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      Conjunctival impression cytology versus routine tear function tests for dry eye evaluation in contact lens wearers

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          Prolonged contact lens wear is often accompanied by dryness of the eyes. The aim of this study was to compare conjunctival impression cytology (CIC) and tear film tests such as tear film break up time (TBUT) and Schirmer test for dry eye evaluation in contact lens wearers and measure their correlation with dry eye symptoms.


          A case control study was done at three referral eye centers.

          Materials and Methods:

          The eyes of 230 contact lens users were compared to 250 eyes of age- and sex-matched controls. Participants were recruited based on their response to a questionnaire of dry eye symptoms, (Dry Eye Scoring System, DESS ©) and measurements of TBUT, Schirmer test, and CIC was done. A correlation analysis between symptom severity and tear film tests was performed. Pearson's coefficient, R 2 > 0.5 was considered significant.


          As compared to controls ( r 2 = 0.010), Nelson grade correlated significantly with dry eye symptoms ( r 2 = 0.765), among cases. However, there was moderate correlation between dry eye symptoms, Schirmer test, and TBUT ( r 2 = 0.557 and 0.530, respectively) among cases and a weak correlation among controls ( r 2 = 0.130 and 0.054, respectively). The sensitivity of TBUT was 86.4%, specificity was 82.4%, positive likelihood ratio (LR) was 4.50 [95% confidence interval (CI) 3.46-5.85)], and negative LR was 0.09. The sensitivity of the Schirmer test was 48.2%, specificity 88%, LR 2.12 (95% CI 1.48-2.96), and negative LR 0.83.


          CIC correlates better than Schirmer and TBUT with dry eye symptoms. It may be the most appropriate test for dry-eye evaluation in contact lens wearers.

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          Most cited references 26

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          The lack of association between signs and symptoms in patients with dry eye disease.

          The purpose of this report was to examine the relation between clinical tests and dry eye symptoms in patients with dry eye disease. 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. 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. These results suggest a poor relation between dry eye tests and symptoms, which represents a quandary in dry eye clinical research and practice.
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            The repeatability of clinical measurements of dry eye.

            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. 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. 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
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              Interleukin-6 and tumor necrosis factor-alpha levels in tears of patients with dry eye syndrome.

              To determine the levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) in tears of patients with dry eye syndrome. IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay in tear samples obtained from 18 patients with dry eye (8 patients with Sjögren syndrome and 10 patients with non-Sjögren syndrome) and 14 control subjects. The correlation between IL-6 and TNF-alpha levels and tear film and ocular surface parameters was analyzed. The relative expression of these cytokines was evaluated in conjunctival impression cytology and conjunctival biopsy specimens by using immunohistochemical staining. The mean levels of IL-6 and TNF-alpha were, respectively, 18.57 +/- 8.92 and 3.68 +/- 3.45 pg/mL in patients with dry eye and 3.59 +/- 3.38 (P < 0.01) and < 0.5 (P < 0.01) pg/mL in control subjects. IL-6 level was significantly increased in tears of patients with Sjögren syndrome compared with those with non-Sjögren syndrome (P < 0.01). IL-6 level correlated significantly with tear film breakup time (P = 0.04), Schirmer test (P < 0.01), tear clearance (P = 0.02), keratoepithelioplasty score (P < 0.01), and goblet cell density (P = 0.03), but not with corneal sensitivity (P = 0.08). There was no significant difference in TNF-alpha level between patients with non-Sjögren and Sjögren syndrome. TNF-alpha levels did not correlate with tear film and ocular surface parameters. Immunohistochemical staining showed positive staining for IL-6 in specimens from patients with dry eye, especially in specimens from patients with Sjögren syndrome. IL-6 and TNF-alpha levels are elevated in tears of patients with dry eye syndrome. IL-6 level, but not TNF-alpha level, is associated with the severity of the disease and correlates with various tear film and ocular surface parameters.

                Author and article information

                J Cytol
                J Cytol
                Journal of Cytology / Indian Academy of Cytologists
                Medknow Publications & Media Pvt Ltd (India )
                Oct-Dec 2015
                : 32
                : 4
                : 261-267
                Department of Pathology, School of Medical Sciences and Research, Sharda University, Greater Noida, India
                [1 ]Department of Ophthalmology, School of Medical Sciences and Research, Sharda University, Greater Noida, India
                [2 ]Department of Ophthalmology, Laser Eye Clinic, Noida, Uttar Pradesh, India
                [3 ]Department of Microbiology, Narayan Medical College and Hospital, Sasaram, Bihar, India
                Author notes
                Address for correspondence: Prof. Rahul Bhargava, B2/004, Ananda Apartments, Sector - 48, Noida - 201 301, Uttar Pradesh, India. E-mail: brahul_2371@ 123456yahoo.co.in
                Copyright: © Journal of Cytology

                This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms

                Original Article


                conjunctival impression cytology (cic), contact lens, dry eye, lens wear time


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