Dry eye in Graves' ophthalmopathy: correlation with corneal hypoesthesia Pembimbing : dr.

Zaldi, SpM
Oleh : Agus Suwandi Gandra Annisa Syifanurhati Fiska Zulistiana

Cornea Transparent, avascular tissue (11-12 m horizontally, 10-11 mm vertically) Aspheric, corneal cap Major source of astigmatism in the optical system Sensory nerve extend from long ciliary nerves and form a subepithelial plexus Have five layers : Epithelium, Bowmans, Stroma, Descements membrane, Endothelium

Tear Film Tears provide a moist environment for epithelial cells, lubricating the ocular surface while they dilute and remove noxious stimuli Provides the cornea with essential nutrients and oxygen, and leukocytes gain access to the cornea through the tear film Have three layers Lipid layer, produced by meibomian glands Aqueous component, produced by lacrimal glands Mucins, produced by goblet cells

Dry eye syndrome The term represent a diverse gropu of conditions characterized by symptoms of ocular discomfort and associated with decreased tear production and/or abnormally rapid tear-film evaporation Damage to the ocular surface results from either decreased aqueous tears production (aqueous tear deficiency, ATD) or excessive tear evaporation (evaporation tear dysfunction, ETD).

Purpose:
To evaluate dry eye disease and corneal sensitivity in patients with early and active Graves ophthalmopathy (GO).

Methods:
A total of 52 eyes of 26 patients with early GO and 74 eyes of 37 age- and sex-matched controls were included in our study. Dry eye disease was assessed based on the criteria of the International Dry Eye Workshop. Diagnosis of early GO was based on the European Group on Graves Orbitopathy consensus statement. Clinical Activity Score (CAS) and Werner-NOSPECS Score were determined. Corneal sensitivity was assessed using a Cochet-Bonnet aesthesiometer.

Results:
A total of 67.8% of patients with early GO and 13.5% of healthy controls had ocular surface dryness (p<0.001). The mean Schirmer test score was significantly lower in patients with early GO (12.88 7.94 mm [right eyes] and 14.04 9.00 mm [left eyes]) than in controls (18.08 7.26 mm [right eyes] and 18.05 7.50 mm [left eyes] [p<0.05]). The tear film break-up time was lower in patients by 5.46 seconds and 5.74 seconds in right and left eyes (p<0.001). We also found a significant reduction in corneal sensitivity in patients with early GO (4.16 0.68 [right eyes] and 4.10 0.89 [left eyes]) than in controls (4.70 0.34 [right eyes] and 4.72 0.34 [left eyes] [p<0.05]). The CAS correlated significantly with the Schirmer test (r = 0.60, p = 0.003).

Conclusions:
Dry eye is common in early GO even in the absence of apparent exophthalmos and is associated with CAS and reduced corneal sensitivity. In conclusion, findings of the present study suggest that DED is very common (almost 68% prevalence) in patients with early GO in the absence of increased proptosis and exophthalmos. In addition, we found that patients with early and active GO have decreased corneal sensitivity, which was associated with a reduction in tear secretion and TBUT as well as with the CAS. Thus, active GO plays a significant role in the pathogenesis of DED, producing corneal hypoesthesia even in early stages of the disease. Therefore, Graves disease should be considered in the differential diagnosis for patients presenting with dry eyes and warrants further investigation, even in the absence of other clinical symptoms.

Referensi
Achtsidis et al.(2013). Dry eye in Graves ophthalmopathy: correlation with corneal hypoesthesia. European Journal of Ophthalmology. 23(4): 473-479. 2. The Eye M.D. Association. American Academy of Ophthalmology. External Disease and Cornea. Section 8. Basic and Clinical Science Course. 2008-2009. 1.