1. Epitheliopathy in the Region of the Eyelid Associated with the Caruncle in Normal Subjects and Dry-Eye Patients Epitheliopathy in the Region of the Eyelid Associated with the Caruncle in Normal Subjects and Dry-Eye Patients Jack V. Greiner, M.S., D.O., Ph.D. Paula J. Oliver, A.S., Rina Wu, Mikhail Salganik, Ph.D. The Schepens Eye Research Institute Massachusetts Eye and Ear Infirmary Harvard Medical School The Boston Ocular Surface Center None of the authors have any financial interest to disclose

2. Purpose To employ vital staining to describe the presence of lid margin epitheliopathy (LME) in the region of the upper and lower eyelids associated with the caruncle and plica semilunaris in normal subjects and dry eye patients.

3. Methods In this prospective study, 100 patients (200 eyes) with evaporative dry eye disease (meibomian gland dysfunction) and 100 normal subjects (200 eyes) were examined. Patients with dry eye disease were defined with a validated Standard Patient Evaluation for Eye Dryness (SPEED) questionnaire score of ≥6 and meibomian gland secretion (MGS) score of ≤20.

4. Methods For the purposes of this study, the region of the eyelid margin associated with the caruncle was defined as that area of the upper and lower eyelid margin medial to the puncta and extending to the medial canthus.

5. Biomicroscopy Biomicroscopy of upper and lower eyelid margins from the puncta to the medial canthus was performed at 25x and 40x magnification 90 sec after instillation of Lissamine green vital stain into the conjunctival sac.

6. Lissamine Green Staining The degree of Lissamine green staining of the lower lid margin between the punctum and the medial canthus (arrows) was determined using the following scale: 1( mild) [left figure], 2 (moderate) [center figure], and 3 (severe) [right figure].

7. Lissamine Green Staining The degree of Lissamine green staining of the upper eyelid margin between the punctum and the medial canthus (arrows) was determined using the following scale: 1( mild) [left figure], 2 (moderate) [center figure], and 3 (severe) [right figure].

8. Results Essentially all normal subjects and dry eye patients exhibited staining in this caruncular zone between the puncta and the medial canthus, although the degree of staining in the area of the lower lid margin was significantly greater in patients with dry eye disease (p<0.05).

9. Results Interestingly there was a significant difference between right and left eyes (p<0.5) in both normal subjects and dry eye patients with the left eye exhibiting a greater degree of staining than the right eye. The most significant difference between dry eye patients and controls is that the degree of staining in the lower eyelid margin associated with the caruncular zone is more intense in dry eye patients than controls (p<0.05).

10. Conclusions In contrast to prior results documenting a lack of correlation between vital staining in temporal regions and dry eye symptoms, 1 symptomatic dry eye patients have more eyelid margin staining in the caruncular region than normal subjects. Vital staining of this clinically-overlooked region of the eyelid margin (although anatomically comprising >10% of the eyelid margin) may have potential benefits as a marker and an additional diagnostic tool that may be particularly informative in those patients with a questionable presentation of dry eye. 1 Greiner JV: Association of epitheliopathy of upper and lower eyelid marginal conjunctiva with meibomian gland dysfunction and symptoms of dry-eye disease. ASCRS, April 27, 2014.

11. Epitheliopathy in the Region of the Eyelid Associated with the Caruncle in Normal Subjects and Dry-Eye Patients Epitheliopathy in the Region of the Eyelid Associated with the Caruncle in Normal Subjects and Dry-Eye Patients Jack V. Greiner, M.S., D.O., Ph.D. Paula J. Oliver, A.S., Rina Wu Mikhail Salganik, Ph.D. The Schepens Eye Research Institute Massachusetts Eye and Ear Infirmary Harvard Medical School The Boston Ocular Surface Center