The economic burden of dry eye disease in the United States: a decision tree analysis

Associations between Biomarkers of Metal Exposure and Dry Eye Metrics in Shipyard Welders: A Cross-Sectional Study

Shipyard welders are often exposed to welding metal fumes. Ocular surfaces are continually exposed to environmental hazards. However, limited information on the associations between metal exposure and dry eye metrics in occupational settings is available. This study employed a cross-sectional design that involved the participation of 59 welders and 25 administrative staff in a shipyard in northern Taiwan from September 2020 to October 2020. The participants' individual information, laboratory data, exposure to particulate matter < 2.5 μm, urinary, and toenail metal concentrations were collected. Dry eye metrics were evaluated using standardized questionnaires and a noninvasive ocular surface analyzer. Urinary V and Cr and toenail V, Cr, Mn, Fe, Ni, Zn, As, and Cd and Pb were significantly higher in the exposed group than in the control group. After adjustment for confounding factors, dry eye metrics were associated with urinary Cd (β = 0.407; p = 0.007) and toenail Pb (β = 0.482; p = 0.002). The participants with higher urinary Cd exhibited higher odds ratios for elevated dry eye metrics. Our study revealed that exposure to welding procedures increases several metal biomarkers. In addition, urinary Cd, and toenail Pb might be related to dry eye disease in shipyard welders.

The Association Between Sleep Disorders and Incidence of Dry Eye Disease in Ningbo: Data From an Integrated Health Care Network

PURPOSE

To investigate the association between sleep disorders and dry eye disease (DED) in Ningbo, China.

METHODS

Our data came from the Yinzhou Health Information System (HIS), including 257932 patients and was based on a 1:1 matching method (sleep disorder patients vs. patients without sleep disorders) during 2013-2020. Sleep disorders and DED were identified using ICD-10 codes. Cox proportional hazards regression was used to identify the association between sleep disorders and DED.

RESULTS

The eight-year incidence of DED was significantly higher in participants with diagnosis of sleep disorders (sleep disorders: 50.66%, no sleep disorders: 16.48%, P < 0.01). Sleep disorders were positively associated with the diagnosis of DED (HR: 3.06, 95% CI: 2.99-3.13, P < 0.01), when sex, age, hypertension, diabetes and other systemic diseases were adjusted. In the sleep disorders patients, advancing age, female sex, and presence of coexisting disease (hypertension, diabetes, hyperlipidemia, thyroid disease, depression, heart disease, and arthritis) were significantly associated with the development of DED by the multivariate cox regression analysis (all P < 0.05).In addition, there was a significantly positive association between estazolam and the incidence of DED in both sleep disorder and non-sleep disorder groups (all P < 0.05).

CONCLUSIONS

Sleep disrder was associated with a three-time increased risk of DED. This association can be helpful in effective management of both sleep disorders and DED.

Outcome Measures to Assess Dry Eye Severity: A Review

Outcome measures used to assess efficacy of dry eye therapeutics have not been consistently applied in clinical settings, nor have they been shown to correlate with functional outcomes. We propose that corneal staining, a clinically meaningful dry eye parameter, should be used as a standard objective outcome measure across all clinical trials evaluating dry eye treatments. We justify this based on evidence regarding its relationship to vision and vision related quality-of-life. In addition, corneal staining has been shown to correlate with ocular surface inflammation, a well elucidated aspect of dry eye pathophysiology and an active area in therapeutics research. No one outcome measure explored herein correlates perfectly to this heterogenous disease. However, there is mounting evidence showing the correlation between corneal staining and functional visual indices. We hope that future clinical trials will standardize corneal staining as a measure to determine the efficacy of interventions and justify their clinical utility.

Biophysical properties of tear film lipid layer I. Surface tension and surface rheology

Tear film lipid layer (TFLL) is the outmost layer of the tear film. It plays a crucial role in stabilizing the tear film by reducing surface tension and retarding evaporation of the aqueous layer. Dysfunction of the TFLL leads to dysfunctional tear syndrome, with dry eye disease (DED) being the most prevalent eye disease, affecting 10%-30% of the world population. To date, except for treatments alleviating dry eye symptoms, effective therapeutic interventions in treating DED are still lacking. Therefore, there is an urgent need to understand the biophysical properties of the TFLL with the long-term goal to develop translational solutions in effectively managing DED. Here, we studied the composition-function correlations of an artificial TFLL, under physiologically relevant conditions, using a novel experimental methodology called constrained drop surfactometry. This artificial TFLL was composed of 40% behenyl oleate and 40% cholesteryl oleate, representing the most abundant wax ester and cholesteryl ester in the natural TFLL, respectively, and 15% phosphatidylcholine and 5% palmitic-acid-9-hydroxy-stearic-acid (PAHSA), which represent the two predominant polar lipid classes in the natural TFLL. Our study suggests that the major biophysical function of phospholipids in the TFLL is to reduce the surface tension, whereas the primary function of PAHSA is to optimize the rheological properties of the TFLL. These findings have novel implications in better understanding the physiological and biophysical functions of the TFLL and may offer new translational insight to the treatment of DED.

Differential Effects of Treatment Strategies in Individuals With Chronic Ocular Surface Pain With a Neuropathic Component

Background: Dysfunction at the ocular system via nociceptive or neuropathic mechanisms can lead to chronic ocular pain. While many studies have reported on responses to treatment for nociceptive pain, fewer have focused on neuropathic ocular pain. This retrospective study assessed clinical responses to pain treatment modalities in individuals with neuropathic component ocular surface pain. Methods: 101 individuals seen at the University of Miami Oculofacial Pain Clinic from January 2015 to August 2021 with ≥3 months of clinically diagnosed neuropathic pain were included. Patients were subcategorized (postsurgical, post-traumatic, migraine-like, and laterality) and self-reported treatment outcomes were assessed (no change, mild, moderate, or marked improvement). One-way ANOVA (analysis of variance) was used to examine relationships between follow up time and number of treatments attempted with pain improvement, and multivariable logistic regression was used to assess which modalities led to pain improvement. Results: The mean age was 55 years, and most patients were female (64.4%) and non-Hispanic (68.3%). Migraine-like pain (40.6%) was most common, followed by postsurgical (26.7%), post-traumatic (16.8%) and unilateral pain (15.8%). The most common oral therapies were α2δ ligands (48.5%), the m common topical therapies were autologous serum tears (20.8%) and topical corticosteroids (19.8%), and the most common adjuvant was periocular nerve block (24.8%). Oral therapies reduced pain in post-traumatic (81.2%), migraine-like (73%), and unilateral (72.7%) patients, but only in a minority of postsurgical (38.5%) patients. Similarly, topicals improved pain in post-traumatic (66.7%), migraine-like (78.6%), and unilateral (70%) compared to postsurgical (43.7%) patients. Non-oral/topical adjuvants reduced pain in postsurgical (54.5%), post-traumatic (71.4%), and migraine-like patients (73.3%) only. Multivariable analyses indicated migraine-like pain improved with concomitant oral α2δ ligands and adjuvant therapies, while postsurgical pain improved with topical anti-inflammatories. Those with no improvement in pain had a shorter mean follow-up (266.25 ± 262.56 days) than those with mild (396.65 ± 283.44), moderate (652 ± 413.92), or marked improvement (837.93 ± 709.35) (p < 0.005). Identical patterns were noted for number of attempted medications. Conclusion: Patients with migraine-like pain frequently experienced pain improvement, while postsurgical patients had the lowest response rates. Patients with a longer follow-up and who tried more therapies experienced more significant relief, suggesting multiple trials were necessary for pain reduction.

Thermogels containing sulfated hyaluronan as novel topical therapeutics for treatment of ocular surface inflammation

The development of long lasting therapeutic agents is critically important for efficient treatment of chronic diseases. We herein report a rational strategy to develop a therapeutic thermogel featured with prolonged anti-inflammatory and corneal-protective effects. Specifically, a hyaluronic acid with different sulfation degrees and an amine-terminated poly(N-isopropylacrylamide) are conjugated to achieve the thermogels. In vitro studies reveal that the thermogels are highly biocompatible to statens seruminstitut rabbit cornea cells and their anti-inflammatory properties are strongly dependent on the sulfation degree. In a rabbit model of ocular inflammation, single-dose topical administration of a thermogel formulation could repair defects in corneal epithelium (∼99% thickness restored), prevent corneal cell apoptosis (∼68.3% cells recovered), and suppress ocular surface inflammation (∼4-fold decrease) for a follow-up period of 7 days. This high treatment efficacy of the thermogel can be attributed to its potent inhibition in selectin-mediated leukocyte infiltration as well as effective corneal protection. These findings show a great promise for topical treatment of ocular inflammation and advancement of ophthalmic formulations using the bioactive thermogel as a therapeutic component that is not rapidly cleared from the eye and thus considerably reduces administration times.

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Sulfated hyaluronan thermogels served as intrinsic therapeutic agents.

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Thermogels exert inhibitory effects on selectin-mediated leukocyte infiltration.

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Sulfation degree is a key to achieve superior therapeutic thermogels.

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Highly sulfated agent reveals potent anti-inflammatory/corneal-protective effects.

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Single dose reduces corneal inflammation by 4-folds at 7 days post-instillation.

Estimated Annual Economic Burden of Dry Eye Disease Based on a Multi-Center Analysis in China: A Retrospective Study

Purpose: To conduct a multi-center analysis and assess the economic burden due to dry eye disease (DED) in China. Design: A retrospective and cross-sectional study. Methods: Patients (n = 598) with diagnosed DED were recruited from 3 eye centers (in central, southeast, and northeast China) from 1 January 2018 to 31 December 2018. Data were collected regarding the examination, pharmacological therapy, and non-pharmacological therapy fees. Sub-group analyses were stratified by eye center, DED severity, types of DED, number of visits to physicians, and residential area. A logistic regression analysis was conducted to investigate the variables influencing total costs. Results: The per capita costs devoted to DED at the 3 centers were 422.6, 391.3, and 265.4 USD, respectively. The costs of non-pharmacological therapy accounted the largest part in three centers (75.6, 76.4, 76.5%, respectively). Patients with severe DED sustained the largest economic burden. Patients with mixed type of DED spent the most comparing to patients with either evaporative or aqueous-deficient types of DED. Patients spent more during the first visit compared with subsequent visits. Patients living in urban areas spent significantly more than did those living in rural areas (P = 0.001). The logistics regression analysis showed that total costs were significantly influenced by DED severity, number of visits to physicians, and area of residence (beta = 2.83, 0.83, 1.48; P < 0.0001). Conclusions: DED is a chronic ocular disease that timely non-cost counseling, early diagnosis, and efficacious treatment can reduce its economic burden on patients and the society.

Outcomes of Sjögren's versus non-Sjögren's related dry eye in a longitudinal, tertiary clinic-based sample

Purpose

To assess the long-term treatment outcomes of dry eye in patients with and without underlying primary Sjögren’s syndrome (SS).

Design

Retrospective longitudinal cohort.

Methods

SS and non-SS dry eye patients with clinic visits for a minimum of 5 consecutive years at a tertiary, dedicated dry eye clinic were included. Electronic health records were reviewed to collect data regarding demographics, objective dry eye parameters, treatments utilized at baseline and final visit, and corneal complications observed during follow-up.

Results

Two hundred and two patients (101 SS and 101 randomly selected non-SS), with a mean follow-up of 7.1 years were included. At baseline, mean conjunctival lissamine green staining score was 2.9 and mean corneal fluorescein staining score was 2.0. At last visit, notable improvement in staining score for cornea (–1.1, P < .001) and conjunctiva (–1.8, P < .001) was seen equally in both dry eye groups. Most patients (88.1%) had an escalation of treatment by the final visit, with similar rates in both groups (P = .51). Half (48.9%) of the patients had no conjunctival staining, and a third (34.4%) had no corneal staining at their last visit. Twenty (9.9%) patients experienced a vision-threatening corneal complication, including ulcers and melt, with no difference in occurrences between the groups (P = .64).

Conclusions

The majority of patients in this longitudinal, tertiary clinic-based sample demonstrated improvement in their ocular surface staining score by the final visit with escalation in treatment. Treatments used, improvement achieved, and corneal complication rates leading to loss of vision were similar in both SS and non-SS dry eye groups.

Emerging therapies for dry eye disease

INTRODUCTION

Dry Eye Disease (DED) is defined as a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and a vicious cycle of inflammation on the ocular surface. Despite its high prevalence and standing as one of the most common eye conditions seen by practitioners, the current treatment options available to patients have not proven adequate.

AREAS COVERED

This review will discuss the burden of DED, its pathophysiology, as well as emerging therapies. These therapies include immunosuppressants, immunomodulators, anti-inflammatory drugs, and corticosteroids. The mechanisms of these drugs will be discussed, as well as their phase of development and results from recent clinical trials. The literature search was performed using PubMed, Cochrane Library, Web of Science, ClinicalTrials.gov, and the Springer AdisInsight database.

EXPERT OPINION

The optimal therapy for DED is associated with improved bioavailability, minimal ocular side effects, and effective dosing. The ideal treatment has not yet been established, but this paper outlines a number of promising therapies. Continued development of therapies targeting the inflammation cascade, as well as the establishment of objective markers to quantify DED severity, are important aspects in the progression of treatment.

Work productivity among Sjögren's Syndrome and non-Sjögren's dry eye patients: a systematic review and meta-analysis

BACKGROUND

Dry eye disease (DED) is one of the most common conditions presenting to eye care providers and is increasingly recognized to have poor outcomes on quality of life, activities of daily living, and social and emotional well-being. Here, we aim to understand the association between dry eye symptoms and workplace productivity experienced by patients with non-Sjögren's dry eye and Sjögren's Syndrome.

METHODS

MEDLINE, PubMed, Embase, Cochrane Library, CINAHL, Healthstar, and PsycINFO were searched from inception to May 2019.

RESULTS

Thirty-one studies consisting of 50,446 study participants from 14 countries were included in this systematic review. Among non-Sjögren's dry eye patients, there was significant absenteeism (ES = 0.19; 95% CI: [0.04, 0.35]), presenteeism (ES = 0.25; 95% CI: [0.15. 0.35]), productivity impairment (ES = 0.24; 95% CI: [0.20, 0.27]), activity impairment (ES = 0.30; 95% CI: [0.21, 0.38]), and subjective difficulties at work (ES = 0.58; 95% CI: [0.40, 0.75]). Patients with Sjögren's Syndrome demonstrated significant absenteeism (ES = 0.13, 95% CI: [0.10, 0.17]), presenteeism (ES = 0.28, 95% CI: [0.24, 0.32]), productivity impairment (ES = 0.31, 95% CI: [0.27, 0.35]), and activity impairment (ES = 0.39, 95% CI: [0.32, 0.47]) in the workplace. In addition, patients with Sjögren's Syndrome demonstrated significantly lower employment rate (ES = 0.42, 95% CI: [0.34, 0.50]), decreased number of hours worked (SMD = -0.21, 95% CI: [-0.39, -0.02]), and increased work disability (ES = 0.18; 95% CI: [0.09, 0.27]).

CONCLUSIONS

This is the first systematic review and meta-analysis to demonstrate the negative association between DED and several work productivity measures.

Prevalence and incidence of dry eye in the USA: a systematic review protocol

INTRODUCTION

Dry eye is a multifactorial chronic condition characterised by tear film insufficiency and instability, and ocular symptoms including foreign body sensation, itching, irritation, soreness and visual disturbance. The prevalence and incidence of dry eye are major determinants of the magnitude of economic and societal costs of the disease. This protocol proposes a systematic review and meta-analysis of the prevalence and incidence of dry eye in the USA.

METHODS AND ANALYSIS

Working with an information specialist, we will develop search strategies for Ovid Medline and Embase for population-based cross-sectional and cohort studies involving US-based populations that report the prevalence and/or incidence of dry eye. We will include studies involving persons of all ages from 1 January 2010 to the current date with no language restrictions. We will also hand-search references of included studies, dry eye epidemiology-related systematic reviews, clinical practice guidelines and literature provided by agencies and organisations. Two investigators will independently screen the titles and abstracts, and then full-text reports to determine eligibility. One investigator will extract study data and perform risk of bias assessments using tools designed specifically for prevalence and incidence studies. A second investigator will verify all extracted study data and risk of bias assessments. We will assess heterogeneity, qualitatively and quantitatively. When appropriate, we will meta-analyse prevalence and incidence estimates.

ETHICS AND DISSEMINATION

This review does not require approval by an ethics committee because it will use published studies. We will publish our results in a peer-reviewed journal and present at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021256934.

Chambered warm moist air eyelid warming devices - a review

BACKGROUND

Eyelid warming is an important treatment for meibomian gland dysfunction (MGD). Specialized chambered devices, using warm moist air have been developed.

PURPOSE

To critically evaluate the literature on the safety and efficacy of chambered warm moist air devices in MGD treatment and pinpoint areas of future research.

METHODS

PubMed and Embase were searched on 06 June 2021. The search term was '(warm OR heat OR steam OR goggle OR spectacle OR moist air) AND (meibomian OR MGD OR blepharitis OR eyelid OR dry eye OR DED)'. All relevant articles with available English full text were included.

RESULTS

Eighteen articles assessing the application of chambered warm moist air eyelid warming devices were identified. In single-application studies, steam-based eyelid warming increased the eyelid temperature and improved symptoms, lipid layer thickness, and tear film breakup time (TBUT). In treatment studies, the steam-based devices improved TBUT and symptom scores. However, in the only randomized controlled trial (RCT) comparing chambered steam-based heat to hot towel treatment, there was no difference between groups for the primary outcome measure; the proportion of subjects noting symptom improvement after 4 weeks.

CONCLUSION

Currently available chambered warm moist air eyelid warming devices are safe and effective at raising eyelid temperature to therapeutic levels and improving signs and symptoms of dry eye. However, it is not clear if they provide a greater benefit than other eyelid warming therapies. Further well-conducted RCTs comparing moist and dry heat devices should be conducted on patients across the range of DED severities and subtype spectrum.

Efficacy of Lifitegrast Ophthalmic Solution, 5.0%, in Patients With Moderate to Severe Dry Eye Disease: A Post Hoc Analysis of 2 Randomized Clinical Trials

Question

What are post hoc treatment outcomes of lifitegrast by severity of dry eye disease (DED)?

Findings

In this post hoc analysis of 2 randomized clinical trials including 1429 patients, treatment with lifitegrast in the subgroup with an inferior corneal staining score of greater than 1.5 and eye dryness score of at least 60 at baseline (ie, moderate to severe DED) showed lifitegrast-treated participants had higher odds of achieving simultaneous improvement in clinical signs and symptoms than placebo-treated participants.

Meaning

The results of this post hoc analysis suggest that lifitegrast treatment may be associated with a response in the signs and symptoms of moderate to severe DED.

Importance

An investigation of the treatment effect of lifitegrast ophthalmic solution, 5.0%, in different subgroups by severity of dry eye disease (DED) seems warranted.

Objective

To explore the heterogeneity across different subgroups of DED and identify which participants were most likely to achieve clinically meaningful benefit with lifitegrast treatment.

Design, Setting, and Participants

This post hoc responder analysis was performed using the data from the phase 3 OPUS-2 and OPUS-3 studies, which were 12-week, prospective, double-masked, multicenter, placebo-controlled, randomized, parallel-arm clinical trials that previously demonstrated the efficacy of lifitegrast in DED. Pooled data were stratified into 4 subgroups based on severity of inferior corneal staining score (ICSS; ≤1.5 vs >1.5) and eye dryness score (EDS; <60 or ≥60) at baseline. Data were collected from December 7, 2012, to October 5, 2015, and post hoc analysis was performed from April 14, 2020, to July 30, 2021.

Interventions

Lifitegrast or placebo twice daily for 84 days.

Main Outcomes and Measures

Proportion of participants with (1) a clinically meaningful improvement in signs (ICSS or total corneal staining score [TCSS]) and symptoms (EDS or global visual analog scale [VAS]) and (2) a composite response for a given sign and symptom end point pair at day 84 were measured. Clinically meaningful improvement was defined as at least 30% improvement in symptoms (EDS or global VAS) and either at least a 1-point improvement in ICSS or at least a 3-point improvement in TCSS. For the composite responder analysis, the end point pairs were defined as at least a 30% reduction in EDS and at least a 1-point improvement in ICSS; at least a 30% reduction in EDS and at least a 3-point improvement in TCSS; at least a 30% improvement in global VAS and at least a 1-point improvement in ICSS; and at least a 30% improvement in global VAS and at least a 3-point improvement in TCSS.

Results

In total, 1429 participants (716 in the placebo group and 713 in the lifitegrast group) were analyzed (1087 women [76.1%]; mean [SD] age, 58.7 [14.3] years). For the overall pooled population, responder and composite responder rates favored lifitegrast vs placebo (odds ratio range, 1.29 [95% CI, 1.05-1.59] to 2.10 [95% CI, 1.68-2.61]; P ≤ .02). In the composite analysis, the subgroup with ICSS of greater than 1.5 and EDS of at least 60 at baseline (ie, moderate to severe DED) demonstrated a 1.70- to 2.11-fold higher odds of achieving clinically meaningful improvement with lifitegrast across all sign and symptom end point pairs (P ≤ .001).

Conclusions and Relevance

These post hoc findings suggest that lifitegrast ophthalmic solution, 5.0%, treatment may be associated with a response in participants with moderate to severe signs and symptoms of DED.

Trial Registration

ClinicalTrials.gov Identifier: NCT02284516

Stimulating Tear Production: Spotlight on Neurostimulation

Dry eye disease (DED) affects up to one-third of the global population. Traditional therapies, including topical lubricants, have been employed with variable success in the treatment of DED. Recently, neurostimulation of the lacrimal functional unit (LFU) has emerged as a promising alternative therapy for DED. In this review, we describe the neuroanatomical and pathophysiological considerations of DED and the LFU that make neurostimulation a viable therapeutic alternative. We further detail the various neurostimulatory approaches taken thus far—from implanted stimulators to external devices to chemical neurostimulation. Existing studies reveal the strengths of the neurostimulatory approach in increasing tear volume and improving dry eye symptoms, but further studies are needed to elucidate its true potential in treatment of DED.

Economic burden and loss of quality of life from dry eye disease in Canada

Objective

To describe the direct and indirect cost estimates of dry eye disease (DED), stratified by disease severity, and the impact of DED on quality of life (QoL) in Canadian patients.

Methods and analysis

A prospective, multicentre, observational, cross-sectional study was conducted at six sites across Canada. Eligible patients completed a 20 min survey on demography, general health, disease severity, QoL and direct (resource utilisation and out-of-pocket expenses for the past 3–24 months) and indirect costs (absenteeism and presenteeism based on Work Productivity and Activity Impairment questionnaire responses). Subgroup analyses were performed according to DED severity and presence of Sjögren’s syndrome.

Results

Responses from 146 of 151 participants were included in the analysis. DED was rated as moderate or severe by 19.2% and 69.2% of patients, respectively. Total mean annual costs of DED were $C24 331 (Canadian dollars) per patient and increased with patient-reported disease severity. Mean (standard deviation [SD]) indirect costs for mild, moderate and severe disease were $C5961 ($C6275), $C16 525 ($C11 607), and $C25 485 ($C22,879), respectively. Mean (SD) direct costs were $C958 ($C1216), $C1303 ($C1574) and $C2766 ($C7161), respectively. QoL scores were lowest in patients with Sjögren’s syndrome (8.2% of cohort) and those with severe DED.

Conclusion

This study provides important insights into the negative impact of DED in a Canadian setting. Severe DED was associated with higher direct and indirect costs and lower QoL compared with those with mild or moderate disease. Increased costs and poorer QoL were also evident for patients with DED plus Sjögren’s syndrome versus DED alone.

Autologous serum eye drops for ocular surface disorders

PURPOSE OF REVIEW

Ocular surface disease is a prevalent, diverse group of conditions that cause patient discomfort and decreased visual acuity and present considerable expense to both patients and healthcare systems. Autologous serum eye drops are a topical treatment modality derived from the patient's own blood. Use of serum eye drops for ocular surface disease has been promising due to biochemical similarities to endogenous tears.

RECENT FINDINGS

Use of serum eye drops for moderate to severe ocular surface diseases such as dry eye, corneal epithelial defects, and inflammatory conditions has become more prevalent. Recent studies have demonstrated that the use of serum eye drops is well-tolerated by patients and associated with improvement in patient-reported outcomes and objective dry eye parameters. Production of serum eye drops may vary, treatment costs can be significant, and the quality of evidence for serum eye drop use published from randomized controlled trials is modest, particularly for long-term treatment. Accessibility remains an area for improvement and may be complemented by allogeneic serum eye drops.

SUMMARY

Serum eye drops are frequently used as a safe, well-tolerated, and effective treatment for ocular surface disease. Further research is needed to assess long-term outcomes and improve accessibility.

TearCare for the Treatment of Meibomian Gland Dysfunction in Adult Patients With Dry Eye Disease: A Masked Randomized Controlled Trial

The aim of this study was to demonstrate the safety and effectiveness of a single TearCare procedure compared with a single LipiFlow procedure in treatment of the dry eye disease associated with meibomian gland dysfunction.

The relationship between smartphone use and dry eye disease: A systematic review with a narrative synthesis

BACKGROUND

Emerging research findings suggest a potential relationship between smartphone use (SPU) and dry eye disease (DED), which has not been systematically reviewed.

OBJECTIVES

The aim of this study was to systematically review and synthesize evidence on the relationship between SPU and DED.

METHODS

A systematic search of Medline, EMBASE, CINAHL, and PsychINFO bibliographic databases from their inception to January 15, 2021. Study screening, full-text assessment, study selection and exclusion, data extraction, and quality assessment was performed independently by at least two review authors.

RESULTS

Four studies were included in the review (3 cross-sectional studies and 1 nonrandomized clinical trial). A narrative synthesis of findings was used due to heterogeneity among study designs and measures of association summarizing the relationship between SPU and DED. All included studies were conducted in South Korea and included school children, college students, or young adults. Three of the 4 included studies showed an association between SPU and DED.

CONCLUSIONS

There is some evidence that SPU is associated with DED. However, this evidence is limited by a small number of studies of satisfactory methodological quality. There is a great need for high-quality studies to further investigate the relationship between SPU and DED and identify mechanisms underlying this potential relationship. This information is important for raising public awareness about the negative effect of SPU on eye health and development of clinical guidelines for this potentially emerging SPU-driven eye condition.

The Relationship Between Dry Eye Disease and Digital Screen Use

Dry eye disease is characterized by tear film instability that can result in ocular surface damage. Patients with dry eye disease may experience ocular pain/discomfort and visual disturbances that may negatively impact quality of life. Increased use of digital screens for work, communication, and entertainment, especially during times of pandemic, may contribute to dry eye. Extensive cross-sectional studies have shown that digital screen use duration is associated with an increased risk of severe symptoms and clinical diagnosis of dry eye disease in adults. Smartphone use duration has also been found to be greater in school-age children with dry eye disease than in those without dry eye disease. A commonly accepted hypothesis for the relationship between digital screen use and dry eye disease is that digital screen use changes blinking dynamics, leading to ocular dryness. This review describes evidence that digital screen use is associated with dry eye disease, that digital device use alters blinking dynamics, and that dry eye affects mental health and work productivity in digital screen users. Helpful prevention and management strategies for dry eye disease exist for those who use digital screens.

Annual direct economic burden and influencing factors of dry eye disease in Central China

PURPOSE

To study the direct economic burden of dry eye diseases (DED) on Chinese residents and analyze the influencing factors of the direct economic burden of patients with DED.

METHODS

Two hundred and twenty-one Chinese adults with DED who underwent treatment in Wuhan Aier Hankou Eye Hospital were enrolled in this health economics research from January 2018 to August 2018 and followed for at least 1 year. Examination, pharmacological therapy, and nonpharmacological therapy costs were collected to calculate the annual direct economic burden of DED on patients through the outpatient medical record system.

RESULTS

Annual direct economic burden caused by DED on each patient was $465.54 ± 303.08. The direct economic burden of female patients in the 40-49 years group was significantly higher than that of male patients (P < .05). Age, number of hospital visits and severity of DED were showed a significant influence on the direct economic burden both in univariate linear regression analysis and multiple linear regression analysis. Subtype of DED was showed a significant influence on the direct economic burden in multiple linear regression analysis after eliminating confounding factors.

CONCLUSION

This study preliminarily analyzed the direct economic burden of Chinese DED patients. Age, number of hospital visits, severity of DED, mixed and evaporative dry eye (EDE) subtypes are shown to be the significant influencing factors of the direct economic burden and sex is a potential influencing factor.

PREVALENCE OF MEIBOMIAN GLAND DYSFUNCTION IN AFRICA: A SYSTEMATIC REVIEW AND META-ANALYSIS OF OBSERVATIONAL STUDIES

PURPOSE

To review and summarize information on meibomian gland dysfunction (MGD) epidemiology in Africa.

METHODS

A systematic search of online databases was conducted for literature/studies on MGD in Africa. Meta-analysis was conducted to estimate the prevalence of MGD in Africa. Meta-regression was used to explore sources of heterogeneity.

RESULTS

Twelve studies conducted in five countries were included in the review. All studies were hospital-based studies. Nine studies were included in the meta-analysis; the total sample size was 4963 and participants' age range was 17-96 years. The overall prevalence estimate of MGD in Africa was 45.9% (95% CI: 27.6-64.1%). Prevalence of MGD among males and females were each pooled from three studies and in urban and rural setting from 6 and 3 studies, respectively. Prevalence of MGD among males and females were 56.0% (95% CI: 22.4-89.5%) and 58.9% (95% CI: 28.5-89.4%) respectively; in urban and rural settings were 42.8% (95% CI: 21.1-64.5%) and 65.7% (95% CI: 25.7-95.7%), respectively. There was no association of MGD with sex (p = .872) and with study setting (p = .231).

CONCLUSION

There is a paucity of evidence on MGD prevalence in Africa, emphasizing the need for epidemiological studies to enhance our understanding of region-specific differences in MGD in Africa. The pooled estimate from hospital-based studies, however, suggests a substantial MGD burden in Africa. Epidemiological studies are needed to assess if this translates to a high disease burden within the general African population.

The transcriptome of rabbit conjunctiva in dry eye disease: Large-scale changes and similarity to the human dry eye

The pathophysiology of dry eye disease (DED) remains largely unknown, accounting in part for the lack of successful treatments. We explored the pathophysiology of DED using a rabbit model of chronic DED induced with 3 weekly injections of Concanavalin A into the periorbital lacrimal glands. The transcriptome of full-thickness's conjunctival tissue from rabbits with DED and from normal controls was determined using microarrays and, as needed, confirmatory real-time polymerase chain reactions. Results were subjected to bioinformatic analysis. DED induced large-scale changes in gene transcription involving 5,184 genes (22% of the total). Differentially expressed genes could be segregated into: functional modules and clusters; altered pathways; functionally linked genes; and groups of individual genes of known or suspected pathophysiological relevance to DED. A common feature of these subgroups is the breadth and magnitude of the changes that encompass ocular immunology and essentially all aspects of cell biology. Prominent changes concerned innate and adaptive immune responses; ocular surface inflammation; at least 25 significantly altered signaling pathways; a large number of chemokines; cell cycle; and apoptosis. Comparison of our findings to the limited extant transcriptomic data from DED patients associated with either Sjogren's syndrome or non-Sjogren's etiologies revealed a significant correlation between human and rabbit DED transcriptomes. Our data, establishing the large-scale transcriptomic changes of DED and their potential similarity to the human, underscore the enormous complexity of DED; establish a robust animal model of DED; will help expand our understanding of its pathophysiology; and could guide the development of successful therapeutic strategies.

Corneal Epithelial Stem Cell Supernatant in the Treatment of Severe Dry Eye Disease: A Pilot Study

PURPOSE

To report the subjective assessment of topical self-administered, cadaver-derived corneal epithelial stem cell supernatant for treatment of severe dry eye disease (DED).

METHODS

Thirty-four eyes of 17 patients with advanced DED as defined by Standardized Patient Evaluation of Eye Dryness (SPEEDTM) questionnaire ≥14, Ocular Surface Disease Index (OSDI©) score ≥40 and documented attempt of at least six conventional dry eye therapies were enrolled into a prospective clinical trial at a single private practice institution. Treatment consisted of patient self-administered topical instillation of the corneal epithelial stem cell-derived product four times daily in both eyes for 12 weeks. Patient-reported outcome measures (PROMs) were taken with the SPEEDTM questionnaire (the main outcome variable), OSDI© score and visual analog score (VAS; UNC Dry Eye Management Scale©), and objective clinical measurements were taken with best-corrected visual acuity (BCVA), corneal topographic index measurements and tear film osmolarity. These measurements were compared at baseline versus the endpoint at completion of the 12-week treatment.

RESULTS

All 34 eyes tolerated the treatment without any adverse events or significant side effects. Compared with baseline, both the SPEEDTM questionnaire and the VAS significantly improved at the conclusion of the 12-week treatment (p = 0.0054 and p = 0.0202, respectively). The OSDI© improved by an average of 10.9 points after the treatment but was not statistically significant (p = 0.1409). There were no significant changes in any of the objective clinical measurements. None of the study subjects failed to complete the treatment course, experienced decrease in any of the PROMs or lost one or more lines of BCVA during the follow-up period.

CONCLUSION

Topical corneal epithelial stem cell-derived supernatant that can be self-administered by the patient shows promise at improving patient symptoms and quality of life in the setting of severe DED that is unresponsive to conventional therapies.

Ocular Discomfort and Quality of Life Among Patients in the Dry Eye Assessment and Management Study

PURPOSE

To assess the association of severity of ocular discomfort with measures of quality of life among patients with moderate to severe dry eye disease (DED).

METHODS

This is a prospective, observational, cohort study within a randomized clinical trial. Patients (N = 535) in the Dry Eye Assessment and Management study with moderate to severe DED completed the Ocular Surface Disease Index on DED symptoms, the SF-36 on quality of life, and the Brief Ocular Discomfort Inventory questionnaire and had a comprehensive ophthalmic assessment by a study-certified clinician. The ocular discomfort on average over the past week was scored on an 11-point scale (0 for no discomfort and 10 for discomfort as bad as you can imagine).

RESULTS

The average ocular discomfort scores for patients ranged from 0 to 10, with a mean of 4.28. Discomfort scores did not vary with demographic characteristics, signs of DED, self-reported depression, or self-reported nonocular pain conditions. Ocular discomfort scores did correlate moderately to strongly with total Ocular Surface Disease Index scores (Spearman correlation coefficient, rs, 0.47-0.67) and with measures of interference with activities of daily living [general activity level, mood, walking ability, ability for normal work, relations with other people, sleep, and enjoyment of life (rs = 0.39-0.65)].

CONCLUSIONS

Among patients in the Dry Eye Assessment and Management study, worse ocular discomfort was associated with worse overall DED symptoms and interfered to a greater degree with activities of daily living. Ocular discomfort is an important part of the assessment of patients with DED.

Comparison of treatment efficacy between 100% platelet-rich plasma and 100% serum eye drops in moderate-to-severe dry eye disease: a randomised controlled trial protocol

INTRODUCTION

Dry eye disease (DED) is a common eye problem. Although the disease is not fatal, it substantially reduces quality of life and creates a high economic burden, especially in patients with moderate-to-severe DED. Several biological tear substitutes (eg, autologous serum (AS), autologous platelet-rich plasma (APRP) and autologous platelet lysate) could effectively improve dry eyes. However, evidence on their comparative efficacy is controversial. This study aims to compare the efficacy of 100% APRP with 100% AS eye drops in patients with moderate-to-severe DED.

METHODS AND ANALYSIS

The study is a single-centre, double-blinded randomised, parallel, non-inferiority trial. One hundred and thirty patients with moderate-to-severe DED, aged 18-70 years will be recruited from outpatient clinic, Department of Ophthalmology, Ramathibodi Hospital, Bangkok from February 2021 to January 2023. Patients will be randomised to receive either 100% APRP or 100% AS eye drops (1:1 ratio) for 4 weeks. The primary outcomes are ocular surface disease index (OSDI) and ocular surface staining (OSS) evaluated using the Oxford scale. Secondary outcomes are fluorescein break-up time, Schirmer's I test, meibomian gland parameters and adverse events. Other measured outcomes include best-corrected visual acuity, intraocular pressure and compliance.

ETHICS AND DISSEMINATION

The study protocol and any supplements used in conducting this trial have been approved by the Ethics Committee of Faculty of Medicine, Ramathibodi Hospital, Mahidol University (MURA2020/1930). Informed consent will be obtained from all patients before study entry. Results will be presented in peer-reviewed journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT04683796.

Phospho-Sulindac (OXT-328) Inhibits Dry Eye Disease in Rabbits: A Dose-, Formulation- and Structure-Dependent Effect

Purpose: Inflammation of the ocular surface is central to dry eye disease (DED). The anti-inflammatory agent phospho-sulindac (PS) at a high dose was efficacious against DED in a rabbit model. We assessed the dose, formulation and structure dependence of PS's effect. Methods: In rabbits with concanavalin A-induced DED we evaluated a range of PS concentrations (0.05%-1.6%) and dosing frequencies, assessed the duration of its effect with PS in 2 solution formulations and one emulsion formulation, and compared the efficacy of PS to that of sulindac, and of the structurally similar phospho-ibuprofen amide. We determined tear breakup time (TBUT) (tear stability), Schirmer's tear test (tear production), and by esthesiometry corneal sensitivity (symptoms). We also determined the biodistribution in the eye of topically applied PS. Results: PS in a solution formulation, given as eye drops q.i.d. was efficacious starting at a dose of 0.1%. The effect was apparent after 2 days of treatment and lasted at least 8 days after the last dose. Both signs (evidenced by TBUT and Schirmer's test) and symptoms (measured by corneal sensitivity) improved significantly. The best formulation was the solution formulation; a cyclodextrin-based formulation was also successful but the emulsion formulation was not. PS and its metabolites were essentially restricted to the anterior chamber of the eye. Sulindac and phospho-ibuprofen amide had no efficacy on DED. Conclusions: PS is efficacious against DED. Its effect, encompassing signs, and symptoms, are dose, formulation, and structure dependent. PS has therapeutic promise and merits further development.

Impact of the COVID-19 pandemic on eye strain and dry eye symptoms

Purpose

Among adult individuals with dry eye, assess the self-reported impact of the COVID-19 pandemic on (1) dry eye-related visual function, (2) reading efficiency, and (3) dry eye treatments used.

Methods

In June–July 2020, we conducted an online survey of adults with dry eye who spent at least somewhat more time at home during the pandemic than before. Consistent with TFOS DEWS II guidelines, we categorized respondents into mild, moderate, or severe dry eye based on treatment usage.

Results

We included 388 respondents: 97 respondents (25%) with mild, 80 (21%) with moderate, and 211 (54%) with severe dry eye. In all three groups, screen/reading time generally doubled during the pandemic. Reduced work-related efficiency was noted by a considerable proportion of respondents (moderate dry eye: 51%, mild: 39%, and severe: 38%). Compared with respondents with mild dry eye, respondents with moderate dry eye were considerably more likely to note worsening symptoms: eye pain (OR = 2.57, 95% CI 1.22–5.41), headache from eye symptoms (OR = 2.34, 95% CI 1.11–4.90), and difficulty concentrating because of eye symptoms (OR = 2.79, 95% CI 1.37–5.66). Respondents with moderate dry eye with Sjögren's syndrome were most likely to note these. Respondents with severe dry eye were more likely than respondents with mild dry eye to report losing access to dry eye-related treatments (OR = 2.62, 95% CI 1.36–5.03).

Conclusions

The COVID-19 pandemic-related eye strain may be impacting symptoms, performance, and ultimately employment, especially for those with moderate dry eye. This may be compounding the already-high dry eye-related societal burden.

The relationship between alcohol consumption and dry eye

PURPOSE

To assess the association between dry eye disease (DED) and alcohol consumption using a large population-based cohort.

METHODS

77,145 participants (19-94 years, 59% female) from the Dutch Lifelines cohort were cross-sectionally assessed for DED using the Women's Health Study (WHS) dry eye questionnaire. Alcohol intake was assessed using self-reported food frequency questionnaires. The relationship between DED and alcohol use was analyzed using logistic regression, corrected for age, sex, BMI, smoking status, education, income, and 55 potentially confounding comorbidities.

RESULTS

Overall, 30.0% of participants had symptomatic dry eye. Alcohol use significantly increased the risk of symptomatic dry eye in females (odds ratio [OR] 1.095, 95%CI 1.045-1.148), but not in males (OR 0.988, 95%CI 0.900-1.084). Contrarily, in male drinkers, increasing alcohol intake (in 10 g/day) had a protective effect on symptomatic dry eye (OR 0.962, 95%CI 0.934-0.992), which was not seen in females (OR 0.986, 95%CI 0.950-1.023). Alcohol use and intake had a sex-specific effect on all outcomes of DED assessed: symptomatic dry eye, highly symptomatic dry eye, clinical diagnosis, and WHS definition dry eye.

CONCLUSIONS

This large population-based study found alcohol use to have a clear sex-specific effect on DED, presenting as a risk-factor only in females. This adds to the evidence of sex-specific pathophysiological mechanisms of dry eye and illustrates the importance of sex stratification in studies investigating DED. The mild protective effect of increased alcohol intake in male drinkers is advised to be interpreted with caution, as alcohol's other health effects might be of greater clinical significance.

Demographic and lifestyle risk factors of dry eye disease subtypes: A cross-sectional study

PURPOSE

To evaluate demographic and lifestyle factors associated with aqueous deficient and evaporative dry eye disease.

METHODS

A total of 1125 general public visitors (707 females, mean ± SD age, 33 ± 21, range 5-90 years) at the Royal Society Summer Science Exhibition were recruited in a cross-sectional study. A demographic and lifestyle factor questionnaire was administered, and dry eye symptomology (DEQ-5 score), ocular surface characteristics (conjunctival hyperaemia, and infrared meibography), and tear film parameters (tear meniscus height, non-invasive breakup time, and lipid layer grade) were evaluated for the left eye of each participant within a single session. The diagnostic criteria for dry eye disease subtypes were adapted from the rapid non-invasive dry eye assessment algorithm.

RESULTS

Overall, 428 (38%) participants fulfilled the diagnostic criteria for dry eye disease, 161 (14%) with aqueous deficient dry eye disease, and 339 (30%) with evaporative dry eye disease. Multivariate logistic regression demonstrated that advancing age, female sex, reduced sleep duration, higher psychological stress, and poorer self-perceived health status were independently associated with aqueous deficient dry eye disease (all p < 0.05). Significant risk factors for evaporative dry eye disease included advancing age, East and South Asian ethnicity, contact lens wear, increased digital device screen exposure, higher psychological stress, and poorer self-perceived health status (all p < 0.05).

CONCLUSIONS

Both subtypes of dry eye disease were associated with several unique and shared demographic and lifestyle factors. The findings of this study could inform future research design investigating the utility of targeted screening and risk factor modification for the prevention and management of dry eye disease.

Interventions for Demodex blepharitis and their effectiveness: A systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis was performed to evaluate the effectiveness of interventions in the treatment ofDemodex blepharitis in adult patients.

METHODS

A systematic review and meta-analysis of studies reporting the efficacy of treatments forDemodex blepharitis in the main databases (PubMed / Scopus / Cochrane / EMBASE / Science Direct / WOS / Scielo / Google Scholar / metaRegister of Controlled Trials / ClinicalTrials.gov/ WHO ICTRP) until November 24, 2020 was performed according to the PRISMA statement for meta-analysis.

RESULTS

Overall, 18 studies were included for 29 different interventions in 1195 participants with 1574 eyes that were positive for Demodex Spp. Demodex counts, total eradication, clinical improvement, Ocular Surface Disease Index, Tear Break-Up Time, cylindrical dandruff, Schirmer test, osmolarity and adverse reactions were analysed, and stratified sub-analyses conducted. The overall effects for Demodex count (mean difference), total eradication (risk ratio) and adverse reactions (risk difference) were -2.07 (95 % CI -3.99 to -0.15) p = 0.03, 1.84 (95 % CI 1.27-2.66) p = 0.001 and 0.24 (95 % CI 0.08 to 0.41) p = 0.005, respectively. The most frequent interventions evaluated in the included studies were tea tree oil (TTO) and its derivatives, such as terpinen 4-ol.

CONCLUSION

Multiple therapeutic choices were evaluated in this meta-analysis. Pharmacological interventions were superior to non-pharmacological (mechanical, thermal and pulsed light) interventions. It was not possible to establish significant differences between TTO and non-TTO-derived treatments. Adverse reactions were more frequent in TTO-derived treatments, however all were mild. It is necessary to execute studies with longer follow-up times to determine whether re-infestation occurs after the administration of different treatments.

The protective role of PHB and its degradation products against stress situations in bacteria

Many bacteria produce storage biopolymers that are mobilized under conditions of metabolic adaptation, for example, low nutrient availability and cellular stress. Polyhydroxyalkanoates are often found as carbon storage in Bacteria or Archaea, and of these polyhydroxybutyrate (PHB) is the most frequently occurring PHA type. Bacteria usually produce PHB upon availability of a carbon source and limitation of another essential nutrient. Therefore, it is widely believed that the function of PHB is to serve as a mobilizable carbon repository when bacteria face carbon limitation, supporting their survival. However, recent findings indicate that bacteria switch from PHB synthesis to mobilization under stress conditions such as thermal and oxidative shock. The mobilization products, 3-hydroxybutyrate and its oligomers, show a protective effect against protein aggregation and cellular damage caused by reactive oxygen species and heat shock. Thus, bacteria should have an environmental monitoring mechanism directly connected to the regulation of the PHB metabolism. Here, we review the current knowledge on PHB physiology together with a summary of recent findings on novel functions of PHB in stress resistance. Potential applications of these new functions are also presented.

Effects on the Ocular Surface from Reading on Different Smartphone Screens: A Prospective Randomized Controlled Study

The purpose of this study was to investigate the influence of smartphone reading on the ocular surface and to compare the various effects of different screens and light conditions on the ocular surface. One hundred nineteen volunteers were randomly divided into: light + organic light-emitting diode (OLED), light + electronic ink (eINK), dark + OLED, and dark + eINK. Ocular surface examinations, including noninvasive break-up time (NIBUT), noninvasive keratograph tear meniscus height (NIKTMH), ocular redness, fluorescein break-up time (FBUT), corneal fluorescein staining, meibomian gland assessment, Schirmer I Test, and blinking frequency, were performed before and after a reading task. Symptoms were evaluated using the Ocular Surface Disease Index (OSDI) and Computer Vision Syndrome Questionnaire (CVS-Q). NIBUT and FBUT were decreased statistically significantly after participants read on an OLED screen for 2 hours compared with the baseline in light and dark environments, whereas no statistically significant decrease was observed on an eINK screen. NIKTMH was statistically significantly decreased after reading on an OLED screen in light and dark settings, and the eINK screen had a lesser effect on NIKTMH. An obvious increase in the ocular redness, OSDI and CVS-Q scores was observed after reading on an OLED screen, whereas the eINK screen had a lesser effect on these indicators. Blink rate increased gradually in OLED subgroups during the reading task, whereas no statistically significant difference was observed in the eINK subgroups. Our research suggested that reading on an OLED screen can cause ocular surface disorder and obvious subjective discomfort, whereas reading on an eINK screen can minimize ocular surface disorder in both dark and light environments.

Relationship between unhealthy sleep status and dry eye symptoms in a Japanese population: The JPHC-NEXT study

PURPOSE

To investigate whether and how unhealthy sleep habits (i.e., the frequency of difficulty falling or staying asleep, and the frequency of waking up tired) and the duration of sleep are related to the prevalence of dry eye disease (DED) in a general population.

METHODS

This study included a total of 106,282 subjects aged 40-74 years who participated in a baseline survey of the Japan Public Health Center-based Prospective Study for the Next Generation. DED was defined as the presence of clinically diagnosed DED or severe symptoms. Multivariable-adjusted logistic regression models were used to assess the relationships of various components of sleep status with DED.

RESULTS

Higher frequencies of having difficulty falling or staying asleep, and waking up tired were significantly related to increased DED in both sexes (P_trend<0.001). Compared with those with 8 h/day of sleep, shorter sleepers had an increased prevalence of DED in both sexes, although DED was increased among men who slept ≥10 h/day. By comparing participants with the greatest vs. the least difficulty of falling asleep, the multivariable-adjusted odds ratios (95% confidence interval [CI]) were 2.23 (95% CI, 1.99-2.49) for men and 1.91 (95% CI, 1.76-2.07) for women. When analyzed separately, the magnitude of each relationship was stronger with severe DED symptoms than with clinically diagnosed DED.

CONCLUSIONS

Sleep deprivation and poor sleep quality were significantly related to DED in a Japanese population.

Dry eye: why artificial tears are not always the answer

Dry eye disease (DED) is a multifactorial disease that manifests in patients with a variety of symptoms and signs such as ocular pain, visual issues, rapid tear evaporation and/or decreased tear production. It is a global health problem and is the leading cause of optometry and ophthalmology clinic visits. The mainstay therapy for DED is artificial tears (ATs), which mimics tears and improves tear stability and properties. ATs have been found to improve symptoms and signs of disease in all DED subtypes, including aqueous deficient DED and evaporative DED. However, given the heterogeneity of DED, it is not surprising that ATs are not effective in all patients. When AT fails to relieve symptoms and/or signs of DED, it is critical to identify the underlying contributors to disease and escalate therapy appropriately. This includes underlying systemic diseases, meibomian gland dysfunction, anatomical abnormalities and neuropathic dysfunction. Thus, this review will discuss the benefits and limitations of ATs and review conditions when escalation of therapy should be considered in DED.

Pigment Epithelium-Derived Factor Enhances the Suppressive Phenotype of Regulatory T Cells in a Murine Model of Dry Eye Disease

Pigment epithelium-derived factor (PEDF) is a widely expressed 50-kDa glycoprotein belonging to the serine protease inhibitor family, with well-established anti-inflammatory functions. Recently, we demonstrated the immunoregulatory role played by PEDF in dry eye disease (DED) by suppressing the maturation of antigen-presenting cells at the ocular surface following exposure to the desiccating stress. In this study, we evaluated the effect of PEDF on the immunosuppressive characteristics of regulatory T cells (Tregs), which are functionally impaired in DED. In the presence of PEDF, the in vitro cultures prevented proinflammatory cytokine (associated with type 17 helper T cells)-induced loss of frequency and suppressive phenotype of Tregs derived from normal mice. Similarly, PEDF maintained the in vitro frequency and enhanced the suppressive phenotype of Tregs derived from DED mice. On systemically treating DED mice with PEDF, moderately higher frequencies and significantly enhanced suppressive function of Tregs were observed in the draining lymphoid tissues, leading to the efficacious amelioration of the disease. Our results demonstrate that PEDF promotes the suppressive capability of Tregs and attenuates their type 17 helper T-cell-mediated dysfunction in DED, thereby playing a role in the suppression of DED.

Systemic Conditions Associated with Severity of Dry Eye Signs and Symptoms in the Dry Eye Assessment and Management Study

PURPOSE

Certain systemic conditions are reported to be risk factors for dry eye disease (DED), but their associations with DED severity are not well studied. We evaluated whether systemic conditions reported to be DED risk factors are associated with severity of DED signs and symptoms.

DESIGN

Secondary analysis of data from the Dry Eye Assessment and Management Study, a large-scale multicenter randomized clinical trial of patients with moderate to severe DED.

PARTICIPANTS

Five hundred thirty-five adult patients with moderate to severe DED from 27 United States centers.

METHODS

Patients reported their medical history at baseline. They underwent ocular surface examinations and symptom evaluation using standardized protocols at baseline, 6 months, and 12 months. We analyzed the associations of systemic conditions (a systemic disease or smoking history) reported as potential DED risk factors with the severity of DED signs and symptoms using generalized linear regression models adjusted by age, gender, race, and visit.

MAIN OUTCOME MEASURES

Dry eye disease symptoms assessed using the Ocular Surface Disease Index (OSDI), 6 DED signs (tear film break-up time, anesthetized Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, tear osmolarity, and meibomian gland dysfunction), and a composite signs severity score from 0 to 1 (1 = most severe).

RESULTS

The mean age was 58 years; 81% were women. More severe DED signs were associated significantly with Sjögren syndrome (mean composite signs severity score 0.52 with disease vs. 0.43 without disease; P < 0.001), facial rosacea (0.47 vs. 0.43; P = 0.002), rheumatoid arthritis (0.47 vs. 0.42; P = 0.002), peripheral artery disease (0.50 vs. 0.43; P < 0.001), and daily smoking history (0.45 vs. 0.43; P = 0.047). Thyroid dysfunction, osteoarthritis, diabetes, irritable bowel syndrome, hypercholesterolemia, hypertension, and hypertriglyceridemia were not associated significantly with DED signs. No conditions were associated significantly with OSDI.

CONCLUSIONS

In this large, well-characterized cohort of patients with DED assessed under standardized procedures, patients with certain systemic diseases and smoking history showed more severe DED signs compared with patients without the conditions. The profile of significant DED signs varied by systemic condition, reflecting different DED causes. Understanding the systemic conditions and underlying causes that predispose some patients to severe DED can improve management.

The Properties and Role of O-Acyl-ω-hydroxy Fatty Acids and Type I-St and Type II Diesters in the Tear Film Lipid Layer Revealed by a Combined Chemistry and Biophysics Approach

The tear film lipid layer (TFLL) that covers the ocular surface contains several unique lipid classes, including O-acyl-ω-hydroxy fatty acids, type I-St diesters, and type II diesters. While the TFLL represents a unique biological barrier that plays a central role in stabilizing the entire tear film, little is known about the properties and roles of individual lipid species. This is because their isolation from tear samples in sufficient quantities is a tedious task. To provide access to these species in their pure form, and to shed light on their properties, we here report a general strategy for the synthesis and structural characterization of these lipid classes. In addition, we study the organization and behavior of the lipids at the air–tear interface. Through these studies, new insights on the relationship between structural features, such as number of double bonds and the chain length, and film properties, such as spreading and evaporation resistance, were uncovered.

Middle East Preferred Practice Patterns for Dry Eye Disease: A Modified Delphi Consensus

Background:

Dry Eye Disease (DED) is a common ophthalmic condition resulting from dysfunction in the ocular surface, main lacrimal gland, meibomian glands, or connecting nerves.

Objective:

A group of local experts met to discuss local challenges and establish consensus in DED management across the Middle East.

Methods:

A modified Delphi method was used to reach consensus, comprising two rounds of the survey and a face-to-face meeting. An expert panel of 8 ophthalmologists voted on 23 statements, with consensus reached if ≥75% responded “strongly agree” or “agree” to a statement.

Results:

The expert panel reached consensus on 23 statements relating to the pathophysiology, diagnosis, treatment, and management of DED. Diagnosis begins with recording a detailed patient history and assessing subjective symptoms such as redness, burning, stinging, foreign body sensation, and/or photophobia. Tear Break-up Time (TBUT; <10 s), corneal spots (>5), and fluorescein staining are essential for diagnosing DED, assessing disease severity and ocular surface condition, and differentiating between types of DED. Ocular surface lubricants are the mainstay of treatment for DED. Treatment approaches should be categorized by etiology (if known). An improvement in symptoms can be observed objectively via an increase in TBUT, reduction in corneal and conjunctival spots, and restoration of normal tear production, or subjectively via less dependence on ocular surface lubricants, improved vision quality, and symptom amelioration.

Conclusion:

This consensus will serve to provide a framework for clinical decisions relating to the management of DED across the region.

A Novel Epidemiological Approach to Geographically Mapping Population Dry Eye Disease in the United States Through Google Trends

PURPOSE

Our study fills the spatiotemporal gaps in dry eye disease (DED) epidemiology by using Google Trends as a novel epidemiological tool for geographically mapping DED in relation to environmental risk factors.

METHODS

We used Google Trends to extract DED-related queries estimating users' intent from 2004 to 2019 in the United States. We incorporated national climate data to generate heat maps comparing geographic, temporal, and environmental relationships of DED. Multivariable regression models were constructed to generate quadratic forecasts predicting DED and control searches.

RESULTS

Our results illustrated the upward trend, seasonal pattern, environmental influence, and spatial relationship of DED search volume across the US geography. Localized patches of DED interest were visualized in urban areas. There was no significant difference in DED queries across the US census regions (P = 0.3543). Regression model 1 predicted DED queries per state (R2 = 0.61), with the significant predictor being urban population [r = 0.56, adjusted (adj.) P < 0.001, n = 50]; model 2 predicted DED searches over time (R2 = 0.97), with significant predictors being control queries (r = 0.85, adj. P = 0.0169, n = 190), time (r = 0.96, adj. P < 0.001, n = 190), time2 (r = 0.97, adj. P < 0.001, n = 190), and seasonality (winter r = -0.04, adj. P = 0.0196, n = 190; spring r = 0.10, adj. P < 0.001, n = 190).

CONCLUSIONS

Our study used Google Trends as a novel epidemiologic approach to geographically mapping the US DED. Importantly, urban population and seasonality were stronger risk factors of DED searches than temperature, humidity, sunshine, pollution, or region. Our work paves the way for future exploration of geographic information systems for locating DED and other diseases through online population metrics.

Formulation Considerations for the Management of Dry Eye Disease

Dry eye disease (DED) is one of the most common ocular surface disorders characterised by a deficiency in quality and/or quantity of the tear fluid. Due to its multifactorial nature involving several inter-related underlying pathologies, it can rapidly accelerate to become a chronic refractory condition. Therefore, several therapeutic interventions are often simultaneously recommended to manage DED efficiently. Typically, artificial tear supplements are the first line of treatment, followed by topical application of medicated eyedrops. However, the bioavailability of topical eyedrops is generally low as the well-developed protective mechanisms of the eye ensure their rapid clearance from the precorneal space, thus limiting ocular penetration of the incorporated drug. Moreover, excipients commonly used in eyedrops can potentially exhibit ocular toxicity and further exacerbate the signs and symptoms of DED. Therefore, formulation development of topical eyedrops is rather challenging. This review highlights the challenges typically faced in eyedrop development, in particular, those intended for the management of DED. Firstly, various artificial tear supplements currently on the market, their mechanisms of action, as well as their application, are discussed. Furthermore, formulation strategies generally used to enhance ocular drug delivery, their advantages and limitations, as well as their application in commercially available DED eyedrops are described.

Modifiable lifestyle risk factors for dry eye disease

PURPOSE

To examine the association between modifiable lifestyle factors and dry eye disease.

METHODS

Three hundred and twenty-two community residents (186 females, 136 males; mean ± SD age, 41 ± 22 years) with no major systemic or ophthalmic conditions (other than dry eye disease) were recruited in a cross-sectional study. A lifestyle factor questionnaire was administered, and dry eye symptomology, ocular surface characteristics, and tear film quality were evaluated for each participant within a single clinical session, in accordance with the global consensus recommendations of the TFOS DEWS II reports.

RESULTS

A total of 111 (34 %) participants fulfilled the TFOS DEWS II diagnostic criteria for dry eye disease. Multivariate regression analysis demonstrated that advancing age, female sex, East Asian ethnicity, and increased digital screen exposure time were positive risk factors for dry eye disease (all p < 0.05), while increased caffeine consumption was a protective factor (p = 0.04).

CONCLUSIONS

Increased digital screen exposure time and reduced caffeine consumption were modifiable lifestyle factors associated with higher odds of dry eye disease. These findings might contribute to informing the design of future prospective research investigating the efficacy of preventative intervention and risk factor modification strategies.

Association between dry eye and traditional Chinese medicine body constitutions: A Taiwanese adults study

In the theory of traditional Chinese medicine (TCM), except for the balanced constitution, other constitutions are unbalanced and may lead to susceptibility to certain diseases. This study made the first efforts to explore the relationship between TCM constitutions and the dry eye condition.This cross-sectional study collected information from 2760 subjects aged 30 to 70 years who had participated in a questionnaire survey conducted by Taiwan Biobank (TWB) in 2012 to 2017. The questionnaire included questions on basic demographic characteristics, chronic diseases, depression, blood lipid levels, lifestyles, and drug allergies, as well as a TCM constitution scale developed by a research team of TCM constitution and syndrome at China Medical University College of Chinese Medicine.Unadjusted and stratified multiple logistic regression analyses were performed to explore the relationships between TCM constitutions and dry eye. The analysis revealed that subjects falling into the constitution category of Yang deficiency, Yin deficiency, or Phlegm stasis were more likely to develop dry eyes (crude odds ratio [OR] = 1.741, 95% confidence interval [CI] = 1.361-2.227; crude OR = 2.4821, 95% CI = 1.968-3.131; and crude OR = 2.082, 95% CI = 1.597-2.714, respectively). After adjusting for important risk factors (demographic characteristics, chronic diseases, blood lipid levels, lifestyles, depression, and drug allergies), subjects with an unbalanced constitution were 1.6 to 2.5 times more likely to develop dry eye than those with a balanced constitution.These results confirm a high correlation of TCM constitution with dry eye. Considering that the current treatment outcome is not fully satisfactory to the patients with dry eyes, integration of TCM and Western medicine may be an alternative treatment option. Individualized treatments and lifestyle recommended should be provided to patients with different TCM constitutions to alleviate dry eye symptoms.

Safety and Efficacy of an Augmented Intense Pulse Light Protocol for Dry Eye Syndrome and Blepharitis

Objective: We evaluated the safety and efficacy of an augmented BroadBand Light (BBL™) protocol on the upper and lower eyelids in improving meibomian gland dysfunction (MGD) and/or dry eye disease (DED). Background: DED, often associated with MGD, can cause significant morbidity and accounts for 3.54 billion U.S. dollars of health care spending yearly. Intense pulsed light (IPL) has been used to treat MGD DED with some success. BBL therapy, a high-quality IPL machine, shows much promise for decreasing inflammation and redness in rosacea, as well as hyperpigmentation from sun damage. Methods: A retrospective medical chart review was performed for MGD DED and/or hyperpigmentation patients who received BBL therapy between January 1, 2015, and February 28, 2020. Inclusion criteria included patients who underwent at least one BBL treatment. Each treatment involved the upper and lower eyelids, as well as cheeks, nose, and face. Each MGD DED subject completed the Ocular Surface Disease Index (OSDI) and underwent pre- and post-treatment standard clinical examinations. Results: Forty-seven patients had treatment without significant adverse effects; all patients with MGD DED reported improvement in their dry eye or blepharitis. BBL was determined to be a safe and effective treatment. There were no changes in visual acuity (p = 0.555) and OSDI scores were improved (p = 0.016). There was one case each of mild corneal/conjunctival abrasion, temporary hyperpigmentation, and two of temporary eyelash thinning. Patients with MGD also showed significant improvement in blepharitis and reduced hordeolum frequency after BBL treatment. Conclusions: This novel IPL/BBL protocol appears safe and effective for treating dry eye and blepharitis.

Cost utility analysis of cryopreserved amniotic membrane versus topical cyclosporine for the treatment of moderate to severe dry eye syndrome

BACKGROUND

The purpose is to perform a cost effectiveness analysis amniotic membrane vs. topical medications in the use of treating dry eye disease. A cost effectiveness analysis comparing amniotic membrane + other topical medications to topical cyclosporine A + other topical medications was evaluated using accepted decision tree modeling software.

METHODS

TreeAge Pro 2019 software was used to evaluate the base case costs over a one year timeframe. Sensitivity analysis was performed on those variables which had the greatest effect on choosing one therapy versus the other based on cost. Monte Carlo simulation was run 1,000 times to determine the most effective, least costly alternative. Costs were evaluated from a societal level (direct + indirect). Quality of life utility scores were evaluated using known time tradeoffs from prior studies (scale 0-1; with 1 being perfect vision).

RESULTS

Over a one year timeframe, the base case demonstrated that amniotic membrane + topical medications was the less expensive alternative and provided for incremental utilities versus topical cyclosporine + other medications (Cost/utility: $18,275/0.78 vs. $20,740/0.74). If examining direct costs only, topical cyclosporine was the least expensive option over a one year timeframe: $4,112 vs. $10,300. Sensitivity analysis demonstrated that in order for topical cyclosporine to be the less expensive alternative the following variables would need to be: < 68 days productivity lost; < $161 productivity lost/day; > 79% of amniotic membrane implants would need to be re-implanted at month 4 (for whatever reason); > $2677 per amniotic membrane implant procedure (Medicare reimbursement rate); > 96% positive response to topical cyclosporine A at month 4; > 58% positive response to topical cyclosporine A at month 6 and; < 54% probability clinical improvement with amniotic membrane. Monte Carlo simulation demonstrated that amniotic membrane was the less costly, most effective alternative 91.5% of the time.

CONCLUSION

Based on improved outcomes using amniotic membrane, patient productivity was improved resulting in lower societal costs (less days lost from work). When considering the untoward effects of dry eye disease on societal costs, an improvement of the dry eye disease condition was accomplished most often with amniotic membrane.

Sex and age differences in symptoms and signs of dry eye disease in a Norwegian cohort of patients

PURPOSE

To investigate sex and age differences in symptoms and signs in a Norwegian clinic-based cohort of patients with dry eye disease (DED).

METHODS

Visitors at the Norwegian Dry Eye Clinic were examined using Ocular Surface Disease Index (OSDI) questionnaire score, tear osmolarity, tear break-up time (TFBUT), ocular surface staining, corneal sensitivity, Schirmer I test, and meibum expressibility (ME) and quality (MQ). A diagnosis of DED was made by an ophthalmologist based on symptoms and signs, and only DED patients were enrolled in the study: 1823 patients (338 males; mean age 51.2 ± 16.2 years; 1485 females; mean age 52.5 ± 16.0 years). The patients were divided into age subgroups: 20-39 years, 40-59 years and ≥60 years. Sex differences in the aforementioned tests were analyzed. Values were reported as mean ± standard deviation (SD), and intergroup comparisons were performed using Mann-Whitney U test. Multiple regression was used to analyze sex and age influences on symptoms and signs.

RESULTS

When patients of all ages were analyzed, females had increased osmolarity, shorter TFBUT, reduced MQ and ME and higher corneal sensitivity. OSDI, Schirmer I test, ocular surface staining and corneal staining were not significantly different between the sexes. Only with TFBUT and ME were the sex difference present in all age subgroups. Multiple regression showed that all parameters were influenced by either sex or age, but only TFBUT and ME were influenced by both sex and age. (all p < 0.05).

CONCLUSIONS

Sex and age differences in dry eye were most consistent in TFBUT and ME, that indicate differences in meibomian gland functionality. Sex and age subgroup stratification is important in future studies investigating DED in other populations.

A Comprehensive Review of the Clinical Trials Conducted for Dry Eye Disease and the Impact of the Vehicle Comparators in These Trials

Dry eye disease (DED) is a multifactorial disease of the ocular surface characterized by loss of homeostasis of the tear film and accompanied by symptoms such as ocular discomfort and visual disturbance. DED is one of the most common reasons for seeking medical care in the United States and across the world. Despite this, there are a limited number of pharmacologic therapies for the treatment of DED in the United States and Europe. This review examines the different pivotal trials for DED medications and the impact the vehicle in each trial.In recent clinical trials, the vehicle of the active formulation of the medication is often used as the active comparator. A literature review of published dry eye clinical trials was performed to identify the pivotal clinical trials of DED medications and to compare treatment effect and further understand the impact of the vehicle on clinical trial outcomes.The pivotal clinical trials for the currently approved treatments for dry eye have widely varying study designs. The variations include differences in inclusion criteria, outcome measures and efficacy endpoints, and whether or not the use of concomitant artificial tears is allowed. These differences make it difficult for accurate comparisons to be made between DED medications. Each trial demonstrated that the vehicle alone has some beneficial effect on signs and symptoms of dry eye disease.This review discusses the varying trial designs and vehicles used in the pivotal studies for the four approved dry eye medications in the United States and Europe, as well as novel vehicles under development and clinical trial recommendations.

The negative effects of dry eye disease on quality of life and visual function

In recent years, dry eye has become a hot topic within ophthalmology and optometry, especially in regards to new frontiers in treatment modalities which include novel devices, procedures, and medications. However, some of the more understudied areas in dry eye involve its impact on quality of life. Although ocular discomfort symptoms are well known to be associated with dry eye, its negative effects on visual function remain underrecognized. This paper reviews these topics within the currently published literature to heighten awareness among clinicians. Key Words: D ry eye, quality of life, visual function, functional visual acuity, patient questionnaire, OSDI, SPEED, SANDE, IDEEL, NEI VFQ-25