Conjunctival HLA-DR Expression and Its Association With Symptoms and Signs in the DREAM Study

Neeta S Roy, Yi Wei, Yinxi Yu, Gui-Shuang Ying, Eric Kuklinski, Brendan Barry, Maureen G Maguire, Reza Dana, Mary Brightwell-Arnold, Penny A Asbell, for the Dry Eye Assessment and Management (DREAM) Study Group, Neeta S Roy, Yi Wei, Yinxi Yu, Gui-Shuang Ying, Eric Kuklinski, Brendan Barry, Maureen G Maguire, Reza Dana, Mary Brightwell-Arnold, Penny A Asbell, for the Dry Eye Assessment and Management (DREAM) Study Group

Abstract

Purpose: Evaluation of dry eye disease (DED) relies on subjective symptoms and signs. We examined HLA-DR expression (HLA-DR%) in conjunctival cells, a minimally invasive biomarker with objective metrics, as an alternative method.

Methods: Dry Eye Assessment and Management (DREAM) study participants completed the Ocular Surface Disease Index questionnaire. Clinicians evaluated tear volume, tear breakup time, and corneal and conjunctival staining. Conjunctival impression cytology samples (n = 1049) were assessed for HLA-DR% in total cells (TCs), epithelial cells (ECs), and white blood cells (WBCs). Associations (categorized into <5%, 5%-15%, >15%-25%, and >25%) with symptoms and signs were evaluated.

Results: The HLA-DR% varied markedly across samples. Over 40% had <5 HLA-DR% positive cells in TCs and ECs and under 23% in WBCs. Higher HLA-DR% was associated with higher conjunctival staining for ECs (mean score 2.77 for <5% and 3.28 for >25%, linear trend P = 0.009) and TCs (mean score 2.82 for <5% and 3.29 for >25%, linear trend P = 0.04) and in TCs was associated with higher corneal staining (mean score 3.59 for <5% and 4.46 for >25%, linear trend P = 0.03). HLA-DR% in WBCs did not correlated with signs (all P ≥ 0.58), and in TCs, ECs or WBCs were not associated with symptoms (P > 0.06).

Conclusions: The distribution of HLA-DR% in conjunctival cells reflects the heterogeneity of disease in DREAM participants. High percentages of samples with <5% positive cells indicate that HLA-DR% may not be a sensitive marker for DED in all patients.

Translational relevance: High HLA-DR% in ECs in association with high conjunctival staining may identify a subgroup of DED patients prone to epithelial disease and possibly need a different approach from current standards of treatment.

Keywords: HLA-DR; conjunctival cells; correlation; dry eye disease; symptoms and sign.

Figures

Figure 1
Figure 1
Flow cytometer analysis. Dot plots of a representative sample from the study. Total analyzable cells (88.61%) (B) were gated out from a scatter plot of FCS-W (Forward Scatter-Width) versus SSC-A (Side Scatter-Area; A). Sequential gating of EpCAM- or CD45-expressing cells from the total population yielded 90.20% ECs (C) and 1.21% WBCs (F). EpCAM+/HLA-DR+ cells (D) comprise 16.52% of the EC population and CD45+/HLA-DR+ cells (G) comprise 71.07% of the total WBCs.
Figure 2
Figure 2
Distribution of HLA-DR in patient conjunctival cells. (A, B, and C) Show the percentage sample distribution (y axis) of HLA-DR% (x axis) in TCs (TCs), EpCAM-expressing ECs, and CD45-expressing WBCs, respectively, in the 1049 eye samples analyzed. (D) Stacked bars showing the percent distribution of samples in the four levels of HLA-DR% (15%–25%, and >25%).

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