PURPOSE To analyse the ocular surface changes in eyes with functioning filtering blebs and to correlate with the size of the bleb. MATERIALS AND METHODS Forty eyes of 40 glaucomatous patients with functioning blebs and 40 normal control subjects underwent double vital staining for ocular surface evaluation, tear film break-up-time (BUT) and Schirmer I-test in a standardized fashion. Mann-Whitney U-test and Spearman's rank correlation were used to correlate bleb height and horizontal extent with BUT, Schirmer I-test, rose bengal and fluorescein staining scores. RESULTS Eyes with functioning blebs presented minimal, but significantly, higher rose bengal and fluorescein staining than controls (p < 0.000). The staining correlated poorly with the height and extent of the bleb. The Schirmer test in the study group showed greater measurements than controls, however, BUT showed shorter values in the study group as compared to controls (p < 0.05). CONCLUSION Filtering blebs can interfere with the ocular surface stability causing few dry eyes like signs.

PURPOSE: To study the demographics and estimate the prevalence of dry eye among elderly Americans. METHODS: A population-based prevalence study was performed in 2,520 residents of Salisbury, Maryland, aged 65 years and older as of September 1993. The population was derived from the Health Care Financing Administration Medicare database. After completing a standardized questionnaire pertaining to dry eye symptoms, 2,420 subjects underwent Schirmer and rose bengal tests and anatomic assessment of the meibomian glands. RESULTS: In this population, 14.6%(363/2,482) were symptomatic, defined as reporting one or more dry eye symptoms often or all the time; 2.2%(53/2,448) were symptomatic and had a low Schirmer test result (< or = 5 mm), and 2%(48/2,432) were symptomatic and had a high rose bengal test score (> or = 5). Furthermore, 3.5%(84/2,425) were symptomatic and had either a low Schirmer score or a high rose bengal score, and 0.7%(17/2,420) were symptomatic and had both a low Schirmer score and a high rose bengal score. No association of symptoms or signs was seen with age, sex, or race. Although anatomic features of meibomianitis were associated with the presence of symptoms (P =.01), 76%(67/88) of the individuals with these anatomic features were asymptomatic; 10.5%(260/2,480) reported that they currently use artificial tears or lubricants. CONCLUSIONS: Symptoms and signs of dry eye are common among the elderly but were not associated with age, race, or sex in this population-based sample of elderly Americans. Extrapolating to the United States population aged 65 to 84 years, the study yields an estimate of 4.3 million who experience symptoms of ocular irritation often or all the time.

PURPOSE: To examine the distribution and association of dry eye symptoms, Schirmer test results, and rose bengal scores in a population-based sample of elderly Americans. DESIGN: Population-based prevalence survey. PARTICIPANTS: Involved were 2240 noninstitutionalized residents of Salisbury, Maryland, aged 65 years and older as of September 1993, and identified by the Health Care Financing Administration Medicare database. MAIN OUTCOME MEASURES: A standardized dry eye symptom questionnaire, rose bengal scoring of ocular surface staining, and Schirmer tests. RESULTS: Fourteen percent of participants reported one or more symptoms to be present often or all the time. The mean Schirmer score in the lower testing eye was 12.4 and 42% had a rose bengal score of 1 or greater. No significant differences by age, gender, or race were seen for symptoms, Schirmer, or rose bengal testing. No association was seen between lower Schirmer scores and presence of more frequent symptoms. Higher rose bengal scores were weakly associated with symptoms. The Schirmer and rose bengal test results, both individually and in combination, were insensitive in identifying individuals who had symptoms. CONCLUSIONS: Although symptoms of ocular irritation are common among the elderly, these population-based data indicate that there is minimal overlap between individuals identified by questionnaire, Schirmer tests, and rose bengal scoring.

OBJECTIVE To evaluate tear production, corneal topography, accuracy of refractive correction, and best spectacle-corrected visual acuity in eyes that had moderate to severe rose bengal staining develop on the flap compared with eyes with little or no staining on the flap, the first few months after laser in situ keratomileusis (LASIK). None of the eyes in this study had significant preoperative dry eye disease. DESIGN Retrospective case control study. PARTICIPANTS Individual eyes of 19 consecutive patients with moderate to severe punctate epithelial erosions and rose bengal staining on the flap 1 to 3 months after LASIK were compared with eyes of 19 concurrent patients who did not have punctate epithelial erosions or more than trace staining on the flap develop. METHODS Nonparametric statistical analyses were used to compare tear secretion, corneal topographic irregularity, spherical equivalent, and visual acuity 3 and 6 months after surgery. Some eyes in both groups also had analysis of tear secretion 1 month after surgery. MAIN OUTCOME MEASURES Schirmer's test without anesthesia, the topographic corneal irregularity measurement (CIM), the difference between attempted and achieved spherical equivalent, and the loss of best spectacle-corrected visual acuity. RESULTS There was no difference in tear production 1, 3, or 6 months after LASIK in patients who had punctate epithelial erosions and rose bengal staining on the flap develop and those who did not. There was no significant difference in the CIM or mean accuracy of the refractive correction in the two groups, but some patients had a transient decrease in best spectacle-corrected visual acuity. Flap rose bengal staining resolved by 6 months after LASIK in most affected patients. CONCLUSIONS LASIK-induced rose bengal staining in patients without preexisting dry eye is likely neurotrophic epitheliopathy, because there is no difference in mean tear production between patients who have significant punctate epithelial erosions and rose bengal staining develop on the flap and those who do not. The signs and symptoms of LASIK-induced (presumed) neurotrophic epitheliopathy tend to resolve approximately 6 months after surgery. This disorder tends to be more common and severe in patients with pre-existing dry eye disease.

BACKGROUND The purpose of this report was to examine the relation between clinical tests and dry eye symptoms in patients with dry eye disease. METHODS Seventy-five patients with dry eye disease (ICD-9 code 375.15) were included in these analyses. There was no specific entry criterion for enrollment in addition to a previous dry eye diagnosis in this clinic-based sample. Patients represented varying types and severity of dry eye disease and were previously diagnosed by clinic attending doctors in this university clinic setting. The study examination included a symptom interview that assessed dryness, grittiness, soreness, redness, and ocular fatigue. The interview was followed by a clinical dry eye examination conducted in the following sequence: meibomian gland assessment, tear meniscus height, tear breakup time test, fluorescein staining, the phenol red thread test, Schirmer test, and rose bengal staining. Partial Spearman correlation coefficients, the Wilcoxon rank sum test, chi 2 test, and multivariate logistic regression were used to evaluate the relationship between dry eye tests and symptoms. RESULTS Symptoms were generally not associated with clinical signs in patients with dry eye disease. There were no significant correlations between signs and symptoms after adjustment for age and artificial tear use. The rank of each clinical test result did not statistically differ when stratified by the presence of patient symptoms in Wilcoxon rank sum analyses. Likewise, the frequency of patient symptoms did not differ statistically when stratified by a positive clinical test result in chi 2 analyses. In multivariate logistic regression analyses, no clinical test significantly predicted frequently reported symptoms after adjustment for age and artificial tear use. CONCLUSIONS These results suggest a poor relation between dry eye tests and symptoms, which represents a quandary in dry eye clinical research and practice.

Tear osmolarity and Rose Bengal staining were studied in a group of patients with keratoconjunctivitis sicca (KCS) before and after treatment with isotonic and one-half isotonic saline to compare treatment with these two solutions and to ascertain whether tear film osmolarity could be correlated with ocular surface disease. When 20 KCS eyes were treated with isotonic saline drops every three hours for one week, the average (+/-SD) tear osmolarity decreased from 365 +/- 77 mOsm/L to 329 +/- 47 mOsm/L, and the average (+/-SD) Rose Bengal staining score decreased from 4.1 +/- 3.1 to 3.6 +/- 3.3. There was no objective difference between treatment with isotonic and one-half isotonic solutions, in a double-masked comparison, however, four of five patients with diagnostically significant Rose Bengal staining preferred the half isotonic solution. There was a significant positive correlation between tear film osmolarity and Rose Bengal staining.

We report a new and reproducible model of thrombosis in the rat femoral artery. The thrombosis is initiated by endothelial injury subsequent to photochemical reaction between systemically injected rose bengal (10 mg/kg, i.v.) and transillumination of filtered xenon lamp (wave length: 540 nm) from the outside of the vessel. The blood flow of the femoral artery, which was monitored by a pulsed doppler flow meter, was fully stopped in 348.68 +/- 36.18 sec (n = 12) after i.v. injection of rose bengal under irradiation with green light. The formation of massive thrombosis was readily evident by visual inspection. The processes of primary endothelial injury and the subsequent formation of thrombosis during this manipulation were observed by light microscopy and analysed by the scanning and transmission electron microscopy. Pretreatment with heparin (30, 100 or 300 units/kg, i.v.) 10 min before rose bengal injection dose-dependently prolonged the time required to interrupt the blood flow. The thrombolytic activity of a tissue-type plasminogen activator (tPA) was also investigated. After the establishment of stable thrombotic occlusion of the femoral artery, infusion of tPA was started from the contralateral femoral vein for 30 min at the rate of 30 or 100 micrograms/kg/min. The occluded artery was reperfused in 2 out of 10 rats and in 9 out of 12 at the lower and higher rates of tPA infusion, respectively. That heparin could prevent the arterial occlusion and that tPA could reperfuse the occluded artery are observations consistent with the histopathological ones that the primary lesion of endothelium injured photochemically activates the platelet aggregation to form platelet-rich thrombus with extensions of erythrocyte-rich lesions. This model is expected to be a useful tool for evaluating the antithrombotic and thrombolytic agents.

PURPOSE The repeatability of individual dry eye diagnostic tests has been reported in the literature on normal samples of patients and to a lesser degree in dry eye patients. In this study, the repeatability of a battery of clinical diagnostic tests for dry eye was assessed on mild to moderate dry eye patients. METHODS A dry eye examination was performed on 75 patients on two occasions by a single examiner. The battery of dry eye tests included symptom assessment, contact lens and medical history, slit-lamp biomicroscopic evaluation of the eyelids, evaluation of Meibomian glands, assessment of tear film quality, tear meniscus height, assessment of blink quality, fluorescein tear breakup time (TBUT), fluorescein and rose bengal staining of the cornea and conjunctiva, phenol red thread test, and Schirmer test. RESULTS The repeatability of subjective report of dryness (kappaW = 0.62) and grittiness (kappaW = 0.73) was moderate to high. In contrast, the repeatability of Meibomian gland disease classification (kappaW = 0.20), presence or absence of inferior corneal fluorescein staining (kappa = 0.25), and inferior conjunctival rose bengal staining (kappa = 0.21) was poor. When a summed staining score of corneal and conjunctival regions was evaluated, weighted kappa reliability was fair. The repeatability of tear breakup time was substantial [95% limits of agreement -5.71 to 5.83 seconds; intraclass coefficient coefficient (ICC) 0.65], and improved when the two timed readings were averaged. Repeatability of the Schirmer test is more variable as wetting scores increase. When the average Schirmer scores </= 10 mm were evaluated, moderate repeatability was demonstrated, indicating that the test performs better with more advanced disease. CONCLUSION Although patient-reported symptoms are moderately repeatable from visit to visit, many of the procedures clinically used to diagnose and monitor dry eye syndromes are largely unrepeatable.

PURPOSE To describe the Oxford Scheme for grading ocular surface staining in dry eye and to discuss optimization of stain detection using various dyes and filters. Also, to propose a sequence of testing for dry eye diagnosis. METHODS The grading of corneal and conjunctival staining is described, using the Oxford Scheme, including biomicroscopy, optical filters, illumination conditions, and the characteristics of and instillation techniques used for, selected clinical dyes. RESULTS A series of panels, labeled A-E, in order of increasing severity, reproducing the staining patterns encountered in dry eye, are used as a guide to grade the degree of staining seen in the patient. The amount of staining seen in each panel, represented by punctate dots, increases by 0.5 of the log of the number of dots between panels B to E. The use of the vital dyes fluorescein, lissamine green, and rose Bengal is described; fluorescein and lissamine green, used in conjunction with appropriate absorption filters, are recommended for use in clinical trials. The placement of staining in relation to the sequence of other diagnostic tests is discussed. CONCLUSIONS The monitoring and assessment of corneal and conjunctival staining can be greatly enhanced by the use of a grading scale, controlled instillation of dyes, and standard evaluation techniques. This is of particular benefit in clinical trials, where ocular surface staining is commonly employed as an outcome measure

PURPOSE: To report two cases of laser in situ keratomileusis-induced neurotrophic epitheliopathy with punctate epitheliopathy and rose bengal staining of the corneal flap. METHODS: Interventional case reports. RESULTS: A 42-year-old woman and a 37-year-old man with no preoperative symptoms or signs of dry eye developed dry eye symptoms and bilateral punctate epithelial erosions as well as rose bengal staining of the corneal flaps after laser in situ keratomileusis. Neither patient had less than 12 mm of wetting with the Schirmer test without anesthesia at any time point between development and resolution of the flap surface abnormalities. The flap surface abnormalities resolved approximately 6 months after laser in situ keratomileusis. CONCLUSIONS: Laser in situ keratomileusis-induced neurotrophic epitheliopathy may be attributable to loss of trophic influence from severed corneal nerve trunks. The condition typically resolves approximately 6 months after laser in situ keratomileusis or laser in situ keratomileusis retreatment.