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Patients with Dry Eye Disease and Low Subbasal Nerve Density Are at High Risk for Accelerated Corneal Endothelial Cell Loss

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Patients with Dry Eye Disease and Low Subbasal Nerve Density Are at High Risk for Accelerated Corneal Endothelial Cell Loss CLINICAL SCIENCE Patients With Dry Eye Disease and Low Subbasal Nerve Density Are at High Risk for Accelerated Corneal Endothelial Cell Loss Ahmad Kheirkhah, MD,* Vannarut Satitpitakul, MD,*† Pedram Hamrah, MD,*‡ and Reza Dana, MD, MPH, MSc* Key Words: corneal endothelium, corneal subbasal nerves, dry eye Purpose: To evaluate changes in corneal endothelial cell density disease over time in patients with dry eye disease (DED) and to correlate endothelial cell loss with corneal subbasal nerve density. (Cornea 2017;36:196–201) Methods: This retrospective study included 40 eyes of 20 patients with DED. Laser in vivo confocal microscopy had been ry eye disease (DED) is the most common reason for performed in the central cornea of both eyes at an initial visit and Dpatients to see an ophthalmic care provider and affects repeated after a mean follow-up of 33.2 6 10.2 months. The 5% to 35% of the population.1–3 Although DED is tradition- densities of corneal endothelial cells and subbasal nerves were ally considered as a disease of the tear film and ocular surface, measured in both visits and compared with 13 eyes of 13 normal recent studies have demonstrated more extensive involvement age-matched controls. of the conjunctiva and cornea in these patients. Using in vivo Results: At the initial visit, the DED group had lower densities of confocal microscopy (IVCM), various conjunctival and 6 2 corneal changes have previously been reported, such as corneal endothelial cells (2620 386 cells/mm ) and subbasal fl 6 2 increased density of conjunctival in ammatory cells, reduced nerves (17.8 7.5 mm/mm ) compared with the control group fi (2861 6 292 cells/mm2 and 22.8 6 3.0 mm/mm2,withP =0.08 density of corneal super cial epithelium, increased density of and P = 0.01, respectively). At the end of follow-up, although there corneal basal epithelium, increased number of subbasal was no significant change in subbasal nerve density (16.7 6 7.2 immune dendritic cells, decreased density of subbasal nerves, 2 and increased number of hyperreflective activated stromal mm/mm , P = 0.43), the mean corneal endothelial cell density 4–6 significantly decreased to 2465 6 391 cells/mm2 (P =0.01),with keratocytes. 6 Furthermore, we have recently observed that patients a mean corneal endothelial cell loss of 2.1 3.6% per year. The fi endothelial cell loss showed a statistically significant negative with moderate to severe DED have a signi cant reduction in correlation with the initial subbasal nerve density (Rs = 20.55, central corneal endothelial cell density (CECD), which is P = 0.02). accompanied with a decreased density of corneal subbasal nerves.7 The cornea has the highest nerve density in the Conclusions: Patients with DED have an accelerated corneal body,8,9 and these nerves are known to provide trophic support endothelial cell loss compared with that reported in the literature for the corneal epithelium.9,10 As a simultaneous reduction of for normal aging. Those with lower subbasal nerve density, in corneal nerves and endothelial cells has been observed in many particular, are at a higher risk for endothelial cell loss over time. local and systemic conditions,11–15 we previously suggested that these nerves may play a role in the maintenance of corneal endothelial cell function and survival.7,16 In this study, we have hypothesized that because of the Received for publication July 25, 2016; revision received August 23, 2016. potential supportive role of nerve-derived molecules for Published online ahead of print November 2, 2016. From the *Cornea and Refractive Surgery Service, Massachusetts Eye and Ear corneal endothelial cells, DED patients with a reduced corneal Infirmary, Department of Ophthalmology, Harvard Medical School, nerve density have an accelerated corneal endothelial loss, Boston, MA; †Department of Ophthalmology, Faculty of Medicine, which is more than that found with normal aging. Therefore, Chulalongkorn University and King Chulalongkorn Memorial Hospital, this study was designed to evaluate corneal endothelial cell ‡ Bangkok, Thailand; and Department of Ophthalmology, Cornea Service changes over time in patients with DED and to correlate these and Boston Image Reading Center, Tufts Medical Center, Tufts University School of Medicine, Boston, MA. changes with corneal subbasal nerve density. P. Hamrah has an impending patent on methods of reducing corneal endothelial cell loss. The remaining authors have no funding or conflicts of interest to disclose. Presented in part at the Annual Meeting of the Association for Research in METHODS Vision and Ophthalmology, May 1–5, 2016, Seattle, WA. Reprints: Reza Dana, MD, MPH, MSc, Massachusetts Eye and Ear Infirmary, This retrospective observational study included 40 eyes 243 Charles St, Boston, MA 02114 (e-mail: [email protected]). of 20 patients with DED (the DED group) and 13 eyes of 13 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. normal age-matched controls (the control group). To evaluate 196 | www.corneajrnl.com Cornea Volume 36, Number 2, February 2017 Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 2, February 2017 Accelerated Corneal Endothelial Cell Loss in DED changes in densities of corneal endothelial cells and subbasal Image Analysis nerves over time, patients included in the DED group were To measure the density of subbasal nerves, 3 representa- those who had 2 full-thickness IVCM scans of the central tive images from various locations of the layer immediately cornea at least 18 months apart as their routine evaluation for posterior to the basal epithelial layer were selected. All visible DED. In all these individuals, images obtained by IVCM nerve fibers in each frame were traced, and their density was were used to measure CECD and subbasal nerves, as detailed calculated using NeuronJ software (http://www.imagescience. below. The patients had been seen at the Cornea and org/meijering/software/neuronj/), which is a semiautomated plug- Refractive Surgery Service, Massachusetts Eye and Ear in program of ImageJ (National Institutes of Health, Bethesda, Infirmary, Boston, MA. The protocol of the study was MD, http://imagej.nih.gov/ij/).17 The nerve density of the 3 approved by the Institutional Review Board of Massachusetts IVCM images was averaged and expressed as mm/mm2. Eye and Ear Infirmary, and the study was in compliance with To measure CECD, 3 representative images of the the Health Insurance Portability and Accountability Act and corneal endothelial layer were chosen for analysis. The in adherence to the tenets of the Declaration of Helsinki. CECD measurement was performed using the variable- The DED group included patients who had typical frame method.7,18 To do this, IVCM images were exported symptoms of DED with a Schirmer test score with anesthesia and then analyzed using ImageJ. First, the boundary of the ,10 mm and/or tear breakup time (TBUT) ,10 seconds. largest possible area in which all cell borders were clearly Exclusion criteria consisted of any of the following before the distinct was traced using the Polygon Selection tool of initial visit or during the follow-up: history of increased ImageJ. Second, the area of the selected part was measured intraocular pressure, history of any ocular surgery, contact in mm2. Third, the number of the cells in the selected area was lens wear, history of use of any medications known to have counted using the Cell Counter plug-in of ImageJ. These were corneal toxicity, any corneal disease including herpetic used to calculate CECD as cells/mm2. The mean CECD of 3 keratitis, or presence of guttae on clinical examination or IVCM images was then calculated. All measurements in this IVCM scans. Patients with diabetes mellitus were excluded study were performed by 2 independent, masked observers, from this study as well. and the average values were used for the analysis. The control group consisted of healthy individuals with normal ocular examination without any previous ocular disease or surgery. Those with endothelial guttae in IVCM, Statistical Analysis a history of contact lens wear, or those with diabetes mellitus SPSS for Windows version 21 (SPSS Inc, Chicago, IL) were excluded from the control group. was used for statistical analysis. The lack of a normal All individuals had a complete ophthalmic evaluation distribution of the data was first confirmed using the including a detailed slit-lamp biomicroscopy with measure- Shapiro–Wilk test. To compare the age and sex between ment of corneal fluorescein staining (Oxford scale, grades DED and control groups, the Mann–Whitney U test and 0–5) and TBUT as well as the Schirmer test with anesthesia. x2 test were used, respectively. To compare CECD and Furthermore, all these individuals had full-thickness IVCM subbasal nerve density between DED and control groups as imaging of the central cornea as described below. well as between initial and follow-up visits in the DED group, mixed model analysis was used to compensate for including both eyes of patients in the DED group. In this model, the In Vivo Confocal Microscopy potential confounding effect of age was also accounted for. All participants had undergone laser-scanning IVCM of To compare CECD and subbasal nerve density between both the central cornea using the Heidelberg Retina Tomograph 3 eyes at the initial and follow-up visits, as well as to compare with the Rostock Cornea Module (Heidelberg Engineering, the changes in CECD and subbasal nerve density over Heidelberg, Germany). The microscope uses a 670-nm diode follow-up in right and left eyes separately, the Wilcoxon laser source and provides images from full thickness of the signed-rank test was used. Moreover, to correlate the changes cornea. These images represent a coronal section of 400 · of CECD over time with age and subbasal nerve density, the 400 mm of the cornea.
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