A Systematic Review on the Association Between Tear Film Metrics and Higher Order Aberrations in Dry Eye Disease and Treatment

Effect of Long-Acting Diquafosol Sodium on Astigmatism Measurement Repeatability in Preoperative Cataract Cases with Dry Eyes: A Multicenter Prospective Study

INTRODUCTION

Dry eye can compromise corneal astigmatism measurement repeatability during preoperative cataract surgery examination. No previous studies have analyzed the effectiveness of long-acting 3% diquafosol sodium (LA-DQS) on astigmatism measurement repeatability. This research assessed the effect of LA-DQS on astigmatism measurement repeatability in preoperative patients with cataract and short tear break-up time (TBUT) type dry eyes in both eyes of the same patient. Correlations between repeatability and TBUT, corneal high-order aberrations (HOAs), and corneal astigmatism magnitude were also analyzed.

METHODS

In total, 122 eyes (61 patients) with short TBUT-type dry eye were enrolled. Preoperatively, only one eye of all patients was treated with LA-DQS for 4 weeks. TBUT and corneal HOAs were checked using CASIA 2 before and 4 weeks post-treatment. The cylindrical power and meridian of astigmatism were measured at 3- and 4-week post-treatment using IOLMaster 700. Power vectors J0 and J45 were used for astigmatism calculations. Repeatability of astigmatism measurements was assessed as the within-subject standard deviation (Sw). The relative effects of TBUT and HOAs on J0 Sw and J45 Sw were also analyzed. Comparative changes in these variables were evaluated between treated and non-treated eyes, with additional analysis of their correlations.

RESULTS

Treated eyes exhibited significant improvements in TBUT, HOAs, and post-treatment measurements of J0 Sw and J45 Sw at 3 and 4 weeks. In non-treated eyes, J0 Sw and J45 Sw showed significant correlation with TBUT and corneal HOAs. HOAs showed stronger relative associations with J0 Sw and J45 Sw than TBUT. In non-treated eyes, no significant correlation was found between cylindrical power and astigmatism measurement repeatability.

CONCLUSIONS

In short TBUT-type dry eye, preoperative treatment with LA-DQS significantly improved astigmatism measurement repeatability. This may improve the precision of intraocular lens (IOL) power calculations regardless of the magnitude of corneal astigmatism, especially when toric IOLs are used.

Moisture chamber goggles for the treatment of postoperative dry eye in patients receiving SMILE and FS-LASIK surgery

BACKGROUND

The incidence of refractive surgery-related dry eye disease (DED) is rising due to the increasing popularity of corneal refractive surgery. The moisture chamber goggles (MCGs) have been shown to tear evaporation by increasing local humidity and minimizing airflow. The current study aims to evaluate the efficacy of moisture chamber goggles for refractive surgery-related DED.

METHODS

In this nonrandomized open-label controlled study, 78 participants (156 eyes) receiving refractive surgery were enrolled between July 2021 and April 2022, and sequentially allocated to MGC and control groups. 39 participants were allocated to the MGC groups, of which 53.8% received small-incision lenticule extraction (SMILE) and 46.2% received femtosecond laser-assisted in situ keratomileusis (FS-LASIK), and were instructed to wear MCGs for the duration of 1 month postoperatively, in addition to the standard postoperative treatment received by the control groups (56.4% SMILE, 43.6% FS-LASIK). Participants underwent full ophthalmic examinations, including visual acuity, manifest refraction, DED evaluations, and higher-order aberrations (HOAs), both preoperatively and at routine follow-ups 1 day, 1 week, and 1 month after surgery. DED parameters included non-invasive tear film break-up time (NIBUT), tear meniscus height (TMH), conjunctival congestion, lipid layer thickness (LLT), and ocular surface disease index (OSDI) questionnaires. Student's t-test was used for comparisons between control and MCG groups, and between preoperative and postoperative parameters within groups.

RESULTS

Postoperative NIBUT decreased in both SMILE and FS-LASIK control groups 1 day after the surgery (SMILE, P = 0.001; FS-LASIK, P = 0.008), but not in the corresponding MCG groups (SMILE, P = 0.097; FS-LASIK, P = 0.331). TMH in the MCG group was significantly higher at 1 week (P = 0.039) and 1 month (P = 0.015) in SMILE, and 1 day (P = 0.003) in FS-LASIK groups. In FS-LASIK participants, significantly lower HOAs and coma levels in the MCG group were observed 1 day (total HOAs, P = 0.023; coma, P = 0.004) and 1 week (total HOAs, P = 0.010, coma, P = 0.004) after surgery. No consistent statistically significant intergroup difference was observed between MCG and control groups in conjunctival congestion, LLT, and OSDI.

CONCLUSIONS

MCGs effectively slowed tear evaporation, increased tear film stability, and improved HOAs in patients receiving SMILE and FS-LASIK surgeries. MCG is an effective adjuvant therapy in the comprehensive management of refractive surgery-related DED.

Influence of perfluorohexyloctane (Evotears®) on higher order aberrations

PURPOSE

To prospectively assess the effect of regular application of perfluorohexyloctane (F6H8; Evotears®) on the tear film lipid layer, higher order aberrations (HOA) and the repeatability of measurements in healthy eyes.

METHODS

This prospective clinical study included 104 eyes treated with F6H8 four times daily for four weeks (group A) and 101 eyes that served as controls (group B). Measurements were performed with the WASCA aberrometer (Carl Zeiss Meditec GmbH, Jena, Germany). Main outcome measurement in addition to subjective refraction were the root mean square values of HOA measured before and after the intervention.

RESULTS

Regular use of F6H8 over a period of four weeks significantly increases HOA in healthy eyes (p < 0.05). In addition, the repeatability of measurement increases after the application of F6H8.

CONCLUSION

F6H8 may be a suitable treatment option to improve the accuracy of refractive assessment, although it increases HOA. Further studies are needed to confirm the effect on HOA and the repeatability of measurement.

Smartphone App-Based and Paper-Based Patient-Reported Outcomes Using a Disease-Specific Questionnaire for Dry Eye Disease: Randomized Crossover Equivalence Study

BACKGROUND

Using traditional patient-reported outcomes (PROs), such as paper-based questionnaires, is cumbersome in the era of web-based medical consultation and telemedicine. Electronic PROs may reduce the burden on patients if implemented widely. Considering promising reports of DryEyeRhythm, our in-house mHealth smartphone app for investigating dry eye disease (DED) and the electronic and paper-based Ocular Surface Disease Index (OSDI) should be evaluated and compared to determine their equivalency.

OBJECTIVE

The purpose of this study is to assess the equivalence between smartphone app-based and paper-based questionnaires for DED.

METHODS

This prospective, nonblinded, randomized crossover study enrolled 34 participants between April 2022 and June 2022 at a university hospital in Japan. The participants were allocated randomly into 2 groups in a 1:1 ratio. The paper-app group initially responded to the paper-based Japanese version of the OSDI (J-OSDI), followed by the app-based J-OSDI. The app-paper group responded to similar questionnaires but in reverse order. We performed an equivalence test based on minimal clinically important differences to assess the equivalence of the J-OSDI total scores between the 2 platforms (paper-based vs app-based). A 95% CI of the mean difference between the J-OSDI total scores within the ±7.0 range between the 2 platforms indicated equivalence. The internal consistency and agreement of the app-based J-OSDI were assessed with Cronbach α coefficients and intraclass correlation coefficient values.

RESULTS

A total of 33 participants were included in this study. The total scores for the app- and paper-based J-OSDI indicated satisfactory equivalence per our study definition (mean difference 1.8, 95% CI -1.4 to 5.0). Moreover, the app-based J-OSDI total score demonstrated good internal consistency and agreement (Cronbach α=.958; intraclass correlation=0.919; 95% CI 0.842 to 0.959) and was significantly correlated with its paper-based counterpart (Pearson correlation=0.932, P<.001).

CONCLUSIONS

This study demonstrated the equivalence of PROs between the app- and paper-based J-OSDI. Implementing the app-based J-OSDI in various scenarios, including telehealth, may have implications for the early diagnosis of DED and longitudinal monitoring of PROs.

P4 Medicine for Heterogeneity of Dry Eye: A Mobile Health-based Digital Cohort Study

During the 5th Science, Technology, and Innovation Basic Plan, the Japanese government proposed a novel societal concept -Society 5.0- that promoted a healthcare system characterized by its capability to provide unintrusive, predictive, longitudinal care through the integration of cyber and physical space. The role of Society 5.0 in managing our quality of vision will become more important in the modern digitalized and aging society, both of which are known risk factors for developing dry eye. Dry eye is the most common ocular surface disease encountered in Japan with symptoms including increased dryness, eye discomfort, and decreased visual acuity. Owing to its complexity, implementation of P4 (predictive, preventive, personalized, participatory) medicine in managing dry eye requires a comprehensive understanding of its pathology, as well as a strategy to visualize and stratify its risk factors. Using DryEyeRhythm®, a mobile health (mHealth) smartphone software (app), we established a route to collect holistic medical big data on dry eye, such as the subjective symptoms and lifestyle data for each individual. The studies to date aided in determining the risk factors for severe dry eye, the association between major depressive disorder and dry eye exacerbation, eye drop treatment adherence, app-based stratification algorithms based on symptomology, blink detection biosensoring as a dry eye-related digital phenotype, and effectiveness of app-based dry eye diagnosis support compared to traditional methods. These results contribute to elucidating disease pathophysiology and promoting preventive and effective measures to counteract dry eye through mHealth.

Analysis of the Changes and Possible Reasons in Aberrations before and after Surgery in Patients with Concomitant Exotropia

Objective. The objective is to observe the changes in aberrations before and after surgery in patients with common horizontal strabismus and to analyze the possible reasons for the changes. Methods. Forty eyes of 40 cases with concomitant exotropia who underwent strabismus correction at the Ophthalmology Department of Nantong University Hospital from October 2020 to July 2021 were included in this study, all of whom underwent unilateral lateral rectus recession combined with a medial rectus resection in the same eye. Aberration parameters were measured 1 day before surgery and 1 week, 1 month, 3 months, and 6 months after surgery. Differences in the indicators at each time period were compared by analysis of variance (ANOVA) of repeated measures data for a single factor, and data were analyzed using SPSS 25.0 statistical application software. Results. 5 mm pupil diameter: the preoperative and postoperative RMS of total aberration showed statistically significant difference ( $P<0.01$ ). Postoperation test (Bonferroni method) and preoperative comparison at each period after surgery showed statistically significant differences between 6 months after surgery ( $P=0.002$ ) and preoperative comparison. The preoperative and postoperative comparison of RMS in LOAs was statistically significant ( $P<0.01$ ); postoperative test (Bonferroni method) and preoperative comparison showed that there were statistically significant differences between 1 week ( $P=0.033$ ) and 6 months ( $P=0.002$ ) after operation. The difference of RMS of defocus before and after operation was statistically significant ( $P<0.01$ ); postoperation test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference between 6 months after operation ( $P=0.007$ ) and preoperative comparison. There was statistically significant difference in preoperative and postoperative RMS of HOAs ( $P=0.013$ ). Postoperative test (Bonferroni method) and preoperative comparison showed that there was statistically significant difference 6 months after surgery ( $P=0.03$ ). The RMS of secondary astigmatism showed a statistically significant difference before and after operation ( $P=0.001$ ), and the postoperation test (Bonferroni method) showed a statistically significant difference 6 months after operation ( $P=0.002$ ). In 5 mm pupil diameter, the preoperative and postoperative RMS of total aberration showed statistically significant difference ( $P<0.01$ ), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery ( $P=0.034$ ), 3 months after surgery ( $P=0.033$ ), and 6 months after surgery ( $P=0.003$ ). The preoperative and postoperative comparison of RMS in LOAs was statistically significant ( $P<0.01$ ), postoperative test (Bonferroni method) was used to compare each period after surgery with that before surgery, and there were statistically significant differences between 1 week after surgery ( $P=0.04$ ), 3 months after surgery ( $P=0.034$ ), and 6 months after surgery ( $P=0.004$ ). The difference of RMS of defocus before and after surgery was statistically significant ( $P=0.002$ ), and the comparison between postoperation test (Bonferroni method) and preoperation showed that the difference was statistically significant 6 months after surgery ( $P=0.027$ ). The RMS of astigmatism showed statistically significant difference before and after operation ( $P=0.002$ ), and the postoperation test (Bonferroni method) showed statistically significant difference between 6 months after operation ( $P=0.009$ ) and before operation. Conclusion. We found that horizontal rectus surgery had a transient effect on LOAs and almost no effect on HOAs. Long-term follow-up is recommended after strabismus surgery to observe eye position and binocular visual function. Because of the high prevalence of strabismus in adolescents, long-term observation of the eye axis and aberration is recommended.

The Effect of Past Cataract Surgery within the Medium to Long-Term Period on Patients with Dry Eye Disease

This study investigates the effects of cataract surgery on dry eye parameters of patients with dry eye disease (DED) in the medium- to long-term post-surgical period (6 months to 5 years). A cross-sectional study was conducted on 438 eyes on first visit to a tertiary clinic (219 eyes with cataract surgery within timeframe, i.e., pseudophakic dry eye group, 219 comparison eyes without such history, i.e., comparison dry eye group). Parameters evaluated include Ocular Surface Disease Index (OSDI) and standard examination for DED. A significantly greater proportion of pseudophakic dry eye group (50%) experienced frequent blurred vision (≥1 episode per week) compared to dry eye control group (38%) (OR = 1.66, 95%CI 1.13, 2.44). Those with ocular discomfort before surgery were more likely to experience blurring at least once a day. However, a significantly greater proportion of the pseudophakic dry eye group (34%) had Schirmer’s I >8mm compared to the comparison group (25%) (OR = 0.605, 95% CI 0.398, 0.921), though the difference was not clinically significant (7.51 mm versus 6.51 mm, p > 0.05). Other DED signs (e.g., overall OSDI score, Tear Break-up Time) were not found to be worse among pseudophakic dry eye group. Pre-operative counselling and preventative measures should be undertaken, especially those with suggestive symptoms pre-operatively.