ARVO 2015 Annual Meeting Abstracts

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1 438 Dry eye disease, II Wednesday, May 06, :00 AM 12:45 PM Exhibit Hall Poster Session Program #/Board # Range: /A0055 A0119 Organizing Section: Cornea Program Number: 4429 Poster Board Number: A0055 Detection of Tear Film Osmolarity Changes After Use of a Hydroxypropyl Guar-Based Lubricating Eye Drop Alison Ng 1, Adam Keech 2, Lyndon W. Jones 1. 1 Centre for Contact Lens Research, School of Optometry & Vision Science, University of Waterloo, Waterloo, ON, Canada; 2 FYidoctors, Grande Prairie, AB, Canada. Purpose: Tear film hyperosmolarity is a recognised hallmark of dry eye disease. Lubricating eye drops have been shown to improve signs and symptoms of dry eye disease. However, their effect upon tear osmolarity has not been established. This study aimed to evaluate tear osmolarity after using lubricating eye drops 4 times daily for 3 weeks. Methods: Thirty participants with dry eye disease (OSDI score 20 and tear osmolarity 300 mosm/l) were enrolled in this prospective, dispensing, non-randomized study involving a baseline visit and 3-week follow-up. The following ocular surface parameters were determined at baseline: osmolarity; non-invasive tear break up time (NITBUT); conjunctival hyperemia; corneal and conjunctival staining. Participants were instructed to instil one drop of a hydroxypropyl guar-based drop (Systane Ultra; Alcon, Fort Worth, TX) 4 times daily in each eye for 3 weeks and completed a symptom questionnaire between visits. At the follow-up visit, the OSDI questionnaire and ocular surface parameters were reassessed. At the end of these assessments, one drop of Systane Ultra was instilled into each eye and osmolarity was measured after 15 minutes to examine short-term changes in osmolarity. Results: Twenty eight participants completed the study (5M; 23F: median age 54 yrs, range yrs). At baseline, mean OSDI score was 44.94±15.23 and mean osmolarity were 312.5±10.6 / 308.8±12.6 mosm/l (OD/OS). After 3 weeks, mean osmolarity reduced to 306.4±16.8 / 305.1±9.9 mosm/l (OD/OS; p<0.05 and p=0.07, respectively). Statistically significant improvements in conjunctival hyperemia, central corneal staining (p<0.05 OU) and NITBUT (p<0.01 OD only) were observed. Mean OSDI scores reduced to 28.27±17.0 (p<0.01). A significant reduction in osmolarity was observed 15 minutes after instilling the lubricating drop (p<0.05 OU). There were no changes in acuity (all p>0.05). Conclusions: A significant, measurable reduction in osmolarity in addition to improvements in dry eye symptoms and some tear film parameters were observed after 3 weeks of daily use of a hydroxypropyl guar-based lubricant drop. A decrease in osmolarity was also demonstrated 15 minutes after drop instillation. Commercial Relationships: Alison Ng, Alcon Laboratories (F); Adam Keech, None; Lyndon W. Jones, Alcon Laboratories (F) Support: This study was funded by Alcon Laboratories. Program Number: 4430 Poster Board Number: A0056 The Effects of Ocular Surface Stimulation on Blinking and Tear Secretion Ziwei Wu 1, 4, Carolyn G. Begley 1, Nicholas Port 1, Arthur Bradley 1, Richard J. Braun 2, Peter E. King-Smith 3. 1 Optometry, Indiana University, Bloomington, IN; 2 Mathematical Sciences, University of Delaware, Minneapolis, MN; 3 College of Optometry, The Ohio State University, Columbus, OH; 4 New England College of Optometry, Boston, MA. Purpose: To determine how increasing ocular surface stimulation affects blinking and tear secretion. Methods: Ten healthy subjects concentrated on a visual task, while a pneumatic device generated air flow toward the central cornea. Six flow rates were randomly presented and one microliter 2% fluorescein was instilled before each trial (2mins) to visualize the lower meniscus. Interblink interval (IBI), tear meniscus height (TMH) and fluorescence intensity were measured simultaneously. Tear meniscus fluorescein concentration (TMFC) was calculated from intensity by a mathematical model. In order to normalize individual variation at the beginning of the trail, the maximum difference of TMH and TMFC within each trial were further calculated. Tear secretion response was disengaged from blinking, by calculating tear turnover rate within each IBI (IBI-TTR). The time to the tearing and blink response were quantified for each trial. Results: Blinking and tear secretion were increased with stimulation. The mean (±SD) IBI was decreased from 9.47±8.79 during the baseline to 1.39±1.11sec during maximum air stimulation. Ocular surface stimulation was significantly correlated with the log IBI, maximum difference of TMFC and TMH (Pearson s r= -0.47, 0.71 and 0.39, p<0.01, respectively). The IBI-TTR was increased from 0.014±0.013 during the baseline to 0.097±0.045 log(%)/sec during maximum air stimulation and it was significantly correlated with surface stimulation (Pearson s r= 0.61, p<0.001). Blinking and tearing responses were significantly correlated with each other (Pearson s r= 0.56, p<0.001). On average, the tear secretion lagged behind the blink response by 6.54±4.07sec. Conclusions: Both blinking and tear secretion showed a doseresponse relationship with increasing ocular surface stimulation, and were highly correlated with each other. The blink response was almost immediate, while tearing lagged by several seconds, possibly due to the time required for tears to arrive in the meniscus. Both of these protective responses originate with ocular surface stimulation, and thus depend on initiation by ocular surface sensory innervation. While this study tested young, healthy subjects to establish normal protective response of the ocular surface, these methods can be used to further understand potential deficiencies in these responses in ocular surface conditions such as dry eye. Commercial Relationships: Ziwei Wu, None; Carolyn G. Begley, None; Nicholas Port, None; Arthur Bradley, None; Richard J. Braun, None; Peter E. King-Smith, None Support: NH Grant R01EY Program Number: 4431 Poster Board Number: A0057 Dry eye profiles in patients with a positive elevated surface matrix metallopeptidase 9 point of care test versus negative patients Allister Gibbons 1, Nicole Lanza 2, Felipe Valenzuela 1, Victor L. Perez 1, Anat Galor 1, 3. 1 Bascom Palmer Eye Institute, Miami, FL; 2 University of Miami, Miller School of Medicine, Miami, FL; 3 Ophthalmology, Veterans Affairs Hospital, Miami, FL.

2 Purpose: To compare dry eye symptoms and signs in patients who tested positive, versus those tested negative for ocular surface matrix metallopeptidase 9 (MMP-9) detection using the InflammaDry point of care test (RPS, Tampa, FL). Methods: In this cross-sectional study, individuals with dry eye symptoms, as evidenced by dry eye questionnaire 5 (DEQ5) seen in the Miami Veterans Affairs eye clinic, were given standardized questionnaires to assess dry eye symptoms and ocular and non-ocular pain complaints. A complete evaluation was conducted to measure ocular surface signs of dry eye. MMP-9 testing was performed using the InflammaDry once in each eye, per the manufacturer s instructions. Our main outcome measure was the comparison of dry eye symptoms and signs in MMP-9 positive versus negative patients. Results: Of the 56 total patients, 46% were positive for MMP-9 by InflammaDry testing in either eye. No statistically significant differences in demographics, co-morbidities, medications, psychiatric status, ocular surface symptoms and signs of dry eye were seen in patients based on MMP-9 detection status. Conclusions: In our population, there was no difference in the profile of dry eye, in both symptoms and signs, between those testing positive versus negative for elevated levels of MMP-9 on the ocular surface. Commercial Relationships: Allister Gibbons, None; Nicole Lanza, None; Felipe Valenzuela, None; Victor L. Perez, Allergan (C), Baush Lomb (C), Eleven (C), EyeGate (C), Genentech (C), Parion (C), Rigel (C); Anat Galor, None Support: Supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development s Career Development Award CDA S (Dr. Galor), NIH Center Core Grant P30EY and NIH Core Grant P30-EY14801, Research to Prevent Blindness Unrestricted Grant, Department of Defense (DOD- Grant#W81XWH and Grant# W81XWH ONOVA) (institutional). Program Number: 4432 Poster Board Number: A0058 Impression cytology of the lid wiper area Alex Muntz, Kevin van Doorn, Lakshman N. Subbaraman, Lyndon W. Jones. CCLR, University of Waterloo, Waterloo, ON, Canada. Purpose: Few reports on the cellular anatomy of the lid wiper (LW) area exist and only one makes use of cytological methods. Impression cytology (IC) is typically performed on bulbar or tarsal conjunctiva and thus requires optimization for use on the LW. The purpose of this study was to optimize a method of collecting, staining and imaging cells from the LW region using IC. Methods: Upon anesthesia (Alcaine, 0.5%), the upper lids of 5 subjects (n=10) were everted and IC was conducted using various membranes (MF-Millipore, PTFE Biopore Millipore, Opia EYEPRIM). Several fixatives (100% Methanol, 95% Ethanol), histological stains (Papanicolaou (hematoxylin GILL-1, OG-6, EA-65), Periodic Acid-Schiff (PAS) and Alcian Blue (AB)) and soak times (1,3,5 minutes) were tested. Varying concentrations of fluorescent dyes (Annexin V, Calcein AM, Ethidium homodimer-1) were tested and imaged using confocal laser scanning microscopy (CLSM). Results: IC delivered optimal results when using the PTFE Biopore membrane. Fixing in 95% Ethanol for >20 minutes then staining in 500ml each of AB, GILL-1, OG-6 and EA-65 for 3 minutes revealed the presence of goblet cells, mucins, cell nuclei and various degrees of pre- and para-keratinization. Calcein AM (4mM), Ethidium (4mM), Annexin V (5ml in 250ml buffer) were combined to successfully show metabolic activity, compromised cell membranes, nucleic acids and apoptosis in cells. Up to 200 microscopy digital images were captured for each sample and stitched into a high-resolution, large scale image of the entire IC span. Conclusions: We have developed a protocol consisting of an optimal selection of membrane, stains and imaging procedures and successfully showed that the sensitivity of IC is appropriate for identifying distinct cellular morphologies surrounding the LW area, as well as showing varying degrees of metabolic activity. To our knowledge, this is the first time this selection of fluorescent dyes was used to image LW IC membranes. This protocol will be effective in future studies to reveal undocumented details of the lid wiper area, such as assessing cellular particularities of contact lens wearers or patients with dry eye or lid wiper epitheliopathy. Squamous cells (left) of the muco-cutaneous junction and columnar cells from the tarsal conjunctival area. Cells show metabolic activity (green fluorescence of Calcein AM) and compromised cell membranes as shown by the penetration of Ethidium causing the red cell nucleus fluorescence Commercial Relationships: Alex Muntz, None; Kevin van Doorn, None; Lakshman N. Subbaraman, None; Lyndon W. Jones, None Program Number: 4433 Poster Board Number: A0059 Systematic review and meta-analysis on the efficacy of LipiFlow device in the treatment of Meibomian Gland Dysfunction Eddie Y. Liu 1, 4, Monali Malvankar 1, 3, Sera Thomas 3, John Costella 2, Cindy M. Hutnik 1, 5. 1 Ophthalmology, Western University, London, ON, Canada; 2 Taylor Library, Western University, London, ON, Canada; 3 Epidemiology, Western University, London, ON, Canada; 4 Schulich School of Medicine, London, ON, Canada; 5 Pathology, Western University, London, ON, Canada. Purpose: To determine the effectiveness of LipiFlow in the treatment of Meibomian gland dysfunction (MGD). Methods: Published and unpublished scientific work from January 1, 2000 to July 15, 2014 were systematically reviewed using bibliographic databases (MEDLINE, EMBASE, BIOSIS Previews, CINAHL, HEED, ISI Web of Science and Cochrane Library) and grey literature by key words and search strategies. Potential

3 studies were screened by two independent reviewers according to the following inclusion criteria: 1) research studies 2) human subjects older than 19 year of age with dry eyes and 3) treated with LipiFlow or a similar thermal pulsation device. Downs and Black checklist was used to assess study quality. Data was extracted by 2 independent reviewers from 13 eligible articles. Standardized mean difference (SDM) was computed as the effect size. Effect sizes were calculated for meibomian gland excretion (MG) score, tear break-up time (TFBUT), SPEED and OSDI questionnaires. Results: Up to 3 months after a single LipiFlow treatment, significant improvement from baseline measures were seen in MG scores (SMD 1.64, 95% CI: 1.42, 1.85), TFBUT (SMD 0.62, 95% CI: 0.42, 0.83), SPEED (SMD -1.15, 95% CI: -1.36, -0.95) and OSDI (SMD -0.81, 95% CI: -1.01, -0.60). Single study data also showed the following significant improvement: up to 48 months after a single Lipiflow treatment significant improvement was seen in MG score (SMD 2.68, 95% CI: 1.77, 3.59); 3 month following MeiboPatch compress with massage treatment significant improvement was seen in MG score (SMD 0.63, 95% Cl: 0.02, -0.81), SPEED (SMD -1.02, 95% Cl: -1.01, 0.30) and OSDI (SMD , 95% Cl: -1.37, -0.13); 3 month after warm compress with massage treatment significant improvement was seen in MG score (SMD 0.91, 95% Cl: 0.36, 1.46); and 2 weeks after iheat treatment significant improvement was seen in OSDI (SMD , 95% Cl: -0.65, -0.18). Conclusions: Lipiflow is an effective treatment option of MGD. It improves objective and subjective measures of dry eye symptoms up to 3 months after a single Lipiflow treatment. Further studies are needed to confirm the effectiveness at and beyond 1 year after treatment. Ultimately, the cost-effectiveness of Lipiflow treatment in the management of MGD will determine its clinical applicability. Commercial Relationships: Eddie Y. Liu, None; Monali Malvankar, None; Sera Thomas, None; John Costella, None; Cindy M. Hutnik, None Program Number: 4434 Poster Board Number: A0060 UNC Dry Eye Management Scale: Spanish Language Translation and Validation Study Jane Reeves Ellis 1, 2, Chris Hwang 2, 3, Jullia Rosdahl 1, Sue Tolleson- Rinehart 2, 4, Richard Davis 3. 1 Duke Department of Ophthalmology, Duke University School of Medicine, Durham, NC; 2 UNC Gillings School of Global and Public Health, Health Care & Prevention MD- MPH Program, University of North Carolina, Chapel Hill, NC; 3 UNC Department of Ophthalmology, University of North Carolina, UNC School of Medicine, Chapel Hill, NC; 4 Department of Pediatrics, University of North Carolina, School of Medicine, Chapel Hill, NC. Purpose: Dry eye disease (DED), a common, chronic disease that diminishes quality of life (QOL), is poorly managed given the poor correlation of patient-reported symptom severity and clinicianobserved disease severity. The UNC Dry Eye Management Scale (DEMS) was developed to improve DED management. The first aim of this study was to translate the UNC DEMS to Spanish and to conduct a feasibility and comprehensibility study of this Spanish DEMS in a Spanish-speaking population. A second aim was to perform initial validity and reliability testing of the Spanish DEMS. This study helps meet the urgent need for valid, reliable patient reported outcome measures (PROM) in languages other than English. Methods: To develop the Spanish DEMS, we used a cross-cultural adaptation method similar to the universal translation method recommended by proponents of PROM translation. Native bilingual speakers performed forward, back, and forward translations, later reconciled by a team. Pre-testing and cognitive interviewing were done in a pilot sample of 13 Spanish-speaking DED patients. I administered the Spanish DEMS to these patients and used cognitive interviewing to evaluate the questionnaire s comprehensibility and utility as an indicator of the effect of symptoms on QOL. I also obtained clinical assessments of disease severity (Schirmer s test, tear break-up time, Oxford grading scheme, and clinician-reported overall assessment). Results: Cognitive interviewing validated the translation. Patients understood and agreed with the wording of the questionnaire. To test internal validity, I compared Spanish DEMS scores to disease severity. Spearman s correlation coefficients showed weak degrees of correlation, as expected given the poor correlation of symptom severity and disease severity; the direction of the correlations was appropriate. To test external validity, I compared performance on the Spanish DEMS to performance on the English DEMS for patients of similar disease severity using the Mann-Whitney test. Performance on the two language versions was significantly similar in the mildto-moderate and severe disease categories. While strictly illustrative, initial analysis was promising for the future validation of the Spanish DEMS. Conclusions: The early stages of our research confirm the Spanish UNC DEMS is an easy to use, easy to understand questionnaire that can improve the management of Spanish-speaking DED patients. Commercial Relationships: Jane Reeves Ellis, None; Chris Hwang, None; Jullia Rosdahl, None; Sue Tolleson-Rinehart, None; Richard Davis, None Support: Translational and Clinical Sciences Institute (TraCS) 2KR491309

4 Program Number: 4435 Poster Board Number: A0061 Effects of punctal occlusion on tear cytokine levels and relationship to baseline clinical characteristics Louis Tong 1, Roger Beuerman 1, Susan Simonyi 2, David A. Hollander 3, Michael E. Stern 3. 1 Singapore National Eye Centre, Singapore, Singapore; 2 Allergan Singapore Ltd., Singapore, Singapore; 3 Allergan, Inc., Irvine, CA. Purpose: Punctal occlusion, which reduces tear turnover, is a common treatment option for dry eye. There is limited evidence that occlusion alters tear protein composition. This longitudinal study evaluated signs and symptoms, and tear cytokine levels after punctal occlusion and assessed factors associated with cytokine changes in dry eye patients. Methods: Non-adsorbable, parasol type silicone plugs were inserted bilaterally in the lower punctum of patients (n=29) with moderate dry eye and persistent symptoms (2 or more symptoms grade 3). Clinical signs and global symptom score were assessed and tears were tested for 15 cytokines and matrix metalloproteinase-9 (MMP- 9) by indirect immunofluorescence, at baseline up to 3 weeks after punctal occlusion. Multivariate analysis used repeat measure general linear modeling with dependent variables of cytokine and MMP-9 levels and effects of age, gender, baseline dry eye characteristics (Schirmer s score, tear break-up time, global irritation), and time (baseline, week 1, week 3) to identify factors associated with cytokine levels. Results: Punctal occlusion reduced fluorescein staining in all zones (P<.01) except inferior zone and decreased global irritation score (P<.001) after 3 weeks. Patients with low Schirmer s scores ( 8 mm) at baseline had higher levels of several cytokines, including TNF-α (P<.001), IL-2 (P<.03) and MIP-1α (P<.002). For most cytokines and MMP-9, there was no relationship between levels and time, and cytokine levels elevated at baseline remained high post-occlusion. Time was a significant factor only in a model of IFN-γ, IL-10, IL-12 and TNF-α, with cytokine levels adjusted by baseline Schirmer s and global irritation scores; increases in all four cytokines after punctal occlusion occurred in patients with Schirmer s score 8 mm and high irritation scores (>55.3) at baseline. The interaction of time and irritation scores was also significant in the model. Conclusions: Overall cytokine and metalloproteinase concentrations were not significantly affected following punctal occlusion. Cytokine modeling identified some baseline characteristics as potential factors associated with cytokine levels. The lack of a significant effect of punctal plugs on tear cytokines suggests that dry eye patients would benefit from earlier treatment with anti-inflammatory agents for management of their disease. Commercial Relationships: Louis Tong, None; Roger Beuerman, Allergan (C); Susan Simonyi, Allergan (E); David A. Hollander, Allergan (E); Michael E. Stern, Allergan (E) Clinical Trial: NCT Program Number: 4436 Poster Board Number: A0062 Reliability of a new modified tear-breakup-time method: Dry tear breakup time Kyung Tae Kim 1, Jae-hyung Kim 1, Ju Byung Chae 1, Young Tae Kong 2. 1 Ophthalmology, Chungbuk National University, Cheongju, Korea (the Republic of); 2 Kong Eye Clinic, Seoul, Korea (the Republic of). Purpose: Tear breakup time (TBUT) is a useful technique to diagnose dry eye disease (DED). Measuring TBUT using fluorescein strips adds supplemental normal saline (NS) to the tear film and does not represent the actual state of the tear film. We introduced a new TBUT dry tear breakup time (DBUT) and investigated its reliability. Methods: For measuring DBUT, 1 ml of 5% fluorescein solution was instilled on the end of an applicator using a micropipette. The applicator was sterilized using ethylene oxide gas after the fluorescein solution dried. The dried fluorescein was then instilled onto the lower palpebral conjunctiva without supplemental NS. Agreement between the two tests and their sensitivity and specificity were analyzed. Results: The average age of the patients was 32.1 ± 9.7 years (n = 124). The DBUT was lower than the TBUT, with a mean difference of 0.63 s. Both tests had a low statistically significant correlation with the Ocular Surface Disease Index. The cutoff value for the TBUT was 4.48 s, and the sensitivity and specificity were and 0.548, respectively. The area under the receiver operative characteristic (AUROC) curve was (95% confidence interval (CI): ). With a cutoff value of 3.5 s for the DBUT, the sensitivity and specificity were and 0.694, respectively. The AUROC curve was (95% CI: ). Conclusions: DBUT had a higher correlation with symptoms and a higher AUROC than conventional TBUT when DED was diagnosed with corneal staining. DBUT could be a useful and effective method in diagnosing DED. Commercial Relationships: Kyung Tae Kim, None; Jae-hyung Kim, None; Ju Byung Chae, None; Young Tae Kong, None Program Number: 4437 Poster Board Number: A0063 Prevalence of Dry Eye Disease in Rheumatoid Arthritis Patients Jasmine W. Yumori 1, Dat Trinh 2, Eric Lee 3, Tina Escobedo 3, 4, Gillian Hollands 1, Robert Gordon 1, Cheng-Tong Wang 5, Thang Le 3, Anthony Hou 3, Michael Finley 6. 1 Optometry, Western University of Health Sciences, Pomona, CA; 2 Family Medicine, Western University of Health Sciences, Pomona, CA; 3 Inland Rheumatology & Osteoporosis Medical Group, Upland, CA; 4 Graduate Nursing, Western University of Health Sciences, Pomona, CA; 5 Sociology, University of California, Irvine, Irvine, CA; 6 Clinical Affairs, Western University of Health Sciences, Pomona, CA. Purpose: Patients with rheumatoid arthritis (RA) often present to non-eye care practitioners with dry eye disease (DED) symptoms but without a clinical diagnosis of DED. We completed a prospective, observational 1-visit multi-center clinical study to determine the prevalence of DED on a large RA patient population recruited from non-eye care settings. Methods: 286 adult RA patients completed a rheumatologic and dry eye evaluation. All patients were asked to self-report a clinical diagnosis of DED. The mean age of patients was 58 years old; 14.3% were male and 85% were female, with unavailable gender information for 0.70%. The following rheumatologic tests were performed: Disease Activity Score in 28 joints (DAS28) and Cyclic Citruillinated Peptide IgG antibody (CCP IgG), C - Reactive Protein (CRP), and Rheumatoid Factor (RF) labs. The following dry eye tests were performed: Ocular Surface Disease Index (OSDI), tear osmolarity (TO), tear break-up time (TBUT), corneal/conjunctival staining, and Schirmer test (ST) without anesthetic. A Modified Dry Eye WorkShop (DEWS) Severity Scale (Table 1) was created to quantify DED severity level. A DED severity level was determined for each eye by averaging the severity level for each test. The eye with the higher DED severity level was used to identify each patient s overall DED severity level. Patients with an overall DED severity level greater than Level 1 were defined as having DED. Results: Data from the 286 RA patients was analyzed. 44% of patients reported a clinical diagnosis of DED. Mean rheumatologic test results were: DAS ±1.40, CCP IgG 91.77±105.80, CRP

5 0.58±1.58, and RF 77.44± Mean dry eye test results were: OSDI 37.21±25.54, TO ±16.32, TBUT 4.20±2.05, staining 4.45±4.52, and ST 11.15±8.99. The prevalence of DED (overall DED severity level greater than Level 1) in RA patients recruited from noneye care settings is 96.15% % of RA patients had an overall severity of at least Level 3. Conclusions: In this population of RA patients recruited from non-eye care settings there is a strong association between RA and DED. Earlier diagnosis and treatment of DED in collaboration with non-eye care professionals and eye care professionals in RA patients is essential. of Tokyo School of Medicine, and adhered to the tenets of the Declaration of Helsinki. Results: Among all subjects, double row MGOs were observed only in upper eyelids and never in lower eyelids. The incidences of the double rows MGOs were 30.7% in children, 32.1% in adult men, 30.0% in adult women, and 30.8% in elderly cadaver eyelids. Among adult men, the numbers of orifices in the upper eyelid was significantly higher in the double row group (n=18) compared to the single row group (n=38) (46.4±4.8 v.s. 36.0±5.3, p<0.0001). All other measurements were not statically different. In histological observation, orifices were connected to the central ducts on a one by one basis in both the single and the double row groups. Conclusions: Double row MGOs exist in about 30% of upper eyelids among healthy Japanese. They are thought to be congenital and one of the anatomical variations of Meibomian gland arrangements with normal function. Table 1: Modified DEWS Severity Scale Commercial Relationships: Jasmine W. Yumori, Allergan (F), TearLab (F); Dat Trinh, None; Eric Lee, None; Tina Escobedo, None; Gillian Hollands, None; Robert Gordon, None; Cheng- Tong Wang, None; Thang Le, None; Anthony Hou, None; Michael Finley, None Support: Allergan Medical Affairs Research Grant IIT Clinical Trial: NCT Program Number: 4438 Poster Board Number: A0064 Clinical and histological investigation of the double rows of Meibomian gland orifices Rika Shirakawa 1, Reiko Arita 2, 1, Masataka Ito 5, Hiromasa Sawamura 1, Shiro Amano 3, 4. 1 Ophthalmology, University of Tokyo, Tokyo, Japan; 2 Ophthalmology, Itoh Clinic, Saitama, Japan; 3 Inoue Eye Hospital, Tokyo, Japan; 4 Miyata Eye Hospital, Miyakonojyo, Japan; 5 Developmental Anatomy, National Defense Med College, Tokorozawa, Japan. Purpose: Although the double rows of meibomian gland orifices (MGOs) have been occasionally seen in daily clinical practice, little is known about their histological structure and influences on the ocular surface. We investigated lid margins and meibomian glands of healthy children and adults and cadaver eyelid tissue to explore the incidence, function and structure of double row MGOs. Methods: Subjects of in vivo observation consisted of children undergoing strabismus surgery under general anesthesia (13 boys and 13 girls) and healthy adult volunteers (56 men and 30 women). The number of MGOs and presence of double row MGOs were obtained after induction of general anesthesia. The eyelid width, number of MGOs in the upper and lower eyelids, fluorescein staining score, tear break-up time (BUT), meibum expressibility grade, tear meniscus height, Schirmer tear production test, meiboscores obtained by noncontact meibography (Topcon Corp.), non-invasive BUT and tear meniscus height measured by Keratograph5M (OCULUS Inc.) and eyelid thickness were obtained in adult men. Histological investigation was conducted on 13 cadaver eyelid tissues (8 men and 5 women). Continuous horizontal sections with hematoxylin and eosin staining were obtained and observed by light microscope. Double rows were defined where more than 5 orifices were aligned in a second row distinctly separate from the primary row. This study was approved by the institutional review board of University Commercial Relationships: Rika Shirakawa, None; Reiko Arita, Japan Focus Company (P), Topcon Corporation (P); Masataka Ito, None; Hiromasa Sawamura, None; Shiro Amano, None Program Number: 4439 Poster Board Number: A0065 Subjective discomfort onset and intensity are correlated to low corneal temperature in dry eye patients Piera Versura, Giuseppe Giannaccare, Michela Fresina, Emilio C. Campos. DIMES-Ophthalmology Unit, Alma Mater Studiorum University of Bologna, Bologna, Italy. Purpose: To measure corneal temperature in mild-moderate dry eye (DE) patients and to correlate values with the onset and intensity of subjective discomfort symptoms. Methods: 40 eyes of DE patients (n=20, DEWS severity grade 2-3) were included in the study along with 30 eyes of age-matched normal control subjects (n=15). Subjective symptoms of discomfort were scored with OSDI questionnaire and a 100 mm horizontal VAS (Visual Analogue Scale) technique served for measuring symptom intensity. Dynamic infrared non-contact thermal imaging (Tomey TG 1000, Nagoya, Japan) was used to measure Central Cornea Temperature (CCT, 4 mm circular area). After training, subjects were asked to force the eye to remain open and signal the moment of discomfort onset while forcedly still not blinking. Temperature was measured at eye opening (T0) and every second during 10 seconds of sustained eye opening (T1). Time of the first occurrence of discomfort sensation (Discomfort Onset Time, DOT) was measured by a chronometer and the corresponding CCT recorded. Schirmer I test, Break Up Time (BUT), Oxford grade score were performed in all subjects. Recorded temperature values were correlated (r or ρ coefficient) with the clinical tests, OSDI, VAS and DOT, and data were statistically evaluated (significance p<0.05). Results: Corneal temperature immediately after eye opening was significantly lower in DE patients as compared to controls, in correlation to subject age, VAS and BUT (r= -0.46, and 0.43

6 respectively,p<0,0001). VAS was also correlated to OSDI score, BUT, Schirmer I test (respectively r=0.818, , p<0,0001 and r=-0.410, p<001) but not to Oxford score ( ρ=0.12, p=0.7). DOT was significantly lower in DE patients vs controls (7.51±1.52 vs 16.3±2.81, p<0.0001) and in correlation to corresponding CCT recorded and BUT in DE patients (r=0.56, p=0.006 and r=0.91, p< respectively). DOT was delayed after BUT with a significantly shorter interval in DE patients vs controls (0.9±1.4 vs 4.2±1.2 seconds, p<0.0001). Conclusions: Subjective sensation of discomfort at eye opening was not found to be related to corneal damage and it occurred earlier in DE patients, in correlation to lower corneal temperature and enhanced tear evaporation. Commercial Relationships: Piera Versura, None; Giuseppe Giannaccare, None; Michela Fresina, None; Emilio C. Campos, None Program Number: 4440 Poster Board Number: A0066 Clinical Effectiveness of Lid Debridement with BlephEx Treatment Charles G. Connor, Christopher Choat, Srihari Narayanan, Kirsti Kyser, Bonnie Rosenberg, Daniel Mulder. Rosenberg School of Optometry, University of the Incarnate Word, San Antonio, TX. Purpose: Eyelid disease is a common cause of evaporative dry eye. Lid scrubs and warm compresses done consistently will address this problem but poor compliance makes an office based procedure desireable. Korb found the debridement-scaling of the lower lid margin provides statistically significant symptom relief and improvement in the meibomian gland (MG)function. The Bleph Ex provides a method of accomplishing lid debridement without using a surgical instrument. This study compares signs and symptoms before and after BlephEx treatment. Methods: Twenty subjects all with MG dysfunction were examined at baseline using a biomicroscope using the Efron scale for grading. Subjects also had a TBUT and OSDI performed. The subjects were then treated with the BlephEx according to manufacturer s directions. 4 weeks later all testing was repeated. Data was analyzed by a t-test with post hoc test for significance. Results: Subjects TBUT improved from 3.31+/-1.3 to 5.47+/-4.3 p=0.05. Blepharitis on the Efron scale improved from 1.24+/-0.69 to /-0.54 p=0.01. MG dysfunction also dramatically improved from 1.65+/-0.5 to / p=0.01. Symptoms also improved based on the OSDI which went from / to / p=0.01. Conclusions: This study suggests BlephEx is a viable alternative to lid scrubs and warm compresses. Statistically significant improvement was observed in signs and symptoms of the subjects treated. Eyelid functions improved based on TBUT increase, reduced inflammation and enhanced MG function. Subjects were 50% less symptomatic after treatment. BlephEx appears to be a reasonable clinical approach for use non-compliant MG dysfunction patients. Commercial Relationships: Charles G. Connor, None; Christopher Choat, None; Srihari Narayanan, None; Kirsti Kyser, None; Bonnie Rosenberg, None; Daniel Mulder, None Program Number: 4441 Poster Board Number: A0067 Intense pulsed light (IPL) and meibomian gland expression (MGX) treatment of ocular rosacea and dry eye disease (DED) in chronic graft-versus-host disease (cgvhd): 12 month pilot study Joanne F. Shen 1, Srav Vegunta 2, Qing Wu 3, Dharmendra (Dave) Patel 1, Nandita Khera 4. 1 Ophthalmology, Mayo Clinic in Arizona, Scottsdale, AZ; 2 University of Arizona, Phoenix, AZ; 3 Research Biostatistics, Mayo Clinic in Arizona, Scottsdale, AZ; 4 Hematology and Oncology, Mayo Clinic in Arizona, Scottsdale, AZ. Purpose: Evaluate tolerability and efficacy of IPL and MGX treatment for severe DED and ocular rosacea in allogeneic hematologic stem cell transplantation (allo-hsct) subjects with controlled cgvhd in a prospective 12 month pilot study. Methods: Nine subjects status post all-hsct with controlled cgvhd and severe DED and ocular rosacea were prospectively examined and treated with IPL and MGX as previously described by Toyos using the DermaMed system under approved institutional review board protocol. Subjects were evaluated by a single ophthalmologist with SPEED2 (scaled from 0-28) and OSDI symptom surveys, visual acuity, intraocular pressure, slit lamp examination with meibomian gland evaluation (MGE), lissamine green and fluorescein vital dye staining, Schirmer s testing, lipid tear film analysis, tear osmolarity, tear meniscus height, infrared meibomography, and tear break up time at baseline, 1, 2, 3, 4, 5, 9 and 12 months post-treatment. Subjects received IPL and lid expression at baseline, months 1, 2, and 3. Results: The average subject age was 47 years, with 5 women and 4 men. One male subject developed active systemic GVHD and had to withdraw from the study. Of the remaining 8 subjects, the mean baseline SPEED2 score was severe at 20.7 (range 17-25). By 5 months after starting IPL/MGX series, the mean SPEED2 significantly improved an average of 8.0 points (paired t-test, p=0.003). At 12 months, this symptom improvement was sustained with an average of 8.0 points (paired t-test, p<0.001). However, MGE quantifying the total number of meibomian glands producing liquid secretions, tear osmolarity, and meibomography showed no change from baseline to 12 months. Conclusions: DED in cgvhd is multifactorial with abnormalities in aqueous as well as meibum production. Novel approaches for treating this severe form of dry eye is needed to improve quality of life for these patients. This pilot study shows tolerability of IPL/ MGX treatment with prolonged symptomatic improvement of dry eye symptoms, but no physical correlation of improvement. This pilot study is limited by lack of case controls and single observer bias. However, the significant symptom improvement in this cohort warrants further investigation under a clinical trial to evaluate IPL as an adjuvant treatment in cgvhd patients with dry eye symptoms. Commercial Relationships: Joanne F. Shen, None; Srav Vegunta, None; Qing Wu, None; Dharmendra (Dave) Patel, None; Nandita Khera, None Support: Mayo Clinic Cancer Center Discretionary Funds, Mayo Clinic Department of Ophthalmology Discretionary Funds, Research to Prevent Blindness Clinical Trial: NCT Program Number: 4442 Poster Board Number: A0068 Dry eye and dry skin- is there a connection? Igor Petricek 1, Martina Tomic 2. 1 Department of Ophthalmology, Zagreb University Hospital, Zagreb, Croatia; 2 Department of Ophthalmology, University Clinic Vuk Vrhovac, Clinical Hospital Merkur, Zagreb, Croatia.

7 Purpose: Ocular surface is part of the body surface which predominantly consists of skin. Just as the eye protects itself from drying with tears, so does the skin with sebum, what enables the body to retain its hydration. In that sense, both parts of the body surface perform the same task. People very frequently complain of dry eye symptoms just as they complain of dry skin. So, is there a connection? Methods: During 2014, 25 dry eye subjects and 25 subjects with no dry eye symptoms were examined. Clinical parameters screened were severity of dry eye symptoms, ocular signs including conjunctival hyperemia, surface staining, Meibomian gland expression, tear film lipid layer thickness, TBUT before and after meibomian gland expression, Lid Parallel Conjunctival folds (LIPCOF) and Schirmer test. In addition, meibometry was performed using commercially available meibometer. To assess skin dryness, patients were asked how they felt their facial skin was, dry or oily, and then facial skin oiliness was measured using commercially available sebumeter. Results: Subjects without dry eye symptoms had self-reported oilier facial skin than those with dry eye (p<0.001). Also, sebumetry scores measured on the forehead and cheek were found to be significantly higher in subjects without dry eye symptoms as compared to dry eye subjects (p=0.002). Dry eye subjects had higher LIPCOF score than subjects without dry eye symptoms (p<0.001). TBUT scores both before and after meibomian gland expression were significantly longer in subjects without dry eye symptoms compared to dry eye subjects. Multiple regression analysis showed that age, gender, self-reported facial skin oiliness and LIPCOF score of both eyes were the main predictors of dry eye symptoms. The increasing prevalence of dry eye symptoms was significantly related with older age, female gender and dry skin. Conclusions: Results of this study show that there is a statistical connection between dry skin and dry eye. People with dry skin also have drier eyes. As both parts of the body surface play the same role of dehydration prevention, there has to be the same regulator of this function. It is known that androgens play a key role in skin sebum secretion, so could dry eye also be hormonally caused? Commercial Relationships: Igor Petricek, None; Martina Tomic, None Program Number: 4443 Poster Board Number: A0069 Patients with Moderate to Severe Dry Eye Disease in Routine Clinical Practice in the UK - Physician and Patient s Assessments Mourad Amrane 1, Alexandre CIVET 2, Alexandre Templier 2, Dian Kang 2, Francisco C. Figueiredo 3. 1 Scientific/Med Div, SANTEN, Evry Cedex, France; 2 Quinten, Paris, France; 3 Department of Ophthalmology, Royal Victoria Infirmary, Newcastle, United Kingdom. Purpose: To identify and highlight differences and similarities of profiles of severe patients according to physician and patients. Methods: This was a prospective, single-centre, registry of adults with moderate to severe KCS recruited from March 2002 to June No treatments were mandated as part of this study and patients were treated over time as in normal clinical practice. Clinical outcomes, medications used and severity assessment by the physician and patient were recorded at each routine clinic visit. Patient reported outcomes included the Dry Eye Disease Impact Questionnaire (DEDIQ). Data analysis was performed by Quinten using its proprietary supervised learning algorithm (Q-Finder) to identify and characterize profiles of severe patients. Results: The study included 80 patients, among which 38% were classified as severe according to PhA (SPhA, from 7 to 9 on a 9-points scale), and 46% according to PaA (SPaA, same scale as PhA). Results show that severity according to physician is driven by Schirmer test lower than 1 SPhA: 77%; SPaA: 53% and Tear Function Index lower than 14 SPhA: 71%; SPaA: 57%, whereas severity according to patients is linked to combinations of subjective symptoms felt all of the time such as irritation SPaA: 87%; SPhA: 40%, discomfort SPaA: 81%; SPhA: 37.5% or grittiness SPaA: 82%; SPhA: 47%. However we identified two profiles reconciling these two views, essentially characterized by extreme use of artificial tears every day (more than 14 times a day) SPaA: 83%; SPhA: 67% or burning sensation at least most of the time SPaA: 87%; SPhA: 60%. Conclusions: Current clinical outcomes evaluation criteria and methods seem to be not sufficient to objectively evaluate severity in KCS patients. Physicians should be more receptive to patients symptoms and ways to improve their quality of life beyond clinical signs. A composite score based on a combination of selected signs and symptoms might be built and validated on multiple cohorts. Commercial Relationships: Mourad Amrane, SANTEN (E); Alexandre CIVET, Quinten (E); Alexandre Templier, Quinten (E); Dian Kang, Quinten (E); Francisco C. Figueiredo, None Support: Grant from Allergan Europe and Santen Program Number: 4444 Poster Board Number: A0070 Automated Determination of Conjunctival Redness in Dry Eye Syndrome David Finis, Maria Borrelli, Stefan Schrader, Gerd Geerling. Ophthalmology, Universitïtsaugenklinik Dsseldorf, Dsseldorf, Germany. Purpose: To evaluate the diagnostic potential of a standardized automated measurement of conjunctival redness in patients with dry eye syndrome. Methods: 717 eyes of 365 patients with dry eye syndrome were included in this retrospective analysis. Conjunctival redness was determined with the Oculus Keratograph 5M, which automatically generates a value (R-score) between 0.0 (absolutely no redness) and 4.0 (maximal redness). A correlation analysis between this parameter and subjective symptoms, tear film lipid layer thickness (LLT), Meibomian gland assessment, meibography, tear film break-up time (BUT), tear osmolarity, corneal and conjunctival staining (Oxford scale), Lid margin parallel conjunctival folds (LIPCOFs), Schirmer test values and tear meniscus height was performed. Results: The results showed significant positive correlations between conjunctival redness and age (r = 0.487, p < ), lipid layer thickness (r = 0.254, p < ), tear meniscus height (r = 0.198, p < ), meibography (r = 0.244, p < ), corneal and conjunctival staining (r = p < ) and LIPCOFs (r = 0.297, p < ). An inverse correlation was found between conjunctival redness and BUT (r = , p < ). For the other investigated parameters no correlation was found. Conclusions: Standardized automated determination of conjunctival redness seems to be a promising new diagnostic parameter in dry eye syndrome. However aging appears to be an important confounding factor. In the future prospective studies are needed to further evaluate the value of this new parameter as a screening as well as a monitoring tool for dry eye syndrome. Commercial Relationships: David Finis, Oculus (R); Maria Borrelli, None; Stefan Schrader, None; Gerd Geerling, Oculus (R)

8 Program Number: 4445 Poster Board Number: A0071 Incomplete response to artificial tears is associated with selfreported features of neuropathic ocular pain Hatim Batawi 1, 2, Roy Levitt 1, 7, Elizabeth Felix 1, 3, Todd P. Margolis 4, Constantine Sarantopoulos 1, 7, Eden R. Martin 5, 6, Anat Galor 1, 2. 1 Ophthalmology, Miami Veterans Administration Medical Center, Miami, FL; 2 Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL; 3 Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL; 4 Ophthalmology, Washington University School of Medicine, St Louis, MO; 5 John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, FL; 6 John T Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, FL; 7 Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, FL. Purpose: Artificial tears are first-line therapy for patients with dry eye symptoms. It is not known, however, which patients will respond to therapy. The purpose of this study was to evaluate whether certain features of dry eye were more frequent in those reporting an incomplete therapeutic response to artificial tears Methods: Cross-sectional study of 71 individuals reporting artificial tear use (hypromellose 0.4%), at least in part, to treat dry eye associated ocular pain. An evaluation was performed to assess dry eye symptoms, as well as ocular and non-ocular pain complaints. The main outcome measures were factors associated with an incomplete response to artificial tears. Results: By self-report, 14 patients reported no improvement, 38 partial improvement, and 19 complete improvement in ocular pain with artificial tears. Dry eye severity impacted treatment response as those with more severe symptoms were less likely to report complete improvement with artificial tears. A similar pattern was seen with respect to self-reported ocular and non-ocular pain. Patients reporting symptoms consistent with NOP including hot-burning ocular pain and/or hypersensitivity to wind were also less likely to report complete improvement with artificial tears compared to those without these complaints. In a multivariable model, hot burning ocular pain (odds ratio (OR) 0.27, 95% confidence interval (CI) , p=0.04) and a higher non-ocular pain score (OR 0.73, 95% CI , p=0.01), were significantly associated with incomplete response to artificial tears. Conclusions: Patients who reported an incomplete response to artificial tears more frequently endorsed symptoms of NOP and more severe ocular and non-ocular pain compared to those who reported complete response to therapy. Commercial Relationships: Hatim Batawi, None; Roy Levitt, None; Elizabeth Felix, None; Todd P. Margolis, None; Constantine Sarantopoulos, None; Eden R. Martin, None; Anat Galor, None Support: Supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research and Development s Career Development Award CDA S (Dr. Galor), NIH Center Core Grant P30EY014801, Research to Prevent Blindness Unrestricted Grant, Department of Defense (DOD- Grant#W81XWH and Grant# W81XWH ONOVA) (institutional); NIH NIDCR R01 DE (Dr. Levitt), and the Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida for funding. Program Number: 4446 Poster Board Number: A0072 Comparison of Bacterial Lipase Activity in the Presence of Eye Lid Cleansers Arthur Epstein 1, 2, Liliana Pang 2, Kathryn Najafi-Tagol 3, 2, Ramin Najafi 2, David Stroman 2, Dmitri Debabov 2. 1 Phoenix Eye Care, Phoenix, AZ; 2 NovaBay Pharmaceuticals, Inc., Emeryville, CA; 3 Eye Institute of Marin, San Rafael, CA. Purpose: Blepharitis is a generalized inflammation of the eyelid and lid margins, which can include meibomian gland dysfunction (MGD). Meibomian gland dysfunction is characterized by obstruction or a secretion abnormality of the glands that can lead to tear film instability and inflammation and irritation of the lids and ocular surface, in turn changing the corneal reflectivity. The meibomian glands are sebaceous glands found in the lid margins that produce a lipid-rich secretion known as meibum. Excessive bacterial lipase production can alter and degrade meibum, potentially leading to tear instability and dry eye disease. We evaluated the lipase inactivation activity of various commonly used eyelid cleansers including: Cliradex, Johnson s Baby Shampoo, NovaBay Avenova (i-lid Cleanser), OCuSOFT Lid Scrub Original, OCuSOFT Lid Scrub Plus, and TheraTears SteriLid. Methods: Each eyelid cleanser was added to a solution of 2 mg/ml of Pseudomonas cepacia lipase. After an hour of incubation at 37 C, the lipase-eyelid cleanser solutions were diluted 500-fold into lipase buffer. The lipase activity was determined using the Lipase Activity Assay Kit III (Sigma Aldrich ). A SpectraMax M5 plate reader was able to continuously incubate the microtiter plate at 37 C and measure the fluorescence (λ ex /λ ex = 529/600 nm) every 5 minutes for 1.5 hours after an initial 10-minute incubation period. Results: In the presence of Cliradex, Johnson s Baby Shampoo, OCuSOFT Lid Scrub Original, OCuSOFT Lid Scrub Plus, and TheraTears SteriLid, bacterial lipase had similar activity to the lipase treated with sterile water, negative control (Figure 1). In the presence of NovaBay Avenova, the bacterial lipase activity was completely inactivated, not distinguishable from no added lipase (Figure 1). Conclusions: Our study compares the inactivation of bacterial lipase by eye care products used to treat blepharitis and MGD. In this in vitro study, NovaBay Avenova completely inactivated bacterial lipase activity while all other products had minimal effect. Activity of bacterial lipase in the presence of various eyelid cleansers measured in relative fluorescence unit (RFU) over time Commercial Relationships: Arthur Epstein, NovaBay Pharmaceuticals, Inc. (C); Liliana Pang, NovaBay Pharmaceuticals, Inc. (E); Kathryn Najafi-Tagol, NovaBay Pharmaceuticals, Inc. (E); Ramin Najafi, NovaBay Pharmaceuticals, Inc. (E), NovaBay Pharmaceuticals, Inc. (I), NovaBay Pharmaceuticals, Inc. (P); David Stroman, NovaBay Pharmaceuticals, Inc. (E); Dmitri Debabov, NovaBay Pharmaceuticals, Inc. (E)

9 Program Number: 4447 Poster Board Number: A0073 Continuous blink recording and the relationship of diurnal blink parameters to diurnal change in signs and symptoms of dry eye Keith J. Lane, George W. Ousler, John D. Rodriguez, Endri Angjeli. Clinical R & D, ORA, Andover, MA. Purpose: To assess differences between dry eye and normal subjects with regard to the diurnal change in blink rate and patterns, and how changes in diurnal blink might relate to the severity of dry eye signs and symptoms Methods: Blink data were collected using an ECG-monitoring device adapted to record myograms that correspond to blink signaling. Three electrodes were affixed to subjects each morning; subjects wore the device for hours and were asked to perform their normal activities. Blink activity was detected using an algorithm based on recognition of the waveform corresponding to the kinematic properties of the blink signal. Results: At both visits, mean IBI measured during the day was higher for normal (Visit 1: 5.30±1.62; Visit 2: 5.60±1.84) than dry eye (Visit 1: 4.57±1.62; Visit 2: 4.72±1.70) subjects, but the difference was not statistically significant at either visit (Visit 1: p=0.27; Visit 2: p=0.23). However, when segmenting the day into blocks of time of 4 hours each (morning, afternoon, evening), mean IBI for normal subjects during the afternoon (5.25±1.81) and evening (5.43±2.61) was significantly longer (p=0.0189, p= respectively) than for dry eye subjects (4.55±1.76 afternoon, 4.31±1.72 evening) at Visit 1. Diurnal worsening of central corneal staining scores at Visit 1, and diurnal worsening of temporal lissamine green staining scores at Visit 2 were significant in dry eye subjects only. Statistically significant correlations were found between the change in fluorescein corneal staining and mean IBI for both normal and dry eye groups. Conclusions: There are differences in blink patterns when data are collected throughout the day instead of at discrete time points in dry eye and normal subjects. Continuous blink tracking reveals significant trending with symptoms and diurnal change in blink patterns may be an appropriate surrogate for such in the study of dry eye. Commercial Relationships: Keith J. Lane, Ora, Inc. (E); George W. Ousler, Ora,Inc. (E); John D. Rodriguez, Ora, Inc. (E); Endri Angjeli, Ora,Inc. (E) Program Number: 4448 Poster Board Number: A0074 Evaluation of clinical response to treatment with FDA approved i-lid Cleanser in patients with blepharitis in an optometric practice Guru Sharma. 1 Family Eye Care Optometry, El Cajon, CA; 2 College of Optometry, Western University of Health Sciences, Pomona, CA. Purpose: To evaluate the efficacy, patient s compliance and tolerability of FDA approved i-lid Cleanser in patients with mild to moderate blepharitis. Methods: Patients with signs and symptoms of mild to moderate blepharitis were treated with FDA approved i-lid Cleanser (NovaBay Pharmaceuticals, Inc.). A total of 18 patients with mild to moderate blepharitis were treated with i-lid Cleanser twice daily for two weeks according to manufacturer s guidelines. Efficacy of the treatment was evaluated based on slit lamp examination pre- and post-treatment at 2 weeks. Following signs and symptoms were used to evaluate the severity of blepharitis and efficacy of treatment: eyelid redness, eyelid debris, eyelid swelling, eyelash collarettes and eyelid irritation. A scale of 0 to 3 (0-absent, 1-mild, 2-moderate, 3-severe) was used to identify and monitor blepharitis progression. Patient compliance, tolerability and ease of use was assessed based on patient feedback. Results: i-lid Cleanser treatment showed improvement in subjective (discomfort, itching, dryness, eyelid irritation) and objective (redness, swelling, eyelash collarettes) symptoms of blepharitis. Patients with mild blepharitis reported good compliance (>95%) and ease of use of i-lid Cleanser. Patients with mild blepharitis (n=10) showed significant improvement in their sign and symptoms. 100% of patients with mild blepharitis improved score by at least one point in all categories. Patients with moderate blepharitis (n=8) showed improvements at a slower rate and needed extended treatment period beyond 2 weeks to achieve similar improvements. The initial improvement ranged between one point to no point in individual categories. These patients had a lower compliance rate of about 80%. However, all patients reported ease of use and post-application comfort and relieve of symptoms. Conclusions: Author believe the results are encouraging in group with mild blepharitis, i-lid Cleanser treatment showed significant improvement in their signs and symptoms. However, patients with moderate blepharitis needed long-term treatment for similar effect. It may be prudent to study the efficacy of i-lid Cleanser in more number of patients with both mild and moderate blepharitis to establish its beneficial effect in difficult to treat chronic blepharitis. Commercial Relationships: Guru Sharma, None Support: n/a Program Number: 4449 Poster Board Number: A0075 Ocular and Systemic Pharmacokinetics of GW559090, an Alpha-4 Integrin Antagonist, in Mouse, Rabbit and Dog Following Topical Administration Clara Andonian. DMPK, GlaxoSmithKline, King of Prussia, PA. Purpose: To evaluate the ocular and systemic pharmacokinetics of a high-affinity α4β1 integrin antagonist (Kd=0.19 nm, MW = ) in mouse, rabbit and dog following eye drop administration and to estimate the likely systemic exposure in humans. Methods: All studies were conducted according to the GSK Policy on the Care, Welfare and Treatment of Laboratory Animals after review by the GSK Institutional Animal Care and Use Committee and in compliance with the ARVO Statement on the Use of Animals in Ophthalmic and Visual Research. Female C57BL/6N mice (2 ml), male Dutch-Belted rabbits (30 ml) and male Beagle dogs (30 ml) were topically dosed with a 30 mg/ml solution of GW Plasma or blood samples were collected to measure the systemic exposure of GW Ocular tissues were collected only from enucleated rabbit eyes at necropsy. GW levels were quantitated in all samples using an UHPLC/MS/MS method. Results: In rabbit eye GW levels were 2210 ng/g to 282 ng/g and 1100 ng/g to 266 ng/g from 0.5hr to 6hr post-dose for bulbar conjunctiva and cornea, respectively. GW concentrations were 28.7 ng/ml and 68.6 ng/g in the aqueous humor and iris/ciliary body at 6hr post-dose, respectively. Circulating levels of GW were generally quantifiable (2-27 ng/ml) up to 6 hours in rabbits and dogs and up to 1 hour in mice with maximum exposure of ng/ml at Tmax ~ hr. AUC (0-t) values were 44.1 ng*h/ml, 31.5 ng*h/ ml and 16.0 ng*h/ml in mouse, rabbit and dog, respectively. These systemic levels were used to estimate the projected human systemic exposure following eyedrop administration, by allometric scaling. The estimated human systemic exposure is 6.4ng*hr/mL, which is low. Conclusions: GW levels observed in the rabbit cornea and conjunctiva following eyedrop administrations were high. Significantly lower levels were observed in the plasma or blood of preclinical species studied. Thus, target exposure will be maximized while systemic exposure in humans will be minimized. Preclinical

10 pharmacokinetic studies with GW have been utilized to provide an estimate of target tissue exposure and human systemic exposure along with an understanding of ocular drug distribution. Topically administered α4β1 integrin antagonists may be an important new class of molecules for inflammatory eye diseases. Commercial Relationships: Clara Andonian, GlaxoSmithKline (E) Program Number: 4450 Poster Board Number: A0076 Correlation of dry eye syndrome with diabetic retinopathy, Kidney Disease Outcomes Quality Initiative and lipids panel Azyadeh Camacho Ordoñez, Oscar Fernandez, Elisa D. Alegria, Cristina Pacheco Del Valle, Regina Velasco, Oscar Baca, Alejandro Babayan. Hospital de la luz, Mexico, Mexico. Purpose: To analize the relation between dry eye syndrome (DES) with diabetic retinopathy (DR), Kidney Disease Outcomes Quality Initiative (KDOQI) and lipids panel. Methods: Cross-sectional, prospective, observational and analytical study. We included patients of DES with DR in differents stages of the disease between july and november of Sociodemographic, clinical characteristics and laboratory studies were available for all patients. DES was measured by the Dry Eyes Work Shop, DR was staged by Early Treatment Diabetic Retinopathy Study and glomerular filtration rate (GFR) by KDOQI. Pearson correlation was used for statistical analysis. Results: A total of twenty-one patients were included (n=42 eyes) with a mean age of 55±8 years. Ocular Surface Disease Index mean score was 43±14, proliferative DR was present in 70% patients, stage 1 and 2 of KDOQI were the more common (80%), lipids mean score was total cholesterol 235±54, high density lipoprotein (HDL) 48±11, low-density lipoprotein (LDL) 140±48, triglycerides (TG) 179±84. Patients with higher DES had a higher relation with advanced DR (r=0.602, p=0.001), higher KDOQI stages (r=0.401, p=0.007, ), higher LDL (r=0.392, p=0.009) and lower HDL ( r=-0.338, p=0.02), total cholesterol and TG showed no significant relation. Conclusions: The present study demostrate a significant relationship between DES with DR, GFR by KDOQI, LDL and HDL, therefore we recommend systematic assessment of these clinical parameters in patients with visual impairment and diabetes in order to promote opportune diagnosis and treatment. Commercial Relationships: Azyadeh Camacho Ordoñez, None; Oscar Fernandez, None; Elisa D. Alegria, None; Cristina Pacheco Del Valle, None; Regina Velasco, None; Oscar Baca, None; Alejandro Babayan, None Program Number: 4451 Poster Board Number: A0077 Expression of SIRT1 and Related Oxidative Stress in Diabetic Dry Eye Mouse Bing Li, Minjie Sheng, Hao Liu, Li Chen, Yihui Chen, Peng Wang. Department of Ophthalmology, Shanghai Tenth People s Hospital, Shanghai, China. Purpose: Observing the change of physiology and pathology in the cornea of diabetic dry eye and exploring the expression of SIRT1 and oxidative stress reaction in pathological process of diabetic dry eye. Methods: Forty-eight C57BL/6Jdb/db mice of eight-week old were divided randomly into two groups: diabetic dry eye group (Group A, n=24) and diabetic group (Group C, n=24). Forty-eight C57BL/6J mice of eight-week old were divided randomly into another two groups: dry eye group (Group B, n=24) and control group (Group D, n=24). After dry eye models were induced at 1 st, 4 th and 8 th week, blood glucose test and aqueous tear production were measured. Its score of corneal fluorescein staining were estimated and the histopathology were also performed. Expression of SIRT1, FOXO3 and MnSOD were detected by western blot. Results: After induction of 1 st, 4 th and 8 th week, blood glucose remained high and stable concentration in group A and group C. Significant decreased tear volume and the increased scores of corneal fluorescein stainings were found in group A, B and C (P<0.05, vs control) ( Figure 1). The least tear volume and the highest score of corneal fluorescein staining were detected in group A (P<0.05) (Figure 1). Compared to control group D, the expression of SIRT1, FOXO3 and MnSOD were higher in the 1 st week and 4 th week (P<0.05), but significantly down-regulated in the 8 th week in group A and C (P<0.05) (Figure 2). A lower expression of SIRT1,FOXO3 and MnSOD was detected in all the 1 st, 4 th and 8 th week in group B (P<0.05) (Figure 2). Conclusions: In the induction of diabetic dry eye, tear volume decreased obviously, coupled with serious wounded corneal epithelium. The oxidative stress of cornea was enhanced significantly with its expression of SIRT1 decreased in the progression of diabetic dry eye. Commercial Relationships: Bing Li, None; Minjie Sheng, None; Hao Liu, None; Li Chen, None; Yihui Chen, None; Peng Wang, None Program Number: 4452 Poster Board Number: A0078 The utility of tear cytokine profiles in the diagnosis of Graft vs Host Disease- Associated Dry Eye Amalia Enriquez-De-Salamanca 1, 2, Lidia Cocho 1, Itziar Fernández 2, 1, Dolores Caballero 3, 4, Lucia López-Corral 3, 4, Verónica Martínez- Tottil 1, Maria-Jesus Gonzalez 1, 2, Carmen García-Vázquez 1, Michael E. Stern 5, Margarita Calonge 1, 2. 1 IOBA-University of Valladolid, Valladolid, Spain; 2 CIBER-BBN (Biomedical Research Networking Center in Bioengeneering, Biomaterials and Nanomedicine), Valladolid, Spain; 3 Hematology Service, University Hospital -University of Salamanca, Salamanca, Spain; 4 IBSAL (Instituto Biosanitario de Salamanca), Salamanca, Spain; 5 Biological Sciences, Allergan Inc, Irvine, CA.

11 Purpose: To analyze a panel of tear cytokines in Graft versus Host Disease (GvHD)-associated Dry Eye (DE) patients, to correlate them with clinical features, and to develop a tear molecule level-based predictive model Methods: 22 GvHD-DE patients and 21 healthy subjects comparable in age and gender were evaluated under standard conditions of relative humidity (45%) and temperature (230C) within The Controlled Environmental Research Laboratory. Patients were medically controlled and had discontinued topical medications for one week before examination. DE-related symptoms and signs were recorded, and unstimulated tears were collected from the most symptomatic eye. Levels of 15 molecules (EGF, IL-1Ra, IL-1β, IL-2, IL-6, IL-8/CXCL8, IL-10, IL-12p70, IL-17A, IP-10/CXCL10, IFN-γ, VEGF, TNF-α, RANTES) were measured in tear samples by multiplex bead assay in a Luminex IS-100, and correlated with clinical parameters. Multivariate logistic regression was used to build a model for predicting GvHD-DE event on the basis of an optimal subset of molecules selected by Akaike Information Criterion (AIC) and adjusted for age and gender. Prediction accuracy was estimated by leave-one-out cross validation (LOOCV). Results: EGF and IP-10/CXCL10 tear levels were significantly (p<0.0001) decreased, whereas IL-1RA, IL-8/CXCL8 and IL-10 levels were significantly (p=0.0007, p= , and p=0.0253) increased in GvHD-DE patients compared to healthy subjects. IL- 1RA and IL-8/CXCL8 tear levels correlated positively with OSDI questionnaire score, conjunctival hyperemia, fluorescein corneal staining and lissamine green conjunctival staining, while that correlation was negative with T-BUT and Schirmer test. EGF and IP-10/CXCL10 levels correlated positively with T-BUT and Schirmer test values and negatively with OSDI, hyperemia, fluorescein and lissamine green staining scores. A predictive model based on IL-8/ CXCL8 and IP-10/CXCL10 tear levels was developed, with an area under the ROC curve of , a sensitivity of 86.36%, and a specificity of 95.24%. Conclusions: Correlations were demonstrated between the levels of inflammatory proteins and the clinical phenotype of the GvHD associated dry eye. A GvHD-DE diagnostic model based on IL-8/ CXCL8 and IP-10/CXCL10 tear levels showed a good sensitivity and specificity. These results add further knowledge to the molecular mechanisms involved in GvHD-DE and can be helpful in its diagnosis. Commercial Relationships: Amalia Enriquez-De-Salamanca, None; Lidia Cocho, None; Itziar Fernández, None; Dolores Caballero, None; Lucia López-Corral, None; Verónica Martínez- Tottil, None; Maria-Jesus Gonzalez, None; Carmen García- Vázquez, None; Michael E. Stern, Allergan Inc (E); Margarita Calonge, Allergan Inc,CA (C) Support: National grant from Ministry of Economy and Competitiveness, Madrid, Spain (SAF ) Program Number: 4453 Poster Board Number: A0079 Effect of punctal occlusion on aqueous tear deficient dry eye evaluated from tear film stability and blink-related friction Norihiko Yokoi, Mengxi Niu, Hiroaki Kato, Rieko Sakai, Aoi Komuro, Yukiko Sonomura, Shigeru Kinoshita. Ophthalmology, Kyoto Prefectural Univ of Med, Kyoto, Japan. Purpose: It is considered that tear film instability and increased friction during blinking are related to the pathophysiology of aqueous tear deficient dry eye. Punctal occlusion increases the tear volume on the ocular surface and is considered to improve both tear film instability- and increased friction-related mechanisms. The purpose of this present study was to investigate the effect of punctal occlusion on those mechanisms. Methods: This study involved 13 eyes of 13 patients with aqueous tear deficient dry eye (mean age: 70.8 years). In all eyes, dry-eyerelated symptoms were evaluated by use of a visual analog scale (VAS, mm), and tear meniscus radius (TMR, mm), interference grade/spread grade (IG/SG) of the tear-film lipid layer (i.e., IG/SG 1-5: 1 being the best), non-invasive breakup time (NIBUT, seconds), fluorescein breakup time (FBUT, seconds), ocular surface epithelial damage score (OSED, cornea: 15 points maximum, conjunctiva: 6 points maximum), corneal filament grade (CFG: 3 points maximum), lid-wiper epitheliopathy grade (LG: 6 points maximum) and superior limbic keratoconjunctivitis grade (3 points maximum) were evaluated before and at more than 1-month post punctal occlusion. The Schirmer 1 test (ST1, mm) was measured only before punctal occlusion. The change of each factor pre and post punctal occlusion were then investigated. Results: Post punctal occlusion, VAS-related subjective symptoms including dryness, difficulty in opening the eye, foreign body sensation, pain, redness, blurred vision, sensitivity to light, heavy eyelid, and eye fatigue were significantly improved (all p<.01). TMR, IG, SG, NIBUT, OSED (both corneal and conjunctival), CFG, and LG were also significantly improved (all p<.02). Conclusions: The findings of this study show that in patients suffering from aqueous tear deficient dry eye, punctal occlusion can improve almost all subjective symptoms and objective findings related to tear film instability and increased friction. It is therefore theorized that aqueous tear deficiency worsens dry eye due to the enhancement of both the tear film instability- and increased frictionrelated mechanisms. Commercial Relationships: Norihiko Yokoi, Kowa (P); Mengxi Niu, None; Hiroaki Kato, None; Rieko Sakai, None; Aoi Komuro, None; Yukiko Sonomura, None; Shigeru Kinoshita, Kowa (P) Program Number: 4454 Poster Board Number: A0080 Relationship between lid-wiper epitheliopathy, tear abnormalities, and blink in dry-eye patients Hiroaki Kato, Norihiko Yokoi, Mengxi Niu, Rieko Sakai, Akihide Watanabe, Shigeru Kinoshita. Ophthalmology, Kyoto Prefectural Univ of Medcine, Kyoto City Kamigyoku, Japan. Purpose: Lid-wiper epitheliopathy (LWE) is defined as an epitheliopathy of the marginal conjunctiva of eyelids that wipes the ocular surface during blinking, and it is thought to be related to the increased friction that occurs during the blink process. It is also reportedly associated with dry eye. The purpose of this present study was to investigate the relationship between LWE, tear abnormalities, and blink in dry-eye patients. Methods: This study involved 45 eyes of 45 female dry-eye patients (mean age: 57.6 years). In all eyes, tear meniscus radius (TMR, mm), spread grade (SG) of the tear-film lipid layer (i.e., SG 1-5: 1 being the best), fluorescein breakup time (FBUT, seconds), LWE grade (LWEG: 3 points maximum) of the upper eyelid, and the Schirmer 1 test (ST1, mm) were evaluated. Blink rate (BR, per minute), palpebral aperture height (PAH, mm), ascending/descending distance (AD/DD, mm) of the upper eyelid, ascending/descending time (AT/ DT, msec) of the upper eyelid, and maximum ascending/descending velocity (MAV/MDV, mm/sec) of the upper eyelid were measured by use of a high-speed blink analyzer. Finally, the factors that determine LWEG were investigated by multiple regression analysis in which the parameters were chosen using the stepwise procedure.

12 Results: Significant correlations were found between LWEG and SG [R=0.75 (p<.0001)] and FBUT [R=-0.79 (p<.0001)]. LWEG was found to be described as: (0.271 x SG) - (0.437 x FBUT) + (0.005 x MDV) (R 2 =0.78, p<0.0001). Conclusions: Considering that LWEG was described by SG, FBUT, and MDV (which are thought to be related to aqueous tear volume, tear viscosity that affects tear film thinning, and eyelid velocity during blinking, respectively), the present results suggest that LWE of the upper eyelid must be caused by the shear friction, which is described by the following equation:η(viscosity of tear) x U (velocity of eyelid) / h (tear film thickness), acting between lid-wiper region of the upper eyelid and eyeball surface. Commercial Relationships: Hiroaki Kato, None; Norihiko Yokoi, Kowa (P); Mengxi Niu, None; Rieko Sakai, None; Akihide Watanabe, None; Shigeru Kinoshita, Kowa (P) Program Number: 4455 Poster Board Number: A0081 Anti-inflammatory effects of EGCG or EGCG3Me against hyperosmotic-induced inflammation in humans conjunctival epithelial cells Junichiro Kizaki 1, 2, Yuko Udaka 1, Akiko Sasaki 1, Mayumi Tsuji 1, Akiko Toju 1, 2, Eiji Tomoyori 1, 2, Shinichi Iwai 1, 3, Katsuji Oguchi 1. 1 Pharmacology, Showa Univ. Sch. Med, Tokyo, Japan; 2 Ophthalmology, Showa Univ. Sch. Med, Tokyo, Japan; 3 Health.Reg. Sch, Showa Univ. Sch. Pharm, Tokyo, Japan. Purpose: Osmotic pressure of the tear in dry-eye patient is usually higher than that in normal people. The cause of dry-eye is reported as two factors; reduction of the tear volume, and destabilization of the tear film. Reduction of the tear raise the osmotic pressure of the tear, and cause inflammation on surface of eyes. And if goblet cell injured, production of mucin will lead to destabilization of the tear film and further reduction of tear. That is a vicious circle in dry-eye patient. Recently, It have reported that the tea caetichin,especially, (-)-Epigallocatechin Gallate (EGCG) and (-)-Epigallocatekin 3-(3 -O-Methyl)Gallate (EGCG3Me) have numerous bioactivity, for example, antiallery, anti-inflammation, and anticancer activity. We used human conjunctival epithelium cell (HCE cell) to elucidate how hyperosmolarity induced inflammation, and reveal the antiinflammatory action of catechin. Methods: We cultivated HCE cells in 2mM glutamine + 1% penicillin streptomycin + 10% Fetal Bovine serum Medium199 with FBS in 5% CO 2 37 environment. HCE cells were exposed to hyperosmotic medium (440mOsm i.e. 123mM sucrose in medium) or were maintained in isosmotic medium (289mOsm). We determined the rate of apoptotic cells and IL-6 level during 1 to 24 hours after applying hyperosmotic stress. Moreover, hyperosmotic stress 1 hour before treatment of EGCG and EGCG3Me, and exposed to hyperosmotic stress, we measured p38 MAPK and phosphorylation of IL-6 level 1 hour later. Results: Both the rate of apoptotic cells and the IL-6 level elevated with time after applying hyperosmotic stress. For this inflammation, EGCG3Me significantly inhibited increase of the IL-6 level and phosphorylated p38 MAPK than EGCG. Conclusions: Hyperosmotic stress to HCE cells induce apoptosis and inflammation with p38mapk. For this inflammation, EGCG and EGCG3Me significantly showed anti-inflammatory action particularly effects of EGCG3Me were strong. These findings suggested that EGCG3Me might be useable as one of therapeutic approaches of dry eyes. Commercial Relationships: Junichiro Kizaki, None; Yuko Udaka, None; Akiko Sasaki, None; Mayumi Tsuji, None; Akiko Toju, None; Eiji Tomoyori, None; Shinichi Iwai, None; Katsuji Oguchi, None Program Number: 4456 Poster Board Number: A0082 Lipid tear turnover in meibomian gland dysfunction: an optical coherence tomography study Maurizio Fossarello, Franco Coronella, Giovanni M. Satta, Pietro E. Napoli. Ophthalmology, Azienda Ospedaliero Universitaria Cagliari, Cagliari, Italy. Purpose: To assess by means of optical coherence tomography (OCT) the turnover of tear lipids in patients with meibomian gland disease (MGD) and its correlation with classical tear tests. Methods: Forty-two adult patients with MGD were evaluated for abnormalities of ocular surface in the same sequence. It included clinical history, a symptom questionnaire (OSDI = Ocular Surface Disease Index), fluorescein tear break-up time (FTBUT), fluorescein staining of the cornea and conjunctiva graded according to the Oxford system (FSOS), standardized visual scale (SVST), Schirmer I test, and a slit lamp examination of the lid margins and meibomian glands. A novel technique of contrast-enhanced OCT imaging was used to determine the clearance of tear lipids (CoL). Results: The correlations between CoL and OSDI, FTBUT, FSOS, Schirmer test scores, were found to be statistically significant (p<0.001, Spearman correlation coefficient was 0.82, -0.79, 0.64, , respectively). Moreover, also a significant relationship between CoL and the aqueous tear clearance (SVST) was observed (Spearman correlation coefficient was 0.82, p<0.001). Conclusions: The reduced dynamics of tear lipids was associated with the MGD. This new finding could lead to a better understanding of the alterations and of the complex pathogenesis of dry eye syndrome. Commercial Relationships: Maurizio Fossarello, None; Franco Coronella, None; Giovanni M. Satta, None; Pietro E. Napoli, None Program Number: 4457 Poster Board Number: A0083 Validation of an objective measure of dry eye severity Sezen Karakus, Esen K. Akpek, Sumayya Ahmad, Robert W. Massof. The Wilmer Eye Institute at Johns Hopkins, Baltimore, MD. Purpose: To determine if a single valid dry eye severity variable can be estimated from a battery of clinical tests and patient self-reports. Methods: This case control study included 150 case and 50 control patients over age 18. Inclusion in the case group required a physician diagnosis of dry eye. Controls were individuals who are not seeking or have not sought eye care services for dry eye. The following tests were performed in the order they are listed here: review of systems, OSDI questionnaire, tear osmolarity, Schirmer s, automated tear break-up time (T-BUT), corneal staining with fluorescein, and conjunctival staining with lissamine green (SICCA grading system was used for grading). A single dry eye severity variable was estimated for each participant from Rasch analysis using the Masters partial credit model of clinical test results and patient responses to the OSDI. For purpose of analysis, continuous clinical test variables (osmolarity, Schirmer s, and T-BUT) were binned into quintiles and assigned rank scores. Rank scores were also assigned to ordinal OSDI response categories for each question and ordinal clinician ratings of corneal and of conjunctival staining. Results: Measures of dry eye severity were estimated for each case and control (person measures) and measures of sensitivity to dry eye severity were estimated for each sign and symptom (indicator measures). The average person measure for cases (-0.39, SD=0.59) was significantly greater (p<0.001) than the average person measure

13 for controls (-1.2, SD=0.83), but the distributions overlapped heavily. The distribution of indicator measures was well matched to the distribution of person measures for cases. Schirmer s at 1 minute was too sensitive to discriminate dry eye severity among cases, whereas the other 17 indicators fell within the range of severity values for cases. Schirmer s at 5 minutes was the most sensitive of these 17 indicators, followed closely by tear osmolarity; OSDI item 9 (watching TV) was the least sensitive. The most informative indicators were corneal and conjunctival staining; OSDI item 7 (driving at night) was the most informative OSDI item. No indicator carried more than 10% of the total information about dry eye severity than that carried by all indicators together. Conclusions: Standard dry eye clinical signs and symptoms can work together to define and measure a latent dry eye severity variable. There is no single best dry eye severity measure. Commercial Relationships: Sezen Karakus, None; Esen K. Akpek, NiCox (C); Sumayya Ahmad, None; Robert W. Massof, None Support: Validation of an Objective Measure of Dry Eye Severity in Saudi and U.S. Populations, King Khaled Eye Specialist Hospital KKESHJHU/02-10 Program Number: 4458 Poster Board Number: A0084 Evaluation of tearing rate, TBUT and corneal surface temperature in aging and tear deficient guinea pig eyes M Carmen Acosta 1, Elisa Alonso 1, 2, Raquel Revert 1, Carolina Luna 1, Carlos Belmonte 1, 3, Juana Gallar 1. 1 Instituto de Neurociencias, Universidad Miguel Hernandez-CSIC, San Juan, Spain; 2 Departamento Fisiología, Universidad Miguel Hernández, San Juan, Spain; 3 Fundación de Investigación Oftalmológica, Instituto Fernández-Vega, Oviedo, Spain. Purpose: To compare in guinea pig eyes, different experimental methods used to quantify tear film changes associated with age and experimental eye dryness (DE). Methods: Guinea pigs of both sexes and different ages were studied. In one group of animals the main lacrimal gland was surgically excised (DE animals). Tearing rate was measured using phenol red threads that were placed in the nasal canthus for 30 s, (tear secretion= mm of wet thread). To determine the tear break-up time (TBUT) 1ml of 2% fluorescein was instilled on the conjunctival sac; lids were closed manually 3-4 times; after that, with the eye open, time to break-up the tear film was measured in seconds. Corneal surface temperature was measured using an infrared thermal camera (InfRec R300SR, Nippon Avionics). Temperature was measured continuously in the full open eye during a period of at least 10s, after keeping the eye closed manually during 3 s. Images were analyzed using the instrument s software. Results: Tear secretion was significantly higher in old (15 months) compared with young (2 months) animals (12.7±1.0 mm vs 19.3±1.5 mm; p<0.001; at 2 and 15 months of age respectively). No differences were observed in the TBUT (2.7±0.1 s vs 2.1±0.1 s). The value of corneal surface temperature measured immediately after the eye opening was higher in older guinea pigs (35.2±0.20C vs 36.9±0.20C; p<0.001; at 2 and 15 months of age respectively). In DE animals tear secretion and TBUT were significantly lower than in controls (8.2±1.5 mm, p<0.001; 1±0 s, p<0.05, respectively). Temperature after the opening was also higher in the DE group (37.2±0.04 0C, p<0.001). The slope of the corneal temperature decrease during the 5s afterwards was faster in older and in DE animals (-0.02±0.02 0C/s, -0.07±0.040C, -0.06±0.010C/s, control 2 months, control 15 months and DE respectively, p=0.254 and 0.179, comparisons with 2 months data). Conclusions: Tear secretion (volume) changes in the eye surface can be detected easily and reproducibly in guinea pig using phenol red threads. TBUT was often very short, making comparisons difficult while dynamic thermography may be useful for indirect evaluation of the tear flow, as those occurring during aging or DED disease. Commercial Relationships: M Carmen Acosta, None; Elisa Alonso, None; Raquel Revert, None; Carolina Luna, None; Carlos Belmonte, None; Juana Gallar, None Support: SAF and BFU , Ministerio de Economía y Competitividad, Spain Program Number: 4459 Poster Board Number: A0085 A Controlled 3-Month Clinical Study to Evaluate the Safety and Efficacy of an Investigational Eye Drop Formulation in Subjects with Dry Eye Disease Minas T. Coroneo 1, Pasquale Aragona 2, Jose Benitez-del-Castillo 3, Jacqueline Tan 4, Evelien Vandewalle 5, Algis J. Vingrys 6, Haixia Liu 7, Peter A. Simmons 7, Joseph G. Vehige 7, Ru Chen 7. 1 Prof M.T. Coroneo Pty. Ltd, Randwick, NSW, Australia; 2 Università di Messina, Messina, Italy; 3 Hospital Clinico Madrid, Madrid, Spain; 4 University of New South Wales, Sydney, NSW, Australia; 5 University Hospitals Leuven, Leuven, Belgium; 6 University of Melbourne Eye Care Clinic, Carlton, VIC, Australia; 7 Allergan Clinical Research, Irvine, CA. Purpose: Artificial tears are commonly used to relieve symptoms of dry eye. The purpose of this investigation was to compare the efficacy and safety of a new artificial tear that combines two commonly used polymers, Carboxymethylcellulose (CMC) and hyaluronic acid (HA), to a standard formulation of CMC alone. Methods: A new preservative-free artificial tear (CMC-HA) was compared with an existing artificial tear (CMC, Optive UD, Allergan). Subjects with mild to moderate signs and symptoms of dry eye were enrolled in this double-masked, randomized multi-center trial, and dosed at least 2X a day for 90 days, with follow-up visits at Days 7, 30, 60, and 90. The Ocular Surface Disease Index (OSDI) was the primary outcome measure. Secondary outcome measures were tear breakup time (TBUT), ocular surface staining, Schirmer test and visual analog (VAS) scales to measure dry eye symptom severity and formulation acceptability. Safety measures included adverse events, biomicroscopy and visual acuity. Results: 460 subjects were enrolled across 45 sites (38 in Europe and 7 in Australia). The mean +/- s.d. change from baseline in OSDI score at the primary timepoint, day 90 (per-protocol population, n=364), was / for CMC-HA and / for CMC. CMC-HA was non-inferior to CMC based upon a confidence interval method. Both treatments produced statistically significant improvements (paired t-tests, p<0.001) from baseline at all follow up visits for OSDI, ocular surface staining, TBUT, and symptom VAS scores, with minimal differences between groups. Acceptability scores for eye drop experience were high (>70 on a scale at day 90) and comparable between groups. The safety profiles of the 2 groups were similar, with approximately 10% of subjects in each group reporting treatment-related adverse events of generally mild to moderate severity. The majority of events are typical in dry eye patients, including eye irritation, conjunctival hyperemia, foreign body sensation, erythema of the eyelid, blepharitis, eye pain, and blurred vision. Conclusions: The new CMC-HA formulation was shown to be effective, safe and well-tolerated during the study. These data are supportive of the implementation of this formula for the management of dry eye patients.

14 Commercial Relationships: Minas T. Coroneo, None; Pasquale Aragona, Allergan (C); Jose Benitez-del-Castillo, None; Jacqueline Tan, None; Evelien Vandewalle, Allergan (F); Algis J. Vingrys, Allergan (F); Haixia Liu, Allergan (E); Peter A. Simmons, Allergan (E); Joseph G. Vehige, Allergan (E); Ru Chen, Allergan, Inc. (E) Support: Allergan, Inc. Clinical Trial: NCT Program Number: 4460 Poster Board Number: A0086 Improvements in Signs and Symptoms of Dry Eye with MIM-D3 1% Ophthalmic Solution Compared to Placebo in Different Patient Populations Karen Meerovitch 1, Kim Brazzell 1, George W. Ousler 2, Garth Cumberlidge 1. 1 Mimetogen Pharmaceuticals, Cote St Luc, QC, Canada; 2 Ora, Inc., Andover, MA. Purpose: Ocular comorbidities are potentially important etiological factors in understanding dry eye and its treatment modalities. To explore the clinical efficacy of MIM-D3 1% Ophthalmic Solution compared to placebo in signs and symptoms of dry eye in patients with cataracts or normal lens. Methods: A multi-center, randomized, double masked, placebo controlled study included a 7-day run-in period and 56 days of twice daily (BID) dosing. For screening purposes, at Visits 1 and 2, patients were exposed to the Controlled Adverse Environment (CAE SM ) chamber. Patients were dosed BID with artificial tears between Visits 1 and 2. Eligible patients had sufficient fluorescein corneal (FCS) and lissamine green staining, tear film break up time 5 seconds, and symptoms at both visits and in patient recorded diaries during the run-in period. Additionally, patients demonstrated an exacerbation of FCS and ocular discomfort after exposure to the CAE SM. Patients were randomized 1:1 to MIM-D3 1% or placebo. A post-hoc analysis was based on ocular medical history. Two subgroups were defined based on slit lamp examination of lens, one for cataract (both pre- and post-surgery) another for normal lens. Results: In the intent to treat population (n=403, mean age 58.8 years), MIM-D3 1% showed significantly less FCS (change from pre- to post-cae SM ) compared to placebo after 56 days of treatment (p=0.050). Improvements were also observed in ocular discomfort symptom and the ocular surface diseases index (OSDI ) questionnaire with MIM-D3 compared to placebo. A dramatic difference in response to treatment with MIM-D3 was observed in a subgroup of patients with cataracts compared to patients without lenticular opacities. Patients with cataracts were observed to have significantly improved treatment differences in FCS (p=0.036) and OSDI (p=0.049). Whereas, patients with normal lens showed significant improvement (p=0.005) in ocular discomfort symptom scores in MIM-D3 treated patients compared to placebo. Conclusions: Topical ophthalmic MIM-D3 demonstrated improvements in signs and symptoms in patients with dry eye. These post-hoc data adjusting for ocular comorbidities show that specific patient populations respond to MIM-D3 for reduction of signs and others for symptoms. Commercial Relationships: Karen Meerovitch, Mimetogen Pharmaceuticals (E); Kim Brazzell, Mimetogen Pharmaceuticals (C); George W. Ousler, Ora, Inc. (E); Garth Cumberlidge, Mimetogen Pharmaceuticals (E) Clinical Trial: NCT Program Number: 4461 Poster Board Number: A0087 The Evaluation of the Effect of New Moist Chamber Spectacles in Dry Eye Patients Exposed to Adverse Environment Conditions Mamoru Ogawa 1, 2, Murat Dogru 1, 2, Daisuke Tomida 2, Takefumi Yamaguchi 2, Kazumi Fukagawa 1, Seika Den 2, Yoshiyuki Satake 2, Tetsuya Kawakita 1, Jun Shimazaki 2, Kazuo Tsubota 1. 1 opthalmology, Keio university school of medicine, Tokyo, Japan; 2 Ophthalmology, Tokyo Dental College, Chiba, Japan. Purpose: To evaluate the effect of a novel moist chamber spectacle wear on the ocular surface and tear functions in a controlled wind exposure environment Methods: Periocular humidity with or without moisture spectacles was initially measured under constant temperature and humidity conditions with a humidity sensor (Sensirion Inc, USA). Twentyfour eyes of twelve probable dry eye subjects according to Japanese dry eye society diagnostic criteria (2 males, 10 females; mean age: 34 years) underwent constant wind exposure at 7 m/ sec for 10 minutes with or without moist chamber spectacle wear. Dryness VAS scores, tear evaporation, blink rate and maximal eye opening time measurements (MOT), tear film break up testing, and corneal fluorescein staining were performed before and after wind exposure. Pre and post exposure differences for all examinations were calculated and compared. All tests were performed in the same sequence under the same settings one hour later on the same day with the moist chamber spectacles worn. ANOVA test was used for statistical analyses. Results: The mean periocular humidity was significantly higher (by 15.6%) with moisture spectacles compared to no spectacle wear (p<0.05). The mean dryness VAS score after wind exposure was significantly higher when no spectacles were born compared to after exposure scores when moist chamber spectacles were worn (p<0.05). The mean MOT score after wind exposure was significantly lower when no spectacles were born compared to after exposure scores when moist chamber spectacles were worn (p<0.05). The mean blink rate increased with wind exposure when no spectacles were worn with no significant changes in the mean blink rate with when the moist chamber spectacles were worn (p>0.05), Conclusions: The new moist chamber spectacles appear to have favorable effects on dry eye symptomatology, blink rates and the ability to open the eyes for longer durations in adverse environment conditions such as wind exposure. Commercial Relationships: Mamoru Ogawa, None; Murat Dogru, None; Daisuke Tomida, None; Takefumi Yamaguchi, None; Kazumi Fukagawa, None; Seika Den, None; Yoshiyuki Satake, None; Tetsuya Kawakita, None; Jun Shimazaki, None; Kazuo Tsubota, JINS (F), JINS (F), JINS (P), JINS (P) Support: None in the Support Program Number: 4462 Poster Board Number: A0088 Longitudinal Evaluation of Seasonal Differences in Patient- Reported Dry Eye Symptoms George W. Ousler 1, Michael Watson 1, Kirk Bateman 2, Keith J. Lane 3, Donna L. Welch 4. 1 Dry Eye, Ora, Inc., Andover, MA; 2 Director, Statistics and Data Corporation, Tempe, AZ; 3 R & D, Ora, Inc., Andover, MA; 4 Ora, Inc., Andover, MA. Purpose: Dry eye syndrome has been reported to exhibit seasonal fluctuations, possibly due to increased evaporation in winter months. [1] To date, no empirical studies have been performed to compare symptoms in and out of season within the same cohort of patients. We

15 performed a meta-analysis of dry eye study data to evaluate seasonal differences in diary-reported symptoms. [1] McCulley JP, Uchiyama E, Aronowicz JD, Butovich IA. Impact of evaporation on aqueous tear loss. Trans Am Ophthalmol Soc. 2006;104: Methods: Diary-reported symptom scores from 10 clinical trials in dry eye, completed over a 6-year period, were compiled in a longitudinal database. Data were selected from subjects treated with placebo in pre-trial run-in periods for the purposes of study eligibility. A subset of 270 subjects who had participated in at least one summer season study (April-September enrollment) and one winter season study (October-March enrollment) were identified and included in the analysis. Differences in diary-recorded ocular discomfort and dryness symptoms (graded using the Ora Calibra TM 4-Symptom Scale) were compared between winter and summer seasons to identify any seasonal differences in symptom severity. Results: There was a significant seasonal difference observed for diary-reported ocular discomfort symptoms (summer winter, ± (p=0.034), with patients experiencing higher levels of symptoms during the winter season. Patients also reported higher dryness levels during the winter season, although this difference did not reach statistical significance (p=0.140). Conclusions: Seasonal differences in patient-reported symptoms were observed in this analysis, with elevated ocular discomfort reported during the winter season. In the context of clinical trials, seasonal variations in symptoms may be a confounding factor, and best efforts should be made to complete trials within a given season to minimize this variability. Commercial Relationships: George W. Ousler, Ora, Inc. (E); Michael Watson, Ora, Inc. (E); Kirk Bateman, SDC, Inc. (E); Keith J. Lane, Ora, Inc. (E); Donna L. Welch, Ora, Inc. (E) Program Number: 4463 Poster Board Number: A0089 The relationship between subjective symptoms and quality of life in conjunctivochalasis patients Aoi Komuro, Norihiko Yokoi, Hiroaki Kato, Mengxi Niu, Rieko Sakai, Shigeru Kinoshita. Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Purpose: The subjective symptoms of conjunctivochalasis (CCh) were evaluated by use of the Dry Eye-Related Quality-of-Life Score (DEQS), which was developed as a quality of life (QOL) questionnaire for dry eye patients and a visual analogue scale (VAS). The VAS results were evaluated according to pathophysiologies, and the relationship between VAS score and QOL score was then examined. Methods: This study involved 42 eyes of 42 CCh patients (8 males and 34 females; mean age: 69.5±7.8 years). Subjective symptoms including dry eye sensation, difficulty in opening the eye, foreign body sensation, pain, redness, tearing, discharge, itchiness, blurred vision, sensitivity to light, heavy eyelids, and eye fatigue were evaluated by use of the VAS (0: no symptoms; 100 mm: maximum symptoms). Those subjective symptoms were then divided into four groups depending on pathophysiologies [S: stability of tear film (dry eye sensation, blurred vision, sensitivity to light, eye fatigue, heavy eyelids), F: friction (difficulty in opening the eye, foreign body sensation, pain), R: reflex (redness, tearing), and T: tear turnover (discharge, itchiness)]. The 15 items related to dry eye symptoms and influence on daily life were evaluated by use of the DEQS, and overall degree of QOL impairment is calculated as a QOL score (0-100). The correlation between the Total VAS score, VAS score of each group, and QOL score were then evaluated. Results: A significant correlation was found between QOL score and Total VAS score, S, and F (r=0.68, 0.79, and 0.58, respectively; all: p<0.0001). No significant correlation was found between QOL score and R or T. Conclusions: The findings of this study showed a relationship between subjective symptoms and QOL score, and that the QOL of CCh patients is strongly determined by decreased tear film stability and increased friction during blinking. Commercial Relationships: Aoi Komuro, None; Norihiko Yokoi, None; Hiroaki Kato, None; Mengxi Niu, None; Rieko Sakai, None; Shigeru Kinoshita, None Program Number: 4464 Poster Board Number: A0090 Antiinflammatory effect of Autologous Serum (AS) and Plasma Rich in Growth Factors (PRGF) for the treatment of dry eye. Edna Lucia Valdez Payan 2, Alejandro Babayan 2, Oscar Fernandez 2, Regina Velasco 2, Oscar Baca 2, Cristina Pacheco Del Valle 2, Elisa D. Alegria 2, Atzin Robles-Contreras 1, David De La O-Altamirano 1. 1 Biomedical Research Center, Hospital de la Luz, Distrito Federal, Mexico; 2 Cornea, Hospital de la Luz, Distrito Federal, Mexico. Purpose: To determine if an anti-inflammatory effect could be attributable to AS and PRGF in the treatment of dry eye, by measuring the cytokines concentrations in the tear film before and after treatment. Methods: An experimental, prospective, longitudinal, analytic study was conducted. Sixteen eyes (6 females, 2 males, years of age, mean 54 years) with dry eye grade 3 and 4 (DEWS Severity Grade), were enrolled for this study. The study was performed with the approval of the institutional ethical commitee. The basal tear samples of μl were obtained from each eye by capillary flow, with no nasal stimulation. No anaesthetic drops were instilled. The samples were collected non- traumatically from the inferior meniscus. The tear sample was stored at -200C refrigeration until processed. The amounts of six inflammatory molecules interleukin (IL- 1β, IL-6, IL-8, IL-10, IL-12p70, and tumour necrosis factor α (TNFα), were measured by CBA (BD Biosciences, San Diego, CA, USA), according to the manufacturer s instructions. The cytokines were measured before and a month after treatment with AS and PRGF. Samples were analyzed using Kolmogorov- Smirnoff test to determine the type of distribution, t -student test for group comparisons (before and after treatment ) were applied, where a value of p < 0.05 was considered statistically significant. Results: One month after treatment with AS we found a decrease in IL-10 (3.30±5.01 vs 0.66±0.89 pg/ml, p =0.0078), IL-12 (2.85± 2.87 vs 0.087± 0.24, p =0.0078) and TNF (2.54±4.03 vs 0.29± 0.42, p = ) In the PRGF group, we found a statistically significant increase in IL-1B, (1.09±0.92 vs 3.33±2.30 pg/ml p =0.0391) IL-12 (0.09± 0.18 vs 2.98± 3.07, p =0.0313), IL-6 (4.02±3.66 vs 8.03±7.32 p= )and IL-10 (0.29±0.20 vs 1.73 ±1.41, p=0.0039) respectively after one month of treatment. Conclusions: Based on the decrease of the inflammatory cytokines detected in the tear film, we were able to conclude that AS has an antiinflammatory effect. On the other hand PRGF appears to have an antiinflammatory compensatory effect by increasing IL-10. Commercial Relationships: Edna Lucia Valdez Payan, None; Alejandro Babayan, None; Oscar Fernandez, None; Regina Velasco, None; Oscar Baca, None; Cristina Pacheco Del Valle, None; Elisa D. Alegria, None; Atzin Robles-Contreras, None; David De La O-Altamirano, None Clinical Trial: 143

16 Program Number: 4465 Poster Board Number: A0091 The Relief of Dry Eye Signs and Symptoms Using a Combination of Lubricants, Lid Hygiene and Ocular Nutraceuticals Sruthi Srinivasan, William Ngo, Lyndon W. Jones. School of Optometry and Vision Science, CCLR, University of Waterloo, Waterloo, ON, Canada. Purpose: To determine the combined effect of TheraTears Lubricant Eye Drops, TheraTears SteriLid Eyelid Cleanser, and TheraTears Nutrition on dry eye signs and symptoms. Methods: This was a prospective, randomized, controlled, singleblind study that enrolled 33 dry eye participants who were already on a dry eye regimen that consisted of using artificial tears at least three times a week. Participants were seen at baseline and were randomized into either the treatment group or the control group. In the treatment group, participants were instructed to use the Lubricant Eye Drops 1-2x (or prn) a day, SteriLid 1-2x (or prn) a day, and Nutrition 3 capsules once a day, as per product label. Participants in the control group remained on their own treatment regimen for the remainder of the study. Each participant was followed up at 1-month (1mo), and 3-month (3mo). The ocular variables were: Ocular Surface Disease Index (OSDI), non-invasive tear break-up time (NITBUT), osmolarity, vascularity, lash loss, lid edema, telangiectasia, tear film debris, number of meibomian glands blocked (#MG blocked), meibum quality, Schirmer s test, tear film lipid layer thickness (TFLLT), meniscus height, lid wiper epitheliopathy (LWE), corneal and conjunctival staining, and meibography. Results: 25 participants completed the study. Data from the left eye only was analyzed. In the treatment group (n = 20, mean age = 42.7±13.0), participants reported having used, on average the Lubricant Eye Drop 2.4x per day, the SteriLid 1.1x per day and the Nutrition 3.0 gelcaps 1x per day. The ocular variables (baseline, 1mo, 3mo, p-value) that showed a significant difference over time were OSDI (42.8±15.9, 24.8±15.1, 24.9±17.0, p<0.01), NIBUT (2.42±0.79, 3.31±1.56, 2.97±0.95, p=0.02), lid edema (0.65±0.49, 0.50±0.51, 0.35±0.49, p=0.05), telangiectasia (2.4±1.4, 2.5±1.4, 2.1±1.3, p=0.04), meibum quality (2.35±0.75, 1.95±0.60, 1.65±0.75, p<0.01), #MG blocked (5.6±2.3, 4.2±2.6, 2.5±2.2, p<0.01), and expressibility (2.3±0.7, 1.9±0.8, 1.7±0.8, p<0.01). The control group (n = 5, mean age = 52.20±19.43) showed no statistical significant differences in any of the ocular variables during the period of the study. Conclusions: By switching over to a combination of TheraTears Lubricant Eye Drops, SteriLid, and Nutrition, patients experienced significant relief in both dry eye symptoms and signs. Commercial Relationships: Sruthi Srinivasan, None; William Ngo, None; Lyndon W. Jones, Advanced Vision Research Inc. (F) Support: This study was funded by Advanced Vision Research Inc. Clinical Trial: NCT Program Number: 4466 Poster Board Number: A0092 Effects of caffeine in dry eye after LASIK Teresita de Jesus D. Islas Ramirez. cornea, hospital nuestra señora de la luz, Pachuca, Mexico. Purpose: To determine if orally ingested caffeine improves dry eye signs and symptoms after LASIK surgery. Methods: A clinical randomized experimental trial was performed including healthy patients with ages between years, diagnosed with dry eye stages 1-3 (DEWS international classification) after a LASIK surgery between May and July The variables studied were: dry eye stage, tear film break up time test(tbut), Schirmer test and ocular surface disease index test (OSDI). All patients had 2 evaluations, the first 1 month after LASIK surgery and the second 1 month after daily consumption of 1 cup of coffee (150cc/200mg caffeine). In both evaluations TBUT, Schirmer test and OSDI were registered before and 30 minutes after ingesting a 200mg caffeine tablet. Student t was analized for all the variables. Results: Results: We evaluated 34 eyes of 17 patients, 13 women and 4 men, in wich 41.1% of the patients improved one stage from their basal dry eye stage, while 58.9% remained unchanged after one month of daily consumption of caffeine. In the first evaluation the averege of basal TBUT was 5.55 ± 2.7 seconds, Schirmer s test ± 9.5 mm and OSDI 37.1 points. After 30 min of 200mg of caffeine ingest, the TBUT improved to 6.61± 2.6 seconds and Schirmer s test ± 10.2 mm (p= >0.05). In the second evaluation TBUT showed a basal average of 6.1 ± 1.9 seconds, Schirmer s test 18.14± 8.1 mm and OSDI 45.6 points, after 30 min TBUT was 6.49 ± 1.7 seconds and Schirmer s test ± 6.5 mm (p= >0.05). Conclusions: Caffeine intake showed an improvement in some of the dry eye variables studied, specially in OSDI test but without a statistical significance for the current number of patients Commercial Relationships: Teresita de Jesus D. Islas Ramirez, None Program Number: 4467 Poster Board Number: A0093 Resident compliance with the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for Dry Eye Syndrome (DES) Jordan Huang 2, Melanie Mihlstin 1, 2, Mark S. Juzych 1, 3, Heidi Kromrei 4, Frank Hwang 1, 3. 1 Ophthalmology, Kresge Eye Institute, Detroit, MI; 2 Wayne State University School of Medicine, Detroit, MI; 3 Ophthalmology, Wayne State University School of Medicine, Detroit, MI; 4 Graduate Medical Education, Detroit Medical Center, Detroit, MI. Purpose: Though DES is not usually sight-threatening, severe cases can result in keratinization, thinning, perforation, and scarring of the cornea, thus leading to severe visual loss. To address such concerns, the AAO developed PPPs for proper diagnosis and management of DES. This study examined compliance with the AAO PPPs for evaluation of DES in a resident ophthalmology clinic. Methods: 101 chart notes were chosen to retrospectively evaluate patients newly diagnosed with DES and evaluated by residents in the resident ophthalmology clinic at Kresge Eye Institute between September 2011 and November Each chart note was evaluated for 29 different PPP elements. Average compliance rates of all elements were found in all charts, and then compared between 1 st, 2 nd, and 3 rd year residents. Results: Mean compliance of all elements was 70.0% for all charts, 69.1% for 1 st year residents, 71.2% for 2 nd year residents, and 70.7% for 3 rd year residents. Mean compliance of historical elements was 74.2%, with low compliance (<25%) in documenting contact lenses wear, eyelid/eyelash hygiene, and menopause in female patients. Mean compliance of physical exam elements was 55.6%, with high compliance (>90%) in documenting best corrected visual acuity (BCVA) and examination of eyelids/lashes, tear film, conjunctiva, and cornea; and low compliance (<40%) in documenting proptosis, cranial nerve examination, and examination of adnexa and puncta. Mean compliance of patient education elements was 51.5%, with high compliance (99.0%) in documenting instructions on treatment regimen and very low compliance (4.0%) in documenting counseling on the chronic nature of DES. Compliance of the only evaluated care management element, addressing contributing factors, was 62.4%.

17 Significant differences in each element between residents of different years is currently undergoing statistical analysis and will be ready to present on poster day at ARVO. Conclusions: Compliance was high for most elements in the PPP guidelines for DES. However documentation of specific historical, physical exam, and patient education elements was poor. Evaluating compliance with AAO PPPs can be useful for evaluating resident administration of care. Setting and maintaining a target compliance rate will ensure that residents develop the necessary skills in proper and evidence-based patient care. Commercial Relationships: Jordan Huang, None; Melanie Mihlstin, None; Mark S. Juzych, None; Heidi Kromrei, None; Frank Hwang, None Program Number: 4468 Poster Board Number: A0094 Efficacy evaluation of a cationic emulsion of cyclosporine in a mouse model of dry eye Philippe Daull 1, Laurence Feraille 2, Stefano Barabino 3, Jean- Sebastien Garrigue 1. 1 Novagali Innovation Center, Santen SAS, Evry, France; 2 Iris Pharma, La Gaude, France; 3 Di.N.O.G.M.I., Azienda Ospedaliera Universitaria San Martino-IST, Clinica Oculistica, Genoa, Italy. Purpose: Dry eye disease is a complex, multifactorial pathology characterized by corneal epithelium lesions and inflammation. The severity of these assaults is often correlated to the severity of the disease. The aim of the present study was to evaluate the efficacy of a cationic emulsion of cyclosporine (CsA) in a mouse model that mimics severe dry eye. Methods: Eight to 12-week-old female C57BL6 mice with tail patches of scopolamine (replaced every other days) were housed in controlled environment chambers (CEC) to induce dry eye. At day three, following dry eye confirmation by corneal fluorescein staining (CFS, score 0-15) and phenol red thread (PRT) lacrimation test, the mice (n=10/gp) were either treated 3 times a day in both eyes with: drug-free cationic emulsion, a 0.1% CsA-loaded cationic emulsion, and 1% methylprednisolone (positive control), or left untreated. Aqueous tear production, CFS score, Goblet cell density in the conjunctiva and CD11b+ count in flat mounted cornea were evaluated at the end of the treatment period (at day 10). Results: The PRT lacrimation test confirmed the scopolamineinduced decrease in aqueous production by the lacrimal gland. After 7 days of treatment, the CFS score was reduced by 59% with the 0.1% CsA-loaded cationic emulsion (CFS score at D3 before treatment: 12.1 ± 1.7; vs D10: 5.5 ± 2.0). The beneficial effect of the cationic emulsion vehicle itself on keratitis was also clearly evidenced by its better performance over the 1% methylprednisolone eye drop, -36%, vs. -28%, respectively. The Goblet cell density and the tear production were not markedly improved by any treatment in this model. A reduction in inflammatory markers was also observed for the 0.1% CsA-loaded cationic emulsion when compared to the untreated group. Conclusions: This study indicates that the cationic emulsion of cyclosporine (0.1%) was a very effective formulation for the management of corneal epithelium lesions in a severe dry eye disease mouse model. In addition, it performed better than a potent glucocorticosteroid (1% methylprednisolone). This cationic emulsion of cyclosporine (0.1%) represents a promising new treatment strategy for the management of the signs of dry eye. Commercial Relationships: Philippe Daull, Santen SAS (E); Laurence Feraille, Iris Pharma (E); Stefano Barabino, Santen SAS (C); Jean-Sebastien Garrigue, Santen SAS (E) Program Number: 4469 Poster Board Number: A0095 EFFECTS OF TEAR DEFICIENCY ON CORNEAL NERVE MORPHOLOGY AND SENSORY NERVE ACTIVITY IN YOUNG AND ADULT GUINEA PIGS Kamila Mizerska 1, Carolina Luna 1, Susana Quirce 1, Illes Kovacs 2, M Carmen Acosta 1, Carlos Belmonte 1, 4, Nicolas Cuenca 3, Juana Gallar 1. 1 Instituto de Neurociencias, Universidad Miguel Hernández - CSIC, San Juan de Alicante, Spain; 2 Department of Ophthalmology, Semmelweis University, Budapest, Hungary; 3 Departamento de Fisiología, Genética y Microbiología, Universidad de Alicante, Alicante, Spain; 4 Fundación de Investigación Oftalmológica, Instituto Fernández-Vega, Oviedo, Spain. Purpose: To examine the effect of experimentally induced teardeficiency (TD) on the morphology and impulse activity of corneal sensory nerve fibers in guinea pigs during maturation. Methods: The morphological changes of corneal nerves were studied in different age groups (1-12 months, n=36) and 1, 3 and 8 months after the main lacrimal gland surgical ablation (n=34) performed in 1-month old animals. Eyes were processed for neuronal class III β-tubulin staining, analyzing the proportion of subbasal nerve fibers, the number, density and length of subbasal nerve leashes and the density of epithelial nerve terminals both in the whole mount cornea and in different zones of the superior quadrant. The activity of corneal sensory nerves was measured using electrophysiological extracellular recording techniques. Spontaneous and stimulus-evoked impulse activity were measured in 1 and 8 months animals after lacrimal gland removal and in their age-matched controls. Results: In intact guinea pigs, the number and density of subbasal nerve leashes was different between 1-month and 12-months animals, with both parameters reaching their peak values at month 2 (1834 ± 135 nerves; 53,9 nerves/mm 2 ). The increase in length of subbasal nerves was significantly correlated with age and with the growth of corneal surface area (P<0.001). The density of nerve terminals and nerve branches decreased with age. In operated animals, changes in corneal subbasal nerve architecture were observed 1 month after lacrimal gland removal (see table) but not at later periods. These data suggest that nerve damage develops shortly after induction of reduced tearing, which causes a transient decrease in the number and density of subbasal nerve leashes, as well as in the density of nerve fibers and terminals. After induction of tear-deficiency, significant changes in nerve impulse activity were found only in cold thermoreceptor nerve activity of the 2 months old animals in comparison with controls. Conclusions: The post-natal corneal nerve architecture in guinea pigs changes during maturation to adulthood. Tear deficiency induces a reduction in the subbasal and epithelial nerve density that occurs in parallel with alterations in the activity of corneal cold sensory nerve fibers, suggesting that functional disturbances in nerve activity caused by eye dryness are primarily due to injury of corneal cold sensory nerve fibers.

18 (all: p<0.01). In the Random break group, a significant correlation was found between QOL score and S, F VAS score (all: p<0.001). Conclusions: Our findings suggest a relationship between QOL score and subjective symptoms, and that the QOL of dry-eye patients is strongly determined by tear-film instability and blink-related friction. In the Area break group, symptoms were affected by various pathologies. Commercial Relationships: Yukiko Sonomura, None; Norihiko Yokoi, None; Mengxi Niu, None; Hiroaki Kato, None; Aoi Komuro, None; Shigeru Kinoshita, None Commercial Relationships: Kamila Mizerska, None; Carolina Luna, None; Susana Quirce, None; Illes Kovacs, None; M Carmen Acosta, None; Carlos Belmonte, None; Nicolas Cuenca, None; Juana Gallar, None Support: SAF and BFU from Ministerio de Economía y Competividad Program Number: 4470 Poster Board Number: A0096 The relationship between quality of life and subjective symptoms in dry- eye patients Yukiko Sonomura 1, 2, Norihiko Yokoi 2, Mengxi Niu 2, Hiroaki Kato 2, Aoi Komuro 2, Shigeru Kinoshita 2. 1 Ophthalmology, Kyoto Yamashiro General Medical Center, Kizu, Japan; 2 Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Purpose: Various pathologies are thought to be associated with the subjective symptoms in dry eye. A dry eye-related quality of life score (DEQS) was developed in Japan as a questionnaire to evaluate the quality of life (QOL) for dry-eye patients. Here we investigated the correlation between QOL score as evaluated by DEQS and subjective symptoms assessed by a visual analog scale (VAS). Methods: This study involved 87 dry eye patients (9 males and 78 females; mean age: 63.7±13.8years). The QOL score (0-100) was evaluated by DEQS. Subjective symptoms included dry-eye sensation, difficulty in opening the eye, foreign body sensation, pain, redness, tearing, discharge, itchiness, blurred vision, sensitivity to light, heavy eyelid, and eye fatigue, and they were categorized into the following 4 groups in relation to pathophysiologies: S: stability of tear film (dry eye sensation, blurred vision, sensitivity to light, eye fatigue, heavy eyelids), F: friction (difficulty in opening the eye, foreign body sensation, pain), R: reflex (redness, tearing), and T: tear turn over (discharge, itchiness). Their total and each score were evaluated by VAS (0mm: no symptoms; 100mm: maximum symptoms). The patients were divided into 4 dry-eye groups according to their tear-film breakup pattern (i.e., Area, Spot, Line, and Random), and we then investigated the correlation between the QOL score and the total and each VAS score in all patients and by dry-eye groups. Results: A significant correlation was found between QOL score and the total and S, F, R, T VAS score (total; S, F, R, and T)(0.80; 0.72, 0.73, 0.38, and 0.32) (all: p<0.01). In the Area break group, a significant correlation was found between QOL score and the total and S, F, R, T VAS score (all: p<0.05). In the Spot break group, a significant correlation was found between QOL score and S, F VAS score (all: p<0.01). In the Line break group, a significant correlation was found between QOL score and the total and S, F, R VAS score Program Number: 4471 Poster Board Number: A0097 Evaluation of the SIRT2 Deficient Mice as Dry Eye Model Mice YASUHISA TANAKA, Takaaki Inaba, Kazuo Tsubota. Ophthalmology, Keio University, Tokyo, Japan. Purpose: Sirtuins (SIRTs) are nicotinamide adenine dinucleotide (NAD)-dependent protein deacetylases which play important roles in modulating the aging process, metabolism and longevity. SIRTs are important genes regulating the physiological function. Various diseases are caused by aging, SIRTs are an important regulatory factor, of protein modification. The change of various factors and the progression of dry eye syndrome are caused by aging, the involvement of SIRT is considered as one of the causes. Here, we focused on SIRT2 gene which is related to cellular senescense. We investigate the tear secretion and histopathological analysis and evaluate the possibility of whether SIRT2 deficient mice can be used as a dry eye model mice. Methods: SIRT2 deficient mice were used in all experiments. As comparison, wild-type and SIRT2 hetero deficient mice were used. The tear volume was measured by the phenol red thread into nasal side of the eyelid margin for 30 seconds once every two weeks. The length of the color change was then measured. The mice were sacrificed and the lacrimal glands were removed. Total protein was extracted from the lacrimal glands of mice and evaluated by western blotting. Histopathological analysis was performed to analyze tissue sections using an optical microscopy after hematoxylin and eosin (H/E) staining. Results: SIRT2 protein expression was shown in the lacrimal glands of wild type mice. Western blotting analysis confirmed a complete disruption of SIRT2 expression in the SIRT2 deficient mice. Tear secretion was measured by the phenol red thread test, results showed a tendency to decrease in SIRT2 deficient mice compared to those in control mice at 9-30 weeks old. Moreover, H/E staining of the lacrimal glands in SIRT2 deficient mice showed histological change with an accelerated aging phenotype. Conclusions: These results suggested that SIRT2 is important to the functional maintenance of tear secretion and the lacrimal glands. Further analysis of these mice will clarify the molecule of senescence and inflammatory markers on the lacrimal glands function, which in turn, should elucidate the mechanisms of age-related dry eye. Commercial Relationships: YASUHISA TANAKA, None; Takaaki Inaba, None; Kazuo Tsubota, None

19 Program Number: 4472 Poster Board Number: A0098 Spectral counting-based LC-MS/MS quantitation of tear film proteins in ocular surface disease Javier Soria Esponera 1, Arantxa Acera 1, Juan A. Duran 2, 3, Jesus Merayo 4, Nerea Gonzalez 1, Tatiana M. Suarez-Cortes 1. 1 Bioftalmik Applied Research, Derio, Spain; 2 Instituto Clínico Quirúrgico de Oftalmología (ICQO), Bilbao, Spain; 3 Department of Ophthalmology, School of Medicine, University of the Basque Country (UPV/EHU), Leioa, Spain; 4 Fernández Vega Ophthalmological Institute, Oviedo, Spain. Purpose: Dry eye (DE) and meibomian gland dysfunction (MGD) are the most common ocular surface diseases. Discrimination between these conditions is difficult because of the overlapping signs and symptoms and the lack of correlation between these symptoms and clinical parameters. We searched for the differences between tear proteomes in these two conditions. Methods: Tear samples were collected from 37 individuals: 7 with DE disease, 12 with MGD, and 18 control subjects. Diagnosis was based on clinical examination including the Schirmer test with anesthesia to measure only the basal secretion, slit-lamp examination of the lid margin and meibomian glands, fluorescein staining, and subjective symptoms. Each patient answered a modified National Eye Institute Visual Functioning Questionnaire 25 (VFQ-25), which included some statements about problems with their vision or wellbeing. The samples were analyzed using spectral counting-based LC-MS/ MS quantitation. Results: Comparative analysis of tear protein profiles revealed discriminating changes in the expression levels of 26 proteins, including protein S100A6, annexin A1, cystatin-s, thioredoxin, phospholipase A2, antileukoproteinase, and lactoperoxidase. Some of the proteins with altered expression have been reported and validated previously. Comparative studies conducted using other proteomics technologies have already discovered some tear biomarkers for DE and MGD. Conclusions: Our study confirmed S100A6, cystatin-s, annexin A1, and phospholipase A2 as valid tear biomarkers for these conditions. Subsequent functional network analysis revealed the main biological processes that should be examined to improve our understanding of ocular surface diseases and identify new candidate therapeutic targets. Study workflow Canonical Discriminant Analysis showing the separation between the samples using APEX expression data. Each of the points represents a sample from each group. Good separation between the groups is apparent. The MGD group was closer to the control group (CT) than the DE group. Key: squares, CT group; triangles, MGD group; circles, DE group. Commercial Relationships: Javier Soria Esponera, None; Arantxa Acera, None; Juan A. Duran, None; Jesus Merayo, None; Nerea Gonzalez, None; Tatiana M. Suarez-Cortes, None Support: This work has been partially supported by the Spanish Ministry of Science and Innovation through the INNPACTO subprogram, grant IPT , and the Centre for the Development of Industrial Technology (CDTI), NEOTEC Program, grant IDI The funding organizations had no role in the design or conduct of this research Program Number: 4473 Poster Board Number: A0099 Determinants of ocular symptoms in postmenopaual women with dry eye. Fiona Stapleton 1, Noor Badarudin 1, Jing Jing You 2, Ulrike Hampel 1, John Eden 3, 4, Leanne Raisin 1, Jennifer Williams 1, Cecilia Chao 1, Blanka Golebiowski 1. 1 School of Optometry and Vision Science, University of New South Wales, Kensington Sydney, NSW, Australia; 2 Save Sight Institute, University of Sydney, Sydney, NSW, Australia; 3 Sydney Menopause Centre, Royal Hospital for Women, Randwick, NSW, Australia; 4 Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia. Purpose: Dry eye in women is more prevalent postmenopause and alterations in sex hormone levels may be implicated. This study explored the relationship between serum concentration of sex hormones and dry eye symptoms and ocular surface signs. Methods: The study involved 46 postmenopausal women diagnosed with non-sjögrens dry eye and not taking hormone replacement therapy (mean age 64±5 years, 14±6 years since menopause). The following measurements were conducted at a single timepoint: Ocular symptoms (Ocular Surface Disease Index (OSDI) and Ocular Comfort Index (OCI)), tear function (non-invasive tear break-up time (NITBUT), tear osmolarity (TearLab), tear volume (Phenol Red Thread and Schirmer tests)), ocular surface staining and meibomian gland assessment using grading scales, ocular surface sensitivity (Cochet-Bonnet aesthesiometer) and venous blood collection. Serum concentrations of 17β-estradiol (E2), 3α-diol-G, DHEA-S and their ratios were determined using Enzyme-linked immunosorbent assay

20 (ELISA). Univariate associations were examined using Spearman s correlations and multiple linear regression analysis was subsequently used to examine predictors of dry eye symptoms. Results: Mean serum concentration of E2 was 10.8±19.7pg/ml, 2.10±2.77ng/ml of 3α-diol-G and 0.73±0.55μg/ml of DHEA-S. Mean symptoms scores were 27.0±18.1 (OSDI) and 40.3±8.4 (OCI). Only tear osmolarity and meibomian gland secretion quality were significant predictors in the OSDI model; this model explained 20% of the variance in the OSDI score (F(6, 39)=2.858, p=0.02, R 2 adj= 0.20). Eyelid vascularity and meibomian gland expressibility were significant predictors in the OCI dryness frequency model, explaining 29% of the variance in dryness frequency (F(6, 39)=4.015, p=0.003, R 2 adj=0.29). Although serum hormones were associated with symptoms scores on univariate correlations, E2, 3α-diol-G, DHEA-S or their ratios were not found to be significant predictors of ocular symptoms in the full multivariate model(p>0.05). Conclusions: Meibomian gland and lid variables are significant predictors of ocular symptoms in postmenopausal women with dry eye, but serum hormone levels were not shown to play a significant role in this study. These findings would suggest that meibomian gland disease underpins dry eye symptoms in this cohort and examination in a lager cohort is required may further elucidate the role of sex hormones in non-sjögrens dry eye in postmenopausal women. Commercial Relationships: Fiona Stapleton, None; Noor Badarudin, None; Jing Jing You, None; Ulrike Hampel, None; John Eden, None; Leanne Raisin, None; Jennifer Williams, None; Cecilia Chao, None; Blanka Golebiowski, None Support: UNSW Interfaculty Seed Funding Program Number: 4474 Poster Board Number: A0100 Fatty acid composition and lipid hydroperoxide in the meibum of patients with meibomian gland dysfunction Tomo Suzuki 1, 2, Satoshi Fujiwara 3, Megumi Maekawa 4, Midori Nagase 4, Yorihiro Yamamoto 4, Shigeru Kinoshita 1. 1 Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2 Ophthalmology, Kyoto City Hospital Organization, Kyoto, Japan; 3 Shimadzu Techno-Research, Inc., Kyoto, Japan; 4 School of Bioscience and Biotechnologyc, Tokyo University of Technology, Tokyo, Japan. Purpose: Most meibomian lipids (meibum) are formed via the esterification of fatty acids (FAs), and the ratio of unsaturated/ branched chain FAs in the lipids highly influences their melting temperature (Tm). We previously reported the composition of fatty acids in meibum of normal subjects; the composition being 40% saturated and 60% unsaturated fatty acids (ARVO 2013). However, the viscosity and Tm may change in meibum according to the severity of meibomian gland dysfunction (MGD). Thus, the purpose of this present study was to examine fatty acid composition and lipid hydroperoxide (HPO) in the meibum of MGD patients. Methods: This study involved 7 MGD patients (age range: years) and 10 normal control subjects (age range: years). Meibum was obtained from the eyes of each subject by Daviel cataract spoon after gently squeezing the eyelid margin by use of a Yoshitomi meibomian gland compressor (T.M.I. Co. Ltd., Saitama, Japan) under a surgical microscope. Meibum was stored in chloroform/methanol and analyzed using gas chromatography mass spectrometry for composition analysis. HPO was analyzed by fluorescence intensity after reaction with a triphenylphosphine derivative. Results: In the meibum of the MGD patients, straight-chain saturated fatty acid (SFA) significantly increased (MGD: 4.7%, NL: 2.8%) (p<0.05), and branched-chain SFA (MGD: 35.6%, NL: 38.0%) (p<0.05) and poly-unsaturated fatty acids (PUFAs) (MGD: 3.2%, NL: 4.0%)(p<0.05) significantly decreased compared to that of the normal control subjects. HPO was found in the meibum obtained from the MGD patients, but not in that obtained from the normal control subjects. The HPO/free cholesterol ration was high in hypo-secretory MGD (1610±520) compared to in hyper-secretory MGD (10±11.1) (p<0.05). Conclusions: FA composition in MGD patients showed a dramatic decrease of PUFAs and production of HPO. This may impact on the increase the viscosity of meibum resulting in tear film instability and the ocular surface damage. Commercial Relationships: Tomo Suzuki, None; Satoshi Fujiwara, None; Megumi Maekawa, None; Midori Nagase, None; Yorihiro Yamamoto, None; Shigeru Kinoshita, None Support: Japanese Ministry of Education, Culture, Sports, Science and Technology (No ) Program Number: 4475 Poster Board Number: A0101 Comparison of Different Tests for Evaluation of the Meibomian Glands J Peter Gierow, Nathalie Larsson, Johanna Boström. Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden. Purpose: The aim of this study was to compare a symptom questionnaire, Meibomian gland dysfunction according to the Efron grading scale, and non-contact meibography with each other. Methods: The study included 31 participants. The examination consisted of three different parts. Each patient was asked to complete the symptom questionnaire, the Texas Eye Research & Technology Center - Dry Eye Questionnaire (TERTC-DEQ). To be included in the study the participant needed a score between The second part was grading, using the Efron grading scale. Conjunctival redness, blepharitis and MGD was graded. Participants with blepharitis more than grade 2 were excluded from the study. The last part was noncontact meibography. Pictures were acquired of both the upper and the lower eyelids in both eyes. The pictures were then analyzed using the software Phoenix to calculate the area of Meibomian gland loss. Results: To analyze whether there was any significant correlation between symptoms and any of the other parameters, multiple regression analyses were performed. No significant correlation (p>0.05; r<0.6) was found. Multiple regression analyses were also performed to analyze the correlation between the stage of MGD according to Efron grading scale and the Meibomian gland loss obtained by non-contact meibography. The upper and the lower eyelids of both eyes were analyzed. A significant correlation (p<0.002) was found between the stage of MGD and the area of loss for the lower eyelid of the right eye. Between the other parameters no significant correlation was found. T-tests were performed between all the parameters for both the right and the left eye. The results showed no significant difference, meaning that the right eye can be assumed to be equal to the left eye. Conclusions: The study shows that there is no significant correlation between symptoms and MGD according to the Efron grading scale and non-contact meibography. The results show a significant correlation between the right eye s lower eyelid MGD score and area of Meibomian gland loss on the same eyelid. Commercial Relationships: J Peter Gierow, None; Nathalie Larsson, None; Johanna Boström, None Support: Supported by a Linnaeus University Faculty of Health & Life Sciences Research Grant (JPG)

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