Poor ocular surface status may manifest as evaporative dry eye in thyroid eye disease
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Key takeaways:
- Patients with thyroid eye disease commonly have dry eye symptoms.
- There was an association of tear film instability with lagophthalmos and severe meibomian gland dysfunction in the lower eyelid.
Dry eye in thyroid eye disease appeared to primarily manifest as evaporative dry eye disease in a cohort of treatment-naive patients in China, according to study results published in Journal of Clinical Medicine.
“TED threatens vision, especially in dysthyroid optic neuropathy and exposure keratopathy. TED imposes psychological and economic burdens on patients and affects their quality of life,” the study authors wrote. “Dry eye symptoms are commonly presented in TED patients; some of them have dry eye as the first sign of their ailments.”
The cross-sectional study included 152 eyes of 76 treatment-naive patients with thyroid eye disease (TED) recruited from the Chinese University of Hong Kong Medical Centre and the Chinese University of Hong Kong Eye Centre between 2020 and 2022 and 93 eyes of 61 healthy controls.
The authors assessed meibomian gland dysfunction, ocular surface exposure and tear film instability, with the aim of appropriately managing patients during the early stage of dry eye disease.
Eyes with TED experienced higher ocular surface disease index, tear meniscus height, lipid layer thickness and corneal punctate epithelial erosions compared with control eyes (P < .05 for all).
In addition, eyes with TED experienced shorter noninvasive tear breakup time and worse meiboscore (P < .05 for all), as well as increased amounts of exophthalmos, longer margin reflex distance to the upper eyelid, more lateral flare and lagophthalmos.
A multivariate analysis found an association of tear film instability with lagophthalmos and severe meibomian gland dysfunction (MGD) in the lower eyelid.
“There should be attention paid to manage MGD at an early stage in TED. However, this study had the limitation of not evaluating the blinking mechanism and biophysical properties of meibum, which may affect the dry eye status in TED,” the authors wrote. “In conclusion, treatment-naive TED patients have poor ocular surface status both in objective and subjective dry eye parameters, which mainly manifested as evaporative dry eyes. ... For untreated TED patients, the dry eye status should not be ignored, and the management approach should mainly focus on meibomian gland dysfunction and lagophthalmos.”
Perspective
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Ngozi C. Chidi-Egboka, OD, MPH, PhD, FNCO, FAAO
The diagnosis of evaporative dry eye disease (DED) in patients with TED in this study is expected, given the ocular surface exposure outcomes. Although this study found worsened MGD in TED treatment-naive patients, there is a lack of published consensus on whether TED treatment worsens or improves meibomian gland function. It would have been interesting if this study compared DED symptoms and signs in TED treatment-naive patients vs. patients undergoing treatment.
Having established from this study that treatment status may not be a yardstick to determining the impact of TED on the ocular surface health, early TED diagnosis and intervention are important to prevent the outcome effect of exposure keratopathy and DED. Optometrists have always played an important role as the first point of contact for patients with eye health problems. Despite the regular busy clinic schedules, clinicians should endeavor to undertake a thorough history to timely identify patients with TED and who may be at risk for DED. Comprehensive DED workup at early TED stage using simple techniques such as observational blinking assessment for frequency and completeness will be helpful to minimize the risks for MGD and tear film evaporation. Index and follow-up visits assessment of DED symptoms using validated questionnaires, tear film stability test and slit lamp examination of MGD expressibility are highly recommended.
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