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Dry-eye Syndrom in Patients with Thyroid Associated Ophthalmopathy (TAO) possible Association to TSH-Receptor-expression in Lacrimal Gland
1Eckstein A., 1Finkenrath A., 2Esser J., 3Krüger C., 3Mohr C., 4Steuhl K. P.,
1Universität-Gesamthochschule Essen, Zentrum für Augenheilkunde (Essen)
2Universität-Gesamthochschule Essen, Zentrum für Augenheilkunde, Abt. Orthooptik/Sehschule (Essen)
3Universität-Gesamthochschule Essen, Klinik für Kiefer- und Gesichtschirurgie (Essen)
4Universität-Gesamthochschule Essen, Zentrum für Augenheilkunde, Abt. für Erkrankungen des vorderen Augenabschnitts (Essen)
Purpose: To evaluate in TAO patients both the relation between ocular surface damage and elevated lid aperture/impaired Bell´s phenomenon as well as the reduced amount of tear production. To determine TSH- receptor-expression in lacrimal gland (LG).
Method: Fourty-nine patients with active TAO and 28 healthy age- and sex-matched persons were examined for dry-eye symptoms. i.e. basal tear secretion (Schirmer I test), rose-bengal and fluorescein staining, impression cytology (IPC), break up time (BUT), and lid aperture and closure as well as Bell´s phenomenon. LG slides of two normal controls were immunohistochemically stained with the monoclonal anti-TSH receptor antibody BA8.
Results: TAO patients showed a significant ocular surface damage in comparison to healthy controls. Rose-bengal staining score: TAO: 2.2 ± 1.9; controls: 0 ± 0.2. Fluorescein staining score: TAO: 2.2 ± 2.1; controls 0 ± 0. IPC score: TAO 3.7 ± 2.3; controls 0.4 ± 0.5. BUT: TAO 4.0 ± 4.0 s vs. 20.0 ± 7.0 s in controls. Tear secretion was significantly reduced in TAO patients (12.0 ± 9.0 mm) as opposed to the controls (17.0 ± 6.0 mm). The ocular surface damage, as judged by a score including BUT, IPC, rose-bengal, and fluorescein staining, correlated significantly with the reduced amount of tear secretion, but to a lesser non-significant degree with lid/eye motility changes. TSH receptor was expressed inhomogenously in LG epithelial cells of healthy controls.
Conclusions: At present, ocular surface damage in TAO patients is considered to be related to the increased aperture of the lid due to lidretraction and proptosis, which results in increased tear-fluid evaporation. According to our data, the strongest correlation of ocular surface damage in TAO patients with their reduced tear production implies that functional impairment of the lacrimal gland is the main cause of ocular-surface drying. One of the reasons underlying this correlation may be the lacrimal epithelial expression of TSH receptor. Another main cause for ocular surface damage is an decreased upward gaze. For that reason recession of inferior rectus muscle should be evaluated in severe ocular surface damage.