Lid-wiper epitheliopathy is defined as disruption of the epithelium of which structure?

The lid-wiper region of the marginal conjunctiva The lid wiper is the portion of marginal conjunctiva on the upper and lower lid that spreads the tear film across the ocular surface; epitheliopathy is disruption of its surface epithelium.

The palpebral conjunctiva over the tarsal plate

The corneal epithelium at the limbus

The meibomian gland ductal lining

Which is the leading proposed mechanism for lid-wiper epitheliopathy?

Increased friction between lid wiper and ocular surface Friction between the lid wiper and the ocular or anterior contact lens surface is thought to cause physical trauma and mechanical abrasion of lid-wiper epithelial cells.

Autoimmune destruction of conjunctival goblet cells

Bacterial colonisation of the lid margin

Ischaemia of the marginal palpebral vessels

Why is hyperosmotic insult thought to matter more for lower lid-wiper epitheliopathy?

The lower lid wiper has a shorter blink excursion Because the lower lid wiper travels a shorter distance during blinks, it sustains less friction-related damage, so changes in tear osmolarity are proposed to play a larger role there.

The lower lid carries a thicker lipid layer

The lower lid has no contact with the tear film

The lower lid wiper lacks surface epithelium

What is the defining diagnostic feature of lid-wiper epitheliopathy?

Staining of the lid-wiper area with vital dyes Diagnosis rests primarily on observing lid-wiper staining with vital dyes, supported by a detailed history of dry eye symptoms and contact lens discomfort.

Reduced corneal sensation on aesthesiometry

Meibomian gland dropout on meibography

Conjunctival papillae on lid eversion

Which environmental exposure is listed as a risk factor for lid-wiper epitheliopathy?

Low humidity with increased airflow Risk factors overlap with those of dry eye and include low humidity and increased airflow environments, alongside contact lens wear, older age and Asian race.

High altitude with reduced oxygen tension

Prolonged exposure to ultraviolet light

Chronic exposure to high ambient humidity

Which behaviour pattern is implicated in provoking lid-wiper epitheliopathy?

Prolonged reading or computer use with incomplete blinking Activities that provoke front surface drying and incomplete or infrequent blinking, such as prolonged reading and computer work, are implicated in lid-wiper epitheliopathy.

Frequent forceful eyelid squeezing

Sleeping with the eyelids partly open

Which slit lamp finding was present in this case of lid-wiper epitheliopathy?

Redness and increased vascularity of the lid-wiper region The anterior segment was otherwise unremarkable with clear corneas; the abnormality was redness and increased vascularity in the lid-wiper region of both upper eyelids.

Diffuse punctate keratopathy across both corneas

Follicles in the inferior fornix of both eyes

Anterior chamber cells with keratic precipitates

Which tear film abnormality supported the diagnosis in this case of lid-wiper epitheliopathy?

Decreased tear breakup time A decreased tear breakup time indicated poor tear film stability, and Schirmer testing with fluorescein staining supported the diagnosis of lid-wiper epitheliopathy.

Elevated tear lysozyme concentration

Raised tear film lipid layer thickness

Which topical agents have shown preliminary efficacy in lid-wiper epitheliopathy?

Corticosteroids, oil-in-water lubricants and rebamipide Preliminary studies support topical corticosteroids, oil-in-water emulsion lubricant drops, basic fibroblast growth factors and topical rebamipide, though efficacy still needs validation.

Topical ganciclovir and oral valaciclovir

Topical atropine and oral pilocarpine

Antihistamine drops and oral antibiotics

Which intervention relieved lid-wiper epitheliopathy in aqueous tear deficient dry eye?

Therapeutic bandage contact lenses

Intense pulsed light to the lid margin

Lid-wiper epitheliopathy: What You Need to Know

CASE REPORT

A 45-year-old female presented with persistent eye discomfort, foreign body sensation, burning, itching, occasional blurry vision, and worsening symptoms during reading or computer use. Previous use of over-the-counter lubricating eye drops provided no relief.

Clinical examination showed normal visual acuity, unremarkable anterior segment, but redness and increased vascularity in the lid wiper region of both upper eyelids. Clear corneas ruled out corneal involvement, while decreased tear breakup time indicated poor tear film stability.

Diagnostic tests, including Schirmer’s test and fluorescein staining, supported the diagnosis of Lid-wiper epitheliopathy.

Lid-wiper epitheliopathy DISEASE entity

Lid-wiper epitheliopathy is defined as a disruption to the surface epithelium of the lid-wiper, a portion of the marginal conjunctiva of the upper and lower lid that acts as a wiping surface to spread the tear film over the ocular surface. It is often observed as staining of the lid wiper area by vital dyes.

The etiology of Lid-wiper epitheliopathy is likely multifactorial, with different causes proposed for those associated with contact lens wear and those associated with dry eye symptoms without contact lens wear.

One of the leading hypotheses is increased friction between the lid wiper and the ocular or anterior contact lens surface, leading to physical trauma and mechanical abrasion of the epithelial cells of the lid wiper. Hyperosmotic insult from changes in tear osmolarity may play an important role in lower LWE as the lower lid wiper is less subject to friction-related damage due to a shorter excursion distance during blinks.

There may also be an inflammatory component as upregulation of inflammatory cells has been observed. Due to the association between Lid-wiper epitheliopathy and dry eye symptoms, many risk factors of LWE overlap with those of dry eye, including but not limited to:

Contact lens wear (both soft and rigid), especially in those with symptoms of dry eye.
Presence of dry eye symptoms in non-contact lens wearers
Older age
Asian race
Low humidity and increased airflow environments

Activities that provoke front surface drying and/or incomplete/infrequent blinking, such as prolonged reading and/or computer use.

Test your knowledge 10 questions from this article

Lid-wiper epitheliopathy Diagnosis

Lid-wiper epitheliopathy is primarily diagnosed by observation of lid-wiper staining by vital dyes, the defining feature of the condition. Because of its common association with dry eye symptoms and/or contact lens wear, a detailed history of dry eye-related symptoms and contact lens-associated discomfort should be collected to differentiate and/or rule out other similar conditions when establishing the diagnosis.

MANAGEMENT of Lid-wiper epitheliopathy

Current therapies for Lid-wiper epitheliopathy have been studied either by directly assessing their benefits on LWE or using LWE as a surrogate marker in the course of alleviating dry eye or contact lens discomfort.

Medical therapy

Several options have demonstrated efficacy in treating Lid-wiper epitheliopathy and its associated signs and symptoms in preliminary studies, including topical corticosteroids, oil-in-water emulsion lubricant eye drops, basic fibroblast growth factors, and topical rebamipide.

Insertion of punctal plugs alleviated signs and symptoms of aqueous tear deficient dry eye, including Lid-wiper epitheliopathy. Other treatments that have been proposed include strategies to improve blinking behavior, which may be beneficial in LWE associated with incomplete blinking behaviors, as well as improving contact lens wear comfort. Topical vitamin A ointment may be helpful.

The efficacy of these strategies remains to be validated further.

REFERENCES

Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye symptoms in contact lens wearers. Eye & Contact Lens. 2002;28(4):211–16.
Efron N, Brennan NA, Morgan PB, Wilson T. Lid wiper epitheliopathy. Progress in Retinal and Eye Research. 2016;53:140-174. doi: 10.1016/j.preteyeres.2016.04.004.
Korb DR, Herman JP, Greiner JV, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye and Contact Lens. 2005;31(1):2-8. Accessed Nov 28, 2020. doi: 10.1097/01.ICL.0000140910.03095.FA.
McMonnies CW. An examination of the relationship between ocular surface tear osmolarity compartments and epitheliopathy. Ocular Surface. 2015;13(2):110-117. Accessed Nov 28, 2020. doi: 10.1016/j.jtos.2014.07.002.
Golebiowski B, Chim K, So J, Jalbert I. Lid margins: Sensitivity, staining, meibomian gland dysfunction, and symptoms. Optometry and Vision Science. 2012;89(10):1443–1449. doi: 10.1097/OPX.0b013e3182693cef.
Morgan P, Petropoulos I, Read M, Malik R, Maldonado-Codina C. Confocal microscopy of the lid margin area of contact lens wearers. Contact Lens and Anterior Eye. 2013;36:e43.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

Lid-wiper epitheliopathy is defined as disruption of the epithelium of which structure?
The lid wiper is the portion of marginal conjunctiva on the upper and lower lid that spreads the tear film across the ocular surface; epitheliopathy is disruption of its surface epithelium.
Which is the leading proposed mechanism for lid-wiper epitheliopathy?
Friction between the lid wiper and the ocular or anterior contact lens surface is thought to cause physical trauma and mechanical abrasion of lid-wiper epithelial cells.
Why is hyperosmotic insult thought to matter more for lower lid-wiper epitheliopathy?
Because the lower lid wiper travels a shorter distance during blinks, it sustains less friction-related damage, so changes in tear osmolarity are proposed to play a larger role there.
What is the defining diagnostic feature of lid-wiper epitheliopathy?
Diagnosis rests primarily on observing lid-wiper staining with vital dyes, supported by a detailed history of dry eye symptoms and contact lens discomfort.
Which environmental exposure is listed as a risk factor for lid-wiper epitheliopathy?
Risk factors overlap with those of dry eye and include low humidity and increased airflow environments, alongside contact lens wear, older age and Asian race.
Which behaviour pattern is implicated in provoking lid-wiper epitheliopathy?
Activities that provoke front surface drying and incomplete or infrequent blinking, such as prolonged reading and computer work, are implicated in lid-wiper epitheliopathy.
Which slit lamp finding was present in this case of lid-wiper epitheliopathy?
The anterior segment was otherwise unremarkable with clear corneas; the abnormality was redness and increased vascularity in the lid-wiper region of both upper eyelids.
Which tear film abnormality supported the diagnosis in this case of lid-wiper epitheliopathy?
A decreased tear breakup time indicated poor tear film stability, and Schirmer testing with fluorescein staining supported the diagnosis of lid-wiper epitheliopathy.
Which topical agents have shown preliminary efficacy in lid-wiper epitheliopathy?
Preliminary studies support topical corticosteroids, oil-in-water emulsion lubricant drops, basic fibroblast growth factors and topical rebamipide, though efficacy still needs validation.
Which intervention relieved lid-wiper epitheliopathy in aqueous tear deficient dry eye?
Punctal plugs alleviated the signs and symptoms of aqueous tear deficient dry eye, including lid-wiper epitheliopathy; improving blinking behaviour has also been proposed.