title: Bowman Break and Subbasal Nerve Plexus Changes in a Patient With Dry Eye Presenting With Chronic Ocular Pain and Vitamin D Deficiency.
abstract: OBJECTIVE
  To report the case of a 40-year-old patient with persistent bilateral ocular pain and discomfort for 2 years in whom conventional management of dry eye had failed. Detailed ocular examination, meibography, and tear film evaluation were suggestive of bilateral meibomian gland dysfunction and evaporative dry eye. Topical medication failed to alleviate the patient's symptoms. To identify the cause of pain, imaging was performed with in vivo confocal microscopy and anterior segment spectral domain optical coherence tomography. Systemic evaluation revealed severe vitamin D deficiency with a value of 5.86 ng/mL.
  
  
  METHODS
  Case report.
  
  
  RESULTS
  In vivo confocal microscopy showed abnormal subbasal nerve plexus morphology, increased dendritic cell density, and enlarged terminal nerve sprouts. A breach in the Bowman layer was detected in both eyes on spectral domain optical coherence tomography. Conventional management having failed, LipiFlow treatment (TearScience, Morrisville, NC) was performed and topical therapy with cyclosporine 0.05%, steroids, and lubricating eye drops was initiated with incomplete symptomatic relief. However, with parenteral therapy for vitamin D deficiency, there was a dramatic improvement in the patient's symptoms.
  
  
  CONCLUSIONS
  Inflammation aggravated by vitamin D deficiency results in an altered epithelial profile, Bowman layer damage, recruitment of dendritic cells, and altered subbasal nerve plexus features in patients with chronic dry eye disease. These can serve as potential imaging markers for studying the underlying mechanisms in patients with dry eye disease with persisting symptoms despite aggressive conventional treatment.
authors.affiliation: Cornea and Refractive Surgery Department, Narayana Nethralaya, Bangalore, Karnataka, India.
authors.forename: Rohit
authors.initials: R
authors.lastname: Shetty
authors.forename: Kalyani
authors.initials: K
authors.lastname: Deshpande
authors.forename: Rashmi
authors.initials: R
authors.lastname: Deshmukh
authors.forename: Chaitra
authors.initials: C
authors.lastname: Jayadev
authors.forename: Rushad
authors.initials: R
authors.lastname: Shroff
mesh_terms: D000328:Adult; D050541:Bowman Membrane / Q000473:pathology*; D002908:Chronic Disease; D003315:Cornea / Q000294:innervation*; D003389:Cranial Nerve Diseases / Q000175:diagnosis* / Q000188:drug therapy; D003713:Dendritic Cells / Q000473:pathology; D015352:Dry Eye Syndromes / Q000175:diagnosis* / Q000188:drug therapy; D058447:Eye Pain / Q000175:diagnosis* / Q000188:drug therapy; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D018613:Microscopy, Confocal; D009412:Nerve Fibers / Q000473:pathology; D009882:Ophthalmic Nerve / Q000473:pathology*; D041623:Tomography, Optical Coherence; D014807:Vitamin D / Q000008:administration & dosage; D014808:Vitamin D Deficiency / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D014807:Vitamin D