Exploring tear fluid biomarkers and the ocular surface in thyroid eye disease

Abstract

Purpose: To examine ocular surface changes and inflammatory tear fluid biomarkers in patients with thyroid eye disease (TED).

Methods: We included 106 Graves' disease (GD) patients (36 without TED, 32 with active and 38 with inactive TED) and 106 age- and sex-matched healthy subjects for ophthalmological evaluation, including ocular surface status and Meibomian gland function. Tear fluid was analysed for 40 inflammatory biomarkers by a Luminex multiplex bead assay. The parameters were compared across subgroups.

Results: GD patients with TED had significantly higher median (min-max) Ocular Surface Disease Index (OSDI) score than GD patients without TED, with a median score of 31.4 (0-86.4) compared to 7.3 (0-45.8) (p < 0.01). Eleven of 50 patients with moderate-to-severe and sight-threatening TED had a meibum quality score above seven, compared to none of the 20 patients with mild TED (p = 0.027). Tear fluid levels of chemokine (C-C motif) ligand 2 (CCL2) were significantly (p = 0.003) higher in GD patients compared to healthy subjects. CD40 ligand (CD40L) and CCL2 were higher in GD patients with TED compared with GD patients without TED (p = 0.002 and 0.013, respectively). As a combined biomarker to distinguish between GD patients with and without TED, OSDI score together with tear fluid levels of CCL2 and CD40L produced an area under the receiver operating characteristic (ROC) curve of 0.80, with sensitivity of 0.69 at a fixed specificity of 0.80.

Conclusions: Our findings demonstrate increased tear fluid levels of CD40L and CCL2 in patients with TED, indicating their potential as diagnostic biomarkers. Increased ocular discomfort in patients with TED could be related to impaired meibum quality.

Keywords: CD40 ligand; Graves' disease; chemokine (C–C motif) ligand 2; dry eye disease; ocular surface disease; thyroid eye disease.

FIGURE 1

(a) Volcano plot comparing 35 inflammatory biomarkers in tear fluid from 106 patients with Graves' disease (GD) and 106 healthy subjects (HSs). BAFF, B‐cell activating factor; CCL2, chemokine (C‐C motif) ligand 2; CCL7, chemokine (C‐C motif) ligand 7; CCL20, chemokine (C‐C motif) ligand 20; CD40L, CD40 ligand; CHI3L, chitinase 3‐like 1; CRP, C‐reactive protein; CXCL10, chemokine (C‐X‐C motif) ligand 10; CXCL11, chemokine (C‐X‐C motif) ligand 11; Flt3L, FMS‐like tyrosine kinase 3 ligand; GM‐CSF, granulocyte‐macrophage colony‐stimulating factor; IFN‐α, interferon α; IL‐2, interleukin 2; IL‐4, interleukin 4; IL‐6, interleukin 6; IL‐8, interleukin 8; IL‐10, interleukin 10; IL‐12p70, interleukin 12p70; IL‐13, interleukin 13; IL‐15, interleukin 15; IL‐17A, interleukin 17A; IL‐17E, interleukin 17 E; IL‐23, interleukin 23; IL‐27, interleukin 27; IL‐28A, interleukin 28A; IL‐31, interleukin 31; IL‐33, interleukin 33; LT‐α, lymphotoxin‐α; M‐CSF, macrophage colony‐stimulating factor; PDGF‐AA, platelet derived growth factor; S100A8, S100 calcium‐binding protein A8; TNF, tumour necrosis factor; TNFRSF9, TNF receptor superfamily member 9; VitDBP, vitamin D binding protein; VCAM‐1, vascular cell adhesion protein 1. (b) Volcano plot comparing 35 inflammatory biomarkers in tear fluid from Graves' disease patients with thyroid eye disease (TED, n = 70) and without (noTED, n = 36). BAFF, B‐cell activating factor; CCL2, chemokine (C–C motif) ligand 2; CCL7, chemokine (C–C motif) ligand 7; CCL20, chemokine (C–C motif) ligand 20; CD40L, CD40 ligand; CHI3L, chitinase 3‐like 1; CRP, C‐reactive protein; CXCL10, chemokine (C–X–C motif) ligand 10; CXCL11, chemokine (C–X–C motif) ligand 11; Flt3L, FMS‐like tyrosine kinase 3 ligand; GM‐CSF, granulocyte‐macrophage colony‐stimulating factor; IFN‐α, interferon α; IL‐2, interleukin 2; IL‐4, interleukin 4; IL‐6, interleukin 6; IL‐8, interleukin 8; IL‐10, interleukin 10; IL‐12p70, interleukin 12p70; IL‐13, interleukin 13; IL‐15, interleukin 15; IL‐17A, interleukin 17A; IL‐17E, interleukin 17E; IL‐23, interleukin 23; IL‐27, interleukin 27; IL‐28A, interleukin 28A; IL‐31, interleukin 31; IL‐33, interleukin 33; LT‐α, lymphotoxin‐α; M‐CSF, macrophage colony‐stimulating factor; PDGF‐AA, platelet‐derived growth factor; S100A8, S100 calcium‐binding protein A8; TNF, tumour necrosis factor; TNFRSF9, TNF receptor superfamily member 9; VitDBP, vitamin D binding protein; VCAM‐1, vascular cell adhesion protein 1.

FIGURE 2

Receiver Operating Characteristic curve, with Ocular Surface Disease Index and tear fluid levels of CD40 Ligand and chemokine (C–C motif) ligand 2 (CCL2) combined, demonstrating an area under the curve (AUC) of 0.80, with sensitivity 0.69 at a fixed specificity of 0.80. The true positive rate (sensitivity) is plotted against the true negative rate (specificity).