A comparison of vitamin a and cyclosporine a 0.05% eye drops for treatment of dry eye syndrome

Changes in conjunctival mononuclear phagocytes and suppressive activity of regulatory macrophages in desiccation induced dry eye

PURPOSE

To evaluate the effects of dry eye on conjunctival immune cell number and transcriptional profiles with attention to mononuclear phagocytes.

METHODS

Expression profiling was performed by single-cell RNA sequencing on sorted conjunctival immune cells from non-stressed and C57BL/6 mice subjected to desiccating stress (DS). Monocle 3 modeled cell trajectory, scATAC-seq assessed chromatin accessibility and IPA identified canonical pathways. Inflammation and goblet cells were measured after depletion of MRC1+ MΦs with mannosylated clodronate liposomes.

RESULTS

Mononuclear phagocytes (monocytes, MΦs, DCs) comprised 72 % of immune cells and showed the greatest changes with DS. Distinct DS induced gene expression patterns were seen in phagocytes classified by expression of Ccr2 and [Timd4, Lyve1, Folr2 (TLR)]. Expression of phagocytosis/efferocytosis genes increased in TLF+CCR2- MΦs. Monocytes showed the highest expression of Ace, Cx3cr1, Vegfa, Ifngr1,2, and Stat1 and TLF-CCR2+ cells expressed higher levels of inflammatory mediators (Il1a, Il1b, Il1rn, Nfkb1, Ccl5, MHCII, Cd80, Cxcl10, Icam1). A trajectory from monocyte precursors branched to terminate in regulatory MΦs or in mDCs via transitional MΦ and cDC clusters. Activated pathways in TLF+ cells include phagocytosis, PPAR/RXRα activation, IL-10 signaling, alternate MΦ activation, while inflammatory pathways were suppressed. Depletion of MRC1+ MΦs increased IL-17 and IFN-γ expression and cytokine-expressing T cells, reduced IL-10 and worsened goblet loss.

CONCLUSIONS

Dryness stimulates distinct gene expression patterns in conjunctival phagocytes, increasing expression of regulatory genes in TLF+ cells regulated in part by RXRα, and inflammatory genes in CCR2+ cells. Regulatory MΦs depletion worsens DS induced inflammation and goblet cell loss.

Reticulated Retinoic Acid Synthesis is Implicated in the Pathogenesis of Dry Eye in Aqp5 Deficiency Mice

Purpose

Abnormalities in aquaporins are implicated in the pathological progression of dry eye syndrome. Retinoic acid (RA) regulates cellular proliferation, differentiation, and apoptosis in the cornea, thereby being associated with dry eye disease (DED). The objective of this study is to explore the underlying mechanisms responsible for RA metabolic abnormalities in corneas lacking aquaporin 5 (AQP5).

Methods

Dry eye (DE) models were induced via subcutaneous scopolamine hydrobromide. Aqp5 knockout (Aqp5-/-) mice and DE mice were utilized to assess corneal epithelial alterations. Tear secretion, goblet cell counts, and corneal punctate defects were evaluated. The impact of Aqp5 on RA-related enzymes and receptors was investigated using pharmacological RA or SR (A JunB inhibitor), a transcription factor JunB inhibitor, treatment in mouse corneal epithelial cells (CECs), or human corneal epithelial cells (HCECs). The HCECs and NaCl-treated HCECs underwent quantitative real-time PCR (qRT-PCR), immunofluorescent, Western blot, and TUNEL assays. The regulation of transcription factor JunB on Aldh1a1 was explored via ChIP-PCR.

Results

Aqp5 and Aldh1a1 were reduced in both CECs of DE mice and NaCl-induced HCECs. Aqp5-/- mice exhibited DE phenotype and reduced Aldh1a1. RA treatment reduced apoptosis, promoted proliferation, and improved the DE phenotype in Aqp5-/- mice. JunB enrichment in the Aldh1a1 promoter was identified by ChIP-PCR. SR significantly increased Aldh1a1 expression, Ki67, and ΔNp63-positive cells, and decreased TUNEL-positive cells in CECs and HCECs.

Conclusions

Our findings demonstrated the downregulation of Aqp5 expression and aberrant RA metabolism in DE conditions. Knockout of Aqp5 resulted in reduced production of RA through activation of JunB, subsequently leading to the manifestation of DE symptoms.

The protective effect of vitamin A palmitate eye gel on the ocular surface during general anaesthesia surgery: a randomized controlled trial

PURPOSE

To investigate the change in tear production associated with general anesthesia and the protective effect of vitamin A palmitate eye gel on the ocular surface during general anesthesia.

METHODS

This double-blind, randomized clinical trial included patients undergoing non-ophthalmic surgery under general anesthesia who randomly received vitamin A palmitate eye gel and taping for one eye (Group A, n = 60) or taping alone for the other eye (Group B, n = 60). Symptom assessment in dry eye (SANDE) score, tear film break-up time (TBUT), corneal fluorescein staining (CFS) score, and Schirmer tear test I (STT-1) were analyzed under a hand-held slit lamp before anesthesia (T0), 0.5 h postoperatively (T1), and 24 h postoperatively (T2).

RESULTS

At 0.5 h postoperatively, an increase in CFS score was observed in both groups (P < 0.05 in Group A and P < 0.01 in Group B), and the participants in Group A had less corneal abrasions than those in Group B. STT-1 significantly increased in Group A (P < 0.05), while it significantly decreased in Group B (P < 0.001). The changes between the two groups were statistically significant (P < 0.001). At 24 h postoperatively, both CFS score and STT-1 almost returned to baseline levels in the two groups. In both groups, the SANDE score and TBUT showed little change at 0.5 h and 24 h postoperatively (all P > 0.05).

CONCLUSION

Vitamin A palmitate eye gel effectively protected the ocular surface and aqueous supplementation during general anesthesia.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052140) on 20/10/2021.

Comparative evaluation of platelet-rich plasma, autologous blood serum, and umbilical cord serum for corneal healing after penetrating keratoplasty in New Zealand rabbits

This study aimed to evaluate the effects of platelet-rich plasma (PRP), autologous blood serum (ABS), and umbilical cord serum (UCS) on corneal healing following penetrating keratoplasty (PK). A total of 120 New Zealand white rabbits, forty were designated as donors, while the remaining eighty rabbits were randomly divided into four groups after undergoing PRP Group (n = 20), ABS Group (n = 20), UCS Group (n = 20) and Control Group (n = 20). Corneal opacity score, corneal vascularization, corneal staining, histopathological analysis, and immunohistochemical analysis (including CD4+, CD8+, and major histocompatibility complex [MHC] II) were assessed at postoperative 1, 2, 3, and 12 weeks. The results showed that corneal opacity score and corneal vascularization did not differ significantly among the groups. However, corneal staining was found to be statistically higher in the PRP group (0.40 ± 0.60) compared to the other groups (p = 0.011). Immunohistochemical examination revealed no significant differences in CD4+, CD8+, and MHC II levels among the groups. Notably, in all groups, CD4+, CD8+, and MHC II levels were significantly higher at 12 weeks compared to other time points. PRP, ABS, and UCS demonstrated positive effects on corneal healing after PK. However, among the three products, PRP exhibited a superior healing effect compared to ABS and UCS crucial in the postoperative period following PK procedures, as they significantly impact visual quality, graft transparency, graft survival, and prevention of stromal resorption caused by infections. Despite the avascular nature of the cornea and its immune privilege, failure to resolve epithelial defects (ED) commonly observed after PK can result in irreversible scarring and ulceration, leading to graft rejection. While epithelial defects are observed in 14-100% of cases on the first postoperative day, approximately 3-7% of them persist as non-healing ED in subsequent periods. In conclusion, our study demonstrated that PRP, ABS, and UCS have a positive effect on corneal healing after PK.

New advances in medical management of dry eye: optimizing treatment strategies for enhanced relief

PURPOSE

Dry eye disease (DED) is a prevalent ocular surface disease that is conventionally characterized by tear film hyperosmolarity and instability. This review presents a summarized classification of DED, followed by a comprehensive discussion of the most recent topical and systemic medications and clinical recommendations for selecting the most appropriate option for each patient.

METHODS

An extensive literature search was conducted on electronic databases, such as PubMed, Scopus, and Web of Science, using keywords including "dry eye syndrome," "ocular surface disease," "medical management," "artificial tears," "topical immunomodulators," and "meibomian gland dysfunction."

RESULTS

The underlying reasons for DED can range from insufficient aqueous tear production to increased tear evaporation. Recent literature has provided a more in-depth understanding of the pathophysiology of DED by examining the tear film's lipid, aqueous, and mucin layers. However, despite these advancements, medical management of patients with symptomatic DED has not fully reflected this modernized knowledge of its pathophysiology.

CONCLUSION

To develop a rationalized strategy for treating DED, it is crucial to have updated knowledge of therapeutic options, their mechanisms of actions, and indications based on the DED type and underlying causes.

Case report: Concomitant use of nightly vitamin A ointment with daily PROSE wear for ocular surface disease associated with chronic Stevens-Johnson syndrome

Purpose

To describe a case of chronic ocular surface disease associated with Stevens-Johnson Syndrome (SJS) in which the addition of nightly topical ophthalmic preservative free vitamin A ointment to the daily use of a customized ocular surface prosthetic device (PROSE) appears to mitigate disease progression.

Observations

A 51-year-old female with SJS secondary to lamotrigine use presented for follow up evaluation. Ocular history was significant for acute SJS twenty-four years prior with chronic ocular surface sequelae predominantly affecting the left eye. The condition had been stabilized without progression by utilizing long term PROSE daytime wear along with nightly application of topical ophthalmic vitamin A ointment. The patient reported non-compliance with vitamin A ointment use for the prior three months. The ocular surface examination of the left eye was notable for significantly progressed inferior keratinization and neovascularization which had been unchanged over the course of the three prior annual exams. After restarting nightly topical ophthalmic vitamin A ointment and continuing regular PROSE use, there was no further ocular surface disease progression in the ensuing 4 years of follow up.

Conclusion and Importance

The use of nightly topical ophthalmic vitamin A ointment may be a viable adjuvant therapy alongside daily PROSE use for progressive chronic SJS ocular surface disease.

Real Life Impact of Dry Eye Disease

Dry Eye Disease (DED) is an increasingly common condition that affects between 5% and 50% of the global population. Even though DED is most frequently diagnosed in older people, it has also been diagnosed in young adults and adolescents more frequently in recent years (employees, gamers). People can experience different types of symptoms and find it challenging to read, watch TV, cook, climb stairs, and meet friends. Mild and severe dry eye can reduce quality of life similarly to mild psoriasis and moderate-to-severe angina. Furthermore, DED patients experience serious difficulties driving vehicles, especially at night, and show a decrease in work productivity, which, when combined with the relevant indirect cost that this condition produces, poses a serious challenge in our days. In addition, DED patients are more likely to develop depression and suicidal ideations and experience frequent sleep disorders. Finally, it is discussed how lifestyle changes, such as increased physical activity, blinking exercises, and a proper diet, have positive implications for the management of this condition. Our aim is to draw attention to the negative effects of dry eye in real life, which are unique to each patient, especially as they relate to the non-visual symptoms experienced by DED patients.

Anti-biofilm activity of a novel nanoemulsion containing Curcuma xanthorrhiza oil

OBJECTIVES

We aimed to solubilize Curcuma xanthorrhiza oil (CXO) using nanoemulsification and evaluate its inhibitory effects against biofilm formation.

METHODS

The components of CXO were evaluated through high-performance liquid chromatography (HPLC) analysis. Healthy human saliva was inoculated onto hydroxyapatite discs to form microcosm biofilms for four days and treated six times with each antimicrobial agent: distilled water (DW), CXO emulsion (EM), CXO nanoemulsion (NE), and positive controls (Listerine and chlorhexidine). Biofilm fluorescence imaging was performed using quantitative light-induced fluorescence, and cell viability and dry-weight measurements were obtained. We compared the bacterial cell and extracellular polysaccharide (EPS) biovolume and thickness using confocal laser scanning microscopy (CLSM).

RESULTS

HPLC analysis revealed that CXO was composed of approximately 47% xanthorrhizol. Compared with DW, NE exhibited significantly lower red fluorescence intensity and area (42% and 37%, p < 0.001 and p < 0.001, respectively), and reduced total and aciduric bacterial cell viability (7.3% and 3.9%, p < 0.001, p = 0.01, respectively). Furthermore, the bacterial cell and EPS biovolume and thickness in NE decreased by 40-80% compared to DW, similar to chlorhexidine. Conversely, EM showed a significant difference only in cell viability against total bacteria when compared with DW (p = 0.003), with EPS biovolume and thickness exhibiting higher values than DW.

CONCLUSIONS

Nanoemulsification successfully solubilized CXO and demonstrated superior anti-biofilm effects compared to the emulsion form.

CLINICAL SIGNIFICANCE

These findings suggest the potential use of NE as a novel antimicrobial agent for preventing oral diseases.

Retinol palmitate in management of chronic Steven-Johnson Syndrome with ocular surface keratinization

PURPOSE

To study the outcomes of topical Retinol Palmitate ophthalmic solution in chronic Stevens-Johnson Syndrome with ocular surface keratinisation.

METHODS

It was a comparative interventional study conducted at Rajendra Prasad Centre for Ophthalmic Sciences, Delhi, India from 2020 to 2022 evaluating outcomes of addition of topical Retinol Palmitate to conventional treatment objectively as well as subjectively from baseline up to 12 weeks.

RESULTS

A statistically significant improvement was seen in patients who received topical Retinol palmitate at 12 weeks in terms of Schirmer-1 test(p=<0.01), tear prism height on ASOCT(p = 0.02), Rose Bengal staining score of cornea(p = 0.01) and conjunctiva (p < 0.01), reduction of ocular surface keratinisation on impression cytology(p = 0.01) and subjective evaluation using OSDI questionnaire(p = 0.04).Impression cytology revealed goblet cells in Retinol palmitate group at 1 week after initiation of therapy, which increased further at 1 month follow up but reduced at 3 months. No goblet cells were seen in control group at any follow-up. No significant difference was noted between the two groups in terms of visual acuity, tear film breakup time, inflammatory cells on impression cytology and inflammatory markers in tears.

CONCLUSION

Topical Retinol palmitate is a safe and effective drug in cases of chronic SJS with ocular surface keratinisation. It has the potential to reverse keratinisation of the ocular surface and promote development of goblet cells. However, the survival of goblet cells is not long lasting.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

Metabolic Engineering of Saccharomyces cerevisiae for Efficient Retinol Synthesis

Retinol, the main active form of vitamin A, plays a role in maintaining vision, immune function, growth, and development. It also inhibits tumor growth and alleviates anemia. Here, we developed a Saccharomyces cerevisiae strain capable of high retinol production. Firstly, the de novo synthesis pathway of retinol was constructed in S. cerevisiae to realize the production of retinol. Second, through modular optimization of the metabolic network of retinol, the retinol titer was increased from 3.6 to 153.6 mg/L. Then, we used transporter engineering to regulate and promote the accumulation of the intracellular precursor retinal to improve retinol production. Subsequently, we screened and semi-rationally designed the key enzyme retinol dehydrogenase to further increase the retinol titer to 387.4 mg/L. Lastly, we performed two-phase extraction fermentation using olive oil to obtain a final shaking flask retinol titer of 1.2 g/L, the highest titer reported at the shake flask level. This study laid the foundation for the industrial production of retinol.

An Evaluation of Popular Online Eye Health Products on Amazon Marketplace

BACKGROUND AND OBJECTIVE

To investigate popular eye health supplements available on Amazon Marketplace to increase awareness about their efficacy, safety, and the validity of their purported benefits.

MATERIALS AND METHODS

An observational quantitative and qualitative analysis of the top 100 eye health products was performed in March 2019. To determine the popular online eye health products on Amazon Marketplace, eight keywords were used for the search: "Eye Health," "Eye Health Supplements," "Eye Health Vitamins," "Retina Vitamins," "Macular Degeneration," "Macular Degeneration Vitamins," "Macular Health," and "Vision Health." The active ingredients, cost, and customer rating were all recorded.

RESULTS

No statistically significant association was found between product type and price of the product, number of supplements, average rating, number of customer reviews, or number of verified customer reviews. The average daily cost of the eye health supplements was $0.72 ± $0.55 (range, $0.05 to $2.67).

CONCLUSION

This study evaluated popular eye health supplements publicly available on Amazon Marketplace. The findings of this study help both patients and physicians better understand the safety and efficacy of these products so they may make more informed choices when supporting their eye health with commercially available supplements. [Ophthalmic Surg Lasers Imaging Retina 2023; 54(3):147-152.].

A Randomised Phase I Study to Assess the Safety, Tolerability and Pharmacokinetics of Palovarotene Ophthalmic Solution

BACKGROUND AND OBJECTIVE

Palovarotene, a selective retinoic acid receptor γ agonist, is under investigation for the treatment of dry eye disease. This study aimed to determine the ocular and systemic safety, tolerability and pharmacokinetics of palovarotene ophthalmic solution (PVO-OS) in healthy adults.

METHODS

This was a randomised, vehicle-controlled phase I study (NCT04762355; retrospectively registered). Participants received either PVO-OS (at 0.025, 0.05 or 0.10 mg/mL) or a vehicle (placebo-to-match PVO-OS) once-daily or twice-daily for seven consecutive days. Safety was assessed by ocular and systemic assessments. Blood samples for pharmacokinetic assessments were collected before and after dose administration.

RESULTS

Thirty-six participants were randomised to PVO-OS and 12 to the vehicle. Overall, 89 treatment-emergent ocular adverse events (TEOAEs) were reported by 22 participants (61.1%) receiving PVO-OS and ten TEOAEs were reported by five participants (41.7%) receiving the vehicle. Erythema, irritation and skin dryness of the eyelid were the most common TEOAEs in participants receiving PVO-OS. The incidence of TEOAEs and eyelid-related findings in the PVO-OS groups increased with ascending dose and frequency compared with participants treated with the vehicle. All TEOAEs were mild (96.6%) or moderate (3.4%) and resolved without sequelae. Plasma palovarotene concentrations were generally measurable for up to 3-4 h for 0.025 mg/mL and 0.05 mg/mL and up to 12 h for 0.10 mg/mL dose regimens, independent of the frequency of administration.

CONCLUSIONS

PVO-OS was generally well tolerated at doses up to and including 0.10 mg/mL twice daily. Similar pharmacokinetic profiles were observed for the once-daily and twice-daily regimens following multiple ascending doses of PVO-OS.

Novel drug delivery systems for the management of dry eye

Dry eye disease (DED) is a frequently observed eye complaint, which has recently attracted considerable research interest. Conventional therapy for DED involves the use of artificial tear products, cyclosporin, corticosteroids, mucin secretagogues, antibiotics and nonsteroidal anti-inflammatory drugs. In addition, ocular drug delivery systems based on nanotechnology are currently the focus of significant research effort and several nanotherapeutics, such as nanoemulsions, nanosuspensions, microemulsions, liposomes and nanomicelles, are in clinical trials and some have FDA approval as novel treatments for DED. Thus, there has been remarkable progress in the design of nanotechnology-based approaches to overcome the limitations of ophthalmic formulations for the management of anterior eye diseases. This review presents research results on diagnostic methods for DED, current treatment options, and promising pharmaceuticals as future therapeutics, as well as new ocular drug delivery systems.

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.

Effect of multivitamin drug on intractable dry eye symptoms

Dry eye is a disorder of tear film and ocular surface characterized by ocular discomforts. It is associated with multiple causes and sometimes intractable. We investigated the effect of oral multivitamin supplementation (MVG) on dry eyes. Tear break-up time (TBUT), fluorescein ocular surface staining score, and tear secretion Schirmer test were measured in dry eye patients refractory to conventional topical treatment. The ocular surface disease index (OSDI), visual analog pain score (VAS), and modified standardized patient evaluation of eye dryness questionnaire were analyzed. In total, 42 eyes of 42 patients were included. TBUT increased at 1 and 3 months compared to baseline (p < 0.05). OSDI decreased at 1 and 3 months compared to baseline (p < 0.05). VAS score, impact on life, and frequency of total symptoms decreased at 3 months compared to baseline (p < 0.05). Oral administration of MVG, a vitamin complex formulation, was effective in stabilizing tear stability and alleviating symptoms in patients with intractable dry eye. Thus, it may be a viable treatment option for intractable dry eye.

Efficacy and safety of manuka honey for dry eye

Dry eye has become an increasingly prevalent public health issue for which there is currently no cure. Manuka honey possesses anti-inflammatory and antioxidant properties that can be used to treat dry eye. The present study aimed to systematically review evidence supporting the treatment of dry eye with manuka honey and quantify this evidence via meta-analysis. Randomised clinical trials that fulfilled the inclusion criteria from database inception until 5 September 2021, were identified through online searches of seven databases, including but not limited to Embase, Medline, and Central. Changes between the point of longest follow-up and baseline subjective symptoms, tear film quality, ocular surface characteristics, adverse events, and compliance were selected for meta-analysis. A total of 288 adult participants with dry eye from five eligible randomised controlled trials were analysed. Compared with the control groups, treatment with manuka honey demonstrated a significant improvement in Ocular Surface Disease Index, Standard Patient Evaluation of Eye Dryness, tear evaporation rate, negative conversion rate of matrix metalloproteinase-9 levels, ocular surface staining, and daily use frequency of lubricant. No serious adverse events were reported, except for temporary stinging and redness, which were generally tolerated. This review found that manuka honey demonstrated promising results for the treatment of dry eye. However, limitations of the included studies and analytical methodology affect the reliability of this conclusion. Therefore, further high-quality randomised clinical trials are required to confirm the efficacy and safety of the use of manuka honey in the treatment of dry eye.

A Narrative Review of Ocular Surface Disease Related to Anti-Glaucomatous Medications

Topical anti-glaucomatous medications are still the most important measure to lower intraocular pressure. Large number of studies have confirmed that long-term use of anti-glaucomatous eye drops, especially containing benzalkonium chloride, a preservative, can cause or aggravate ocular surface injury. Ocular surface diseases damage the ocular microenvironmental health status, reduce the patients’ compliance with the treatment, and finally affect the treatment result. Therefore, the ocular surface management of patients with glaucoma is very important. This includes the selection of drugs that are better tolerated according to individual conditions, preservative-free formulations, drugs that protect against ocular surface disease, or selecting surgery and laser treatment, to prevent the damage to the ocular surface by topical anti-glaucomatous drugs.

Dry Eye Disease and Vitamins: A Narrative Literature Review

Dry eye disease (DED) is a major public health problem worldwide that seriously impairs the quality of life, reduces work productivity, and poses significant economic burden. In DED, tear film instability or hyperosmolarity activates a self-perpetuating vicious cycle that may aggravate ocular surface inflammation and damage. Thus, treatment approaches should focus on interrupting this cycle and ameliorating inflammation. In addition to anti-inflammatory medications, such as corticosteroids, cyclosporine, and lifitegrast, nutrients with anti-inflammatory and anti-oxidative properties may also be effective for the treatment of DED. Evidence indicates that vitamin deficiencies may be associated with an increased risk of DED and that vitamin supplementation can be an effective treatment for DED. In the present review, we introduce the results of clinical and experimental studies on the association between vitamin deficiencies and DED. The potential efficacy of systemic and topical supplementation in the treatment of DED is also discussed.

Artificial Tears: Biological Role of Their Ingredients in the Management of Dry Eye Disease

Dry eye disease (DED) is the most common ocular surface disease, characterized by insufficient production and/or instability of the tear film. Tear substitutes are usually the first line of treatment for patients with DED. Despite the large variety of tear substitutes available on the market, few studies have been performed to compare their performance. There is a need to better understand the specific mechanical and pharmacological roles of each ingredient composing the different formulations. In this review, we describe the main categories of ingredients composing tear substitutes (e.g., viscosity-enhancing agents, electrolytes, osmo-protectants, antioxidants, lipids, surfactants and preservatives) as well as their effects on the ocular surface, and we provide insight into how certain components of tear substitutes may promote corneal wound healing, and/or counteract inflammation. Based on these considerations, we propose an approach to select the most appropriate tear substitute formulations according to the predominant etiological causes of DED.

In vitro and in vivo evaluation of cyclosporine-graphene oxide laden hydrogel contact lenses

Drug-eluting contact lens can substitute the multiple eye drop therapy. However, loading hydrophobic drug like cyclosporine in the contact lens is very challenging, due to low drug uptake (via soaking method); and alteration in the swelling and optical properties which restricts its clinical application. To address the above issues, graphene oxide (GO, large surface area with oxygen containing functional groups) was incorporated in the contact lenses during fabrication. These GO-laden contact lenses (SM-GO-Cys) as well as blank contact lenses (SM-Cys) were soaked in the solution of cyclosporine. Alternatively, cyclosporine-laden contact lenses (DL-Cys-20) and cyclosporine-GO-laden contact lenses (DL-Cys-20-GO) were fabricated by adding drug and drug-GO (at various level of GO) during fabrication, respectively. Contact angle and swelling data showed increase in water holding capacity of GO laden contact lenses. Optical property was significantly improved due to molecular dispersion of drug on the surface of GO sheets. The drug uptake and in vitro release profile was improved with GO-laden contact lenses by soaking method (SM-GO-Cys-400n) due to hydrophobic interactions between GO and drug. Adding cyclosporine-GO (DL-Cys-20-GO-800n) during fabrication significantly improved drug release kinetics with higher drug leaching (during extraction and sterilization) due to increased swelling, improved dissolution and molecular dispersion of drug on GO sheets. Ocular irritation and histopathological studies demonstrated the safety of GO-contact lens. The in vivo drug release studies in the rabbit eye showed significant improvement in mean residence time (MRT) and area under the curve (AUC) using DL-Cys-20-GO-800n contact lens compared to eye drop solution with reduction in protein adherence value. The study demonstrated that the incorporation of GO into the contact lens can control the release of cyclosporine as well as improved the lens swelling and transmittance properties.

A Review of Topical and Systemic Vitamin Supplementation in Ocular Surface Diseases

In the homeostasis of the ocular surface, vitamins play a critical role in regulating inflammatory responses and promoting cell differentiation, development and correct function. Systemic vitamin supplementation has been available for many decades; in recent years, thanks to pharmacological advancements, topical vitamin delivery has also become available in an attempt to better treat ocular surface disease (OSD) and dry eye disease (DED). In this paper, we reviewed the current evidence on the role of vitamin supplementation in OSD and DED. We originally searched the PubMed archive, inspected the references and restricted the search to pertinent papers. The body of evidence was evaluated using the amelioration of both signs and symptoms as the outcome, when available. We found that in patients with vitamin deficiency, systemic supplementation of Vitamin A is effective in treating OSD, reducing both DED signs and symptoms. Additionally, systemic supplementation of vitamin D is useful in reducing DED symptoms and increasing tear volume. Vitamin A is also effective in reducing DED signs and symptoms when administered locally. The efficacy of supplementation with other vitamins is still not fully proven. In conclusion, the inclusion of vitamins into the treatment strategies for OSD and DED allows for better treatment customization and better outcomes in these patients.

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.

Prospective trial of a 2940 nm Er:YAG laser for the treatment of meibomian gland dysfunction

PURPOSE

The primary objective was to evaluate the efficacy and safety of Er:YAG laser treatment for meibomian gland dysfunction (MGD) in a prospective study.

METHODS

A total of 128 eyes from 64 patients with MGD were enrolled to receive either three Er:YAG laser treatments with meibomian gland expression (MGX) or MGX-alone treatment sessions at 3-week intervals. The Standard Patient Evaluation of Eye Dryness (SPEED) validated questionnaire; fluorescein breakup time of the tear film (FBUT); corneal fluorescein staining (CFS); lid margin abnormalities; meibomian gland morphology (meiboscore); lower tear meniscus height (TMH); and assessment of 15 meibomian glands in the lower eyelids, including total meibomian gland secretion quality (TMGS), the number of glands secreting any liquid (GSAL), and the number of glands yielding optimal clear liquid secretion (GYCL), were assessed at day (D)0, D21, D42, and D63 for the Er:YAG-MGX group and D0 and D63 for the MGX group.

RESULTS

At D63, significant decreases in SPEED scores and lid margin abnormalities as well as significant increases in FBUT, TMGS, and GSAL were observed in both groups (all p < 0.05). The Er:YAG-MGX group showed a significantly better improvement in SPEED scores, TMGS, and GYCL than the MGX group (all p < 0.05).

CONCLUSION

Although preliminary, the study results of Er:YAG laser treatment for dry eye syndrome caused by MGD are promising. Er:YAG laser treatment may be a new direction for managing MGD.

TRIAL REGISTRATION

The study was registered at www.chictr.org.cn : ChiCTR1900026004.

Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours

Simple Summary

The ocular surface represents a finely regulated system that allows the protection of the eye. It can be affected by therapies used for the treatment of various intraocular tumours, particularly conjunctival cancers and uveal melanoma. In these conditions, treatments are chosen according to the characteristics of the lesion, and include a combination of selective surgery, anticancer eye drops, and/or radiotherapy delivered through different mechanisms. Possible side effects affecting the ocular surface range from transient dry eye or keratitis up to more severe complications such as corneal melting and perforation. These complications deserve careful evaluation for the risk of permanent sight-threatening sequelae. Physicians involved in the management of patients affected by ocular tumours should be aware of this risk in order to reach an early diagnosis and promptly set up an adequate treatment. The present review summarizes acute and chronic complications affecting the ocular surface following different therapies for the treatment of conjunctival cancers and uveal melanoma, and also reports clinical cases of representative patients who experienced these complications.

Abstract

The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.

Modern approach to the treatment of dry eye, a complex multifactorial disease: a P.I.C.A.S.S.O. board review

Dry eye disease (DED) is a growing public health concern affecting quality of life and visual function, with a significant socio-economic impact. It is characterised by the loss of homoeostasis, resulting in tear film instability, hyperosmolarity and inflammation of the ocular surface. If the innate immune response is unable to cope with internal bodily or environmental adverse conditions, the persistent, self-maintaining vicious circle of inflammation leads to the chronic form of the disease. Treatment of DED should be aimed at the restoration of the homoeostasis of the ocular surface system. A proper diagnostic approach is fundamental to define the relevance and importance of each of the DED main pathogenic factors, namely tear film instability, epithelial damage and inflammation. Consideration also needs to be given concerning two other pathogenic elements: lid margin changes and nerve damage. All the factors that maintain the vicious circle of DED in the patient's clinical presentation have to be considered and possibly treated simultaneously. The treatment should be long-lasting and personalised since it has to be adapted to the different clinical conditions observed along the course of the disease. Since DED treatment is frequently unable to provide fast and complete relief from symptoms, empathy with patients and willingness to explain to them the natural history of the disease are mandatory to improve patients' compliance. Furthermore, patients should be instructed about the possible need to increase the frequency and/or change the type of treatment according to the fluctuation of symptoms, following a preplanned rescue regimen.

Topical tretinoin in chronic rhinosinusitis with nasal polyps: a randomized clinical trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is usually treated with corticosteroids, given their anti-inflammatory effects. Unlike the nasal administration, the oral and ocular use of tretinoin, an immunoregulatory drug, is well established. Therefore, tretinoin was thought to act on nasal polyps, and possible adverse and/or therapeutic effects were investigated.

METHODS

A first-in-human open-label trial was conducted enrolling patients with CRSwNP randomized into: a control group (CTR, n = 15), treated with budesonide for 24 weeks; and an intervention group (TRT, n = 15), who received budesonide and 0.1% tretinoin in the last 12 weeks. Primary endpoint included histopathological analysis and tissue immunoassay (Multiplex) for tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-4, IL-5, IL-13, and matrix metalloproteinase 9 (MMP-9) at 12 and 24 weeks. Secondary endpoints were: adverse events report, endoscopy (modified Lund-Kennedy scoring system [LKS]), quality of life (22-item Sino-Nasal Outcome Test [SNOT-22]), and olfactory test (Connecticut Chemosensory Clinical Research Center) at baseline, at 12 weeks, and at 24 weeks, in addition to serum biochemistry and tomographic findings (Lund-Mackay computed tomography [CT] staging system [LMS]) at baseline and 24 weeks.

RESULTS

TRT showed less microscopic edema (2/13 [15.4%] vs 8/13 [61.5%]; p = 0.044) as well as no increase in cytokines levels. All adverse events were categorized as "grade 1" (asymptomatic; mild). The most interesting part of this study was the improvement in smell between baseline (T0) and week 24 (T2) in TRT only (p = 0.041).

CONCLUSION

Transnasal tretinoin associated with budesonide was safe and well tolerated, and it should be investigated as a treatment option for some CRSwNP endotypes. ©2021 ARSAAOA, LLC.

The Role of Nano-ophthalmology in Treating Dry Eye Disease

Dry eye disease (DED) is a common multifactorial disease linked to the tears/ocular surface leading to eye discomfort, ocular surface damage, and visual disturbance. Antiinflammatory agents (steroids and cyclosporine A), hormonal therapy, antibiotics, nerve growth factors, essential fatty acids are used as treatment options of DED. Current therapies attempt to reduce the ocular discomfort by producing lubrication and stimulating gland/nerve(s) associated with tear production, without providing a permanent cure for dry eye. Nanocarrier systems show a great promise to revolutionize drug delivery in DED, offering many advantages such as site specific and sustained delivery of therapeutic agents. This review presents an overview, pathophysiology, prevalence and etiology of DED, with an emphasis on preclinical and clinical studies involving the use of nanocarrier systems in treating DED. Lay Summary: Dry eye disease (DED) is a multifactorial disease associated with tear deficiency or excessive tear evaporation. There are several review articles that summarize DED, disease symptoms, causes and treatment approaches. Nanocarrier systems show a great promise to revolutionize drug delivery in DED, offering many advantages such as site specific and sustained delivery of therapeutic agents. Very few review articles summarize the findings on the use of nanotherapeutics in DED. In this review, we have exclusively discussed the preclinical and clinical studies of nanotherapeutics in DED therapy. This information will be attractive to both academic and pharmaceutical industry researchers working in DED therapeutics.

Analysis of Clinical and Regional Distribution Characteristics of Obstructive Meibomian Gland Dysfunction in China: A Multicenter Study

Purpose: To analyze the clinical and regional distribution characteristics of obstructive meibomian gland dysfunction (OMGD) in China. Methods: A total of 2900 patients (2900 eyes) diagnosed with OMGD were enrolled in this multicenter, cross-sectional, observational study. The Ocular Surface Disease Index (OSDI), tear film breakup time (FBUT), Schirmer test (SI), lipid layer thickness (LLT), OMGD grade, meibomian gland loss score (Meiboscore), meibum expressibility score (MES), meibum quality score (MQS), Lid margin abnormality score(LMS) and other tear film stability markers were evaluated. Results: The prevalence of dry eye in OMGD patients was 89%. There were gender differences among OMGD patients in the 30-39 and 50-59 years age groups (p < .05), and FBUT, Meiboscore, MES and MQS were significantly different among different OMGD grades (p < .05). There were significant differences in the detection indexes of OMGD patients in the six regions (p < .05), except LLT (p = .329). According to the Qinling-Huaihe River in China, OMGD patients were divided into the North Group (Shenyang and Beijing) and South Group (Wuhan, Changsha, Chongqing, and Chengdu). There was a significant difference in the detection indexes, except LLT (p = .600), between the two groups (p < .05). FBUT was significantly correlated with the OSDI (r = -0.131; p < .000). Meiboscore and LLT were significantly correlated with the OMGD grade (r = 0.299 and r = 0.106; p < .001). Age, LMS and MQS were significantly correlated with Meiboscore (r = 0.415, r = 0.256 and r = 0.328; p < .001). Conclusions: The prevalence of dry eye was high among OMGD patients. OMGD patients in different age groups may show different gender distributions. The symptoms of patients showed variation among subgroups with different OMGD grades and among different regions.

An Updated Systematic Review With Meta-Analysis Of Randomized Trials On Topical Cyclosporin A For Dry-Eye Disease

Background/Aims

To evaluate the effects of topical cyclosporin A (CsA) and artificial tears (ATs) for treating patients with dry-eye disease (DED).

Methods

On January 25, 2019, five electronic databases and reference lists were searched for randomized clinical trials (RCTs) comparing CsA with ATs among patients with DED. The search strategy had no restriction on language or time. Two authors extracted surgery, mean age, anesthesia for Schirmer’s test, tear-breakup time, Schirmer’s test score, fluorescein-staining score, ocular surface–disease index, and adverse events. Mean differences (MDs) were calculated for continuous outcomes and Peto ORs for dichotomous data with zero cells. Results were analyzed with 95% CIs in a random-effect model.

Results

Eleven RCTs recruiting 1,085 cases with DED were included. Pooled results showed that CsA had better tear-breakup time (MD 0.94, 95% CI 0.08–1.80), fluorescein-staining score (standardized MD −0.72, 95% CI −1.28 to −0.16), and ocular surface–disease index (MD −4.75, 95% CI −6.31 to −3.18) when compared to ATs. Although CsA had more adverse events than ATs (Peto OR 7.70, 95% CI 3.17–18.68), no serious adverse events were reported.

Conclusion

Overall, CsA is an effective option for treating patients with DED, yet our evidence indicated decreasing effects when CsA was combined with ATs. CsA may be worth suggesting to relatively older patients with DED. We anticipate further RCTs to explore the effects of treatment duration, optimal dosage, and efficacy of CsA in different DED etiology.

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Immune - Goblet cell interaction in the conjunctiva

The conjunctiva is a goblet cell rich mucosal tissue. Goblet cells are supported by tear growth factors and IL-13 produced by resident immune cells. Goblet cell secretions are essential for maintaining tear stability and ocular surface homeostasis. In addition to producing tear stabilizing mucins, they also produce cytokines and retinoic acid that condition monocyte-derived phagocytic cells in the conjunctiva. Aqueous tear deficiency from lacrimal gland disease and systemic inflammatory conditions results in goblet cell loss that amplifies dry eye severity. Reduced goblet cell density is correlated with more severe conjunctival disease, increased IFN-γ expression and antigen presenting cell maturation. Sterile Alpha Motif (SAM) pointed domain epithelial specific transcription factor (Spdef) gene deficient mice that lack goblet cells have increased infiltration of monocytes and dendritic cells with greater IL-12 expression in the conjunctiva. Similar findings were observed in the conjunctiva of aged mice. Reduced retinoic acid receptor (RXRα) signaling also increases conjunctival monocyte infiltration, IFN-γ expression and goblet cell loss. Evidence suggests that dry eye therapies that suppress IFN-γ expression preserve conjunctival goblet cell number and function and should be considered in aqueous deficiency.

Perfluorohexyloctane (F6H8) as a delivery agent for cyclosporine A in dry eye syndrome therapy - Langmuir monolayer study complemented with infrared nanospectroscopy

One of the key challenges in dry eye syndrome therapy is to find a suitable carrier for immunosuppressant drug - cyclosporine A (CsA) - delivery to the eye. To investigate this issue, herein we present a methodology based on the combined analysis in macro- (Langmuir monolayers), micro- (Brewster angle microscopy) and nanoscale (atomic force microscopy and infrared nano-spectroscopy). The applied approach proves that CsA affects the phospholipid part of the tear film lipid layer by loosening molecular packing. This effect can be reversed by the addition of perfluorohexyloctane (F₆H₈). We have highlighted that F₆H₈ increases the availability of CsA and therefore is appropriate carrier for CsA topical delivery to the eye in the dry eye syndrome. In addition, the applied herein procedure provides a simple, low-cost laboratory tool for preliminary studies involving membrane active pharmaceuticals, preceding in vivo tests.

Topical cyclosporine A therapy for dry eye syndrome

BACKGROUND

Topical cyclosporine A (also known as ciclosporin A) (CsA) is an anti-inflammatory that has been widely used to treat inflammatory ocular surface diseases. Two CsA eyedrops have been approved by US Food and Drug Administration for managing dry eye: Restasis (CsA 0.05%, Allergan Inc, Irvine, CA, USA), approved in 2002, and Cequa (CsA 0.09%, Sun Pharma, Cranbury, NJ, USA), approved in 2018. Numerous clinical trials have been performed to assess the effectiveness and safety of CsA for dry eye; however, there is no universal consensus with regard to its effect.

OBJECTIVES

To assess the effectiveness and safety of topical CsA in the treatment of dry eye.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 16 February 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people with dry eye regardless of age, sex, severity, etiology, or classification of dry eye. We included RCTs in which different concentrations of topical CsA were compared with one another or with artificial tears, placebo, or vehicle. We also included RCTs in which CsA in combination with artificial tears was compared to artificial tears alone.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodology and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 30 RCTs (4009 participants) with follow-up periods ranging from 6 weeks to 12 months. We studied dry eye of various severity and underlying causes. The interventions investigated also varied across RCTs: CsA versus artificial tears; CsA with artificial tears versus artificial tears alone; and in some studies, more than one concentration of CsA. Artificial tears were used as adjunctive to study medication in all but five trials. Almost all trials had deficiencies in the reporting of results (e.g. reporting P values or direction only), precluding the calculation of between-group estimates of effect or meta-analysis.Eighteen trials compared topical CsA 0.05% plus artificial tears versus vehicle plus artificial tears or artificial tears alone. One trial reported subjective symptoms of dry eye at 6 months and the results were in favor of CsA (mean difference (MD) -4.80, 95% confidence interval (CI) -6.41 to -3.19; low-certainty evidence). Two trials reported MD in ocular surface dye staining at 6 months, but the results were inconsistent in these two trials (MD -0.35, 95% CI -0.69 to -0.01 in one and MD 0.58, 95% CI 0.06 to 1.10 in the other; low-certainty evidence). Four trials reported MD in Schirmer test scores at 6 months and the estimates ranged from -4.05 (95% CI -6.67 to -1.73) to 3.26 (95% CI -1.52 to 5.00) (low-certainty evidence). Three trials reported risk ratio (RR) of improved Schirmer test scores at 6 months; estimates ranged from 0.98 (95% CI 0.83 to 1.17) to 3.50 (95% CI 2.09 to 5.85) (low-certainty evidence). Four trials reported MD in tear film stability measured by tear break-up time at 6 months and the estimates ranged from -1.98 (95% CI -3.59 to -0.37) to 1.90 (95% CI 1.44 to 2.36) (low-certainty evidence). Three trials reported RR of improved tear break-up time at 6 months and the estimates ranged from 0.90 (95% CI 0.77 to 1.04) to 4.00 (95% CI 2.25 to 7.12) (low-certainty evidence). Three trials reported frequency of artificial tear usage at 6 months without providing any estimates of effect; the direction of effect seem to be in favor of CsA (low-certainty evidence). Because of incomplete reporting of the results data or considerable statistical heterogeneity, we were only able to perform a meta-analysis on mean conjunctival goblet cell density. Mean conjunctival goblet cell density in the CsA treated group may be greater than that in the control group at the end of follow-up at four and 12 months (MD 22.5 cells per unit, 95% CI 16.3 to 28.8; low-certainty evidence). All but two trials reported adverse events that included burning and stinging. Participants treated with CsA may be more likely to have treatment-related adverse events than those who treated with vehicle (RR 1.33, 95% CI 1.00 to 1.78; low-certainty evidence).Other comparisons evaluated were CsA 0.05% plus artificial tears versus higher concentrations of CsA plus artificial tears (4 trials); CsA 0.05% versus placebo or vehicle (4 trials); CsA 0.1% plus artificial tears versus placebo or vehicle plus artificial tears (2 trials);CsA 0.1% cationic emulsion plus artificial tears versus vehicle plus artificial tears (2 trials); CsA 1% plus artificial tears versus placebo plus artificial tears (3 trials); and CsA 2% plus artificial tears versus placebo plus artificial tears (3 trials). Almost all of these trials reported P value or direction of effect only (mostly in favor of CsA), precluding calculation of between-group effect estimates or meta-analyses.

AUTHORS' CONCLUSIONS

Despite the widespread use of topical CsA to treat dry eye, we found that evidence on the effect of CsA on ocular discomfort and ocular surface and tear film parameters such as corneal fluorescein staining, Schirmer's test, and TBUT is inconsistent and sometimes may not be different from vehicle or artificial tears for the time periods reported in the trials. There may be an increase in non-serious, treatment-related adverse effects (particularly burning) in the CsA group. Topical CsA may increase the number of conjunctival goblet cells. However, current evidence does not support that improvements in conjunctival mucus production (through increased conjunctival goblet cells) translate to improved symptoms or ocular surface and tear film parameters. All published trials were short term and did not assess whether CsA has longer-term disease-modifying effects. Well-planned, long-term, large clinical trials are needed to better assess CsA on long-term dry eye-modifying effects. A core outcome set, which ideally includes both biomarkers and patient-reported outcomes in the field of dry eye, is needed.

Dry Eye Disease: A Review of Epidemiology in Taiwan, and its Clinical Treatment and Merits

Dry eye disease (DED) has become common on a global scale in recent years. There is a wide prevalence of DED in different countries based on various ethnicities and environment. DED is a multifactorial ocular disorder. In addition to advanced age and gender, such factors as living at high altitude, smoking, pterygium, prolonged use of consumer electronics or overingesting of caffeine or multivitamins are considered to be the major risk factors of DED. We report the DED epidemiology in Taiwan firstly in this article. According to the pathophysiological factors and changes inthe composition of the tear film in DED, it can be categorized into several subtypes, including lipid anomaly dry eye, aqueous tear deficiency, allergic and toxic dry eye among others. Each subtype has its own cause and disease management; therefore, it is important for ophthalmologists to identify the type through literature review and investigation. The management of DED, relies not only on traditional medications such as artificial tears, gels and ointments, but also newer treatment options such as acupuncture, SYL1001, and nanomedicine therapy. We also conducted a comprehensive literature review including common subtypes and treatment of DED. Clearly, more clinical trials are needed to assess the efficacy and safety of the various treatments and common subtypes of DED.

A retrospective analysis of characteristic features of responder patients to autologous serum eye drops in routine care

PURPOSE

Autologous serum eye drops (ASEDs) are used worldwide to treat dry eye disease (DED). However, the biological composition of ASEDs has not been well investigated, and effectiveness predictive factors remain to be identified. The main objective of this study was to compare the response of patients treated with ASEDs biologically characterized and used for DED routine care.

METHODS

This retrospective observational study was conducted in a single university hospital, and included 50 patients (87 eyes) with DED refractory to conventional treatment and resulting from various etiologies with Ocular Surface Disease Index (OSDI) ≥ 20. Each patient used eight drops a day per treated eye with 20% diluted ASEDs. Undiluted serum extensive biological characterizations were performed, and symptoms were recorded before the initiation of ASEDs and closer to the sixth month of treatment. Responders were defined as presenting an improvement from baseline ≥14 points in OSDI and/or ≥1 grade in corneal fluorescence staining for all eyes treated.

RESULTS

The OSDI and the Oxford scale were significantly reduced from 68.7 ± 23.2 to 54.8 ± 25.7 and 3.2 ± 1.5 to 2.1 ± 1.3 (p ≤ 0.0001), respectively. A total of 68% of the patients were responders. Nonresponding patients had significantly higher epidermal growth factor concentrations in the serum compared to responders (p = 0.017).

CONCLUSIONS

ASED administration resulted in significant clinical improvement in the management of DED. Biological differences observed between responders and nonresponders suggested that a better understanding of the biological activity of ASEDs is still required.

Reconsidering the central role of mucins in dry eye and ocular surface diseases

Mucins are key actors in tear film quality and tear film stability. Alteration of membrane-bound mucin expression on corneal and conjunctival epithelial cells and/or gel-forming mucin secretion by goblet cells (GCs) promotes in ocular surface diseases and dry eye disease (DED). Changes in the mucin layer may lead to enhanced tear evaporation eventually contributing to tear hyperosmolarity which has been associated with ocular surface inflammation. Inflammatory mediators in turn may have a negative impact on GCs differentiation, proliferation, and mucin secretion. This sheds new light on the position of GCs in the vicious circle of DED. As contributor to ocular surface immune homeostasis, GC loss may contribute to impaired ocular surface immune tolerance observed in DED. In spite of this, there are no tools in routine clinical practice for exploring ocular surface mucin deficiency/dysregulation. Therefore, when selecting the most appropriate treatment options, there is a clear unmet need for a better understanding of the importance of mucins and options for their replacement. Here, we comprehensively revisited the current knowledge on ocular surface mucin biology, including functions, synthesis, and secretion as well as the available diagnostic tools and treatment options to improve mucin-associated homeostasis. In particular, we detailed the potential link between mucin dysfunction and inflammation as part of the uncontrolled chronic inflammation which perpetuates the vicious circle in DED.

Eficácia dos colírios ciclosporina e tacrolimo no tratamento de ceratoconjuntivite seca em cães

RESUMO O objetivo deste estudo foi avaliar os efeitos do tacrolimo e da ciclosporina na produção lacrimal de cães com ceratoconjuntivite seca (CCS) durante 90 dias. Para tanto, foram utilizados colírios de tacrolimo 0,02% (TcL) e ciclosporina 0,1% (CsA) em 14 cães com CCS. Os animais foram distribuídos em dois grupos e avaliados antes do início do tratamento (T0) e aos 15 (T1), 30 (T2), 45 (T3), 60 (T4), 75 (T5) e 90 (T6) dias após o início do tratamento. Na avaliação clínica, observou-se maior redução da secreção ocular, da opacidade e do edema corneano e da vascularização conjuntival. no grupo tacrolimo. No teste de Schirmer, verificou-se produção basal de 6(4,07 e 5,86(2,85mm/min no TcL e CsA, respectivamente, com aumento significativo da produção lacrimal em ambos os grupos, contudo houve aumento significativo da produção lacrimal a partir dos 15 dias de tratamento no grupo TcL (17,88(5,51mm/min), mas apenas a partir dos 45 dias no grupo CsA (11,86(4,74mm/min). Conclui-se que o uso do colírio tacrolimo aumentou em 68,83% a produção lacrimal em 90 dias de tratamento, comparado com a ciclosporina (56,82%), além de diminuir as manifestações clínicas inerentes à CCS, quando comparado à terapia com ciclosporina.

Patient and physician perspectives on the use of cyclosporine ophthalmic emulsion 0.05% for the management of chronic dry eye

Dry eye disease (DED) is a multifactorial disease of the ocular surface and is one of the most common reasons for patients to visit an eye care provider. Cyclosporine A (CsA) is an immune modulating drug that was approved in the US for topical use in the treatment of DED in 2003, which led to a paradigm change in our understanding and treatment of DED, turning attention to control of inflammation for treatment. This review summarizes the literature to date regarding the impact of CsA on the treatment of DED. A special focus is given to the patient and physician perspectives of CsA, including dry eye symptom improvement, medication side effects, and overall patient satisfaction. Studies evaluating CsA in DED have considerable heterogeneity making generalized conclusions about the effect of CsA difficult. However, most studies have demonstrated improvement in at least some symptoms of dry eye in CsA-treated patients. Side effects, most commonly ocular burning on administration of CsA, are common. The literature is sparse regarding long-term follow-up of patients treated with CsA, optimal duration of treatment, and identifying which patients may receive the most benefit from CsA.

The Use of Cyclosporine A in Rheumatology: a 2016 Comprehensive Review

Cyclosporine A, an inhibitor of calcineurin, exerts an immunomodulator action interfering with T cell activation. Even though novel therapeutic tools have emerged, CyA still represents a suitable option in several clinical rheumatology settings. This is the case of refractory nephritis and cytopenias associated with systemic lupus erythematosus. Furthermore, CyA is a valued therapeutic tool in the management of uveitis and thrombophlebitis in course of Behçet's disease. Topical CyA has been proven to be beneficial in the dry eye of Sjogren's syndrome, whereas oral treatment with CyA can be considered for the severe complications of adult onset Still's disease. CyA provides a therapeutic option in psoriatic arthritis, being rather effective in skin disease. CyA is currently regarded as a second-line option for patients with inflammatory myopathies refractory to standard regimen. CyA is used even in paediatric rheumatology, in particular in the management of juvenile dermatomyositis and macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Importantly, CyA has been shown to suppress the replication of HCV, and it can thus be safely prescribed to those patients with chronic hepatitis C. Noteworthy, CyA can be administered throughout the gestation course. Surely, caution should be paid to CyA safety profile, in particular to its nephrotoxicity. Even though most evidence comes from small and uncontrolled studies with few randomised controlled trials, CyA should be still regarded as a valid therapeutic tool in 2016 rheumatology.

[Prospective, monocentric, uncontrolled study of efficacy, tolerance and adherence of cyclosporin 0.1 % for severe dry eye syndrome]

PURPOSE

To evaluate the efficacy, tolerability and treatment adherence of Ikervis^® (Santen, SAS) (ciclosporine 0.1 %) for first line therapy or following treatment with Restasis^® (Allergan, Inc.) (ciclosporine 0.05 %) for severe dry eye syndrome.

MATERIAL AND METHODS

A prospective, monocentric, uncontrolled study was conducted between January 2012 and March 2015 on 110 eyes of 55 patients with severe dry eye on first line therapy or previously treated with Restasis^® who required the introduction of Ikervis^®. Patients' quality of life was assessed before and after treatment was started using a standardized questionnaire (Ocular Surface Disease Index^© [OSDI]), clinical efficacy was quantified at the slit lamp, by measurement of the Break Up time Test (BUT) and the Oxford classification. Tolerability and adherence to treatment were measured using a simple questionnaire.

RESULTS

A total of 72 eyes of 37 patients were included. Etiologies of dry eye syndrome were dominated by Sjögren syndrome (32 %) and severe ocular surface conditions (48 %). The mean age was 57.7 years (±17.45) and mean follow-up was 458 days (±292). The mean BUT increased by 2.043seconds [1.522-2.563] (P<0.0001). Corneal/conjunctival involvement evaluated by the Oxford classification was also improved with a difference in level of 1.68 [1.290-2.071] (P<0.0001). Ocular Surface Disease Index^© (OSDI) decreased by 21.7 [16.372-27.024] (P<0.0001). Treatment tolerability was moderate, with more than 50 % of patients experiencing pain on instillation. Overall satisfaction with treatment was good, with more than 60 % of patients feeling better after initiation of treatment.

CONCLUSION

Ikervis^® is an effective treatment of severe dry eye. Its indications tend to evolve towards less severe dry eye. However, the tolerability profile remains poor, and an improvement in this would be desirable.

Dry eye syndrome: developments and lifitegrast in perspective

Dry eye (DE) is a chronic ocular condition with high prevalence and morbidity. It has a complex pathophysiology and is multifactorial in nature. Chronic ocular surface inflammation has emerged as a key component of DE that is capable of perpetuating ocular surface damage and leading to symptoms of ocular pain, discomfort, and visual phenomena. It begins with stress to the ocular surface leading to the production of proinflammatory mediators that induce maturation of resident antigen-presenting cells which then migrate to the lymph nodes to activate CD4 T cells. The specific antigen(s) targeted by these pathogenic CD4⁺ T cells remains unknown. Two emerging theories include self-antigens by autoreactive CD4 T cells or harmless exogenous antigens in the setting of mucosal immunotolerance loss. These CD4 T cells migrate to the ocular surface causing additional inflammation and damage. Lifitegrast is the second topical anti-inflammatory agent to be approved by the US Food and Drug Administration for the treatment of DE and the first to show improvement in DE symptoms. Lifitegrast works by blocking the interaction between intercellular adhesion molecule-1 and lymphocyte functional associated antigen-1, which has been shown to be critical for the migration of antigen-presenting cells to the lymph nodes as well as CD4⁺ T cell activation and migration to the ocular surface. In four large multicenter, randomized controlled trials, lifitegrast has proven to be effective in controlling both the signs and symptoms of DE with minimal side effects. Further research should include comparative and combination studies with other anti-inflammatory therapies used for DE.

Experimental and Clinical Applications of Chamaecyparis obtusa Extracts in Dry Eye Disease

Purpose

To investigate the effects of Chamaecyparis obtusa (CO) on human corneal epithelial (HCE) cells, a murine experimental dry eye (EDE) model, and the efficacy of antioxidant eye mask in dry eye disease (DED) patients.

Methods

0.001%, 0.01%, and 0.1% CO extracts were used to treat HCE cells, cell viability, and production of antioxidative enzymes, and reactive oxygen species (ROS) were assessed. Afterwards, CO extracts or balanced salt solution (BSS) was applied in EDE. Clinical and experimental parameters were measured at 7 days after treatment. In addition, DED patients were randomly assigned to wear either an eye mask containing CO extracts or a placebo. Clinical parameters were evaluated.

Results

The viability of HCE cells and antioxidative enzyme expression significantly improved after treatment with 0.1% CO extracts. Mice treated with 0.1% CO extracts showed significant improvement in clinical parameters. During the trial, the clinical parameters significantly improved in the treatment group at 4 weeks after application.

Conclusions

0.1% CO extracts could promote the expression of antioxidative proteins and ROS production. In addition, an eye mask containing CO extracts could improve DED clinical parameters. These suggest that CO extracts may be useful as an adjunctive option for the DED treatment.

Epigallocatechin Gallate-Loaded Gelatin-g-Poly(N-Isopropylacrylamide) as a New Ophthalmic Pharmaceutical Formulation for Topical Use in the Treatment of Dry Eye Syndrome

Given that biodegradable in situ gelling delivery systems may have potential applications in the design of ophthalmic pharmaceutical formulations, this study, for the first time, aims to develop gelatin-g-poly(N-isopropylacrylamide) (GN) carriers for topical epigallocatechin gallate (EGCG) administration in the treatment of dry eye disease (DED). By temperature triggered sol-gel phase transition of copolymers, EGCG-loaded GN was prepared at 32 °C and characterized by FTIR, NMR, and HPLC analyses. Results of WST-1 and live/dead assays showed that GN materials have good compatibility with corneal epithelial cells. Gradual biodegradation of delivery carriers allowed sustained release of EGCG without drug toxicity. Anti-inflammatory and antioxidant activity studies also indicated effective therapeutic drug levels at each time point within 3 days of release. In a rabbit dry eye model, corneal epithelial defects was ameliorated by treatment with single-dose administration of EGCG-containing GN. Furthermore, drug molecules released from carrier materials could prevent further tear evaporation and loss of mucin-secreting goblet cells in diseased animals. Our findings suggest that GN carrier is responsible for enhanced pharmacological efficacy of topically instilled EGCG, thereby demonstrating the benefits of using biodegradable in situ gelling delivery system to overcome the drawbacks of limited dry eye relief associated with eye drop dosage form.

Dry Eye Management: Targeting the Ocular Surface Microenvironment

Dry eye can damage the ocular surface and result in mild corneal epithelial defect to blinding corneal pannus formation and squamous metaplasia. Significant progress in the treatment of dry eye has been made in the last two decades; progressing from lubricating and hydrating the ocular surface with artificial tear to stimulating tear secretion; anti-inflammation and immune regulation. With the increase in knowledge regarding the pathophysiology of dry eye, we propose in this review the concept of ocular surface microenvironment. Various components of the microenvironment contribute to the homeostasis of ocular surface. Compromise in one or more components can result in homeostasis disruption of ocular surface leading to dry eye disease. Complete evaluation of the microenvironment component changes in dry eye patients will not only lead to appropriate diagnosis, but also guide in timely and effective clinical management. Successful treatment of dry eye should be aimed to restore the homeostasis of the ocular surface microenvironment.

Efficacy and safety of retinol palmitate ophthalmic solution in the treatment of dry eye: a Japanese Phase II clinical trial

Purpose

The purpose of this study was to investigate the efficacy and safety of the administration of retinol palmitate (VApal) ophthalmic solution (500 IU/mL) for the treatment of patients with dry eye.

Patients and methods

This study included 66 patients with dry eye. After a 2-week washout period, patients were randomized (1:1) into either a VApal ophthalmic solution or a placebo group, and a single drop of either solution was administered six times daily for 4 weeks. Efficacy measures were 12 subjective symptoms, rose bengal (RB) and fluorescein staining scores, tear film breakup time, and tear secretion. Safety measures included clinical blood and urine analyses and adverse event recordings.

Results

In comparisons of the two groups, the mean change in RB staining score from baseline was significantly lower in the VApal group at 2 and 4 weeks (P<0.05 and P<0.01, respectively). Furthermore, the fluorescein clearance rate (fluorescein staining score) was significantly higher in the VApal group at 4 weeks (P<0.05). The VApal group showed a significant improvement in blurred vision at 1 and 2 weeks (P<0.01 and P<0.05, respectively), and the mean change in the total score for subjective symptoms from baseline was significantly lower in the VApal group at 1 week (P<0.05). In before- and after-intervention comparisons, the fluorescein and RB staining scores showed improvement in both groups. Improvement was noted for 11 subjective symptoms in the VApal group and for seven symptoms in the placebo group. No significant differences in adverse events and reactions were found between the groups.

Conclusion

VApal ophthalmic solution (500 IU/mL) is safe and effective for the treatment of patients with dry eye.

Clinical utility of cyclosporine (CsA) ophthalmic emulsion 0.05% for symptomatic relief in people with chronic dry eye: a review of the literature

To review the literature on the efficacy of cyclosporine (CsA) ophthalmic emulsion 0.05% on symptomatic relief in chronic dry eye disease. There is consistent evidence of objective improvements in chronic dry eye disease (Schirmer score, corneal and interpalpebral dye staining, and tear breakup time) with CsA, but variable results with symptomatic improvement, possibly due to patient tolerance of CsA, similar comforting effect with artificial tears and CsA vehicle, and the inherent subjective nature of symptom monitoring and analysis. This review explores the literature on CsA with special attention to symptomatic relief.

Brand Medications and Medicare Part D: How Eye Care Providers' Prescribing Patterns Influence Costs

PURPOSE

To quantify costs of eye care providers' Medicare Part D prescribing patterns for ophthalmic medications and to estimate the potential savings of generic or therapeutic drug substitutions and price negotiation.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Eye care providers prescribing medications through Medicare Part D in 2013.

METHODS

Medicare Part D 2013 prescriber public use file and summary file were used to calculate medication costs by physician specialty and drug. Savings from generic or therapeutic drug substitutions were estimated for brand drugs. The potential savings from price negotiation was estimated using drug prices negotiated by the United States Veterans Administration (USVA).

MAIN OUTCOME MEASURES

Total cost of brand and generic medications prescribed by eye care providers.

RESULTS

Eye care providers accounted for $2.4 billion in total Medicare part D prescription drug costs and generated the highest percentage of brand name medication claims compared with all other providers. Brand medications accounted for a significantly higher proportion of monthly supplies by volume, and therefore, also by total cost for eye care providers compared with all other providers (38% vs. 23% by volume, P < 0.001; 79% vs. 56% by total cost, P < 0.001). The total cost attributable to eye care providers is driven by glaucoma medications, accounting for $1.2 billion (54% of total cost; 72% of total volume). The second costliest category, dry eye medications, was attributable mostly to a single medication, cyclosporine ophthalmic emulsion (Restasis, Allergan, Irvine, CA), which has no generic alternative, accounting for $371 million (17% of total cost; 4% of total volume). If generic medications were substituted for brand medications when available, $148 million would be saved (7% savings); if generic and therapeutic substitutions were made, $882 million would be saved (42% savings). If Medicare negotiated the prices for ophthalmic medications at USVA rates, $1.09 billion would be saved (53% savings).

CONCLUSIONS

Eye care providers prescribe more brand medications by volume than any other provider group. Efforts to reduce prescription expenditures by eye care providers should focus on increasing the use of generic medications, primarily through therapeutic substitutions. Policy changes enabling Medicare to negotiate prescription drug prices could decrease costs to Medicare.