Antiinflammatory therapy for dry eye

Autologous Serum Eye Drops Diluted with Cyclosporine A 0.05% and Sodium Hyaluronate 0.1%: An Experimental Comparative Study

PURPOSE

The purpose of this study was to assess in-vitro efficacy of a suffusion of autologous serum withcyclosporine 0.05% (CsA) and sodium hyaluronate 0.1% (SH).

METHODS

The expression of proinflammatory markers interleukin 6 (IL-6) and TNF-Alpha (TNF-α) in limbal epithelial cells was evaluated. Also, assessment of the stability of epithelial growth factor and transforming growth factor-beta (EGF, TGF-β) in the 50% combinations with autologous serum (AS) was done. The characteristics (pH, density, osmolality) of the two combinations were also evaluated. Additionally, cytotoxicity effect of given test compounds was evaluated on human limbal epithelial cells (LEpiC).

RESULTS

The percentage of cells expressing IL-6 subjected to AS + SH and AS + CsA were 6.23% and 5.69% respectively. There was no significant difference in percentage of cells expressing TNF-α between the formulations (5.87%, 5.83% respectively). The growth factors; EGF and TGF-β remained stable forone month duration (on 2 and 4 weeks) at 4 °C without significant difference between the time intervals tested. The results of MTT assay suggested that limbal epithelial cells treated with AS + CsA and AS + SH combinations showed minimal toxicity however it was not significant statistically (p ≤ 0.05).

CONCLUSION

Two test combinations (AS + CsA, AS + SH) showed stable growth factors (EGF, TGF-β) and good anti-inflammatory property against pro-inflammatory markers. Also, the 2 combinations were found safe on cultured limbal epithelial cells. The novel combination of autologous serum in CsA may provide added benefit in dry eye disease (DED) through their combined anti-inflammatory and epitheliotropic effects.

Global research hotspots and trends in anti-inflammatory studies in dry eye: a bibliometric analysis (2004-2024)

Background

Inflammation plays a crucial role in the pathophysiology of dry eye (DE). This study aims to provide a comprehensive overview of the current status, hotspots and trends in DE anti-inflammatory research through bibliometric analysis.

Method

All publications were searched using the Web of Science Core Collection (WoSCC) database from 2004 to 2024. Bibliometric analyses were performed using VOSviewer, R-bibliometrix, and CiteSpace, and data were managed using Microsoft Office Excel 2019.

Results

There were 603 papers published between 2004 and 2024 included in this study, with the number of papers increasing each year. The United States was the major contributor, with the largest number of publications and the greatest impact. Baylor College of Medicine was the most influential research institution. Pflugfelder, Stephen C. and Tsubota, Kazuo were the most prolific authors in this area of research, while Dana, Reza was the most cited author in the field with the highest impact. The Journal with the highest number of publications was Investigative Ophthalmology & Visual Science, while the highest impact journal was Ocular Surface. Research hotspots were focused on the mechanisms of inflammation in DE and interventions for anti-inflammatory therapy. Future studies would favor more inflammation-related targeted therapies and physical therapies.

Conclusion

This study is the first bibliometric analysis to comprehensively summarize research trends and developments in DE anti-inflammatory treatments, pointing out recent research frontiers and hot directions for scholars studying DE anti-inflammatory treatments.

Advances in the ocular complications after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has benefited an increasing number of patients with hematological disease in the clinic. It is a curative therapy for malignant and nonmalignant hematological diseases. With the advancement and further clinical application of HSCT in recent years, the life expectancy of patients has increased, but complications have become more common. The occurrence of ocular complications is receiving increasing attention because they can seriously affect the quality of life of patients. Ocular complications require increased attention from clinicians because of their negative impact on patients and increasing incidence. Most of recent reports on posttransplant ocular complications involve ocular manifestations of graft-versus-host disease (GVHD), and a few ocular complications that do not originate from GVHD have also been reported. This review summarizes the diagnosis, scoring criteria, pathophysiology, and clinical manifestations of and common therapies for ocular graft-versus-host disease(oGVHD) after HSCT, and includes a description of some rare cases and novel therapies.

Successful management of dry eye disease with a new eye drop formulation combining hyaluronic acid, trehalose, and N-acetyl-aspartyl-glutamic acid (NAAGA)

PURPOSE

To assess the clinical efficacy and safety of T2769, a new preservative-free eye drop combining hyaluronic acid (HA), trehalose and N-acetyl-aspartyl-glutamic acid (NAAGA), in dry eye patients.

PATIENTS AND METHODS

This was a multicenter, non-comparative, open-label study. After a run-in period with NaCl 0.9% solution, 62 patients with moderate-to-severe dry eye disease (DED) were included and treated with T2769, 3 to 6 times/day for 42 days. The primary efficacy endpoint was the change in global ocular symptomatology assessed on a visual analog scale between Day 1 (D1) and D42. Other efficacy endpoints included ocular surface disease index (OSDI), soothing sensation, individual dry eye symptoms, conjunctival hyperemia, global ocular staining, tear break-up time, Schirmer test, and global efficacy assessed by the investigator. Safety was assessed throughout the study.

RESULTS

A marked reduction in ocular symptomatology was observed from D1 to D42 with a mean change of -55.9±23.1mm (P<0.001). This was accompanied by a mean change in OSDI score from baseline of -44.6±15.9 (P<0.001) and a substantial soothing sensation in 82.3% of patients. Clinically significant improvements were observed for all ocular symptoms (mainly burning/irritation, stinging/pain, feeling of ocular dryness, foreign body sensation, itching/pruritus). Conjunctival hyperemia significantly decreased in 96.8% of patients (56.5% displayed no conjunctival hyperemia at D42 versus 0% at baseline). All signs and symptoms improved by D14 and further improved at D42. Investigators assessed the ocular efficacy of T2769 as very satisfactory or satisfactory for 91.9% of patients at D42. T2769 was well tolerated, with no ocular adverse events and only a few ocular symptoms upon instillation.

CONCLUSION

Management of moderate-to-severe DED patients with the new formulation T2769, combining NAAGA to HA and trehalose, led to rapid and significant improvements in dry eye signs and symptoms with good tolerability.

Frequency of Topical Immunomodulatory and Immunosuppressive Therapies for Ocular Chronic Graft-versus-Host Disease

Introduction: The purpose of the study was to evaluate the frequency of topical immunomodulatory and immunosuppressive therapies in patients with ocular chronic graft-versus-host disease (cGVHD) in consideration of inflammatory activity and systemic immunosuppressive therapies in a tertiary care university hospital setting. Methods: We included 95 adult patients (48 male, 47 female) with ocular chronic graft-versus-host disease (cGVHD) after alloHSCT (median age 49.5 years). Clinical ophthalmological findings and the grade of ocular cGVHD according to the NIH eye score and the German-Austrian-Swiss Consensus (GAS) Grading were analyzed. Systemic GVHD manifestations as well as the prevalence of topical and systemic (immunomodulatory) therapies were assessed. Results: A total of 74 of 95 patients (77.8%) had manifestations of systemic chronic graft-versus-host disease other than ocular GVHD. 68.42% (65/95) of patients were under systemic immunosuppressive therapy with at least one immunosuppressive medication. All patients (95/95) received lid-margin hygiene and phosphate- and preservative-free lubricating eye drops. Twenty-five percent of the cohort (24/95) were treated with autologous serum eye drops (ASEDs). In total, 80% (76/95) of patients required topical steroid therapy to treat acute exacerbation of inflammation at least once; continuous topical steroid therapy was only necessary for a minor part (12%) with refractory chronic inflammation. A total of 92.63% (88/95) were primarily treated with ciclosporin A 0.1% as Ikervis®, of whom at least one third did not continue the therapy because of intolerable side effects during follow-up and received alternative topical formulations. Conclusions: Our data show that patients with ocular cGVHD mostly need topical therapy including anti-inflammatory agents despite systemic immunosuppressive therapy. In our cohort, 80% of patients received topical steroids, and more than 90% received topical ciclosporin A eye drops, which were tolerated by only two thirds of patients due to side effects.

Investigating Neutrophil-to-Lymphocyte and C-Reactive Protein-to-Albumin Ratios in Type 2 Diabetic Patients with Dry Eye Disease

BACKGROUND

Patients with Diabetes mellitus (DM) are at risk of developing dry eye disease (DED). We investigated routine laboratory parameters in patients with type 2 DM (T2D) and T2D-DED to identify potential inflammatory markers.

METHODS

A retrospective study of 241 randomly selected patients (30 DED non-diabetic, 120 T2D, and 91 with T2D-DED). The neutrophil-to-lymphocyte ratios (NLR), CRP-to-albumin ratios (CAR), and the glycosylated haemoglobin A1c (HbA1c) results were correlated between groups.

RESULTS

The NLR and HbA1c were significantly higher in the T2D-DED group (p≤0.001 and 0.0001, respectively) when compared with T2D and DED non-diabetic groups. CAR was insignificantly high in the three groups (p=0.192). A positive correlation was identified between CAR and NLR in T2D-DED patients (p= 0.008).

CONCLUSION

In T2D-DED patients, NLR was significantly high and positively correlate with CAR. These results predicate diabetes with dry eye complications, and biomarker-mediated inflammation may have important roles in DED pathogenesis.

Recombinant human nerve growth factor (cenegermin) for moderate-to-severe dry eye: phase II, randomized, vehicle-controlled, dose-ranging trial

BACKGROUND

Dry eye disease (DED) includes neurosensory abnormalities as part of its multifactorial etiology. Nerve growth factor is important for maintaining corneal nerve integrity and wound healing. Cenegermin (recombinant human nerve growth factor) is a topical biologic that promotes corneal healing in patients with neurotrophic keratitis. The purpose of this study was to evaluate efficacy and safety of cenegermin in moderate-to-severe DED and identify an optimal dosing strategy.

METHODS

This was a phase II, multicenter, randomized, double-masked, vehicle-controlled, dose-ranging clinical trial in patients with moderate-to-severe DED, including Sjögren's DED (NCT03982368). Patients received 1 drop of cenegermin 3 times daily (t.i.d.; 20 mcg/mL), cenegermin 2 times daily (b.i.d.; 20 mcg/mL) and vehicle once daily, or vehicle t.i.d. for 4 weeks. Follow-up continued for 12 additional weeks. The primary endpoint was change in Schirmer I score from baseline to week 4. Other key endpoints included rate of responders (Schirmer I test > 10 mm/5 min) after treatment and change in Symptoms Assessment iN Dry Eye (SANDE) scores from baseline to end of follow-up. A 1-sided test (α = 0.025) was used to evaluate statistical significance.

RESULTS

At week 4, mean changes in Schirmer I scores were not statistically significantly different in either cenegermin group versus vehicle (cenegermin vs vehicle [treatment difference; 95% CI]: t.i.d., 2.60 mm and b.i.d., 3.99 mm vs 1.68 mm [t.i.d.: 0.93; -1.47 to 3.32, P = 0.078; b.i.d.: 2.31; -0.08 to 4.70, P = 0.066]). More patients responded to treatment with cenegermin t.i.d. and b.i.d. versus vehicle (t.i.d.: 25.9% [21/81, P = 0.028]; b.i.d.: 29.3% [24/82, P = 0.007] vs 11.9% [10/84]), with statistical significance (set at P < 0.025) observed in the b.i.d. group. Only cenegermin t.i.d. yielded statistically significant (P < 0.025) reductions in SANDE scores versus vehicle, which were sustained up to the end of follow-up (P value range, 0.002-0.008). Eye pain, primarily mild and transient, was the most frequently observed treatment-emergent adverse event with cenegermin. Similar results were observed in patients with Sjögren's DED.

CONCLUSIONS

Cenegermin was well tolerated and although this study did not meet its primary endpoint, significant improvement in patient-reported symptoms of dry eye was observed through follow-up. Larger studies evaluating cenegermin in patients with DED are warranted.

TRIAL REGISTRATION

NCT03982368; registered May 23, 2019.

Experimental interventions attenuate a conjunctival epidermal metaplasia model

The conjunctiva is a non-keratinized, stratified columnar epithelium with characteristics different from the cornea and eyelid epidermis. From development to adulthood, a distinguishing feature of ocular versus epidermal epithelia is the expression of the master regulator PAX6. A conditionally immortalized conjunctival epithelial cell line (iHCjEC) devoid of stromal or immune cells established in our laboratory spontaneously manifested epidermal metaplasia and upregulated expression of the keratinization-related genes SPRR1A/B and the epidermal cytokeratins KRT1 and KRT10 at the expense of the conjunctival trait. In addition, iHCjEC indicated a significant decrease in PAX6 expression. Dry eye syndrome (DES) and severe ocular surface diseases, such as Sjögren's syndrome and Stevens-Johnson syndrome, cause the keratinization of the entire ocular surface epithelia. We used iHCjECs as a conjunctiva epidermal metaplasia model to test PAX6, serum, and glucocorticoid interventions. Reintroducing PAX6 to iHCjECs resulted in upregulating genes related to cell adhesion and tight junctions, including MIR200CHG and CLDN1. The administration of glucocorticoids or serum resulted in the downregulation of epidermal genes (DSG1, SPRR1A/B, and KRT1) and partially corrected epidermal metaplasia. Our results using an isolated conjunctival epidermal metaplasia model point toward the possibility of rationally "repurposing" clinical interventions, such as glucocorticoid, serum, or PAX6 administration, for treating epidermal metaplasia of the conjunctiva.

Effect of low dose honey on the apoptosis and inflammation gene expression in corneal limbal stem cells and keratocytes and its efficacy as an ophthalmic formulation in the treatment of dry eye: in-vitro and clinical study

Background

The use of honey as an eye treatment encounters challenges due to its high osmolarity, low pH, and difficulties in sterilization. This study addresses these issues by employing a low concentration of honey, focusing on both in-vitro experiments and clinical trials for treating dry eye disease in corneal cells.

Methods

In the in-vitro experiment, we investigated the impact of a 1% honey-supplemented medium (HSM) on limbal stem cells (LSCs) and keratocytes using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay and real-time polymerase chain reaction (PCR) for BCL-2, BAX, and IL-1β gene expression. Simultaneously, in the clinical trial, 80 participants were divided into two groups, receiving either a 1% w/v honey ophthalmic formulation or a placebo for 3 months. Study outcomes included subjective improvement in dry eye symptoms, tear break-up time (TBUT), and Schirmer's test results.

Results

MTT results indicated that 1% HSM did not compromise the survival of corneal cells and significantly reduced the expression of the IL-1β gene. Additionally, participants in the honey group demonstrated a higher rate of improvement in dry eye symptoms and a significant enhancement in TBUT values at the three-month follow-up. However, there was no significant difference between the study groups in terms of Schirmer's test values. No adverse events were observed or reported.

Conclusion

In conclusion, 1% honey exhibits anti-inflammatory and anti-infective properties, proving effective in ameliorating dry eye symptoms and enhancing tear film stability in patients with dry eye disease.Clinical Trial Registration: https://irct.behdasht.gov.ir/trial/63800.

Studies on cationic ocular emulsions containing bipartitioned oil droplets to codeliver cyclosporin A and etodolac

Background: To prepare ocular emulsions containing bipartitioned oil droplets to entrap cyclosporin A (0.05% w/w) and etodolac (0.2% w/w) by using castor, olive and silicon oils. Methods: The physicochemical characterizations of prepared emulsions were performed. The drug's biodistribution profiles and pharmacokinetic parameters from emulsions were checked using the ultraperformance liquid chromatography-tandem mass spectrometry method in the ocular tissues of the healthy rabbit eye model. Results: The emulsions displayed 365.13 ± 7.21 nm size and 26.45 ± 2.09 mV zeta potential. The ferrying of two drugs after releasing from emulsions occurred across corneal/conjunctival tissues to enter the vitreous and sclera following a single drop administration into the rabbit's eyes. Conclusion: The dual drug-loaded emulsions were more likely to produce synergistic anti-inflammatory activity for managing moderate-to-severe dry eye disease.

Fabrication and Characterization of an Enzyme-Triggered, Therapeutic-Releasing Hydrogel Bandage Contact Lens Material

PURPOSE

The purpose of this study was to develop an enzyme-triggered, therapeutic-releasing bandage contact lens material using a unique gelatin methacrylate formulation (GelMA+).

METHODS

Two GelMA+ formulations, 20% w/v, and 30% w/v concentrations, were prepared through UV polymerization. The physical properties of the material, including porosity, tensile strain, and swelling ratio, were characterized. The enzymatic degradation of the material was assessed in the presence of matrix metalloproteinase-9 (MMP-9) at concentrations ranging from 0 to 300 µg/mL. Cell viability, cell growth, and cytotoxicity on the GelMA+ gels were evaluated using the AlamarBlueTM assay and the LIVE/DEADTM Viability/Cytotoxicity kit staining with immortalized human corneal epithelial cells over 5 days. For drug release analysis, the 30% w/v gels were loaded with 3 µg of bovine lactoferrin (BLF) as a model drug, and its release was examined over 5 days under various MMP-9 concentrations.

RESULTS

The 30% w/v GelMA+ demonstrated higher crosslinking density, increased tensile strength, smaller pore size, and lower swelling ratio (p < 0.05). In contrast, the 20% w/v GelMA+ degraded at a significantly faster rate (p < 0.001), reaching almost complete degradation within 48 h in the presence of 300 µg/mL of MMP-9. No signs of cytotoxic effects were observed in the live/dead staining assay for either concentration after 5 days. However, the 30% w/v GelMA+ exhibited significantly higher cell viability (p < 0.05). The 30% w/v GelMA+ demonstrated sustained release of the BLF over 5 days. The release rate of BLF increased significantly with higher concentrations of MMP-9 (p < 0.001), corresponding to the degradation rate of the gels.

DISCUSSION

The release of BLF from GelMA+ gels was driven by a combination of diffusion and degradation of the material by MMP-9 enzymes. This work demonstrated that a GelMA+-based material that releases a therapeutic agent can be triggered by enzymes found in the tear fluid.

Application of topical 2% cyclosporine A in inflammatory ocular surface diseases

PURPOSE

To report our experience with the 2% cyclosporin A (CsA) in a series of challenging inflammatory ocular surface diseases due to different etiologies.

METHODS

The records of patients who received topical 2% CsA for different indications were reviewed retrospectively. Demographic characteristics, indications for treatment, patient symptoms and clinical findings were recorded.

RESULTS

Fifty-two eyes of 52 patients were included. Mean age was 43.2 ± 14.3 (11-66) years with a F/M ratio of 34/18. Indications included pediatric acne rosacea (n = 4), adenoviral corneal subepithelial infiltrates (n = 12), filamentary keratitis (n = 14), pterygium recurrence (n = 15), herpetic marginal keratitis (n = 2) and graft versus host disease (n = 5 patients). Mean duration of treatment was 7.3 ± 2.8 (3-10) months. Forty-three (83%) patients reported favorable outcome with improvement in symptoms after a mean time of 4.4 ± 2.7 (2-6) months.

CONCLUSIONS

Topical 2% CsA may address the needs of different cases with ocular surface inflammation, as a safe option for long-term therapy.

Assessment of Tear Meniscus Dimensions Using Anterior Segment Optical Coherence Tomography in Vitamin D Deficiency in a Pediatric Population

BACKGROUND

To investigate of the effect of vitamin D (Vit-D) deficiency on the tear film in children and compare it with that of healthy subjects.

METHODS

This prospective and cross-sectional study comprised 75 eyes of children who had Vit-D deficiency (Group 1) and 85 eyes of age- and gender-matched healthy children (Group 2). The tear-film break-up time (TF-BUT) and Schirmer test values, as well as the Ocular Surface Disease Index (OSDI) scores, were recorded for the participants in all groups. Measurement of the tear meniscus area (TMA) and tear meniscus height (TMH) was performed 2 times in the same day via the use of anterior segment-optical coherence tomography (AS-OCT).

RESULTS

The mean age of the participants in Group 1 was 12.42 ± 3.40 years, while in Group 2, it was 12.59 ± 2.32 years (p = 0.758). Group 1 comprised 43 females and 32 males, while Group 2 comprised 44 females and 41 males (p = 0.250). The mean TMH, TMA, and Schirmer test values were found to be significantly lower in children with Vit-D deficiency (Group 1) than in healthy children (Group 2), with p < 0.05 for all the values. It was concluded that there was no significant difference in the values for the mean TF-BUT and OSDI scores (p = 0.029 and p = 0.596, respectively).

CONCLUSION

The children with Vit-D deficiency exhibited lower TMH, TMA, and Schirmer test values. The alterations that were observed in these parameters were more prominent in the participants who had lower Vit-D levels.

NLRP3 Inflammasome as a Potential Therapeutic Target in Dry Eye Disease

Dry eye disease (DED) is a multifactorial ocular surface disorder arising from numerous interrelated underlying pathologies that trigger a self-perpetuating cycle of instability, hyperosmolarity, and ocular surface damage. Associated ocular discomfort and visual disturbance contribute negatively to quality of life. Ocular surface inflammation has been increasingly recognised as playing a key role in the pathophysiology of chronic DED. Current readily available anti-inflammatory agents successfully relieve symptoms, but often without addressing the underlying pathophysiological mechanism. The NOD-like receptor protein-3 (NLRP3) inflammasome pathway has recently been implicated as a key driver of ocular surface inflammation, as reported in pre-clinical and clinical studies of DED. This review discusses the intimate relationship between DED and inflammation, highlights the involvement of the inflammasome in the development of DED, describes existing anti-inflammatory therapies and their limitations, and evaluates the potential of the inflammasome in the context of the existing anti-inflammatory therapeutic landscape as a therapeutic target for effective treatment of the disease.

Eyes on Topical Ocular Disposition: The Considered Design of a Lead Janus Kinase (JAK) Inhibitor That Utilizes a Unique Azetidin-3-Amino Bridging Scaffold to Attenuate Off-Target Kinase Activity, While Driving Potency and Aqueous Solubility

An unmet medical need remains for patients suffering from dry eye disease (DED). A fast-acting, better-tolerated noncorticosteroid anti-inflammatory eye drop could improve patient outcomes and quality of life. Herein, we describe a small-molecule drug discovery effort to identify novel, potent, and water-soluble JAK inhibitors as immunomodulating agents for topical ocular disposition. A focused library of known 3-(4-(2-(arylamino)pyrimidin-4-yl)-1H-pyrazol-1-yl)propanenitriles was evaluated as a molecular starting point. Structure-activity relationships (SARs) revealed a ligand-efficient (LE) JAK inhibitor series, amenable to aqueous solubility. Subsequent in vitro analysis indicated the potential for off-target toxicity. A KINOMEscan selectivity profile of 5 substantiated the likelihood of widespread series affinity across the human kinome. An sp²-to-sp³ drug design strategy was undertaken to attenuate off-target kinase activity while driving JAK-STAT potency and aqueous solubility. Tactics to reduce aromatic character, increase fraction sp³ (Fsp³), and bolster molecular complexity led to the azetidin-3-amino bridging scaffold in 31.

How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives

Dry eye disease (DED) is a common ocular condition, but the diagnosis relative to other ocular conditions and the evaluation of severity of the condition has often been difficult. This challenge can be due to clinical signs and symptoms not always correlating with each other. An understanding of the various components which create the condition, as well as the diagnostic measures used to evaluate these components, is useful to the clinician working with DED patients. This review paper will discuss traditional diagnostic options, diagnostic imaging, and Advanced Point of Care testing capabilities to determine the severity level of dry eye disease more adequately.

Role of topical and systemic immunosuppression in aqueous-deficient dry eye disease

Immunosuppression in aqueous-deficient dry eye disease (ADDE) is required not only to improve the symptoms and signs but also to prevent further progression of the disease and its sight-threatening sequelae. This immunomodulation can be achieved through topical and/or systemic medications, and the choice of one drug over the other is determined by the underlying systemic disease. These immunosuppressive agents require a minimum of 6-8 weeks to achieve their beneficial effect, and during this time, the patient is usually placed on topical corticosteroids. Antimetabolites such as methotrexate, azathioprine, and mycophenolate mofetil, along with calcineurin inhibitors, are commonly used as first-line medications. The latter have a pivotal role in immunomodulation since T cells contribute significantly to the pathogenesis of ocular surface inflammation in dry eye disease. Alkylating agents are largely limited to controlling acute exacerbations with pulse doses of cyclophosphamide. Biologic agents, such as rituximab, are particularly useful in patients with refractory disease. Each group of drugs has its own side-effect profiles and requires a stringent monitoring schedule that must be followed to prevent systemic morbidity. A customized combination of topical and systemic medications is usually required to achieve adequate control, and this review aims to help the clinician choose the most appropriate modality and monitoring regimen for a given case of ADDE.

Effect of illuminance and colour temperature of LED lighting on asthenopia during reading

PURPOSE

A self-controlled study to determine the influence of illuminance and correlated colour temperature (CCT) of light-emitting diode (LED) lighting on asthenopia.

METHODS

Twenty-two healthy postgraduates (nine women) were recruited to read under eight LED lighting conditions with four illuminances (300 lx, 500 lx, 750 lx and 1000 lx) and four CCTs (2700, 4000, 5000 and 6500 K) for 2 h. A subjective asthenopia questionnaire, the optical quality analysis system (OQAS) and an inflammatory cytokine assay were used to assess the levels of asthenopia.

RESULTS

Increased asthenopia was observed after reading, but the degree varied with lighting conditions. There were significant differences among the groups in terms of subjective symptoms (inattention, eye pain, dry eye and total score), optical performance parameters (modulation transfer function [MTF] cut-off frequency, Strehl ratio [SR], objective scattering index [OSI], mean OSI and accommodative amplitude [AA]) as well as inflammatory cytokines in the tears (epidermal growth factor [EGF], transforming growth factor [TGF]-α, interleukin [IL]-6, IL-8, macrophage inflammatory protein [MIP]-1β, tumour necrosis factor [TNF]-α, TNF-β and vascular endothelial growth factor [VEGF]-A). All of the subjective and objective measurements collectively suggested that asthenopia was lessened for the 500 lx-4000 K condition. However, asthenopia was significantly worse for 300 lx-2700 K and 1000 lx-6500 K in terms of subjective symptoms and objective optical performance, respectively.

CONCLUSIONS

LED illuminance and CCT do have a significant effect on asthenopia during reading. 500 lx-4000 K lighting resulted in the lowest level of asthenopia. Conversely, low illuminance at low CCT (300 lx-2700 K) and high illuminance at high CCT (1000 lx-6500 K) promoted more severe asthenopia.

Factors affecting the prevalence, severity, and characteristics of ocular surface pain

Introduction

Ocular surface pain has been traditionally lumped under the umbrella term "dry eye" (DE) but is now understood as its own entity and can occur in the absence or presence of tear dysfunction. Identifying patients at risk for the development of chronic ocular surface pain, and factors contributing to its severity are important in providing precision medicine to patients.

Areas covered

In this review, we discuss factors linked to the presence and severity of ocular surface pain, including eye related features, systemic characteristics, and environmental findings. We discuss corneal nerves, whose anatomic and functional integrity can be characterized through in vivo confocal microscopy images and testing of corneal sensitivity. We review systemic diseases that are co-morbid with ocular surface pain, including physical and mental health diagnoses. Finally, we identify environmental contributors, including air pollution, previous surgeries, and medications, associated with ocular surface pain.

Expert opinion

Intrinsic and extrinsic factors contribute to ocular surface pain and must be considered when evaluating an individual patient. These factors can inform the suspected etiology of the pain, and guide management decisions such as tear replacement or medications targeting nerve pain.

Dual Delivery of Cyclosporin A and Etodolac Using Polymeric Nanocapsules in a Rabbit Eye Model: Ocular Biodistribution and Pharmacokinetic Study

Purpose: Commercially available eye drops are loaded only with a single drug. By using the polymeric nanocapsules, dual delivery of 0.05% w/w cyclosporin A (CsA) and 0.2% w/w etodolac (Edc) was achieved. An ultraperformance liquid chromatography/tandem mass spectrometry (UPLC-MS/MS) method was developed for determining simultaneously the biodistribution and pharmacokinetic profile of CsA and Edc in ocular tissues. Methods: After one single drop instillation of nanocapsules into healthy right eyes of rabbits, the eyeballs were enucleated at 5, 15, 30, 60, and 90 min time periods to separate the 5 different ocular tissues. A liquid/liquid extraction method was used for ocular sample extraction using darunavir as internal standard. Using 3 diverse conditions such as bench-top, autosampler, and freeze-thaw, the stability of the analytes at 3 quality control samples in ocular tissues was also checked. Results: Intra- and interday precisions for both CsA and Edc in multiple ocular tissues were <10.32%, and the accuracy was <11.98%. The % bias and % RSD values for CsA and Edc were found within the acceptable limit of ±15%. The highest C_max values were attained in cornea for both the drugs at 60 min postinstillation time point. Despite molecular size and structural differences, both CsA and Edc after liberation from nanocapsule drops can permeate into the tissues of the anterior as well as posterior segments of the eye. Conclusion: The biodistribution and pharmacokinetic data might help and strengthen our understanding of synergetic anti-inflammatory activity of CsA and Edc from nanocapsules after its ocular topical application for managing keratoconjunctivitis sicca.

Therapeutic Effects of Acer palmatum Thumb. Leaf Extract (KIOM-2015E) on Benzalkonium Chloride-Induced Dry Eye in a Mouse Model

We determined the effects of two extracts from Acer palmatum Thumb. leaves (hot water extract KIOM-2015EW and 25% ethanol extract KIOM-2015EE) in a benzalkonium chloride (BAC)-induced dry eye mouse model. Dry eye was induced by 0.2% BAC for 2 weeks, followed by treatment three times (eye drop) or once (oral administration) daily with KIOM-2015E for 2 weeks. Treatment with both KIOM-2015EE and KIOM-2015EW resulted in a marked increase in tear volume production for the 4 days of treatment. The Lissamine Green staining score, TUNEL-positive cells, and inflammatory index were significantly decreased after 2 weeks. Topical KIOM-2015EE administration exhibited a greater improvement in decreasing the ocular surface staining scores, inflammation, dead cells, and increasing tear production in a dose-dependent manner compared with the other groups. Furthermore, KIOM-2015E significantly reduced the phosphorylation of NF-κB, which was activated in the BAC-treated cornea. Topical administration was much more effective than oral administration for KIOM-2015E and KIOM-2015EE was more effective than KIOM-2015EW. Application of KIOM-2015E resulted in clinical improvement, inhibited the inflammatory response, and alleviated signs of dry eye. These results indicate that KIOM-2015E has potential as a therapeutic agent for the clinical treatment of dry eye.

Comparison of seven cyclosporine A formulations for dry eye disease: A systematic review and network meta-analysis

Background: Dry eye disease is a common ocular surface disease affecting tens of millions of people worldwide. It is characterized by an unstable tear film and increasing prevalence. Different commercial formulations of cyclosporine A for dry eye have been approved, however, it is still unclear whether the differences in formulations of these products will make a difference in clinical efficacy and safety. Methods: Randomized controlled trials of commercial cyclosporine A formulation for dry eye disease were searched in Pubmed, EMBASE, Scopus, and Cochrane controlled trials registries and Web of Science from inception till 1 December 2021. Independent literature screening, data extraction, quality evaluation, and the study in line with quality standards were analyzed by using Stata16.0 software. The study is registered with PROSPERO under the number CRD42022301423. Code and data for this study is publicly available (https://github.com/DongYangGao/Dongyang.github.io.git). Results: 21 randomized clinical trials with a total of 4,107 participants were included in this study. Restasis® (OR-4.82, 95% CI-6.18 to 3.45, SUCRA 77.2%) was the most effective commercial formulation for reducing OSDI, Zirun® (SUCRA 73.9%) performed better in improving Schirmer's test. TJ Cyporin® (SUCRA 65.3%) ranked first in terms of improving tear film break-up time. For treatment-emergent adverse events incidence, Clacier® was close to placebo. The risk of reporting bias is considered low. Conclusion: In the comparison of outcomes included in this study, the optimal order of various commercial cyclosporine A formulations is different, so it is difficult to select the optimal formula. Appropriate commercial formulations should be selected according to patients' conditions in clinical practice.

Short-term results of a pulsed therapy with hydrocortisone eye drops to treat moderate to severe dry eye in primary Sjögren syndrome patients

BACKGROUND

We investigated the safety and efficacy of short-term treatment with topical low-dose hydrocortisone sodium phosphate 0.335% (PFH) in patients with moderate to severe primary Sjögren syndrome (SS)-related dry eye disease (DED).

METHODS

A retrospective single-centre interventional study. All patients received PFH for 6 days with a pulsed posology: three times daily for 2 days, twice daily for 2 days, and once daily for 2 days. This scheme was repeated for 3 consecutive months and then alternated for 3 months. Data were collected at baseline, 3 months, and 6 months of follow-up.

RESULTS

A total of 40 SS patients were enrolled. Conjunctival hyperaemia and corneal-conjunctival stain significantly improved (p < 0.001). Ocular Surface Disease Index score reduced significantly between baseline and 3 months and between baseline and 6 months (p < 0.001). The tear film osmolarity lowered significantly in each eye from baseline to 3 months and from baseline to 6 months (p = 0.002 and p = 0.037, respectively). Comparing results at 3 and 6 months, the Ocular Surface Disease Index score (p = 1.000), the frequency of lacrimal substitutes installation (p = 0.632), and tear film osmolarity (right eye p = 0.518, left eye p = 1.000) did not change significantly. Intraocular pressure did not change during the study period.

CONCLUSION

PFH eye drops with a pulsed posology improve signs and symptoms, not affecting the intraocular pressure in SS-related DED. Therefore, this pulsed treatment is safe and efficacious.

Current approaches for the regeneration and reconstruction of ocular surface in dry eye

Significant research revealed the preocular tear film composition and regulations that remain vital for maintaining Ocular surface functional integrity. Inflammation triggered by many factors is the hallmark of Ocular surface disorders or dry eyes syndrome (DES). The tear deficiencies may lead to ocular surface desiccation, corneal ulceration and/or perforation, higher rates of infectious disease, and the risk of severe visual impairment and blindness. Clinical management remains largely supportive, palliative, and frequent, lifelong use of different lubricating agents. However, few advancements such as punctal plugs, non-steroidal anti-inflammatory drugs, and salivary gland autografts are of limited use. Cell-based therapies, tissue engineering, and regenerative medicine, have recently evolved as long-term cures for many diseases, including ophthalmic diseases. The present article focuses on the different regenerative medicine and reconstruction/bioengineered lacrimal gland formation strategies reported so far, along with their limiting factors and feasibility as an effective cure in future.

Clinical and Molecular Outcomes After Combined Intense Pulsed Light Therapy With Low-Level Light Therapy in Recalcitrant Evaporative Dry Eye Disease With Meibomian Gland Dysfunction

PURPOSE

Dry eye disease (DED) is a leading cause of ocular morbidity worldwide. This study evaluates the effects of combined light therapy [intense pulsed light (IPL) and low-level light therapy (LLLT)] on clinical and molecular outcomes in evaporative DED with meibomian gland dysfunction (MGD).

METHODS

This prospective study evaluated 94 eyes (47 subjects) with chronic MGD treated with combined light therapy. Patients underwent a detailed evaluation of MGD and DED using the Ocular Surface Disease Index, dry eye tests-tear breakup time and Schirmer test, ocular surface staining, meibomian gland expressibility scoring, and meibography. Patients underwent a single session of combined light therapy (IPL + LLLT treatment) using the Eye-light device. All these tests were repeated at 3 and 6 months after treatment. Tear fluid and ocular surface wash samples were collected from a subset of patients before and after treatment for cellular and secreted immune factor profiling by flow cytometry.

RESULTS

Combined light therapy (IPL + LLLT) demonstrated a marked improvement in the clinical metrics studied. Three months after treatment, Ocular Surface Disease Index showed a significant reduction in 95.6% ( P < 0.0001), tear breakup time increased in 72.3% ( P < 0.0001), and meibomian gland expressibility scoring increased in 80.8% ( P < 0.0001) of the eyes. These effects were observed to be sustained during the 6-month follow-up visit. Significant ( P < 0.05) reduction in tear fluid levels of interleukin-1β, interleukin-17F, and MMP9; MMP9/TIMP1 ratio; and ocular surface B-cell proportions was observed.

CONCLUSIONS

Combined light therapy shows promising results in patients with chronic MGD and DED, even in recalcitrant cases. Clinical and molecular factor alterations support the improved symptomatology and reduced inflammation.

Proteases and Their Potential Role as Biomarkers and Drug Targets in Dry Eye Disease and Ocular Surface Dysfunction

Dry eye disease (DED) is a multifactorial disorder that leads to ocular discomfort, visual disturbance, and tear film instability. DED is accompanied by an increase in tear osmolarity and ocular surface inflammation. The diagnosis and treatment of DED still present significant challenges. Therefore, novel biomarkers and treatments are of great interest. Proteases are present in different tissues on the ocular surface. In a healthy eye, proteases are highly regulated. However, dysregulation occurs in various pathologies, including DED. With this review, we provide an overview of the implications of different families of proteases in the development and severity of DED, along with studies involving protease inhibitors as potential therapeutic tools. Even though further research is needed, this review aims to give suggestions for identifying novel biomarkers and developing new protease inhibitors.

Current trends in pharmaceutical treatment of Dry Eye Disease: A review

Dry eye disease (DED), keratoconjunctivitis sicca or dysfunctional tear syndrome, is the most prevalent ophthalmic disease which affects a substantial segment of people worldwide with increasing frequency. It is considered a multifactorial disease of the ocular surface and tear film, characterized by a variation of signs and symptoms. The symptoms range from mild to severe itching, burning, irritation, eye fatigue, and ocular inflammation that may lead to potential damage to the cornea, conjunctiva and even vision loss. Correspondingly, depending on the different manifestations and pathophysiology, the treatment must be tailored specifically to each patient by targeting the specific mechanisms implicated in their disease. Currently, there are several medical products and techniques available or under investigation for the treatment of DED. The present article focused on the pathophysiology of DED, the new diagnostic approach and the recently developed drug delivery systems or devices reducing the progress of the disease and treating the causes.

Porcine Corneas Incubated at Low Humidity Present Characteristic Features Found in Dry Eye Disease

Dry eye is a multifactorial disease that affects the ocular surface and tear fluid. Current treatment options include lubricant eye drop application several times a day. However, these eye drops often cause local side effects like ocular allergies or blurred vision after the application. To test new treatment options, a robust dry eye model is needed. Here, a porcine ex vivo model was established by means of incubation of porcine corneas in low humidity (LH) and characterized by histological damage evaluation, epithelial thickness and by relevant dry eye markers, such as interleukin 1 beta (IL-1β), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), occludin and galectin-3. In the dry eye model proposed, an increased secretion of IL-1β was observed, as well as an upregulation of NF-κB, occludin and galectin-3 mRNA expression. Moreover, the model presented a higher rate of cell death in comparison to the controls. These effects could be reversed with successful treatment of dexamethasone (dexa) and partially reversed with hyaluronic acid (HA) containing eye drops. Furthermore, medium-molecular-weight HA stimulated an increase in IL-1β in the model proposed. In conclusion, this dry eye model mimics the in vivo condition and hence allows for animal-free testing of novel dry eye treatments.

MicroRNA Therapy for Dry Eye Disease

Purpose: We tested the role of microRNA-328 in dry eye disease (DED). Benzalkonium chloride (BAC) has been used to induce DED in animal models. We first demonstrated that both BAC and hyperosmotic stress induced overexpression of miR-328 in corneal cells and then tested whether anti-miR-328 could be a new therapy. Methods: BAC was instilled to both eyes of 41 rabbits and 19 mice from day 0 to 21 to induce DED. Animals of each species were divided to receive topical instillation of saline or anti-miR-328 eye drops between day 8 and 21. The DED signs were assessed by corneal fluorescein staining, histological examination, apoptosis of corneal cells, and inflammatory cytokines in rabbit eyes. For mice, only corneal fluorescein staining was assessed for the therapeutic effects. The corneal fluorescein staining scores ranged from 0 of no staining to 4 of coalescent. Results: For the rabbits, the staining score was significantly reduced (P = 0.038) after the 14-day anti-miR-328 treatment (n = 42 eyes), but the score was not improved by saline treatment (n = 40 eyes). Furthermore, rabbit eyes treated with anti-miR-328 had thicker corneal epithelium (P = 9.4 × 10^-5), fewer apoptotic cells in corneal epithelium (P = 0.002), and stroma (P = 0.029) compared with the saline-treated eyes. Anti-miR-328 was more effective than saline to reduce the block of orifices of Meibomian glands, although such an effect was only marginally significant (P = 0.059). Similarly, anti-miR-328 was more effective than saline in reducing corneal staining in mouse eyes (P = 0.005). Conclusion: Overexpression of miR-328 may contribute to DED. Anti-miR-328 protects corneal cells and promotes re-epithelialization for DED treatment.

Assessment of Tear Film Anomalies in Childhood Obesity

PURPOSE

To determine if childhood obesity has an effect on the ocular surface and tear film of children who are afflicted.

METHODS

Patients who had childhood obesity, 85 eyes, and patients who were healthy, 75 eyes, were enrolled in this prospective and comparative study. The tear film breakup time (TF-BUT), tear meniscus area and height (TMA and TMH) values, Schirmer test scores, and ocular surface disease index (OSDI) scores were obtained for all participants.

RESULTS

The TMH, TMA, TF-BUT, and Schirmer test results were statistically significantly lower in the obesity group (p < 0.001 for all). The children with obesity and insulin resistance had lower TMH, TMA, TF-BUT, and Schirmer test results when compared to the children without insulin resistance (p < 0.05 for all). The body mass index was found to be correlated with the TMH, TMA, TF-BUT, and Schirmer test results (p < 0.001 for all).

CONCLUSION

Children with obesity had lower TMA, TMH, TF-BUT, and Schirmer test results than healthy subjects. When insulin resistance was added to obesity, these values were even lower.

A phase I study to evaluate the safety, tolerability, pharmacodynamic and pharmacokinetic profiles of ocular GLH8NDE in healthy male adults

GLH8NDE, a derivative of eupatilin, is currently under development to treat dry eye disease. We conducted a randomized, double-masked, placebo-controlled, single- and multiple-day study to evaluate safety, tolerability, pharmacodynamics, and pharmacokinetics of ocular GLH8NDE in healthy male adults. Subjects randomly received topical ocular dosing of GLH8NDE or its matching placebo for a day, then for 7 consecutive days with a 62-h washout at one of the following daily doses: 9, 18, 36 (Koreans), and 36 mg (Whites). The study drug was administered in divided doses over 10 h with 2- or 5-h intervals. Thirty-nine (97.5%) out of 40 subjects completed the study. A total of 17 subjects experienced 31 treatment-emergent adverse events, all of which were mild in severity and recovered without sequelae. Neither pathological changes in eye compartments nor clinically significant systemic effects were observed. GLH8NDE was rapidly absorbed reaching the peak concentration within 0.25-0.75 h postdose. The systemic exposure as measured by area under the concentration-time curve from time of administration up to the time of the last quantifiable concentration (AUC_last ) after single-day administration of the same dose was 109% higher in Koreans than in Whites. In conclusion, GLH8NDE was safe and well-tolerated in healthy Korean and White male adults at 9-36 mg/day after single- and multiple-day administrations.

Assessment of the Compliance with 0.1% Cyclosporine A in Dry-Eye Patients with Sjögren's Syndrome

Purpose: To evaluate the compliance with 0.1% cyclosporine A in dry eye patients with Sjögren's syndrome and identify factors affecting the compliance. Methods: This study included 67 dry eye patients with Sjögren's syndrome who had used 0.1% cyclosporine A for over 6 months. Clinical parameters including sex, age, the number of eye drops used, side effects, the use of steroid eye drops, and the visit interval were investigated. Additionally, the ocular surface disease index, tear break-up time (TBUT), Schirmer test score, and corneal fluorescein staining (CFS) score were assessed. Patients were classified into compliant and non-compliant groups, using a criterion of 50% compliance; relevant factors were evaluated accordingly. Results: Of the 67 patients, 36 (53.7%) were classified into the compliant group and 31 (46.3%) into the non-compliant group. Compared to the non-compliant group, the compliant group showed a longer TBUT (p = 0.03) and a lower CFS score (p = 0.04) at 6 months of follow-up. Altogether, 39 subjects (58.2%) experienced side effects, of which the most common was stinging pain (71.8%). In the multivariate analysis, severe dry-eye symptoms (p = 0.03), non-use of the steroid eye drops (p = 0.02), and longintervals between exam vitists (p = 0.02) were identified as factors reducing compliance. Conclusions: Factors related to a decrease in the compliance with 0.1% cyclosporine A in dry-eye patients with Sjögren's syndrome, included severe dry eye symptoms, long visit intervals, and non-use of steroid eye drops. Taking these factors into consideration may help increase patient compliance.

A Novel Multi-Ingredient Supplement Reduces Inflammation of the Eye and Improves Production and Quality of Tears in Humans

INTRODUCTION

Dry eye is a multifactorial condition of the eye caused by insufficient tear production and imbalance in tear composition leading to faster evaporation of tear fluid. It is also associated with inflammation that often leads to ocular surface damage. Symptoms of dry eyes include itchiness, soreness, red eyes, a burning sensation, eye fatigue and blurred vision. The objective of this study was to evaluate the efficacy and safety of our multi-ingredient supplement in subjects with dry eye syndrome (DES).

METHODS

We recruited 60 subjects with mild to moderate DES who were randomized in a 1:1 ratio in a single-center study to receive LCD (lutein 20 mg, zeaxanthin 4 mg, curcumin 200 mg curcuminoids, vitamin D3 600 IU) or placebo (soybean oil) capsules for 8 weeks. The primary outcomes evaluated were changes in tear volume by Schirmer's test and ocular symptoms by the Ocular Surface Disease Index (OSDI); secondary outcomes included evaluation of changes in Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, tear film break-up time (TBUT), corneal and conjunctival staining, tear osmolarity, matrix metalloproteinase-9 (MMP-9), artificial tear use and safety assessments. The outcomes were compared between the LCD and placebo groups at baseline and day 56 of supplementation.

RESULTS

Fifty-nine subjects, 30 from LCD and 29 from placebo group, completed the study. The LCD group showed significant improvements (P < 0.0001) for Schirmer's test, OSDI, TBUT, SPEED, ocular staining scores, tear osmolarity (P = 0.0005), MMP-9 (P = 0.0017) and reduced artificial tear use (P = 0.0004) and its frequency of use (P < 0.0001) in subjects compared to placebo from baseline to day 56. No safety issues were observed in the study.

CONCLUSION

The LCD supplement showed significant improvements in the production, stability and quality of tears by reducing ocular surface damage and tear inflammation and can be used as an adjuvant to artificial tears in subjects with DES.

TRIAL REGISTRATION

Clinical Trials Registry of India (http://ctri.nic.in/) identifier: CTRI/2021/01/030493.

Dry Eye Treatment with Topical Cyclosporine 0.1% in Chondroitin Sulfate Ophthalmic Emulsion

Purpose

To evaluate the efficacy of topical cyclosporine 0.1% in chondroitin sulfate emulsion for the treatment of dry eye.

Methods

This retrospective multicenter study included 100 eyes of 50 dry eye patients aged ≥18 years, with preoperative ocular surface disease index (OSDI) score >12 or corneal staining grade >1 (in either eye) who underwent dry eye treatment with topical cyclosporine 0.1% in chondroitin sulfate emulsion (Klarity-C, ImprimisRx) for 3 months. Postoperative evaluation included comparison of the changes in OSDI score and corneal staining grade after 3 months of treatment from baseline.

Results

From baseline to 3 months, a statistically significant improvement in mean OSDI scores (38.19 vs 24.18, p <0.001) as well as mean corneal staining grade (3.62 vs 2.20, p <0.001) was observed. The proportion of subjects with severe dry eye decreased from 62% to 20% and more than one-third (34%) of patients were in the normal OSDI range. The percentage of eyes with corneal staining grade of 2 or 3 decreased from 21% (baseline) to 8% at 3 months; 50% of the eyes had corneal staining grade of 0. The treatment was found to be safe with no adverse events observed in the study.

Conclusion

Dry eye treatment with twice daily cyclosporine 0.1% in chondroitin sulfate emulsion was found to be safe and effective in reducing signs and symptoms of dry eye.

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.

Efficacy, Safety, and Tolerability of a Novel Cyclosporine, a Formulation for Dry Eye Disease: A Multicenter Phase II Clinical Study

PURPOSE

The purpose of this study was to explore the efficacy, safety, and tolerability of a novel cyclosporine formulation for dry eye disease (DED).

METHODS

This is an exploratory, multicenter, single-blind, randomized, positive-controlled Phase II clinical trial between cyclosporine ophthalmic gel (CyclAGel) and an open-label comparator (Restasis, positive control). A total of 240 eligible patients with moderate to severe DED were randomized to 4 study groups: CyclAGel 0.05%/once daily (QD) (n = 59), CyclAGel 0.05%/BID (n = 60), CyclAGel 0.1%/QD (n = 60), and Restasis 0.05%/BID (n = 61). After receiving BID dosing of hypromellose eye drops during a 2-week run-in period, patients were randomized to the respective treatment group and dosed QD or BID for 12 weeks. Efficacy was assessed based on a number of sign and symptom end points, including eye dryness score (visual analog scale), 6 other parameters of symptoms for dryness (burning/stinging, itching, foreign body sensation, discomfort, sensitivity to light, and pain), and corneal fluorescein staining. The Schirmer test was used to assess dry eye symptoms (visual analog scale severity) at visit 3 (week 2), visit 4 (week 6), and visit 5 (week 12).

FINDINGS

CyclAGel showed a consistent improvement in eye dryness score and the 6 other parameters of symptoms for dryness, corneal fluorescein staining, breakup time, and Schirmer test scores compared with Restasis over the 12-week treatment period. However, there were no statistically significant differences between CyclAGel and Restasis after baseline corrections were made, and the results of the full analysis set remained consistent with those of the per-protocol set (P > 0.05). Moreover, each CyclAGel-treated group (0.05%/QD, 0.05%/BID, and 0.1%/QD) exerted better effects than the Restasis group, and CyclAGel 0.05%/QD showed the most significant improvement. The number of ocular-related treatment-emergent adverse events was low in all treatment groups, with no serious drug-related treatment-emergent adverse events.

IMPLICATIONS

CyclAGel showed excellent safety, tolerability, and comfort profiles at 2 concentrations and frequency in moderate to severe DED.

Effect of Stem Cell-Derived Extracellular Vesicles on Damaged Human Corneal Endothelial Cells

Purpose

Human corneal endothelial cells (HCECs) are essential to visual function; however, since they have limited proliferative capacity in vivo, they are prone to corneal endothelial dysfunction. At present, the only treatment is a corneal transplantation from donor cadavers. Also, due to a global shortage of donor corneas, it is important to find alternative strategies. Recent studies highlight that stem cell–derived extracellular vesicles (EVs) play a relevant role in stem cell-induced regeneration by reprogramming injured cells and inducing proregenerative pathways. The aim of this work is to evaluate whether EVs derived from mesenchymal stem cells (MSC-EVs) are able to promote regeneration of damaged HCECs.

Methods

We isolated HCECs from discarded corneas in patients undergoing corneal transplantation or enucleation (N = 23 patients). Bone marrow mesenchymal stem cells (MSCs) were obtained from Lonza, cultured, and characterized. MSC-EVs were obtained from supernatants of MSCs. In order to establish a valid in vitro damage model to test the regenerative potential of EVs on HCECs, we evaluated the proliferation rate and the apoptosis after exposing the cells to serum-deprived medium at different concentrations for 24 hours. We then evaluated the HCEC migration through a wound healing assay.

Results

In the selected serum deprivation damage conditions, the treatment with different doses of MSC-EVs resulted in a significantly higher proliferation rate of HCECs at all the tested concentrations of EVs (5‐20 × 10³ MSC-EV/cell). MSC-EVs/cell induced a significant decrease in number of total apoptotic cells after 24 hours of serum deprivation. Finally, the wound healing assay showed a significantly faster repair of the wound after HCEC treatment with MSC-EVs.

Conclusions

Results highlight the already well-known proregenerative potential of MSC-EVs in a totally new biological model, the endothelium of the cornea. MSC-EVs, indeed, induced proliferation and survival of HCECs, promoting the migration of HCECs in vitro.

Disruption of blood-aqueous barrier in dry eye disease

PURPOSE

To evaluate level of flare in aqueous humor of dry eye disease (DED) and compare it with normal controls.

METHODS

In this cross-sectional study, we compared the anterior chamber flare between 28 patients with DED (the DED group) and 27 normal age- and gender-matched controls (the control group). DED group was divided in Sjӧgren's syndrome dry eye (SDE, n = 10) and non- Sjӧgren's syndrome dry eye (non-SDE, n = 18) groups.

RESULTS

This study enrolled 55 participants including 28 patients with DED and 27 normal controls. The mean age was 53.4 ± 14.7 years in the DED group and 48.5 ± 14.7 years in the control group (P = 0.086). Mean flare was significantly higher in DED group (12.1 ± 10.2 ph/ms, range 2.7-68.3) compared to the control group (5.0 ± 3.9 ph/ms, range 1.30-30.0, P < 0.001). There was no statistically significant difference in the flare intensity between the Sjӧgren syndrome dry eye (SDE) group (14.5 ± 14.4 ph/ms) and the non-Sjӧgren dry eye (non-SDE) group (10.8 ± 6.9 ph/ms, P = 0.330). A significant correlation was observed between the flare intensity and the ocular surface staining in the SDE group (r = 0.62, P = 0.018).

CONCLUSION

There is a significant increase in aqueous humor flare in patients with DED. Such finding, which is a marker of disruption of blood-aqueous barrier, demonstrates deeper tissue involvement than ocular surface in these patients.

Preclinical Efficacy Comparison of Cyclosporine Ophthalmic Solution 0.09% vs Cyclosporine Ophthalmic Emulsion 0.05% vs Ciclosporin Ophthalmic Emulsion 0.1% in a NOD Mouse Model of Dry Eye Disease

Introduction

Cyclosporine ophthalmic solution 0.09% (CsA 0.09% sol) is approved to increase tear production in patients with keratoconjunctivitis sicca. This study evaluated the efficacy of CsA 0.09% sol vs cyclosporine ophthalmic emulsion 0.05% (CsA 0.05% eml) vs ciclosporin ophthalmic emulsion 0.1% (CsA 0.1% eml) in a NOD mice model.

Methods

Mice were randomized and administered placebo, CsA 0.09% sol twice daily, CsA 0.05% eml twice daily, CsA 0.09% sol once daily, or CsA 0.1% eml once daily in the conjunctival sac of both eyes for 60 days. Tear volume was measured with phenol red threads at baseline and 4 hours after treatment every 15 days. On day 58, the corneal surface was observed under a slit-lamp after staining with 3% lissamine green administered into the inferior lateral conjunctival sac. On day 61, mice were euthanized, globes excised, sliced into 4 µm sections in 3 areas per section, and stained. Total number of stained goblet cell/µm was counted, and the sum per eye was averaged. Lacrimal gland tissues were removed and interleukin (IL) 1-β cytokine levels estimated.

Results

Groups comprised 11 mice each, including an untreated normal and untreated diseased control group (7 groups total). CsA 0.09% sol twice daily significantly increased tear volume on day 30, 45, and 60 vs CsA 0.05% eml (P<0.05, <0.001, <0.001, respectively) and vs CsA 0.1% eml on day 60 (P<0.05); CsA 0.09% sol once daily significantly increased tear volume on day 45 vs CsA 0.05% eml (P<0.05). Goblet cell density significantly increased with CsA 0.09% sol twice daily vs placebo and NOD control (P<0.01 both). There was no significant difference in corneal staining and IL-1β levels with CsA 0.09% sol.

Conclusion

Sixty-day treatment with CsA 0.09% sol showed comparatively improved preclinical results vs CsA 0.05% eml and CsA 0.1% eml.

Evaluation of Ocular Parameters in Adult Patients with Celiac Disease

PURPOSE

To evaluate ophthalmic parameters in adult celiac patients.

METHODS

This cross-sectional study included 31 celiac patients (58 eyes) and 25 healthy controls (50 eyes). Tear break up time (TBUT), schirmer test were measured; corneal thickness, anterior chamber parameters were obtained using scheimpflug camera; retinal nerve fiber layer thickness (RNFL) evaluated by using spectral domain optical cohorence tomography.

RESULTS

There were no statistically significant differences between the groups in terms of gender, age, and intraocular pressure (p > .05). Schirmer's test results and TBUT were significantly lower in celiac patients (p < .001, p < .001). Additionally, the superior RNFL was significantly thinner (p = .017), nasal RNFL thicker (p = .007), and anterior chamber depth larger (p = .037) in celiac patients. The tissue transglutaminase 2 IgA antibody and superior RNFL were negatively correlated (r = -0.394, p = .012). The anterior chamber volume and anti-gliadin IgA antibody were positively correlated (r = 0.369 p = .027).

CONCLUSION

Celiac disease affects Schirmer's test results, TBUT, segmental RNFL thickness, and anterior chamber parameters. Ocular parameters might be affected in celiac disease especially in the presence of high antibody titer.

Age Is a Determining Factor of Dry Eye-Related Signs and Symptoms

PURPOSE

The reported signs and symptoms of dry eye (DE) have been discordant. This study evaluated risk factors of DE-related symptoms and signs to explore their association with patient demographics, focusing on the age factor.

METHODS

The study enrolled 704 consecutive patients visiting general eye clinics who complained of ocular discomfort, but had normal vision. The patients were asked about the presence of six common symptoms related to DE and, tear break-up time (TBUT). The severity of patients' keratopathy was also examined, and patients underwent Schirmer's test.

RESULTS

Logistic regression analysis demonstrated that younger age (≤29 years) was associated with non-visual symptoms and keratopathy, while older age (≥60 years) was associated with short TBUT and low values on Schirmer's test. Middle age was associated with both severe symptoms and signs.

CONCLUSIONS

Discrepancies in the signs and symptoms of DE may depend, in part, on age, with younger subjects showing severe non-visual symptoms with apparently normal tear function and severe keratopathy, and older subjects showing fewer symptoms and less severe keratopathy despite worse tear function.

Sensory neurons directly promote angiogenesis in response to inflammation via substance P signaling

Blood vessels and nerves travel together to supply most tissues in the body. However, there is a knowledge gap in the mechanisms underlying the direct regulation of angiogenesis by nerves. In the current study, we examined the regulation of angiogenesis by sensory nerves in response to inflammation using the cornea, a normally avascular and densely innervated ocular tissue, as a model. We used desiccating stress as an inflammatory stimulus in vivo and found that sub-basal and epithelial nerve densities in the cornea were reduced in dry eye disease (DED). We established a co-culture system of trigeminal ganglion sensory neurons and vascular endothelial cells (VEC) and found that neurons isolated from mice with DED directly promoted VEC proliferation and tube formation compared with normal controls. In addition, these neurons expressed and secreted higher levels of substance P (SP), a proinflammatory neuropeptide. SP potently promoted VEC activation in vitro and blockade of SP signaling with spantide I, an antagonist of SP receptor Neurokinin-1, significantly reduced corneal neovascularization in vivo. Spantide I and siRNA knockdown of SP abolished the promotion of VEC activation by DED neurons in vitro. Taken together, our data suggested that sensory neurons directly promote angiogenesis via SP signaling in response to inflammation in the cornea.