Rose M. Sullivan

Androgen Deficiency, Meibomian Gland Dysfunction, and Evaporative Dry Eye

Abstract: Objective. We have recently discovered that women with primary and secondary Sjögrens syndrome are androgen‐deficient. We hypothesize that this hormone insufficiency contributes to the meibomian gland dysfunction, tear film instability, and evaporative dry eye that are characteristic of this autoimmune disorder. If our hypothesis is correct, we predict: (1) that androgens regulate meibomian gland function, control the quality and/or quantity of lipids produced by this tissue, and promote the formation of the tear films lipid layer; and (2) that androgen deficiency, due to an attenuation in androgen synthesis (e.g., during Sjögrens syndrome, menopause, aging, complete androgen‐insensitivity syndrome [CAIS] and anti‐androgen use), will lead to meibomian gland dysfunction and evaporative dry eye. The following studies were designed to test these predictions. Methods. Experimental procedures included clinical studies, animal models, and histological, biochemical, molecular biological, and biomedical engineering techniques. Results. Our results demonstrate that: (1) androgens regulate the meibomian gland. This tissue contains androgen receptor mRNA, androgen receptor protein within acinar epithelial cell nuclei, and Types 1 and 2 5α‐reductase mRNAs. Moreover, androgens appear to modulate lipid production and gene expression in mouse and/or rabbit meibomian glands; and (2) androgen deficiency may lead to meibomian gland dysfunction, altered lipid profiles in meibomian gland secretions, tear film instability, and evaporative dry eye. Thus, we have found that anti‐androgen therapy in men is associated with meibomian gland disease, a decreased tear film breakup time, and functional dry eye. Furthermore, we have discovered that androgen receptor dysfunction in women with CAIS is associated with meibomian gland changes and a significant increase in the signs and symptoms of dry eye. Of interest, we have also found that androgen deficiency is associated with significant and striking alterations in the neutral and polar lipid patterns of human meibomian gland secretions. Conclusions. Our findings show that the meibomian gland is an androgen target organ and that androgen deficiency may promote meibomian gland dysfunction and evaporative dry eye. Overall, these results support our hypothesis that androgen deficiency may be an important etiologic factor in the pathogenesis of evaporative dry eye in women with Sjögrens syndrome.

Lacrimal Gland, Tear Film, and Dry Eye Syndromes 2

European Vision and Eye Research Meeting (October, 2001, Alicante, Spain). 84. Krenzer KL, Dana MR, Ullman MD, Cermak JM, Tolls BD, Evans JE, Sullivan DA. Effect of androgen deficiency on the human meibomian gland and ocular surface. J Clin Endocr Metab. 2000; 85:4874-4882. 85. Sullivan BD, Evans JE, Krenzer KL, Dana MR, SulIivan DA. Impact of anti-androgen treatment on the fatty acid profile of neutral lipids in human meibomian gland secretions. J Clin Endocr Metab. 2000; 85:4866-4873. 86. Sullivan BD, Evans JE, Dana MR, SulIivan DA. Impact of androgen deficiency on the lipid profiles in human meibomian gland secretions. Adv Exp Med Bio!. 2001; in press. 87. Cermak JM, Krenzer KL, Dana MR, Sullivan DA. Do individuals with complete androgen insensitivity display the signs and symptoms of dry eye? Invest Ophthalmol Vis Sci. 1999; 40:S2836. 88. SulIivan BD, Evans JE, Krenzer KL, Dana MR, Sullivan DA. Complete androgen insensitivity syndrome: intluence on the polar and neutral lipid profiles of human meibomian gland secretions. Manuscript submitted, 2001. 89. Sullivan BD, Evans JE, Krenzer KL, Dana MR, SulIivan DA. Effect of aging on lipid patterns in human meibomian gland secretions. Manuscript submitted, 2001. 90. Zeligs MA, Gordon K. Dehydroepiandrosterone therapy for the treatment of dry eye disorders. Int Patent Application WO 94/04155, March, 1994. 91. Radn6t VM, Nemeth B. Wirkung der Testosteronpräparate auf die Tränendrüse. Ophthalmologica 1955; 129:376-380. 92. Radn6t M, Nemeth B. Testosteronkeszftmenyek hatisa a könnymirigyre. Orvosi Hetilap 1954; 95:580-581. 93. Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone replacement therapy and the prevalence of dry eye syndrome. Submitted, 200 1. 94. Schafer G, Krause W. The effect of estradiol on the sebaceous gland of the hamster ear and its antagonism by tamoxifen. Arch Dermatol Res. 1985; 277:230-234. Sex Steroids, the Meibomian Gland and Evaporative Dry Eye 95. Sweeney TM, Szarnicki RJ, Strauss JS, Pochi PE. The effect of estrogen and androgen on the sebaceous gland turnover time. J Invest Dermatol. 1969; 53:8-10. 399 96. Strauss JS, Kligman AM, Pochi PE. The effect of androgens and estrogens on human sebaceous glands. J luvest Dermatol. 1962; 39:139-155. 97. Sansone-Bazzano G, Reisner RM, Bazzano G. A possible mechanism of action of estrogen at the cellular level in a model sebaceous gland. J luvest Dermatol. 1972; 59:299-304. 98. Saihan EM, Burton JL. Sebaceous gland suppression in female acne patients by combined glucocortieoid-oestrogen therapy. Br J Dermatol. 1980; 103:139-142. 99. Poehi PE, Strauss JS. Sebaeeous gland inhibition from eombined glueocortieoid-estrogen treatment. Areh Dermatol. 1976; 112:1108-1109. 100. Smith E, Szego CM. Direct photomicroseopic evidenee for rapid nuclear penetration of lysosomal produets in steroid targets afterestrogen in vivo. Endoerinol. 1971; 88: Suppl XRA-151:AI51. 101. Gurwood AS, Gurwood I, Gubman DT, Brzeziek U. Idiosyneratie ocular symptoms associated with the estradiol transdermal estrogen replaeement patch system. Optom Vis Sei. 1995;72:29-33. 102. Verbeek B. Augenbefunde und stoffweehselverhalten bei einnahme von ovulationshemmern. Klin Mbl Augenheilk 1973; 162:612--621. 103. Christ T, Marquardt R, Stodtmeister R, Pillunat LE. Zur Beeinflussung der tränenfilmaufreibzeit dureh hormonale kontrazeptiva. Fortsehr Ophthalmol. 1986; 83: 108-111. 104. Brennan NA, Efron N. Symptomatology of HEMA eontaet lens wear. Optom Vis Sei. 1989;66:834-838. 105. Ruben M. Contaet lenses and oral eontraceptives. Brit Med J. 1966;1:1110. 106. Esmaeli B, Harvey JT, Hewlett B. Immunohistochemical evidence for estrogen receptors in meibomian glands. Ophthalmology 2000; 107: 180-184. 107. Suzuki T, Schaumberg DA, Sullivan BD, Liu M, Richards SM, Sullivan RM, Dana MR, Sullivan DA. Do estrogen and progesterone playa role in the dry eye of Sjögrens syndrome. Ann NY Acad Sei 200 I; in press. 108. Suzuki T, Sullivan BD, Liu M, Schirra F, Richards SM, Yamagami H, Sullivan DA. Estrogen and progesterone effects on the morphology of the mouse meibomian gland. Adv Exp Med Biol. 200 1; in press. 109. Sullivan BD, Evans JE, Sullivan RM, Sehaumberg DA, Dana MR, Sullivan DA. Impact of hormone replacement therapy on the lipid profile of meibomian gland secretions in postmenopausal women. Manuscript submitted, 2001. 110. Chew CKS, Hykin PG, Janswijer C, Dikstein S, Tiffany JM, Bron AI. The casuallevel of meibomian lipids in humans. Curr Eye Res. 1993;12:255-259. THE LIPID LA YER AND STABILITY OF TEARS IN HUMAN NEWBORNS Sherwin J. Isenberg, Madeline DeI Signore, Anthony Chen, and Jeffrey Wei Jules Stein Eye Institute and Harbor-UCLA Medical Center UCLA School of Medicine Los Angeles and Torrance, Califomia, USA

Proteomic analysis of human meibomian gland secretions

Background/aim: Human tears contain hundreds of proteins that may exert a significant influence on tear film stability, ocular surface integrity, and visual function. The authors hypothesise that many of these proteins originate from the meibomian gland. This study’s aim was to begin to develop the proteomic methodology to permit the testing of their hypothesis. Methods: Meibomian gland secretions were collected from the lower eyelids of adult volunteers and placed in a chloroform-methanol mixture. Samples were partitioned in a biphasic system and non-lipid phase materials were reduced, alkylated, and trypsin digested to obtain peptides for protein identification. This peptide mixture was separated by µ-capillary reverse phase chromatography and the effluent examined by nano-electrospray MS and data dependent MS/MS. SEQUEST software was used to identify proteins from the MS/MS spectra. Results: The methodological approach to date has permitted the identification of more than 90 proteins in human meibomian gland secretions. Proteins include the α2-macroglobulin receptor, IgA α chain, farnesoid X activated receptor, interferon regulatory factor 3, lacritin precursor, lactotransferrin, lipocalin 1, lysozyme C precursor, potential phospholipid transporting ATPase IK, seven transmembrane helix receptor (also termed somatostatin receptor type 4), testes development related NYD-SP21 (also termed high affinity IgE receptor β subunit), and TrkC tyrosine kinase. Conclusions: These findings indicate that the meibomian gland secretes a number of proteins into the tear film. It is quite possible that these proteins contribute to the dynamics of the tear film in both health and disease.

Is Complete Androgen Insensitivity Syndrome Associated with Alterations in the Meibomian Gland and Ocular Surface

Purpose. This studys purpose was to determine whether complete androgen insensitivity syndrome (CAIS) is associated with alterations in the meibomian gland and ocular surface. Methods. Individuals with CAIS, as well as age-matched female and male controls, completed questionnaires which assessed dry eye symptoms and underwent slit lamp evaluations of the tear film, tear meniscus, lids and lid margins and conjunctiva. The quality of meibomian gland secretions was also analyzed. Results. Our results demonstrate that CAIS is associated with meibomian gland alterations and a significant increase in dry eye signs and symptoms. Clinical assessment revealed that CAIS women, as compared to controls, had a significant increase in telangiectasia, keratinization, lid erythema and orifice metaplasia of the meibomian glands, and a significant decrease in the tear meniscus and quality of meibomian gland secretions. Questionnaire results showed that dry eye symptoms were increased over twofold in CAIS individuals, as compared to controls, including a significant increase in the sensations of dryness, pain and light sensitivity. Conclusion. Our results suggest that androgen insensitivity may promote meibomian gland dysfunction and an increase in the signs and symptoms of dry eye.

Sex steroids, the meibomian gland and evaporative dry eye.

Our recent research has led to our hypothesis that gender and sex steroid hormones are critical factors in the regulation of the meibomian gland and pathogenesis of evaporative dry eye. The objective of this article is to briefly summarize the experimental basis for this hypothesis.

Correlations between nutrient intake and the polar lipid profiles of meibomian gland secretions in women with Sjögren's syndrome.

Very recently, we discovered that women with Sjogren’s syndrome exhibit one of two distinct profiles in the polar lipid fraction of their meibomian gland secretions (Fig. 1). The first pattern is characterized by a single predominant peak eluting early on in the total ion current during HPLC analysis. The second pattern is characterized by multiple peaks spread over time. To begin to explore the mechanism(s) underlying these differences, we sought to determine whether the nutrient intake, and particularly the lipid consumption, of Sjogren’s syndrome patients may vary between those individuals expressing the “single” versus the “multiple” profile.

Do Estrogen and Progesterone Play a Role in the Dry Eye of Sjögren's Syndrome?

We hypothesize that this sex-related difference in the prevalence of dry eye syndromes is due, at least in part, to the influence of female sex steroids. We also hypothesize that these hormone effects are mediated primarily through the estrogen, and possibly progestin, regulation of gene expression in the lacrimal and meibomian glands. These tissues produce the aqueous and lipid layers of the tear film, and their dysfunction leads to “aqueous-deficient” and “evaporative” dry eye syndromes (e.g., such as occur in Sjögren’s syndrome). 5,6

Nutrient intake in women with primary and secondary Sjögren's syndrome

Objective: Recently, it has been proposed that dietary factors may contribute to the etiology and progression of Sjögrens syndrome, and that nutritional intervention may modify the severity of pathological abnormalities. The objective of this study was to determine whether the nutrient intake of women with primary (1°SS) or secondary (2°SS; ie with systemic lupus erythematosus (2°SS/SLE) or rheumatoid arthritis (2°SS/RA) Sjögrens syndrome is significantly different than that of age- and gender-matched controls.Design: Women with Sjögrens syndrome were asked to complete the 97 General Purpose Semi-Quantitative Food Frequency Questionnaire, which consists of a list of 147 separate food items that represent the major sources of multiple nutrients. Nutritional data were evaluated in terms of absolute and energy-adjusted nutrient amounts and analyzed by ANOVA.Results: Our results showed: (a) greater intake of energy, glutamate, carbohydrates, lactose, phosphorus, caffeine and unsupplemental thiamin and riboflavin in 1°SS, as well as supplemental calcium in 2°SS/SLE, compared with controls; (b) greater nutrient intake of energy, protein, glutamate, methionine, tryptophan, carbohydrates, lactose, supplemental calcium and phosphorus, sodium, caffeine and unsupplemental calcium, riboflavin and thiamin in 2°SS/RA, relative to 1°SS and/or 2°SS/SLE; (c) higher energy-adjusted values for supplemental calcium in 2°SS/SLE, and for vitamin A and supplemental iron and zinc in 2°SS/RA, compared with other groups; and (d) higher energy-adjusted intake of supplemental calcium, and a lower energy-adjusted intake of unsupplemental vitamin C, polyunsaturated fat, linoleic acid, omega-3 fatty acid, and specific other unsaturated fatty acids, in the Sjögrens syndrome group as a whole, relative to controls.Conclusions: Our findings demonstrate that nutrient intake is altered in Sjögrens syndrome.Sponsorship: This research was supported by a grant from Allergan Inc.

Economic and Quality Of Life Impact of Dry Eye Symptoms in Women with Sjögren’s Syndrome

Meibomian gland function is extremely important in promoting the health and integrity of the ocular surface.1–5 This gland, through its synthesis and secretion of lipids, enhances the stability and prevents the evaporation of the tear film.1–5 Meibomian gland dysfunction, in turn, leads to lipid insufficiency, tear film instability and evaporative dry eye.1–5 In fact, meibomian gland dysfunction is thought to be the primary cause of dry eye syndromes throughout the world.6 However, despite the importance of the meibomian gland in maintaining the well-being of the eye, very little research has been published concerning the physiological regulation of this tissue.

Meibomian Gland Dysfunction in Primary and Secondary Sjögren Syndrome

Purpose: We hypothesized that women with primary (pSS) and secondary Sjögren syndrome (sSS; with systemic lupus erythematosus [SLE] or rheumatoid arthritis [RA]) have meibomian gland dysfunction (MGD). We sought to test our hypothesis. Methods: Subjects with pSS, sSS + SLE, sSS + RA, and non-SS-related MGD were recruited from the Sjögren’s Syndrome Foundation or outpatient clinics at Tufts University School of Dental Medicine or Brigham and Women’s Hospital. The control population was recruited from the Greater Boston area. After providing written informed consent, the subjects underwent an eye examination and/or completed two questionnaires that assess symptoms of dry eye disease (DED). Results: Our results demonstrate that pSS and sSS patients have MGD. These subjects had meibomian gland orifice metaplasia, an increased number of occluded meibomian gland orifices, and a reduced quality of meibomian gland secretions. Further, patients with pSS, sSS + SLE, sSS + RA, and MGD had significant alterations in their tear film, lid margin, cornea, and conjunctiva. Symptoms of DED were increased ∼10-fold in all pSS, sSS, and MGD groups relative to controls. Conclusions: Our findings support our hypothesis and show that individuals with pSS, sSS + SLE, and sSS + RA have MGD. In addition, our study indicates that patients with pSS and sSS have both aqueous-deficient and evaporative DED.