Optimal methodology for lid wiper epitheliopathy identification

Abstract

Purpose: Lid wiper epitheliopathy (LWE) is a clinical sign that has been associated with dry eye disease. This study used a semi-automated method to identify the effect of drop instillation and post-dye viewing time on the absorption of lissamine green (LG) and sodium fluorescein (NaFl) on the upper eyelid in order to ascertain the optimal identification for LWE assessment. Methods:In 37 participants with LWE, 1-drop of 1% LG (10μL) was applied to the superior bulbar conjunctiva in the right eye, and photographs of the lid margin were taken 1, 3, and 5 minutes after instillation. Measurements were repeated in the same eye following instillations of 2-drops of 1% LG. The same procedures were followed for application of 2% NaFl (2μL) to the left eye. Staining area was determined using software to detect and measure dye-stained images. Analysis used a linear mixed model with fixed effects of time, number of drops and their interaction.Results: For LG, multivariate analysis showed that time of drop instillation was significant (p=0.0091) as was the area of staining in the 2-drop versus 1-drop condition (p<0.0001).For NaFl, there was a significant effect of time (p<0.0001), drops (p<0.0001), and a time/drops interaction (p<0.0134), suggesting that both time and number of drops are important. Conclusion:A single drop of dye is insufficient to reveal the full extent of LWE staining.A 2-drop instillation is recommended and observation is recommended between 1-5 minutes (LG) and between 3-5 minutes (NaFl).

<p>Impact of Improper Approach to Identify Lid Wiper Epitheliopathy (LWE)</p>

“…The dye amply covered the ocular surface and was akin to the typical amount administered in clinical practice through the usage of dye impregnated paper strips. Predictably, an underestimation of the area of LWE was observed for single-dosage (regardless of time evaluation) when compared to the optimal methodology described by Lievens et al 9 More importantly, this study emphasizes the risk of false negatives if a nonoptimal methodology is used for LWE evaluation. The present data suggest that with a single-instillation, there is a 70% risk of false negatives when using LG and a 95% risk of false negatives when using NaFl.…”

“…This approach is consistent with previous studies using alternative semi-automated methodologies. 9,17,18 Statistical analyses were performed using SAS software v9.4 (Cary, NC, USA). Tests for normality confirmed parametric data sets and the proper use of the paired Student's t-test.…”

“…This paper reports previously unpublished data from excluded participants of a previous study by Lievens et al 9 Participants were recruited from the Southern College Optometry (SCO; Memphis, TN, USA) patient base. Participants were financially compensated for their time and travel expenses.…”

“…Korb et al [6][7][8] showed that the use of impregnated paper dye strips oftentimes does not provide an adequate concentration and volume of dye to disclose LWE staining. An optimized methodology to identify LWE has recently been described by Lievens et al 9 Though the relationship of LWE to other clinical signs and patient symptomatology has been questioned, the variation in approach to detect this condition creates confusion when comparing findings and/or establishing its presence. Of additional concern is the potential relationship between LWE and dry eye disease (DED).…”

“…A consistent approach to future research as well as clinical patient care is key to optimize patient care and diagnostic errors. The present study specifically examines the impact of LWE identification for the two most common dyes used in clinical practice, lissamine green (LG) and sodium fluorescein (NaFl), using a single-dose at 1minute post-dye instillation (referred to short visual protocol) and comparing it to single-dose evaluations at 3-and 5-minute as well as an optimized methodology described by Lievens et al 9 (2-dose at 3-minute post-dye instillation, referred to optimal protocol). Thus, the principle aim of this study is to evaluate whether the use of a non-optimal methodology leads to a false-negative misdiagnosis of LWE.…”