What is Lid Wiper Epitheliopathy?
Lid wiper epitheliopathy (LWE) is a condition where the eyelid becomes inflamed. It usually occurs along with various eye diseases. Specifically, LWE affects the “lid wiper,” which is the area where the upper eyelid and the eye’s surface meet during blinking. In LWE, the cells in the lid wiper become inflamed, resulting in a variety of symptoms.
Common signs of LWE include discoloration or staining of the eyelid’s edge, and staining on the eye’s surface. People with LWE may also feel like there is something in their eye, experience a burning sensation or discomfort in the eyes, or have blurred vision. Taken together, these symptoms indicate the presence of LWE and help doctors diagnose and manage this condition.
What Causes Lid Wiper Epitheliopathy?
The exact cause of LWE, or Lid Wiper Epitheliopathy, isn’t known, but it’s likely caused by a combination of factors. One idea suggests that LWE is caused by friction between the eyelid and the cornea (the clear front part of the eye) when we blink, which can cause small injuries and inflammation in the lid wiper area. Another idea is that LWE can be related to the increased exposure of the surface of the eye due to incomplete blinking or not fully closing the eyelid, which can dry out the cornea and conjunctiva (the clear layer covering the front of the eye and the inside of the eyelids).
Extended-wear contact lenses, even though they allow a large amount of oxygen to pass through, have been linked with LWE. This is possibly due to their greater toughness, which can increase the friction.
Ultimately, LWE likely involves a mix of factors, including mechanical trauma (injury caused by an external force), chemical irritation, inflammation, and environmental exposures. Mechanical trauma could be caused by wearing contact lenses, blinking excessively, or rubbing the eyelids. Chemical irritation may happen due to topical medications, preservatives, or cosmetics. Inflammation can be worsened by other health conditions like autoimmune diseases, infections, or allergic reactions. Exposure to irritants like air pollution or cigarette smoke can also contribute to LWE.
Risk Factors and Frequency for Lid Wiper Epitheliopathy
Lid Wiper Epitheliopathy, also known as LWE, is a fairly recent disease classification and there’s still a lot that experts don’t know about it. However, it’s believed to impact up to 88% of individuals who have dry eye disease.
- No clear difference in rates of LWE between genders has been found.
- Study results show that people of Asian heritage have almost twice the rate of LWE compared to non-Asians.
- Those who wear contact lenses are more prone to this condition than those who don’t.
- These facts point out that ethnicity and contact lens use could be risk factors for getting LWE.
At the moment, researchers don’t have enough information to definitively say how LWE affects different age groups. More extensive research is needed to accurately define how often it occurs in each age group. The lack of solid data highlights how crucial it is for research to continue, helping us understand more about how LWE prevalence changes with age.
Signs and Symptoms of Lid Wiper Epitheliopathy
Lid Wiper Epitheliopathy (LWE) is a condition that is diagnosed through detailed patient history and a specific type of eye examination known as a slit lamp examination. Those with LWE usually notice feelings of discomfort in their eye, a sensation of a foreign body in the eye, and difficulty tolerating contact lenses. They can often pinpoint the sensation to their upper eyelid. Doctors can use a slit lamp to check for signs of inflammation, such as redness, swelling, or increased blood vessels in the region around the eyelid. These signs might be due to a lack of oxygen, mechanical irritation, or other forms of stress.
To assess for areas of damage, doctors use special eye dyes. These can identify areas of cell damage along the edge of the eyelids and the goblet cells (using dyes like lissamine green and rose bengal) and any small areas of erosion in the eye (using a dye like sodium fluorescein). While sodium fluorescein can highlight specific damaged areas along the cornea or bulbar conjunctiva of the eye, lissamine green is typically used to better highlight LWE. Patients may also experience reddening around the upper bulbar conjunctiva, which might also include the upper eyelid margin.
Additional tests like the Schirmer test, tear break-up time, tear osmolarity, and conjunctival impression cytology can also help with LWE diagnosis, particularly in cases related to dry eye and ocular surface disease.
It’s crucial to know that LWE often occurs alongside other eye surface diseases. These could include anterior blepharitis, posterior blepharitis, chalazia, hordeola, aqueous deficiency dry eye, conjunctivochalasis, pinguecula, pterygia, various types of conjunctivitis, marginal keratitis, punctate keratitis, and ulcerative keratitis. In unusual cases, eye margin diseases like sebaceous cell carcinoma, basal cell carcinoma, and squamous cell carcinoma can also occur. These conditions typically require a biopsy for confirmation. Therefore, healthcare professionals should not overlook these potential related conditions and should take appropriate steps to identify and manage these associated eye surface diseases.
Testing for Lid Wiper Epitheliopathy
When checking for an eye condition called lid wiper epitheliopathy (LWE), which involves irritation and inflammation of the inner edge of the eyelids, your doctor will carry out a detailed examination using a device called a slit lamp. This machine magnifies the eye, making it easier for your doctor to examine your eyelids, the transparent outer layer of your eye (known as the bulbar conjunctiva), and the inside of your lower eyelid (inferior palpebral conjunctiva). All of these checks will help rule out other possible reasons for discomfort in your eye.
To help identify possible eye surface problems that may seem like LWE, a fluorescent yellow-orange dye known as sodium fluorescein might be used. This dye can help spot any areas where the eye surface might be worn away, check the stability of your tear film (the thin layer of tears that always covers our eyes), and spot any inflammation of the cornea, the clear front surface of your eye.
There are some other eye conditions that may seem similar to LWE, such as Superior Limbic Keratoconjunctivitis (a chronic inflammation of the superior conjunctiva and superior corneal epithelium), foreign bodies trapped along the lining of the eye, and Giant Papillary Conjunctivitis (a type of allergic reaction primarily affecting the inner surface of the eyelid). To rule out these conditions, your doctor will ask you to look up and down while your upper and lower eyelids are turned inside out. This allows the doctor to properly check the inside lining of your eyelids.
Lastly, to further assess the likelihood of LWE, your doctor might apply lissamine green stain or rose bengal dye. In patients with LWE, these dyes tend to show different levels of staining, usually starting at the junction where the outer, skin part of your eyelid meets the inner, mucous part. This junction is also termed as the Line of Marx, and it’s located on your upper eyelid.
Treatment Options for Lid Wiper Epitheliopathy
The main goal of treating lid wiper epitheliopathy (LWE), a condition that affects the part of the eyelid that makes contact with the eye during blinking, is to decrease the irritation and stress caused by the blinking action. This is important because this condition usually comes from the inflammation caused by the constant rubbing or friction on the eye’s surface whenever you blink. To make the eyes less irritated, various treatments can be used to reduce this friction.
Common treatments include warm compresses, cleaning the eyelids, artificial tears, medicated eye drops, and protective contact lenses. These strategies are designed to ease any discomfort and promote the healing process by making the surface of the eyes smoother. Additionally, it’s also important to manage any other conditions that affect your eye’s surface, such as dry eyes, meibomian gland dysfunction (a common cause of dry eye), and allergic conjunctivitis, as they often occur together with LWE.
Besides focusing on eye-related issues, it’s also crucial to manage any other health conditions that can contribute to the problems on your eye’s surface. These may include disorders like Sjogren’s syndrome, rheumatoid arthritis, and systemic lupus erythematosus. Taking care of both eye-specific and overall health issues is important in successfully treating LWE.
If the usual treatments like regular cleaning of the eyelids and easing symptoms aren’t enough to reduce the rubbing on the surface of the eye, other treatment options are available. These treatments aim to ease symptoms and reduce inflammation caused by irregularities in the tear film, which is the thin layer of tears covering the eye.
One specific treatment is punctal occlusion where the tear ducts are blocked to help retain more tears on the eye’s surface, reducing the friction between the eyelid and the eye. Medications targeting inflammation in the tear film, such as loteprednol, fluorometholone, prednisolone, and dexamethasone, can be applied. Other medications like cyclosporine and lifitegrast, also known as immunomodulators, can be used to manage inflammation. Furthermore, oral antibiotics with anti-inflammatory properties like doxycycline and azithromycin can help soothe inflammation and modify the environment of your eye’s surface, easing symptoms and effectively managing LWE.
Another set of treatments involve specific procedures targeting the area along your eyelid in LWE, especially when there is visible staining along the “Line of Marx” seen in the specific colorful staining tests.
One such procedure is called Microblepharoexfoliation, where a rotating sponge soaked in an antimicrobial cleanser is used to mechanically scrub away the base of the eyelash follicle and the eyelid’s edge. This directly addresses the root cause of LWE. Other procedure-based treatments like thermal pulsation and intense pulsed light are primarily for meibomian gland dysfunction but may also benefit LWE. However, Microblepharoexfoliation is better suited for directly addressing this problem.
Remember though that while these treatments can help manage the symptoms, they can’t fully cure the condition. The frequency of treatments will adjust based on various factors like any accompanying eye condition, overall health, and how well you keep up with the aftercare like warm compresses, eye lid scrubs, lubrication, and prescribed medications. It’s important to note that merely stopping the use of contact lenses hasn’t been shown to resolve this condition.
What else can Lid Wiper Epitheliopathy be?
Superior limbic keratoconjunctivitis (SLK), often linked with thyroid eye disease, is a reaction to substances found in contact lens solutions. Typically affecting both eyes, though not always evenly, it can cause uncomfortable symptoms similar to lid wiper epitheliopathy (LWE). These include eye pain, feeling like something is stuck in the eye and difficulty wearing contact lenses. An examination using a slit lamp, a tool for examining the eyes, can show signs of swelling and inflammation. Stains like lissamine green or rose bengal can make these issues more visible. Other signs may include tiny rough spots on the eye surface and swelling of the upper eyelid lining.
Foreign objects in the eye are a common issue that can lead to major discomfort. Symptoms can include eye pain, discomfort when blinking, redness, sensitivity to light, and excessive tearing. Roughly 80% of these occur on the cornea, the clear front surface of the eye, while around 13% happen on the eyelid lining. It’s important to remove foreign objects right away to avoid serious complications like infection and scarring of the cornea that could result in permanent vision loss. After removal, the eye area should be treated with antibacterial and anti-inflammatory drops to prevent infection and inflammation. Regular check-ups are important to watch over the healing process and tackle any arising issues.
Floppy eyelid syndrome (FES) is seen mostly in men with a high body mass index. It happens when the eyelid easily turns inside out during sleep. Symptoms can be similar to lid wiper epitheliopathy (LWE), including the feeling of a foreign object in the eye. An examination with a slit lamp can reveal tiny rough spots and chronic inflammation of the eye and eyelid. Another common issue is eye discharge, which can be watery or thicker. This happens when the eyelid flips inside out while sleeping, causing the eye surface to be exposed for a long period.
Giant papillary conjunctivitis (GPC) is a specific type of conjunctivitis linked with wearing contact lenses. It’s characterized by the formation of large bumps on the upper lining of the eyelid. People with GPC usually experience symptoms like eye itching, difficulty wearing contacts, blurred vision, and excessive mucus production in the eyes. It can happen due to improper contact lens usage, such as not replacing the lenses frequently, wearing them for too long, poor lens hygiene, and a history of allergies. It’s thought that GPC is caused by trauma to the eyelid lining alongside an immune response to deposits on the lens. This can set off an inflammation leading to the formation of large bumps. Recognizing GPC and its link with contact lens wear, and the potential allergic and immune reactions involved, is very important.
What to expect with Lid Wiper Epitheliopathy
The outlook for people with Lid Wiper Epitheliopathy (LWE) – a condition affecting the part of the eyelid that comes into contact with the eye, is generally good. Many patients find their symptoms get better and the condition improves when they start using eye drops to reduce inflammation and keep the eye surface lubricated.
However, it’s important to be aware that simply stopping wearing contact lenses hasn’t been shown to fully clear up the signs of LWE.
Possible Complications When Diagnosed with Lid Wiper Epitheliopathy
If LWE (or dry eyes) isn’t treated properly, patients can develop scarring on the upper eyelid lining and inward turning of the upper eyelid. This may occur with or without inward growing eyelashes.
Furthermore, patients who develop breaks or tears in the cornea’s surface are at risk of getting a serious eye infection called microbial keratitis and scarring of their cornea. This can lead to permanent loss of vision or distortion of the eye’s shape, causing an irregular focus of light in the eye, which is known as irregular astigmatism.
Risks of not Treating LWE:
- Scarring on the upper eyelid lining
- Inward turning of the upper eyelid
- Inward growing eyelashes
- Eye infections (microbial keratitis)
- Corneal scarring
- Permanent vision loss
- Distortion of the eye (irregular astigmatism)
Preventing Lid Wiper Epitheliopathy
To stop a condition called lid wiper epitheliopathy (LWE) from developing, it’s very important to keep the surface of your eye moist. Artificial tears that don’t have preservatives in them, along with contact lenses that stay wet easily, can help reduce friction between the lid wiper (the part of the eyelid that cleans and spreads tears over the surface of your eye) and the surface of your eye. Decreasing this friction can help prevent LWE.
