[OCT Article] Dry eye and irregular epithelial thickness map

However, the frequency of fluctuation and the recovery of good visual acuity after blinking or instillation of ocular surface wetting agents will help to identify the conditions responsible for the symptomatology.

Clinical case:

A 55-year-old male patient presents with complaints of blurred and fluctuating vision of months' duration, more accentuated in tasks such as reading, watching TV, driving, etc. He has recently upgraded to glasses and contact lenses for occasional sports use. His last medical examination was performed two months before our visit excluding diabetes or other systemic conditions. He does not take any medication.

Visual examination:

Pupils equal and normoreactive.
Normal ocular motility.
Good binocular status.
Refractive error:

•  OD: +4.25-0.75X80º AV: 10/10 -2.
•  OI: +4.75 Sf. AV: 10/10

Addition: +2.00 Sf. 0.8 M at 35 cm. (coincident with your spectacles)
IOP: OD: 12 mm Hg/OI: 13 mm Hg (11:00 a.m.)

Biomicroscopy:

+ Conjunctival staining grade I-II, in areas exposed to evaporation (image 3).
Corneas transparent.
BUT 3-4" OD/OI (image 2).
Lacrimal meniscus ¼ mm.
DGM Non telangiectatic. 
Clear crystalline lens.

OCT anterior segment: irregular epithelial thickness map with superior thinning in both eyes (image 1).
Posterior pole: retina and optic nerves without relevant findings.

Impressions:

This is a case with dry eye, whose main complaint is visual. Examination of the anterior segment shows signs of dry eye such as early tear film breakage, conjunctival staining and altered function of the meibomian glands. An anterior segment computed tomography (OCT) scan, shows an irregular epithelial thickness map characteristic of the dry eye condition.

Discussion:

The dry eye condition as well as having a multifactorial aetiology presents with diverse symptomatology. Complaints of blurred and fluctuating vision were the chief complaint of the case presented. Clinical signs of reduced BUT, conjunctival epithelial staining and meibomian gland dysfunction confirm the diagnosis of dry eye condition. Corneal topographical analysis with optical coherence tomography provides objective and complementary data to the other clinical analyses of dry eye.

Corneal Epithelial Thinning (CET) is more accentuated in the upper areas as has been described by Mohamed Abou Shousha et al (1).

Loreta B. Szczotza-Flynn, OD, PhD et al, (2) published the impact of dry eye condition on visual acuity as well as contrast sensitivity. Central corneal irregularity affects visual acuity by increasing higher order aberrations and light scattering.

Xinhan Cui et al, (3) evaluated epithelial thickness in dry eyes and concluded that the higher CEA is significant in dry eyes and more accentuated in higher dry eye grades. They also report a lack of concordance of corneal epithelial changes with other values such as reduced BUT or degree of DGM.

Fluctuations in vision are a complaint that, although common, is often undiagnosed or its aetiology confused.It is interesting to note that dry eye disease is not only very prevalent but also impairs quality of life and its clinical presentation presents the eye care professional (optometrist or ophthalmologist) with a major challenge.
The contribution of new technologies such as OCT helps to establish the most suitable treatments more precisely and to improve the clinical follow-up of the case.

Figure 1. Corneal pachymetric map obtained with OCT.

Figure 2. Reduced invasive BUT 3-4".

Figure 3. Alteration of the conjunctival epithelium with + staining.

References

Abou Shousha M, Wang J, Kontadakis G, et al. Corneal epithelial thickness profile in dry-eye disease. Eye (Lond). 2020;34(5):915-922. doi:10.1038/s41433-019-0592-y

Szczotka-Flynn LB, Maguire MG, Ying GS, et al. Impact of Dry Eye on Visual Acuity and Contrast Sensitivity: Dry Eye Assessment and Management Study. Optom Vis Sci. 2019;96(6):387-396. doi:10.1097/OPX.0000000000001387

Cui X, Hong J, Wang F, et al. Assessment of corneal epithelial thickness in dry eye patients. Optom Vis Sci. 2014;91(12):1446-1454. doi:10.1097/OPX.0000000000000417

Dr. Fernando Hidalgo Santa Cruz, OD, PhD, FAAO

He received his PhD from The New England College of Optometry, Boston, in 1987.
He obtained the qualification of outstanding Magna Cum Laude for his doctoral thesis defended at the Camilo José Cela University in Madrid. 2014. Accredited with professional licensure in Massachusetts, USA. Fellow of the American Academy of Optometry since 1990.

He has been adjunct clinical professor at:

• The New England College of Optometry.
• University of Houston College of Optometry.
• Western University of Health Sciences. Pomona, California.
• University of the Incarnate Word, Rosenberg School of Optometry. San Antonio, Texas.

Founder and director of Centro Boston de Optometría, Madrid.

He has directed the Master's programmes in Optometry since its creation in 1990. Author of numerous scientific publications and international lecturer.

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