Assessment of Corneal Fluorescein Staining in Different Dry Eye Subtypes Using Digital Image Analysis

Abstract

Purpose: To describe a new objective technique of digital image analysis for the quantification and the morphological characterization of corneal staining in the setting of dry eye disease (DED), and to apply it to distinguish Sjögren syndrome (SS) from ocular graft versus-host disease (oGVHD).Methods: Slit-lamp photographs of corneal staining obtained from 40 patients with DED (20 with SS and 20 with oGVHD; mean age 60.7 6 12.3 years) were evaluated. Images were subjectively graded using Oxford and National Eye Institute (NEI) scales, the staining pattern was classified as micropunctate, macropunctate, coalescent, or patch. The corneal staining index (CSI) was calculated automatically using the software ImageJ 1.51s. Particles analysis was used to calculate mean area, circularity, and roundness of staining spots.Results: CSI was significantly correlated with Oxford and NEI scales (respectively Rs ¼ 0.823 and Rs ¼ 0.773; both P , 0.001), and showed a good interobserver reliability (intraclass correlation coefficient [ICC] ¼ 0.988 [95% confidence interval [CI]: 0.978-0.994]). The mean area of staining spots calculated with particles analysis was significantly correlated with the subjective classification of the staining pattern (Rs ¼ 0.550, P , 0.001). The circularity and roundness of staining spots were significantly higher in oGVHD patients compared with SS (respectively, 0.51 6 0.11 vs. 0.44 6 0.10, P ¼ 0.040; 0.61 6 0.03 vs. 0.59 6 0.02, P ¼ 0.004). Sensitivity and specificity to distinguish oGVHD from SS were respectively 65.0% and 60% for circularity and 80.0% and 70.0% for roundness. Conclusions:The new algorithm showed good reliability and was well correlated with the traditional subjective grading scales. Particles analysis for the objective assessment of the staining pattern may help to differentiate patients with oGVHD from those with SS.Translational Relevance: The digital image analysis technique may be a reliable alternative to evaluate corneal staining objectively in the clinic and in clinical trials.

The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases

“…The measurement of tear osmolarity is considered one of the best metric to grade the DED severity [5]. Finally, dyes such as fluorescein, rose bengal, and lissamine green are used to stain the ocular surface and evaluate the epithelial integrity ( Figure 1a) [6].…”

Polyethylene eye-cover versus artificial teardrops in the prevention of ocular surface diseases in comatose patients: A prospective multicenter randomized triple-blinded three-arm clinical trial

“…These were assessed with the Corneal Fluorescein Staining Pattern. The corneal fluorescein staining is a valuable clinical tool to examine the viability of the epithelium [ 24 ] and is able to provide extensive knowledge about the ocular surface [ 25 ]. As this clinical ocular examination is introduced as a feasible, cheap, safe, acceptable, reasonably sensitive, and specific in identifying corneal damage in ICU patients as well [ 26 ], fluorescein testing was considered to measure and classify the patients’ OSD.…”

“…To spread the Fluorescein over the entire surface of the eye, the patient’s eyelid was gently opened and closed a few times to spread the Fluorescein on the eye surface. The concentration and the breadth of the corneal staining provide valuable evidence to measure disease severity and to monitor the response to treatment [ 24 ]. Punctate epithelial erosions (PEE) are counted and scored from zero to six, the maximum possible score for each cornea.…”

Update on ocular graft-versus-host disease

“…A novel digital imaging analysis technique for quantification and morphological characterization of corneal fluorescein staining which may help distinguish DED due to Sjogren’s and oGVHD has been recently proposed by Pelligrini et al . [ 93 ] Shimizu et al . evaluated corneal higher-order aberrations (HOAs) using Zernike analysis in anterior segment optical coherence tomography (CASIA system, SS-1000, Tomey, Japan) and found higher corneal HOAs in chronic ocular GVHD eyes than the non-GVHD and normal eyes, which correlated with visual acuity and severity scores.…”