Eyelid tattooing – what’s the harm?

Eyelid Tattooing Induces Meibomian Gland Loss and Tear Film Instability

Lee YB, Kim JJ, Hyon JY, et al. Cornea 2015; 34: 750-755

This study looked at meibomian gland (MG) changes and tear film stability in 40 female subjects. Ten subjects had eyelid tattoos and 30 did not (control group). The tear film was evaluated using tear film break up time (TBUT) and fluorescein staining. A tattoo score was assigned using the distance between the eyelid tattoo and the MGs. The overall tattoo score (upper lid tattoo score + lower lid tattoo score) was determined for each eye. The total “meiboscore” for each eye was determined by adding together the MG loss for each eyelid using meibography. Values between tattoo and control groups were examined and compared.

Results showed that the TBUT was shorter in the tattoo group compared to the control group (4.3 + 0.9 seconds vs 11.0 + 4.3 seconds; P <0.001). Corneal erosion measured by fluorescein staining was more severe in the tattoo group (1.6 + 0.5) compared to the control group (0.2 + 0.2; P <0.001), as was MG loss (3.4 + 1.5 vs 0.9 + 0.6; P <0.001). The total tattoo score was correlated with the total meiboscore (r = 0.852, P <0.001, Spearman correlation coefficient).

The authors came to the conclusion that eyelid tattooing shortened TBUT, increased fluorescein staining, and induced MG loss, therefore increasing tear film instability through MG disturbance. This may lead to the exacerbation of ocular surface disease signs and symptoms.

My comment:

Eyelid tattooing is becoming a common cosmetic procedure that has the potential to cause meibomian gland loss via direct mechanical damage by the needle, ink toxicity causing chronic inflammation, MG obstruction by ink, blepharitis from infection and/or dermatitis. We all know that healthy meibomian glands are essential in maintaining tear film stability and a healthy ocular surface, so when patients with eyelid tattoos are examined it is worth carefully checking them for signs of MGD and evaporative tear dysfunction.


Plugs for dry eye?

Safety and Efficacy of Lacrimal Drainage System Plugs for Dry Eye Syndrome: A Report by the American Academy of Ophthalmology

Marcet MM, Shtein RM, Bradley EA, et al. Ophthalmology 2015; 122: 1681-1687

The authors reviewed the literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults. The 27 reviewed studies included punctal, intracanalicular, and dissolving plugs. Twenty-five studies included safety data, 15 studies reported improvement in dry eye symptoms, ocular surface status, artificial tear use, contact lens comfort, and tear break up time. Plug placement resulted in >50% improvement of symptoms, improvement in ocular surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Plug use infrequently led to serious complications. On average 40% of patients experienced plug loss, making it the most commonly reported problem with punctal plugs. Overall, approximately 9% of patients experienced epiphora and 10% required plug removal due to irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs, occurring in approximately 8% of patients. On average less than 4% of patients reported problems, including tearing, discomfort, pyogenic granuloma, and dacryocystitis. The authors concluded that the literature shows punctal plugs improve the signs and symptoms of moderate dry eye that is not improved with topical lubrication, and they are well tolerated.

My comment:

I confess I am not a great fan of plugs as tear flow as well as tear volume is important. Where do all the foreign materials and shed epithelial cells go in plugged patients?  Surely in some patients the retained tears are a further irritant. I don’t find dissolving plugs helpful as I never know if they are really there a few days later and how to interpret patient’s symptoms after placement. Pity the silicone ones are so expensive. I agree that some patients benefit, even those with evaporative tear dysfunction. In these cases upper occlusion seems to work best. I certainly use temporary plugs before performing permanent punctal occlusion. Lastly, the Coroneo punctal ‘sizer’ is one of the best pieces of kit I’ve bought of late. It eliminates the guesswork of which plug size to use.


Is it worth removing floaters?

Vitrectomy for Vitreous Floaters: Analysis of the Benefits and Risks

Sommerville DN. Curr Opin Ophthalmol 2015; 26:173-176

Nd:YAG vitreolysis and pars plana vitrectomy are current treatment options for floaters-procedures that have both risks and benefits associated with them. However, micro-incision vitrectomy surgery (MIVS) is less invasive than traditional 20-gauge vitrectomy, allowing the surgery to be performed without the need for sutures, resulting in less post-operative irritation, and it has also been shown to have a lower complication rate with fewer retinal breaks and detachments. Studies have also shown MIVS to have a high patient satisfaction rate, and stable or improved post-operative visual acuity and contrast sensitivity.

My comment:

Many of the patients we examine have vitreous floaters, some of which may be reported as causing symptoms of visual impairment. Historically, for most patients, the risks involved with Nd:YAG laser vitreolysis and pars plana vitrectomy have outweighed the benefits of treatment. With a less invasive method of floater removal available to us now, it is a procedure that should be given consideration when our patients are greatly troubled by symptomatic floaters.


Do dietary B vitamins affect cataract formation?

The Association of Dietary Lutein plus Zeaxanthin and B Vitamins with Cataracts in the Age-Related Eye Disease Study: AREDS Report No. 37

Glaser TS, Doss LE, Shih G, et al. Ophthalmology 2015; 122: 1471-1479

The purpose of this study is to evaluate whether dietary intake of lutein/zeaxanthin and B vitamins is associated with cataract prevalence and incidence. This was a large study of 3115 patients (6129 eyes) aged 55-80 years and followed up for a mean of 9.6 years. The participants completed baseline food frequency questionnaires and baseline, then annual, lens photographs that were graded centrally.

Multivariate models showed that, at baseline, increased dietary riboflavin and B12 were inversely associated with nuclear and cortical lens opacities. Comparing participants with and without cataract, persons with the highest riboflavin intake versus those with the lowest intake had the following associations: mild nuclear cataract: odds ratio (OR), 0.78; 95% confidence interval (CI), 0.63–0.97; moderate nuclear cataract: OR, 0.62; 95% CI, 0.43–0.90; and mild cortical cataract: OR, 0.80; 95% CI, 0.65–0.99. For B12, the results were: mild nuclear cataract: OR, 0.78; 95% CI, 0.63–0.96; moderate nuclear cataract: OR, 0.62; 95% CI, 0.43–0.88; and mild cortical cataract: OR, 0.77; 95% CI, 0.63–0.95. Highest dietary B6 intake was associated with a decreased risk of moderate nuclear lens opacity developing compared with the lowest quintile (OR, 0.67; 95% CI, 0.45–0.99). Highest dietary intake levels of niacin and B12 were associated with a decreased risk of development of mild nuclear or mild cortical cataracts in participants not taking Centrum (Pfizer, New York, NY) multivitamins. For participants taking multivitamins during the study, the highest intake of dietary folate was associated with an increased risk of mild posterior subcapsular lens opacity development. No statistically significant associations were found between lutein plus zeaxanthin intake and presence at baseline or development of nuclear or cortical lens opacity outcomes. The authors concluded that the findings are consistent with earlier studies and suggest that dietary intake of B vitamins may affect the occurrence of age-related lens opacities, warranting further investigations.

My comment:

It is well known that cataract is a leading cause of blindness worldwide, a cost burden that will only increase with time. If it can be proven that dietary intake of particular micronutrients slows or prevents the development of age-related cataract it would be a very cost-effective way of reducing the burden of the disease. We shall see…


Can a unilateral eye infection cause bilateral dry eye?

Do Unilateral Herpetic Stromal Keratitis and Neurotrophic Ulcers Cause Bilateral Dry Eye?

Jabbarvand M, Hashemian H, Khodaparast M, et al. Cornea 2015; 34:768-772

The purpose of this observational, cross-sectional case-control study was to evaluate and compare the ocular surface condition in unilateral herpetic interstitial stromal keratitis and neurotrophic ulcer groups with their normal fellow eyes. The study included 85 consecutive patients (56 cases of treated herpetic interstitial keratitis and 29 cases of neurotrophic ulcers) and 56 age- and sex-matched control patients from a normal population. The subjective and objective measures of dry eye were evaluated and scored for both eyes of all patients. The scores of the two groups were compared with one another and also with the control group. Main outcome measures were discomfort level, visual symptoms of dry eye, conjunctival injection, conjunctival staining, corneal staining, corneal tear signs of dry eye, meibomian gland dysfunction, tear break-up time (TBUT), Schirmer test score with anaesthetic, and tear osmolarity.

Results showed that the normal fellow eye of the herpetic keratitis group had significantly higher discomfort levels (1.4 ± 0.9 vs. 1.3 ± 0.5, P = 0.003), visual symptoms (1.7 ± 0.8 vs. 1.3 ± 0.7, P = 0.002), TBUT (8.3 ± 3.2 vs. 12.1 ± 3.3 seconds, P = 0.003), Schirmer test scores (9.2 ± 3.9 vs. 12.9 ± 3 mm, P = 0.04), and tear osmolarity (9.2 ± 3.9 vs. 12.9 ± 3 mm, P = 0.003) in comparison with normal controls. The normal fellow eyes of the neurotrophic ulcer group had significantly worse values for discomfort level (1.9 ± 0.9 vs. 1.3 ± 0.5, P < 0.001), TBUT (7.9 ± 4 vs. 12.1 ± 3.3, P = 0.004), Schirmer test score (8.1 ± 3.9 vs. 12.9 ± 3, P = 0.005), and tear osmolarity (295 ± 9.2 vs. 292.7 ± 5.9, P = 0.02) compared with normal controls.

The authors concluded that both eyes of patients with interstitial herpetic keratitis and neurotrophic ulcer have a significantly poorer ocular surface condition compared with that of normal controls.

My comment:

This is very interesting research that highlights our emerging understanding of complex connections between the two eyes (and other body parts), presumably mediated by CNS neurons. As the authors state, previous studies have demonstrated bilateral but asymmetric effects from unilateral herpetic eye disease such as higher tear osmolarity, lower Schirmer scores and TBUT levels, and lower corneal sensitivity. Bilateral corneal nerve plexus loss has also been reported in cases of unilateral herpes zoster ophthalmicus. This study showed that both eyes of affected patients were drier compared to normal controls. This serves to remind us that fellow eyes must still be thoroughly evaluated for ocular surface disease in unilateral cases of herpetic eye disease to minimize patient symptoms.