Effect of diquafosol tetrasodium 3% on the conjunctival surface and clinical findings after cataract surgery in patients with dry eye

A comparison between hyaluronic acid and other single ingredient eye drops for dry eye, a review

Dry eye disease (DED) is a highly prevalent and debilitating condition. Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan that has a long history as a safe and effective DED treatment. HA is frequently used as a comparator when assessing other topical DED treatments. This study aims to summarise and critically evaluate the literature describing all isolated active ingredients that have been directly compared with HA in the treatment of DED. A literature search was conducted in Embase using Ovid on the 24th of August 2021 and in PubMed including MEDLINE on the 20th of September 2021. Twenty-three studies met the inclusion criteria, 21 of which were randomised controlled trials. Seventeen different ingredients representing six treatment categories were compared with HA treatment. Most measures showed no significant difference between treatments, suggesting either equivalency of treatments or that studies were underpowered. Only two ingredients were represented in more than two studies; carboxymethyl cellulose treatment appears equivalent to HA treatment, while Diquafosol treatment appears superior to HA treatment. Drop-frequency varied from one to eight drops daily. No single study explained the choice of drop frequency. Nine studies used a HA concentration of 0.1% which may be below therapeutic levels. Nine studies reported using preserved formulations, six of them with differences in preservatives between the compared groups. Thirteen studies were financially linked to industry. No major complications were reported. Studies were not designed to find differences in treatment effects for different types or severities of DED. HA is a good comparator treatment when assessing other DED treatments, although consensus after decades of use is still lacking for best choice of concentration, molecular weight and drop tonicity. Well-designed studies are needed to determine an evidence-based standard for HA treatment to be used as comparator.

A protocol for a single center, randomized, controlled trial comparing the clinical efficacy of 3% diquafosol and 0.1% hyaluronic acid in diabetic patients with dry eye disease

BACKGROUND

The global prevalence of diabetes mellitus (DM) continues to rise and 70% of diabetic individuals have dry eye disease (DED) that leads to subsequent abnormalities of the corneal epithelium, corneal nerves, tear film, or corneal endothelium. In addition, persons with diabetes produce fewer tear secretions than healthy individuals. While several anti-inflammatory drug-based therapies for dry eye in diabetic individuals are currently being administered, their efficacy has not been studied in detail. Therefore, the aim of this study was to compare the effectiveness of 3% diquafosol (DQS) vs 0.1% hyaluronic acid (HA) eye drops in diabetic dry eye patients.

METHODS

This triple-blind randomized, control trial will include 202 diabetic-related DED and will be assigned to DQS (n = 101) and HA (n = 101) one drop, six times per day for 8 weeks. Tear film lipid layer, non-invasive breakup time, conjunctivocorneal staining score, corneal sensitivity, tear MMP-9 levels, meibomian gland expression and quality, tear meniscus height, corneal nerves, immune/inflammatory cell change, conjunctival hyperemia, and ocular surface disease index questionnaire score will be assessed and compared at baseline, week 4, and week 8.

DISCUSSION

This study will be a standardized, scientific, clinical trial designed to evaluate the therapeutic effects and safety of DQS and HA for diabetic dry eye treatment.

TRIAL REGISTRATION

ClinicalTrials.govNCT05682547. Registered on December 05, 2022.

Topical diquafosol versus hyaluronic acid for the treatment of dry eye disease: a meta-analysis of randomized controlled trials

BACKGROUND

Diquafosol enhances fluid transfer and mucin secretion on ocular surface, which has been suggested as an effective treatment for dry eye disease (DED). The aim of the systematic review and meta-analysis was to compare the efficacy and safety of topical diquafosol versus hyaluronic acid (HA) for DED.

METHODS

Relevant randomized controlled trials were obtained via search of electronic including PubMed, Embase, Cochrane Library, and Web of Science. A random-effects model was used to pool the results after incorporating the influence of potential heterogeneity.

RESULTS

A total of nine RCTs involving 1295 patients with DED were included in the meta-analysis. Compared to treatment with 0.1% HA, topical treatment with 3% diquafosol significantly improved the Ocular Surface Disease Index (mean difference (MD): - 3.59, 95% confidence interval (CI): - 4.68 to - 2.50, p < 0.001; I2 = 6%), results of Schirmer's test (MD: 1.08 mm, 95% CI: 0.41 to 1.76, p = 0.002; I2 = 0%), tear breakup time (MD: 0.60 s, 95% CI: 0.20 to 0.99, p = 0.003; I2 = 63%), corneal fluorescein staining score (MD: - 0.20, 95% CI: - 0.37 to - 0.03, p = 0.02; I2 = 58%), and ocular rose bengal staining score (MD: - 0.62, 95% CI: - 0.88 to - 0.35, p < 0.001; I2 = 15%). No severe adverse events were reported. Topical use of diquafosol was associated with a higher risk of overall adverse events as compared to HA (odds ratio: 1.71, 95% CI: 1.08 to 2.71, p = 0.02; I2 = 18%).

CONCLUSIONS

Topical treatment with 3% diquafosol may be more effective than 0.1% HA for patients with DED. However, the long-term efficacy and tolerability of diquafosol still need to be determined.

The Efficacy and Safety of Rebamipide Ophthalmic Suspension (OPC-12759) in Patients with Dry Eye Disease: A Systematic Review of Randomized Controlled Trials

The aim of this paper is to evaluate the efficacy and safety of Rebamipide (REB) ophthalmic suspension in dry eye disease (DED). A systematic review that only included full-length randomized controlled studies (RCTs) reporting the effects of REB ophthalmic suspension in three databases, PubMed, Scopus and Web of Science, was performed according to the PRISMA statement. The Cochrane risk of bias tool was used to analyze the quality of the studies selected. A total of seven studies were included in this systematic review. Although the overall risk of bias was low, most studies were sponsored by the manufacturer. REB ophthalmic suspension treatment achieved higher improvement than the control group in all reported variables. The mean differences between both groups were in favor of the REB group and were as follows: dry eye-related quality of life score (DEQS) -3.5 ± 2.9 points, tear film break-up time (TBUT) of 0.7 ± 0.6 s, Schirmer test (ST) without anesthesia of 0.3 ± 0.6 mm and total corneal fluorescein staining (tCFS) of -1.2 ± 0.7 points. Adverse events (AEs) were 5.2 ± 7.6% superior in the REB group, with an overall compliance > 95%. Therefore, REB ophthalmic suspension is a safe and effective treatment that could be recommended in patients with DED.

The effect of 3% diquafosol on the improvement of ocular surface post cataract surgery: A meta-analysis for time of intervention

Purpose

The effect of interventional time for 3% Diquafosol reatment in post-cataract surgery has not been well established. A meta-analysis was performed to evaluate the improvement of ocular surface condition in post-cataract surgery patients who received 3% DQS for various treatment durations.

Methods

Studies were performed based on 5 databases: PubMed, Cochrane Library, Web of Science, Embase, and China National Knowledge Infrastructure. Data on changes in Schirmer's test, tear breakup time (TBUT), corneal staining score, and OSDI score were collected for meta-analysis.

Results

A total of 621 affected eyes from 9 independent clinical studies were included. 6 studies conducted Schirmer's test after the application of 3% DQS. Meta-analysis showed that the difference between 3% DQS and control groups was not statistically significant for short-term application (less than or equal to 1 month) (WMD ​= ​0.14, P ​= ​0.27, 95% CI:-0.11 to 0.39), but was statistically different for long-term application (longer than or equal to 3 months) (WMD ​= ​0.76, P ​= ​0.03, 95% CI:0.08 to 1.45). For the corneal fluorescence staining score, the data from 6 studies indicated that the improvement was statistically significant for short-term application (WMD ​= ​-0.40, P <0.00001, 95% CI:-0.72 to -0.08) and but not long-term application (WMD ​= ​-0.21, P ​= ​0.26, 95% CI:-0.57 to 0.15). For TBUT, the data from 9 studies indicated that both short-term and long-term application showed significant improvement (WMD ​= ​1.70, P <0.00001, 95% CI:1.38 to 2.03; WMD ​= ​1.52, P <0.00001, 95% CI:1.09 to 1.95). Similar results were observed in data from 5 studies with OSDI scores, where both short-term and long-term application showed statistically significant improvements (WMD ​= ​-5.41, P <0.00001, 95% CI: -7.02 to -3.81; WMD ​= ​-6.10, P <0.00001, 95% CI:-8.52 to -3.67).

Conclusions

The application of 3% DQS in post-operative cataract patients has a positive effect on improving the ocular surface conditions. Short-term application resulted in lower corneal staining scores, prolonged TBUT, and improved OSDI scores. Long-term application improved Schirmer's test results, TBUT, and subjective symptoms.

Key messages

The updated article suggests that 3% Diquafosol is less effective in the short term after cataract surgery, and that application over three months can improve the patient's ocular surface condition.

Prevention of Surgery-Induced Dry Eye by Diquafosol Eyedrops after Femtosecond Laser-Assisted Cataract Surgery

Purpose: To analyze the protective effects of diquafosol eyedrops on the ocular surface following femtosecond laser-assisted cataract surgery (FLACS). Design: A prospective, randomized contralateral study. Methods: Bilateral FLACS with a trifocal IOL (PanOptix) implantation was performed in 40 eyes in 20 patients (10 males, 10 females, average age 68.8 ± 6.3 years old). Patients received 3% diquafosol eyedrops six times daily in one randomly chosen eye (diquafosol group), and physiological saline six times a day in the other eye (control group). Other medication included 1.5% levofloxacin, 0.1% dexamethasone and 0.1% diclofenac three times daily in both eyes. The pre and post-operative tear break-up time (BUT), superficial punctate keratopathy (SPK) scores and visual function were compared between both eyes, and all patients answered the dry-eye-related quality of life score (DEQS) questionnaire. Results: The BUT between groups was similar pre-operatively and on the first day post-op; however, the BUT was statistically longer in the diquafosol group compared to saline at 1 week (5.5/3.7 s) and 2 weeks (4.8/3.0 s) (p < 0.05). There was no difference in the SPK score, best corrected distance visual acuity, tear meniscus height, contrast sensitivity, DEQS and Schirmer test at all time points. Spherical aberration was statistically lower in the diquafosol group at 1 week. The protective effects of diquafosol on the BUT was more pronounced in patients with a pre-operative BUT of less than 5 s compared with those with a BUT longer than 6 s. Conclusions: Diquafosol eyedrops prevented the shortening of the BUT following FLACS, even in patients with short pre-operative BUT values.

Prevalence and Characteristics of Dry Eye Disease After Cataract Surgery: A Systematic Review and Meta-Analysis

Dry eye disease (DED) after cataract surgery is associated with various risk factors, while causing a wide range of heterogeneous symptoms including decreased quality of vision. This systematic review and meta-analysis aimed to determine the prevalence and characteristics of DED after cataract surgery. We searched PubMed and EMBASE and included studies on patients with DED after cataract surgery, between January 2011 and June 2020. Study-specific estimates (DED prevalence rates after cataract surgery in patients without preexisting DED) were combined using one-group meta-analysis in a random-effects model. We included 36 studies published between 2013 and 2020. We included nine of these in the meta-analysis of DED prevalence after cataract surgery. Overall 37.4% (95% CI 22.6-52.3; 206/775) of patients without preexisting DED developed DED after cataract surgery. The risk factors for DED after cataract surgery included age, female sex, systemic diseases, systemic medications, psychiatric conditions, preexisting DED, meibomian gland dysfunction, preservatives in eye drops, surgery techniques, and lifestyle. DED severity peak occurred 1 day postoperatively and persisted for at least 1-12 months following cataract surgery; therefore, consistent follow-up for DED is warranted for at least 1 month after cataract surgery. Topical administration of preservative-free diquafosol tetrasodium solution and preoperative meibomian gland treatment were effective in preventing and treating DED following cataract surgery. As more than one-third of patients develop DED after cataract surgery, careful DED management and treatment is needed after cataract surgery to improve satisfaction and vision quality.

Clinical efficacy of diquafosol sodium 3% versus hyaluronic acid 0.1% in patients with dry eye disease after cataract surgery: a protocol for a single-centre, randomised controlled trial

INTRODUCTION

The number of cataract surgeries, the most common ophthalmic surgery, is expected to increase due to ageing populations. Dry eye disease (DED) is a frequent side effect of cataract surgery, contributing to lower postoperative patient satisfaction and suboptimal quality of vision. It is unclear which eye-drops commonly used in these patients should be recommended for postoperative DED treatment. This study aims to compare the efficacy of topical administration of diquafosol sodium 3% vs hyaluronic acid 0.1% eye-drops in patients with DED after cataract surgery.

METHODS AND ANALYSIS

The study is designed as a single-blind randomised controlled trial. The participants will be randomly (1:1) allocated to either the diquafosol sodium 3% topical administration group (n=21) or the hyaluronic acid 0.1% topical administration group (n=21). Each group will receive its assigned eye-drop intervention over a 12-week period. The primary outcome will be measured using the total score of the Japanese version of the Ocular Surface Disease Index during the visit 5 weeks postoperatively. Both groups will be followed up after their respective eye-drop application for 12 weeks according to the intervention regimens. Secondary outcome measures including meibomian gland function assessment, tear film break-up time, keratoconjunctival staining score, maximum blink interval and tear secretion volume using Schirmer's test I will be assessed at 1, 5, 9, 13 and 25 weeks postoperatively.

ETHICS AND DISSEMINATION

This study has been approved by the Juntendo Hospital Certified Review Board, Tokyo, Japan (Approved protocol V.7.0 dated 7 May 2021. Approval number: J20-018) and has been registered with the Japan Registry of Clinical Trials. Written informed consent will be collected from every patient prior to study participation. The results of this trial will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

jRCT1031210018.

Trehalose/sodium hyaluronate eye drops in post-cataract ocular surface disorders

Purpose

Prospective, randomised, open-label, comparative study to evaluate efficacy of trehalose/sodium hyaluronate eye drops for post-operative discomfort and tear film stability in patients undergoing cataract surgery.

Methods

Patients with healthy ocular surface, subclinical, or mild dry eye were enrolled. Tear breakup time (TBUT), Schirmer test, dry eye symptoms, corneal fluorescein staining (CFS), and ocular surface disease (OSDI) evaluation were performed pre-operatively and at two and four weeks after surgery. Patients were assigned to receive trehalose/sodium hyaluronate eye drops b.i.d (Group A), or 0.9% unpreserved sodium chloride eye drops b.i.d for 4 weeks (Group B).

Results

One hundred and thirty-five patients were randomised, 66 patients in Group A (73.2 ± 4.5 years) and 69 patients in Group B (74.3 ± 3.8 years), 60.8% females. Fifteen patients (8 Group A) were lost at follow-up. Pre-operatively, no between-group differences were observed, and TBUT increased in Group A between the pre-operative and 2 and 4 week evaluations and was higher in group A than in Group B at 4 weeks. Schirmer test and CFS showed an improvement only in Group A four weeks post-operatively. In Group A an improvement was observed after two and four weeks in foreign body and puncture sensation, whilst a difference in blinking discomfort was observed after four weeks. In Group B we observed an improvement in puncture sensation two and four weeks after surgery. Mean OSDI scores differences between the two groups were significant at four weeks.

Conclusions

Trehalose/sodium hyaluronate eye drops were effective in reducing signs and symptoms of dry eye and improving tear film stability

Cataract surgery and dry eye disease: A review

AIM

To review published literature concerning cataract surgery and dry eye disease (DED).

METHODS

A search was undertaken using the following: PubMed (all years), Web of Science (all years), Ovid MEDLINE(R) (1946 to 12 December 2019), Ovid MEDLINE(R) Daily Update 10 December 2019, MEDLINE and MEDLINE non-indexed items, Embase (1974-2019, week 49), Ovid MEDLINE (R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily (1946 to 12 December 2019), CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Search terms included 'cataract surgery', 'phacoemulsification' and 'cataract extraction', combined with 'dry eyes' and 'ocular surface'. Relevant in-article references not returned in our searches were also considered.

RESULTS

Publications identified included systematic reviews, meta-analysis, randomized controlled trials, cohort studies, case series and laboratory-based studies. Published data highlighting the burden of DED both prior and following cataract surgery were reviewed as well as studies highlighting the effects of cataract surgery on the ocular surface, intra-operative measures to reduce deleterious effects on the ocular surface and current evidence on the management options of post-operative DED.

CONCLUSIONS

DED is common and can be exacerbated by cataract surgery. Ophthalmologists need to assess for pre-existing DED and instigate treatment before surgery; be aware of reduced accuracy of measurements for surgical planning in the presence of DED; limit intra-operative surgical factors damaging to the ocular surface; and consider management to reduce DED post-operatively.

Management of Postoperative Inflammation and Dry Eye After Cataract Surgery

Surgical intervention is the most effective treatment for decreased vision resulting from cataracts. Although the current procedures for cataract surgery are safe and effective, it is well known that several complications can develop after surgery. Postoperative cystoid macular edema (CME) is a well-known complication, and prophylactic medications such as steroids and/or nonsteroidal antiinflammatory drugs are routinely used for its prevention. Ocular surface abnormalities, such as dry eye, have also been reported to develop after cataract surgery. However, the causative mechanisms for postoperative dry eye have not been definitively determined. At present, there are no prophylactic medications that are commonly used to prevent the development of postoperative dry eye. Although nonsteroidal antiinflammatory drugs are very effective in reducing the incidence and degree of postoperative CME, it is known that they can cause adverse side effects, including ocular surface abnormalities. Thus, perioperative medications must be carefully selected to improve surgical outcomes and patient satisfaction. Here, we summarize the results of recent studies on postoperative dry eye and CME that can develop after cataract surgery. We suggest appropriate combinations of medications that can be used to minimize these postsurgical complications.

The Protective Effect of a Topical Mucin Secretagogue on Ocular Surface Damage Induced by Airborne Carbon Black Exposure

Purpose

Exposure to airborne particulate matter can induce ocular surface damage and inflammation. We evaluated the effects of a topical mucin secretagogue on the mitigation of ocular surface damage induced by exposure to airborne carbon black (CB).

Methods

Sprague-Dawley rats were exposed to ambient CB for 2 hours twice daily for 5 days. Corneal staining score and tear lactic dehydrogenase (LDH) activity were measured to evaluate ocular surface damage. Serum immunoglobulin (Ig) G and IgE levels and the sizes of cervical lymph nodes were also measured. The expressions of interleukin (IL)-4, IL-17, and interferon (IFN)-γ were measured by Western blot analysis. Diquafosol tetrasodium was instilled six times a day for 5 days, and the extent of ocular surface damage was evaluated.

Results

After exposure to airborne CB, the median corneal staining score and LDH activity were significantly increased. Serum IgG and IgE levels and the sizes of cervical lymph nodes were also significantly increased. Additionally, the expression of IL-4 and IFN-γ was elevated in the anterior segment of the eyeball. Furthermore, the expression of IL-4, IL-17, and IFN-γ was elevated in the cervical lymph nodes. When exposed to airborne black carbon, topical diquafosol tetrasodium significantly increased tear MUC5AC concentration and decreased tear LDH activity.

Conclusions

Exposure to airborne CB induced ocular surface damage and increased proinflammatory cytokines in the eyes and cervical lymph nodes. Topical mucin secretagogues seem to have a protective effect on the ocular surface against exposure to airborne particulate matters.