Efficacy of different dry eye treatments with artificial tears or ocular lubricants: a systematic review

Comparison of novel lipid-based eye drops with aqueous eye drops for dry eye: a multicenter, randomized controlled trial

Background

Dry eye may be caused or exacerbated by deficient lipid secretion. Recently, lipid-containing artificial tears have been developed to alleviate this deficiency. Our study compared the efficacy, safety, and acceptability of lipid-containing eye drops with that of aqueous eye drops.

Methods

A non-inferiority, randomized, parallel-group, investigator-masked multicenter trial was conducted. Subjects with signs and symptoms of dry eye were randomized to use one of two lipid-containing artificial tears, or one of two aqueous artificial tears. Subjects instilled assigned drops in each eye at least twice daily for 30 days. The primary efficacy analysis tested non-inferiority of a preservative-free lipid tear formulation (LT UD) to a preservative-free aqueous tear formulation (AqT UD) for change in Ocular Surface Disease Index (OSDI) score from baseline at day 30. Secondary measures included OSDI at day 7, tear break-up time (TBUT), corneal and conjunctival staining, Schirmer’s test, acceptability and usage questionnaires, and safety assessments.

Results

A total of 315 subjects were randomized and included in the analyses. Subjects reported instilling a median of three doses of study eye drops per day in all groups. At days 7 and 30, all groups showed statistically significant improvements from baseline in OSDI (P<0.001) and TBUT (P≤0.005). LT UD was non-inferior to AqT UD for mean change from baseline in OSDI score at day 30. No consistent or clinically relevant differences for the other efficacy variables were observed. Acceptability was generally similar across the groups and there was a low incidence of adverse events.

Conclusion

In this heterogeneous population of dry eye subjects, there were no clinically significant differences in safety, effectiveness, and acceptability between lipid-containing artificial tears and aqueous eye drops. The results suggest that lipid-containing artificial tears can be used to counteract lipid deficiency that is common in dry eye, without compromising overall acceptability.

A hyaluronic acid-binding contact lens with enhanced water retention

PURPOSE

As a main component of an artificial tear or eyedrop, hyaluronic acid (HA) prolongs water retention, slows tear removal, improves tear film stability, reduces protein adsorption at the ocular surface and permits uninterrupted blinking. Here, we hypothesized that the contact lens modified with an HA-binding peptide (HABpep) could locally bind and concentrate exogenous HA present in eyedrops to the modified contact lens surface, which exhibited superior water retention.

METHODS

To bind HA, a contact lens surface was covalently modified by HABpep with and without a poly(ethylene glycol) (PEG) spacer. Bound HA and its retention over time on the modified surfaces were evaluated by fluorescence measurements. A comparative water evaporation study was performed to determine water retention in an HA-bound contact lens.

RESULTS

Fluorescence studies showed that the contact lens was successfully modified by HABpep with or without a PEG spacer, and HA bound to the contact lens surface. Furthermore, the bound HA via HABpep significantly reduced water loss from the modified contact lens.

CONCLUSION

HABpep strategies that locally bind and concentrate HA to create a thin coating of a therapeutic molecule on surfaces could provide physical and biological benefits to treat ocular surface dysfunction. The surface bound HA via HABpep enhanced water retention in the modified contact lens.

Abdominal breathing increases tear secretion in healthy women

PURPOSE

To determine the relationship between abdominal breathing and tear meniscus volume in healthy women, we investigated the change in tear meniscus volume in two groups: normal breathing and abdominal breathing.

METHODS

We used a crossover experimental model and examined 20 healthy women aged 20-54 years (mean ± SD, 32.7 ± 11.1 years). The participants were randomly assigned to one of two groups. During the first visit, the normal breathing group was subjected to normal breathing for 3 min, whereas the abdominal breathing group was subjected to abdominal breathing (4-second inhalation and 6-second exhalation) for 3 min. During the second visit, the protocols were swapped between the two groups. We estimated the R wave to R wave (R-R) interval, tear meniscus volume, salivary amylase activity, pulse, and blood pressure before and immediately after, 15 min after, and 30 min after completion of the breathing activity.

RESULTS

After abdominal breathing, compared to that before breathing, the tear meniscus volume increased significantly 15 min after breathing (P<.01). Furthermore, systolic blood pressure showed a significant decrease immediately after abdominal breathing (P<0.05). No significant difference was found in the test parameters in the normal breathing group.

CONCLUSION

Abdominal breathing for 3 minutes increases the tear meniscus volume in healthy women. Consequently, abdominal breathing may be considered in the treatment of dry eye disease.

Perceptions of dry eye disease management in current clinical practice

OBJECTIVE

To assess the perceptions of eye care providers regarding the clinical management of dry eye.

METHODS

Invitations to complete a 17-question online survey were mailed to 400 members of the North Carolina Ophthalmology and Optometry Associations including community optometrists, comprehensive ophthalmologists, and cornea specialists.

RESULTS

The survey was completed by 100 eye care providers (25% response rate). Providers reported burning (46.5%) as the most frequent symptom described by patients, followed by foreign body sensation (30.3%) and tearing (17.2%). Most respondents (80.8%) listed artificial tears as the recommended first-line treatment, even though providers reported high failure rates for both artificial tears and cyclosporine A (Restasis). Rheumatoid arthritis, Sjögren syndrome, affective disorders such as anxiety and depression, history of photorefractive surgery, smoking, and thyroid disease were acknowledged as common comorbid conditions.

CONCLUSIONS

The survey provided an informative snapshot into the preferences of eye care providers concerning the diagnosis and management of dry eye disease. Overall, burning was the most common symptom reported by patients. Providers relied more on patient history in guiding their clinical decisions than objective signs. The survey underscores the incongruence when comparing subjective symptoms with objective signs, thereby highlighting the urgent need for the development of reliable metrics to better quantify dry eye symptoms and also the development of a more sensitive and specific test that can be used as the gold standard to diagnose dry eye.

Use of preservative-free hyaluronic acid (Hylabak(®)) for a range of patients with dry eye syndrome: experience in Russia

Artificial tear preparations are important in the management of dry eye syndrome. We present the findings from four recently published studies conducted in Russia assessing Hylabak(®) (marketed as Hyabak(®) in Europe), a preservative-free hyaluronic acid preparation, for the treatment of dry eye syndrome. All studies had an open, noncomparative design, but one compared the findings with those from 25 patients treated with Tear Naturale(®) in previous studies. A total of 134 children and adults were enrolled, and the etiologies of dry eye syndrome included contact lens use, intensive office work, adenovirus eye infection, postmenopausal status, persistent meibomian blepharitis, Sjögren's syndrome, phacoemulsification with intraocular lens implantation, and refractive surgery. The patients were treated with Hylabak for 2 weeks to 2 months. All studies showed that Hylabak resulted in marked improvement as assessed by subjective sensations/complaints, Schirmer's test, Norn's test, impression cytology and biomicroscopy, staining, and tear osmolarity. Greater benefits were also reported compared with Tear Naturale, including a faster onset of action. Hylabak was well tolerated. In conclusion, Hylabak provided rapid and safe relief from the signs and symptoms of dry eye syndrome, as well as improvement in objective measures, in a wide range of patients.

Histology of a novel injectable filler (polymethylmethacrylate and cross-linked dextran in hydroxypropyl methylcellulose) in a rat model

A novel injectable filler of polymethylmethacrylate (PMMA) and cross-linked dextran in hydroxypropyl methylcellulose was introduced in the commercial filler market. For soft tissue augmentation, safety and biocompatibility should be evaluated and the stability at the implantation site should be assessed using histologic evaluation. In order to evaluate the biocompatibility of the novel soft tissue filler, PMMA and cross-linked dextran in hydroxypropyl methylcellulose was subdermally injected into the skin of Sprague-Dawley Rats. Histologic evaluation was performed at 13 weeks and 12 months after the injection. Inflammatory cell infiltration, neovascularization, and fibrosis were scored according to defined grading systems. The mean score of the histologic evaluation was 5.7 and 3.9 at 13 weeks and 12 months, respectively. At 12 months after injection, the PMMA and cross-linked dextran in hydroxypropyl methylcellulose appeared to be kept in place through fine fibrous capsules. The mixture of PMMA and cross-linked dextran in hydroxypropyl methylcellulose can be safely applied for soft tissue augmentation with longevity of greater than 12 months.

Efficacy of a novel moist cool air device in office workers with dry eye disease

PURPOSE

To evaluate the efficacy and safety of new moist cool air device (MCAD) for ocular symptoms, tear film stability and ocular surface status in office workers with dry eye disease (DED).

METHODS

In this prospective single-centre clinical trial, 40 eyes of 20 patients with DED were recruited and randomly divided into two groups (group with MCAD exposure and group without MCAD). All subjects are visual display terminals (VDTs) workers spending at least 4 h/day in front of VDTs. Patients using MCAD underwent moist air applications for 4 h/day for a total of five working weekdays during VDT works at their offices. The other group of patients performed their VDT work without moist cool air device exposure. The change in symptoms of ocular surface (OS) dryness, fatigue and discomfort was evaluated using visual analogue scale (VAS) scores. Changes in visual function, tear functions and ocular surface status were evaluated using best-corrected visual acuity (BCVA), the functional visual acuity (FVA) test, blink rate, BUT measurements, strip meniscometry (SM), tear evaporation rate, fluorescein staining and rose bengal staining scores. Tear film lipid layer interferometry was also performed to assess the status of the lipid layer over the tear film. In addition, adverse events were recorded.

RESULTS

In group with MCAD, symptoms of OS dryness during VDTs work, and FVA and BUT were significantly improved. SM and tear evaporation rate were significantly improved. There were no statistically significant differences on lipid layer stability and corneal staining scores in both groups. Blink rate was significantly increased in group without MCAD. No adverse events were reported during this trial.

CONCLUSION

Moist cool air device use provided symptomatic relief of ocular dryness and improvement on tear stability in office workers with DED. This new device seems to be a safe and promising alternative in the treatment of DED.

Topical biological agents targeting cytokines for the treatment of dry eye disease

Because inflammation plays a key role in the pathogenesis of dry eye disease and Sjögren’s syndrome, topical anti-inflammatory agents such as corticosteroids and cyclosporine A have been used to treat inflammation of the ocular surface and lacrimal gland. Systemic biological agents that target specific immune molecules or cells such as tumor necrosis factor (TNF)-α, interferone-α, interleukin (IL)-1, IL-6, or B cells have been used in an attempt to treat Sjögren’s syndrome. However, the efficacy of systemic biological agents, other than B-cell targeting agents, has not yet been confirmed in Sjögren’s syndrome. Several studies have recently evaluated the efficacy of topical administration of biological agents targeting cytokines in the treatment of dry eye disease. Topical blockade of IL-1 by using IL-1 receptor antagonist could ameliorate clinical signs and inflammation of experimental dry eye. Using a mouse model of desiccating stress-induced dry eye, we have demonstrated that topical application of a TNF-α blocking agent, infliximab, could improve tear production and ocular surface irregularity, decrease inflammatory cytokines and Th-1 CD4+ cells on the ocular surface, and increase goblet cell density in the conjunctiva. Although controversy still remains, the use of topical biological agents targeting inflammatory cytokines may be a promising therapy for human dry eye disease.

Dry eye disease treatment: a systematic review of published trials and a critical appraisal of therapeutic strategies

Dry eye disease (DED) treatment is an area of increasing complexity, with the emergence of several new treatment agents in recent years. Evaluation of the efficacy of these agents is limited by heterogeneity in outcomes definition and the small number of comparative studies. We provide a systematic review of clinical trials (CTs) related to DED treatment and a critical appraisal of CT public databases. CT reports obtained from eight databases were reviewed, as well as public free-access electronic databases for CT registration. Data evaluation was based on endpoints such as symptoms, Schirmer test, ocular surface staining scores, recruitment of patients, type and efficacy of the drug, and the design and site of performance of the study. Forty-nine CTs were evaluated involving 5,189 patients receiving DED treatment. Heterogeneity in study design prevented meta-analysis from yielding meaningful results, and a descriptive analysis of these studies was conducted. The most frequent categories of drugs for DED in these studies were artificial tears, followed by anti-inflammatory drugs and secretagogues. Although 116 studies have been completed, according to the registration database for clinical trials, only 17 of them (15.5%) were published. Out of 185 registered CTs related to DED, 72% were performed in the USA. The pharmaceutical industry sponsored 78% of them. The identification of effective DED treatment strategies is hindered by the lack of an accepted set of definitive criteria for evaluating disease severity.

The effect of pH, dilution, and temperature on the viscosity of ocular lubricants--shift in rheological parameters and potential clinical significance

OBJECTIVE

To investigate the effect of temperature, dilution, and pH on the viscosity of ocular lubricants.

DESIGN

Laboratory based investigation of viscosity.

PARTICIPANTS

No human subjects.

METHODS

Hypromellose 0.3%, sodium hyaluronate 0.4%, carboxymethylcellulose sodium 0.5%/glycerin 0.9%, and carmellose sodium 0.5% were investigated. Ostwald capillary viscometers were utilised for viscosity measurements. The kinematic viscosity of each lubricant was tested quantitatively from 22 to 40 °C, and over a pH range of 5-8 under isothermal conditions. The kinematic viscosity of each eye drop was also tested under dilution by varying the mass fraction of each eye drop under isothermal conditions.

MAIN OUTCOME MEASURE

Changes in kinematic viscosity.

RESULTS

Hypromellose 0.3% had an initial pH of 8.34, while the other lubricants had a pH close to neutral. From 22 to 35 °C, the kinematic viscosity of sodium hyaluronate 0.4 fell by 36% from 37.8 to 24.4 mm(2)/s, carboxymethylcellulose sodium 0.5%/glycerin 0.9% fell by 35% from 16.98 to 11.1 mm(2)/s, hypromellose fell by 37% from 6.89 to 3.69 mm(2)/s, and carmellose sodium 0.5% fell by 25% from 2.77 to 1.87 mm(2)/s. At 32 °C only sodium hyaluronate 0.4%, and carboxymethylcellulose sodium 0.5%/glycerin 0.9% retained sufficient kinematic viscosity to maintain precorneal residence. Kinematic viscosities of all the topical lubricants were unaffected by pH but decreased significantly with dilution.

CONCLUSIONS

This study suggests that currently used ocular lubricants have limited bioavailability due to reductions in viscosity by temperature and dilutional changes under physiological conditions. Developing lubricants with stable viscosities may maximise therapeutic efficacy.

Evaluation of dry eye

Dry eye is a common yet complex condition. Intrinsic and extrinsic factors can cause dysfunction of the lids, lacrimal glands, meibomian glands, ocular surface cells, or neural network. These problems would ultimately be expressed at the tear film-ocular surface interface. The manifestations of these problems are experienced as symptoms such as grittiness, discomfort, burning sensation, hyperemia, and secondary epiphora in some cases. Accurate investigation of dry eye is crucial to correct management of the condition. Techniques can be classed according to their investigation of tear production, tear stability, and surface damage (including histological tests). The application, validity, reliability, compatibility, protocols, and indications for these are important. The use of a diagnostic algorithm may lead to more accurate diagnosis and management. The lack of correlation between signs and symptoms seems to favor tear film osmolarity, an objective biomarker, as the best current clue to correct diagnosis.

Autologous platelet lysate for treatment of refractory ocular GVHD

Current treatment of ocular GVHD (oGVHD), represented by systemic immunosuppressive regimens and local therapies (mainly artificial tears and corticosteroids), gives unsatisfactory results. We investigated the safety and efficacy of autologous plasma rich in PDGFs to treat oGVHD unresponsive to standard medications. A total of 23 patients with refractory oGVHD (grade II-IV) unresponsive to standard therapy were treated with autologous plasma rich in PDGFs eye drops (PRGD) four times/day for 6 months. Symptoms and signs (best visual acuity, Schirmer's test and tear break up time (TBUT), evaluation of the anterior segment and fluorescein and lissamine staining) were always assessed by the same ophthalmologist. Patients were defined as 'responders' when showing improvement for total complaints and at least one sign. At 30 days of treatment, 17 patients (73.9%) were classified as responders. The symptom that improved most was photophobia (improved in 19 patients, 82.6%). TBUT improved in 20 patients (86.9%) and anterior segment score in 19 patients (82.6%). Response was maintained over time. No serious adverse events occurred. PRGD proved to be safe and effective in treating oGVHD and may be a valid treatment option from the early stages of the disease to avoid irreversible ocular damage.

Assessment and Management of Dry Eye Patients for Non-Ophthalmic Healthcare Practitioners

Dry eye is a very common condition in many parts of the world. Both ophthalmologists and other healthcare professionals, such as optometrists and general practitioners, are often involved in the care of these patients. The main thrust of dry eye management is over-the-counter tear lubricants. There is a wide range of tear lubricants available today. These lubricants vary in viscosity, duration of action, type of preservatives, osmolarity/osmolality and pH. This article aims to educate healthcare professionals on 1) how to assess and manage patients with mild to moderate dry eyes and 2) how to identify patients who may need a referral to an ophthalmologist. Strategies on the use of available treatments and their limitations, as well as factors that may affect patient compliance will be discussed.

Transduction, tropism, and biodistribution of AAV vectors in the lacrimal gland

PURPOSE

The lacrimal gland (LG) delivers defensive and metabolic factors to the ocular surface. These functions may be disrupted in several diseases, and for most of them there is no cure. The aim of this study is to investigate conditions and limitations for using adeno-associated virus (AAV) vectors as gene transfer agents to LG.

METHODS

Eight-week-old Balb/c mice were used to investigate route, gene expression, and time course of AAV gene vector transfer to LG. AAV vectors encoding firefly luciferase were administered to the LG and luciferase expression was evaluated in vivo by immunohistochemistry. Ocular surface and neutralizing antibodies were also evaluated.

RESULTS

The present work revealed that AAV vectors are able to delivery DNA to the LGs of mice. Direct injection had the highest level of transduction, and topical ocular drops the lowest. Overall, the AAV strain with highest transduction activity as measured by both luminescence and immunohistochemistry was AAV9, followed by AAV 5w8 and AAV5. Transduction was not different between sexes, could be detected as soon as 24 hours after injection, and lasted for at least 30 days (study termination). No tissue damage was observed when compared with controls. All vectors with detectable LG transduction induced neutralizing antibodies.

CONCLUSIONS

LG gene delivery by AAV vectors appears to be both safe and well tolerated. The choice of vector influences both the overall transduction activity, as well as the spread of vector to other organs. This work supports the use of AAV-mediated gene therapy for dry eye.

Cyclosporine 0.05% ophthalmic emulsion for dry eye in Korea: a prospective, multicenter, open-label, surveillance study

Purpose

To assess the effectiveness and tolerability of cyclosporine ophthalmic emulsion (CsA) 0.05% in patients with moderate to severe dry eye disease in Korea.

Methods

This was a prospective, multicenter, open-label, surveillance study of 392 Korean patients with moderate to severe dry eye disease who were treated with CsA 0.05% for three months. An assessment of effectiveness was performed at baseline, and after 1, 2, and 3 months. The primary effectiveness outcomes were changes in ocular symptoms and Schirmer score. The secondary effectiveness outcomes were a change in conjunctival staining, use of artificial tears, global evaluation of treatment, and patient satisfaction. The primary safety outcome was the incidence and nature of adverse events.

Results

A total of 362 patients completed the study. After three months, all ocular symptom scores were significantly reduced compared to the baseline values, while the Schirmer scores were significantly increased relative to baseline (p < 0.0001). After three months, there were significant reductions from baseline in conjunctival staining (p < 0.01) and use of artificial tears (p < 0.0001). According to clinicians' global evaluations, most patients (>50%) experienced at least a 25% to 50% improvement in symptoms from baseline at each follow-up visit. The majority of patients (72.0%) were satisfied with the treatment results, and 57.2% reported having no or mild symptoms after treatment. The most common adverse events were ocular pain (11.0%).

Conclusions

Our findings indicate that CsA 0.05% is an effective and tolerable treatment for dry eye disease in Korean clinical practice.

Current insights into ocular graft-versus-host disease

PURPOSE OF REVIEW

To update our knowledge on hematopoietic stem cell transplantation (SCT) and graft-versus-host disease (GVHD) and summarize the current treatment options for ocular GVHD.

RECENT FINDINGS

Allogeneic (allo)-SCT represents a treatment option for a number of hematological malignancies and bone marrow disorders; the indications for this procedure are still increasing. Ocular GVHD develops in 40-60% of patients after allo-SCT, can cause severe ocular surface disease and has a negative impact on quality of life. There are no widely accepted guidelines for the treatment of ocular GVHD. In addition to the usual treatment with artificial tears, topical steroids, punctal occlusion and contact lenses, recent treatment options include anti-inflammatory medications including topical cyclosporine A and tacrolimus. Unfortunately, none of the treatment regimens are completely satisfactory and systematic data on the efficacy of these agents are lacking. The preventive treatment possibilities for ocular GVHD have not been defined.

SUMMARY

This review summarizes current data on ocular GVHD and focuses on novel treatment options for this severe ocular disorder. More data on the impact of ocular GVHD and the development of therapeutic and preventive measures are needed.

Improved signs, symptoms, and quality of life associated with dry eye syndrome: hydroxypropyl cellulose ophthalmic insert patient registry

OBJECTIVES

To evaluate the acceptability, ease of use, and efficacy of hydroxypropyl cellulose ophthalmic inserts in reducing signs and symptoms of moderate-to-severe dry eye syndrome (DES), and improving quality of life (QoL) and activities of daily living (ADL).

METHODS

The multicenter, prospective, open-label, 4-week registry comprised 520 patients with bilateral DES and a history of artificial tear use, or a desire to use artificial tears within the previous week. Visit 1 encompassed a clinical evaluation and symptom and QoL questionnaires, including the Ocular Surface Disease Index. Patients were trained to use inserts, which were used once daily, thereafter, as monotherapy or with existing therapy. At visit 2, clinical evaluation and questionnaires evaluated changes in signs, symptoms, ADL, and QoL. Adverse events were monitored throughout the registry.

RESULTS

There were 418 (80.4%) completers. Statistically significant improvements in discomfort, burning, dryness, grittiness, stinging, and light sensitivity, as well as clinical signs of keratitis, conjunctival staining, and tear volume were seen (P<0.05). Mean Ocular Surface Disease Index total scores improved by 21.3% (P<0.05). Blurred vision, affecting 8.7% of patients, was the most commonly reported adverse event leading to discontinuation.

CONCLUSIONS

Hydroxypropyl cellulose ophthalmic inserts significantly improved signs and symptoms of moderate-to-severe DES, as well as ADL and QoL. Benefits were additive to those seen with patients' existing care.

Acupuncture for dry eye: a randomised controlled trial protocol

BACKGROUND

Dry eye is usually managed by conventional medical interventions such as artificial tears, anti-inflammatory drugs and surgical treatment. However, since dry eye is one of the most frequent ophthalmologic disorders, safer and more effective methods for its treatment are necessary, especially for vulnerable patients. Acupuncture has been widely used to treat patients with dry eye. Our aim is to evaluate the effectiveness and safety of acupuncture for this condition.

METHODS/DESIGN

A randomised, patient-assessor blinded, sham (non-acupuncture point, shallow acupuncture) controlled study was established. Participants allocated to verum acupuncture and sham acupuncture groups will be treated three times weekly for three weeks for a total of nine sessions per participant. Seventeen points (GV23; bilateral BL2, GB4, TE23, Ex1 (Taiyang), ST1 and GB20; and left SP3, LU9, LU10 and HT8 for men, right for women) have been selected for the verum acupuncture; for the sham acupuncture, points have been selected that do not coincide with a classical acupuncture point and that are located close to the verum points, except in the case of the rim of the eye. Ocular surface disease index, tear film breakup time, the Schirmer I test, medication quantification scale and general assessment of improvement will be used as outcome variables for evaluating the effectiveness of acupuncture. Safety will also be assessed at every visit. Primary and secondary outcomes will be assessed four weeks after screening. All statistical analyses will be performed using analysis of covariance.

DISCUSSION

The results of this trial will be used as a basis for clarifying the efficacy of acupuncture for dry eye.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00969280.