG acini Lower -0.357* -0.352 0.208 -0.069 -0.032 -0.207

Number of Upper 0.518# -0.254 -0.432# 0.212 0.457# 0.404#

gland drop-outs Lower 0.399# -0.018 -0.199 0.253 0.250 0.189

BUT = Break-up time of tear filmFS = Fluorescein staining scoreTFLLI = Tear film lipid layer interferometry　

　　 Summary of the Results Summary of the Results

Success rate for evaluation of MG Success rate for evaluation of MG

・・ The length of the MG ducts could be evaluated in almost all cases The length of the MG ducts could be evaluated in almost all cases in both the upper and lower eyelids, but the percent area of MG in both the upper and lower eyelids, but the percent area of MG acini in the upper eyelid could be evaluated only in approximately acini in the upper eyelid could be evaluated only in approximately half of the eyes.half of the eyes.

Morphometric values of MGMorphometric values of MG

・　 ・　 The length of the upper MG ducts was significantly longer than The length of the upper MG ducts was significantly longer than that of the lower MG ducts.that of the lower MG ducts.

　　 Summary of the ResultsSummary of the ResultsAgingAging・ ・ Both the length of the MG ducts and percent area of MG acini in Both the length of the MG ducts and percent area of MG acini in the upper and lower eyelids showed a negative correlation with age.the upper and lower eyelids showed a negative correlation with age.・ ・ The number of gland drop-outs in the upper and lower eyelids showed a positive The number of gland drop-outs in the upper and lower eyelids showed a positive

correlation with age.correlation with age.

Correlation between meibomian gland morphology and ocular surfaceCorrelation between meibomian gland morphology and ocular surfaceThe groups which showed a positive correlationThe groups which showed a positive correlation・・ 　　 Percent area of MG acini (upper) and BUT Percent area of MG acini (upper) and BUT ・・ 　　 Number of gland drop-outs (upper) and TFLLINumber of gland drop-outs (upper) and TFLLI・・ 　　 Number of gland drop-outs (upper) and meibumNumber of gland drop-outs (upper) and meibumThe groups which showed a negative correlationThe groups which showed a negative correlation・・ 　　 Length of MG ducts (upper) and meibumLength of MG ducts (upper) and meibum・・ 　　 Length of MG ducts (lower) and FSLength of MG ducts (lower) and FS・・ 　　 Percent area of MG acini (upper) and TFLLIPercent area of MG acini (upper) and TFLLI・・ 　　 Percent area of MG acini (upper) and meibumPercent area of MG acini (upper) and meibum・・ 　　 Number of gland drop-outs (upper) and BUTNumber of gland drop-outs (upper) and BUT

DiscussionDiscussion・・ We could conduct a morphologic assessment of the MG using new We could conduct a morphologic assessment of the MG using new

indices including the length of the MG ducts and the percent area of indices including the length of the MG ducts and the percent area of MG acini. MG acini.

・・　　　　　　 Improvement of the camera and video system may increase the Improvement of the camera and video system may increase the number of eyes with successful evaluation.number of eyes with successful evaluation.

・・ Age showed a strong correlation with the MG morphology.Age showed a strong correlation with the MG morphology. Similar to the previous report,Similar to the previous report,1,6,71,6,7 the structure of the MG increased the structure of the MG increased

changes with aging.changes with aging.

・・ The morphological values of the MG in the upper eyelid had a stronger The morphological values of the MG in the upper eyelid had a stronger correlation with the condition of the tear film or ocular surface epithelia correlation with the condition of the tear film or ocular surface epithelia than that in the lower eyelid.than that in the lower eyelid.

The result suggests that it is important to observe the MG in the upper The result suggests that it is important to observe the MG in the upper eyelid.eyelid.

6, Den S, et al. Association between meibomian gland changes and aging, sex, or tear function. Cornea. 2006 ;25:651-5.7, Obata H. Anatomy and histopathology of human meibomian gland. Cornea. 2002 ;21::S70-4

ConclusionsConclusions

・　・　 Noncontact infrared meibography offers a useful tool for Noncontact infrared meibography offers a useful tool for obtaining a morphological analysis of the MG in ocular obtaining a morphological analysis of the MG in ocular surface evaluation.surface evaluation.

・ ・ MG morphology is related to aging and various ocular MG morphology is related to aging and various ocular surface conditions.surface conditions.