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Heidari Z, Hashemi H, Sotude D, Ebrahimi-Besheli K, Khabazkhoob M, Soleimani M, Djalilian AR, Yousefi S. Applications of Artificial Intelligence in Diagnosis of Dry Eye Disease: A Systematic Review and Meta-Analysis. Cornea 2024:00003226-990000000-00617. [PMID: 38984532 DOI: 10.1097/ico.0000000000003626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 06/06/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE Clinical diagnosis of dry eye disease is based on a subjective Ocular Surface Disease Index questionnaire or various objective tests, however, these diagnostic methods have several limitations. METHODS We conducted a comprehensive review of articles discussing various applications of artificial intelligence (AI) models in the diagnosis of the dry eye disease by searching PubMed, Web of Science, Scopus, and Google Scholar databases up to December 2022. We initially extracted 2838 articles, and after removing duplicates and applying inclusion and exclusion criteria based on title and abstract, we selected 47 eligible full-text articles. We ultimately selected 17 articles for the meta-analysis after applying inclusion and exclusion criteria on the full-text articles. We used the Standards for Reporting of Diagnostic Accuracy Studies to evaluate the quality of the methodologies used in the included studies. The performance criteria for measuring the effectiveness of AI models included area under the receiver operating characteristic curve, sensitivity, specificity, and accuracy. We calculated the pooled estimate of accuracy using the random-effects model. RESULTS The meta-analysis showed that pooled estimate of accuracy was 91.91% (95% confidence interval: 87.46-95.49) for all studies. The mean (±SD) of area under the receiver operating characteristic curve, sensitivity, and specificity were 94.1 (±5.14), 89.58 (±6.13), and 92.62 (±6.61), respectively. CONCLUSIONS This study revealed that AI models are more accurate in diagnosing dry eye disease based on some imaging modalities and suggested that AI models are promising in augmenting dry eye clinics to assist physicians in diagnosis of this ocular surface condition.
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Affiliation(s)
- Zahra Heidari
- Psychiatry and Behavioral Sciences Research Center, Mazandaran University of Medical Sciences, Sari, Iran
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Danial Sotude
- Psychiatry and Behavioral Sciences Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Kiana Ebrahimi-Besheli
- Cellular and Molecular Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Khabazkhoob
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Ali R Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL
| | - Siamak Yousefi
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, TN; and
- Department of Genetics, Genomics, and Informatics, University of Tennessee Health Science Center, Memphis, TN
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Lin N, Chen X, Liu H, Gao N, Liu Z, Li J, Pflugfelder SC, Li DQ. Ectoine Enhances Mucin Production Via Restoring IL-13/IFN-γ Balance in a Murine Dry Eye Model. Invest Ophthalmol Vis Sci 2024; 65:39. [PMID: 38935032 PMCID: PMC11216279 DOI: 10.1167/iovs.65.6.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/25/2024] [Indexed: 06/28/2024] Open
Abstract
Purpose This study aimed to explore protective effects and potential mechanism of ectoine, a natural osmoprotectant, on ocular surface mucin production in dry eye disease. Methods A dry eye model was established in C57BL/6 mice exposed to desiccating stress (DS) with untreated (UT) mice as controls. DS mice were topically treated with 2.0% ectoine or PBS vehicle. Corneal epithelial defects were assessed by Oregon Green Dextran (OGD) fluorescent staining. Conjunctival goblet cells, ocular mucins, and T help (Th) cytokines were evaluated by immunofluorescent staining or ELISA, and RT-qPCR. Results Compared with UT mice, corneal epithelial defects were detected as strong punctate OGD fluorescent staining in DS mice with vehicle, whereas ectoine treatment largely reduced OGD staining to near-normal levels. Conjunctival goblet cell density and cell size decreased markedly in DS mice, but was significantly recovered by ectoine treatment. The protein production and mRNA expression of two gel-forming secreted MUC5AC and MUC2, and 4 transmembrane mucins, MUC1, MUC4, MUC16, and MUC15, largely decreased in DS mice, but was restored by ectoine. Furthermore, Th2 cytokine IL-13 was inhibited, whereas Th1 cytokine IFN-γ was stimulated at protein and mRNA levels in conjunctiva and draining cervical lymph nodes (CLNs) of DS mice, leading to decreased IL-13/IFN-γ ratio. Interestingly, 2.0% ectoine reversed their alternations and restored IL-13/IFN-γ balance. Conclusions Our findings demonstrate that topical ectoine significantly reduces corneal damage, and enhances goblet cell density and mucin production through restoring imbalanced IL-13/IFN-γ signaling in murine dry eye model. This suggests therapeutic potential of natural osmoprotectant ectoine for dry eye disease.
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Affiliation(s)
- Na Lin
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xin Chen
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Haixia Liu
- Allergan, an AbbVie company, Irvine, California, United States
| | - Ning Gao
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
- Department of Ophthalmology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhao Liu
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
- Department of Ophthalmology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jin Li
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
- National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, China
| | - Stephen C. Pflugfelder
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
| | - De-Quan Li
- Ocular Surface Center, Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, United States
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Antonietti M, Taylor Gonzalez DJ, Djulbegovic MB, Gameiro GR, Uversky VN, Sridhar J, Karp CL. Intrinsic disorder in the human vitreous proteome. Int J Biol Macromol 2024; 267:131274. [PMID: 38569991 PMCID: PMC11182622 DOI: 10.1016/j.ijbiomac.2024.131274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/05/2024]
Abstract
The vitreous is a vital component of the eye, occupying a substantial portion of its volume and maintaining its structure. This study delves into the presence and significance of intrinsically disordered proteins (IDPs) within the vitreous, utilizing a dataset of 1240 vitreous proteins previously discovered in the vitreous proteome by Murthy et al.in five healthy subjects. The results indicate that 26.9 % of vitreous proteins are highly disordered, 68.8 % possess moderate disorder, and only 4.3 % are highly ordered. A complex interaction network among these proteins suggests their biological importance, and approximately 25 % may undergo liquid-liquid phase separation (LLPS). These findings offer new perspectives on the vitreous' molecular composition and behavior, potentially impacting our understanding of eye-related diseases, physiological changes such as vitreous syneresis. Further research is needed to translate these insights into clinical applications, although the intrinsic protein disorder and its association with LLPS appears to play a role in vitreous proteome function.
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Affiliation(s)
- Michael Antonietti
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | | | - Mak B Djulbegovic
- Wills Eye Hospital, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Gustavo R Gameiro
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America; Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, SP, Brazil
| | - Vladimir N Uversky
- Department of Molecular Medicine and USF Health Byrd Alzheimer's Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America
| | - Jayanth Sridhar
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America
| | - Carol L Karp
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, United States of America.
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Guo M, Liu T, Miao Y, Pan X, Liu B. Role of NADPH Oxidase 4 on Dry Eye Syndrome in Mice. J Ocul Pharmacol Ther 2024. [PMID: 38669123 DOI: 10.1089/jop.2024.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Objective: This study aims to investigate the effect of NADPH oxidase 4 (NOX4)-mediated inflammation on concanavalin A (ConA)-induced dry eye syndrome (DES) in mice. Methods: Thirty-six mice were randomly divided into Control, Model, no-load Control, and NOX4 interference group. Adenovirus was injected (10 μL) into the lacrimal glands of both eyes of mice in no-load Control group and NOX4 interference group. Four days after adenovirus injection, the Control group was injected with phosphate-buffered saline, and the other groups were injected with ConA (200 μg) in the lacrimal glands of mice to establish DES models. The tear secretion rate was estimated by phenol red thread test. Lissamine green eye staining was used to evaluate conjunctival damage. The corneal surface was observed by hematoxylin-eosin (HE) staining and scanning electron microscopy (SEM). The morphology and quantity of conjunctival epithelial cells and goblet cells were observed by Periodic acid-Schiff staining. The expression of NOX4, NOD-like receptor thermal protein domain-associated protein 3 (NLRP3), interleukin-1β (IL-1β), and mucin 5 subtype AC (MUC5AC) was detected by immunohistochemistry. Results: Compared with the Control group, the Model group showed a significant decrease in tear secretion and an upregulation in microscopic image score. The HE staining and SEM showed corneal and conjunctiva damage in the Model group. The protein expression of NOX4, NLRP3, and IL-1β was upregulated, but MUC5AC was downregulated in the Model group. After interfering with NOX4, all these indicators were reversed. Conclusion: The pathological process of concanavalin A-induced DES appears to be related to NOX4.
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Affiliation(s)
- Mian Guo
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou Province, China
- Guizhou Eye Hospital, Zunyi, Guizhou Province, China
- Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi, Guizhou Province, China
- Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi, Guizhou Province, China
| | - Taixiang Liu
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou Province, China
- Guizhou Eye Hospital, Zunyi, Guizhou Province, China
- Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi, Guizhou Province, China
- Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi, Guizhou Province, China
| | - Yuan Miao
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou Province, China
- Guizhou Eye Hospital, Zunyi, Guizhou Province, China
- Guizhou Provincial Branch of National Eye Disease Clinical Research Center, Zunyi, Guizhou Province, China
- Special Key Laboratory of Ocular Diseases of Guizhou Province, Zunyi, Guizhou Province, China
| | - Xiaoli Pan
- Department of Rheumatology and Immunology, Afliated Hospital of Zunyi Medical University, Huichuan District, Zunyi, China
| | - Bo Liu
- Key Lab for Basic Pharmacology and Joint International Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, China
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Jiao X, Qi Y, Gao N, Zhang C, Zhao S, Yang R. Exploration of efficacy and mechanism of 0.05% cyclosporine eye drops (II) monotherapy in allergic conjunctivitis-associated dry eye. Eye (Lond) 2024; 38:937-944. [PMID: 37904000 DOI: 10.1038/s41433-023-02807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/10/2023] [Accepted: 10/20/2023] [Indexed: 11/01/2023] Open
Abstract
PURPOSE To explore the efficacy and relevant mechanism of 0.05% cyclosporine A (CsA) eye drops (II) monotherapy in patients with allergic conjunctivitis-associated dry eye (ACDE). METHODS Prospective, randomized, controlled study. Fifty-three patients with mild-to-moderate ACDE were randomly assigned to two groups. The CsA group received 0.05% CsA eye drops (II) monotherapy four times daily. The control group received 0.1% olopatadine twice daily combined with 0.1% preservative-free artificial tears four times daily. Clinical symptoms and signs, tear total IgE, and lymphotoxin-α (LT-α) concentrations were assessed at pre- and post-treatment days 7, 30, and 60. And we further measured six tear cytokines levels using a microsphere-based immunoassay. RESULTS The CsA group showed significant improvement in symptoms (Ocular Surface Disease Index and itching scores) and signs (conjunctival hyperaemia, conjunctival oedema, conjunctival papillae, tear break-up time (TBUT), corneal fluorescein staining, and goblet cell density) at each follow-up period compared to pre-treatment (all P < 0.050). And its improvement in itching scores (P7th < 0.001, P30th = 0.039, and P60th = 0.031) and TBUT (P7th = 0.009, P30th = 0.003, and P60th = 0.005) was more significant than the control group at all follow-up periods. The tear total IgE, interleukin (IL)-5, IL-6, periostin, eotaxin-3, and MMP-9 levels significantly decreased in the CsA group at day 60 after treatment (all P < 0.050). And the changed values in tear total IgE were positively correlated with the change in itching scores. CONCLUSIONS 0.05% CsA eye drops (II) monotherapy can rapidly improve the symptoms and signs, especially in ocular itching and TBUT, in patients with ACDE. And its efficacy is superior to 0.1% olopatadine combined with artificial tears. Moreover, CsA downregulates the expression levels of tear inflammatory cytokines, including tear total IgE, IL-5, IL-6, periostin, eotaxin-3, and MMP-9. Among that, the reduction in tear total IgE levels may reflect the improvement of ocular itching.
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Affiliation(s)
- Xiting Jiao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Yuanyuan Qi
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Ning Gao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Chen Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Shaozhen Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China.
| | - Ruibo Yang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, 300384, China.
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6
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Suárez-Cortés T, Stepp MA. EDITORIAL: Special issue on the Tear Film and the Ocular Surface. Exp Eye Res 2024; 238:109705. [PMID: 37944850 DOI: 10.1016/j.exer.2023.109705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Affiliation(s)
| | - Mary Ann Stepp
- Department of Anatomy and Cell Biology, Department of Ophthalmology, George Washington University, USA.
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7
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Carnero E, Irigoyen-Bañegil C, Gutiérrez I, Extramiana L, Sabater AL, Moreno-Montañes J. Comparison of Transcriptomic Analysis of the Conjunctiva in Glaucoma-Treated Eyes with Dry Eyes and Healthy Controls. Biomolecules 2023; 14:30. [PMID: 38254630 PMCID: PMC10813521 DOI: 10.3390/biom14010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Ocular surface disease (OSD) associated with topical glaucoma drugs is a common issue impacting treatment adherence. We aimed to identify conjunctival transcriptomic changes in glaucoma and dry eye patients, comparing them to healthy controls. Bulbar conjunctival specimens were collected via impression cytology from 33 patients treated for glaucoma, 9 patients with dry eye, and 14 healthy controls. RNA extraction and bulk RNA sequencing were performed, followed by bioinformatics analysis to detect gene dysregulation. Ingenuity pathways analysis (IPA) identified pathways and biological processes associated with these transcriptomic changes. Sequencing analysis revealed 200 modified genes in glaucoma patients compared to healthy individuals, 233 differentially expressed genes in dry eye patients versus controls, and 650 genes in treated versus dry eye samples. In glaucoma patients, 79% of altered pathways were related to host defense, while dry eye patients showed a 39% involvement of host response, 15% in cellular proliferation and integrity, and 16% of mitochondrial dysfunction. These findings were validated through qRT-PCR. Glaucoma patients showed an intensified conjunctival immune response as a potential cause of OSD, whereas in dry eye patients, in addition to the immune response, other mechanisms such as mitochondrial dysfunction or reduced cellular proliferation were observed.
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Affiliation(s)
- Elena Carnero
- Department of Ophthalmology, Clínica Universidad de Navarra, University of Navarra, 31008 Pamplona, Navarra, Spain; (E.C.); (I.G.); (J.M.-M.)
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Navarra, Spain;
| | - Cristina Irigoyen-Bañegil
- Department of Ophthalmology, Clínica Universidad de Navarra, University of Navarra, 31008 Pamplona, Navarra, Spain; (E.C.); (I.G.); (J.M.-M.)
| | - Itziar Gutiérrez
- Department of Ophthalmology, Clínica Universidad de Navarra, University of Navarra, 31008 Pamplona, Navarra, Spain; (E.C.); (I.G.); (J.M.-M.)
| | - Leire Extramiana
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Navarra, Spain;
| | - Alfonso L. Sabater
- Department of Ophthalmology, Ocular Surface Center, Bascom Palmer Eye Institute, Miami, FL 33136, USA;
| | - Javier Moreno-Montañes
- Department of Ophthalmology, Clínica Universidad de Navarra, University of Navarra, 31008 Pamplona, Navarra, Spain; (E.C.); (I.G.); (J.M.-M.)
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Navarra, Spain;
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Gijs M, Adelaar TI, Vergouwen DPC, Visser N, Dickman MM, Ollivier RCI, Berendschot TTJM, Nuijts RMMA. Tear Fluid Inflammatory Proteome Analysis Highlights Similarities Between Keratoconus and Allergic Conjunctivitis. Invest Ophthalmol Vis Sci 2023; 64:9. [PMID: 38064228 PMCID: PMC10709806 DOI: 10.1167/iovs.64.15.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/18/2023] [Indexed: 12/18/2023] Open
Abstract
Purpose Keratoconus is characterized by the progressive thinning of the cornea, which leads to a cone-like appearance of the eye over time. Although conventionally defined as a noninflammatory condition, a number of recent studies have associated keratoconus (KC) with allergic conjunctivitis (AC) based on clinical parameters. This study aimed to consolidate this association by performing a proteomic analysis of tear fluid from patients with keratoconus and/or allergic conjunctivitis. Methods Of 51 patients, 17 were diagnosed with KC, 17 were diagnosed with AC, and 17 were diagnosed with both KC and AC (combined). Nine of 34 patients with KC had a progressive form of the disease. Tear fluid samples (n = 51, one eye per patient) were collected by the Schirmer's strips. Tear proteins were extracted from the Schirmer's strips. Proteomic profiling of 384 inflammatory proteins was assessed by a multiplex proximity extension assay (Olink Explore 384 Inflammation Panel I). Results A total of 384 inflammatory proteins were measured. Two hundred seventy-two of the 384 proteins passed stringent data cleaning and were compared among the patient groups. Compared to the 2 other groups, LGALS9 was upregulated uniquely in KC, whereas FGF19, PDGFB, HPCAL1, OSM, and FCAR were downregulated in KC. Similarly, TNFRSF4 and CCL13 were specifically upregulated in AC, whereas ectodysplasin A receptor (EDAR) was uniquely downregulated in AC. Conclusions High-throughput proteomic profiling of tear fluid confirms the association between KC and AC on a molecular level and raise the importance of redefining KC as an inflammatory condition.
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Affiliation(s)
- Marlies Gijs
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Tuneille I. Adelaar
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Daphne P. C. Vergouwen
- Department of Ophthalmology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nienke Visser
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Mor M. Dickman
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Robin C. I. Ollivier
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Tos T. J. M. Berendschot
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
| | - Rudy M. M. A. Nuijts
- University Eye Clinic Maastricht, School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, The Netherlands
- Department of Ophthalmology, Zuyderland Medical Center, Heerlen, The Netherlands
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Leonardi A, Righetti G, Giovannini G, De Marchi V, Occhiuto M. Diagnostic criteria of chronic conjunctivitis: atopic keratoconjunctivitis and vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2023; 23:390-396. [PMID: 37284778 DOI: 10.1097/aci.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Chronic ocular allergies, vernal (VKC) and atopic keratoconjunctivitis (AKC) are relatively rare conditions that require definite diagnostic criteria to the most appropriate therapeutical approach. RECENT FINDINGS The diagnosis of both VKC and AKC is generally based on clinical history, signs and symptoms, and the results of allergic tests, which allow to identify the different diseases phenotypes. However, other subtypes of the two diseases and/or overlaps may occur making the diagnosis non always so clear, such as VKC and AKC overlaps or adult-like VKC disease. Each of these phenotypes may be sustained by different mechanisms which are still not well defined but not only related to a type 2 inflammation. The further challenges will be to correlate clinical or molecular biomarkers to a single subtype or disease severity. SUMMARY Definite criteria of chronic allergies will further guide to more specific therapeutical approaches.
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Affiliation(s)
- Andrea Leonardi
- Department of Neuroscience, Ophthalmology Unit, University of Padua, Padua, Italy
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10
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Cao F, Liu ZR, Ni QY, Zha CK, Zhang SJ, Lu JM, Xu YY, Tao LM, Jiang ZX, Pan HF. Emerging roles of air pollution and meteorological factors in autoimmune eye diseases. ENVIRONMENTAL RESEARCH 2023; 231:116116. [PMID: 37182831 DOI: 10.1016/j.envres.2023.116116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/16/2023]
Abstract
Autoimmune eye diseases (AEDs), a collection of autoimmune inflammatory ocular conditions resulting from the dysregulation of immune system at the ocular level, can target both intraocular and periorbital structures leading to severe visual deficit and blindness globally. The roles of air pollution and meteorological factors in the initiation and progression of AEDs have been increasingly attractive, among which the systemic and local mechanisms are both involved in. Exposure to excessive air pollution and extreme meteorological conditions including PM2.5/PM0.1, environmental tobacco smoke, insufficient sunshine, and high temperature, etc., can disturb Th17/Treg balance, regulate macrophage polarization, activate neutrophils, induce systemic inflammation and oxidative stress, decrease retinal blood flow, promote tissue fibrosis, activate sympathetic nervous system, adversely affect nutrients synthetization, as well as induce heat stress, therefore may together deteriorate AEDs. The crosstalk among inflammation, oxidative stress and dysregulated immune system appeared to be prominent. In the present review, we will concern and summarize the potential mechanisms underlying linkages of air pollution and meteorological factors to ocular autoimmune and inflammatory responses. Moreover, we concentrate on the specific roles of air pollutants and meteorological factors in several major AEDs including uveitis, Graves' ophthalmopathy (GO), ocular allergic disease (OAD), glaucoma, diabetic retinopathy (DR), etc.
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Affiliation(s)
- Fan Cao
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, China; Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Zhuo-Ran Liu
- Department of Ophthalmology, Ningbo Hospital, Renji Hospital, Shanghai Jiao Tong University School of Medicine, 1155 Binhaier Road, Ningbo, Zhejiang, China
| | - Qin-Yu Ni
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, China; Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Chen-Kai Zha
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Shu-Jie Zhang
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Jia-Min Lu
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Yue-Yang Xu
- Department of Clinical Medicine, The First School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
| | - Li-Ming Tao
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, China.
| | - Zheng-Xuan Jiang
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, China.
| | - Hai-Feng Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China.
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11
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van Setten GB. Ocular Surface Allostasis-When Homeostasis Is Lost: Challenging Coping Potential, Stress Tolerance, and Resilience. Biomolecules 2023; 13:1246. [PMID: 37627311 PMCID: PMC10452761 DOI: 10.3390/biom13081246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/20/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
The loss of ocular surface (OS) homeostasis characterizes the onset of dry eye disease. Resilience defines the ability to withstand this threat, reflecting the ability of the ocular surface to cope with and bounce back after challenging events. The coping capacity of the OS defines the ability to successfully manage cellular stress. Cellular stress, which is central to the outcome of the pathophysiology of dry eye disease, is characterized by intensity, continuity, and receptivity, which lead to the loss of homeostasis, resulting in a phase of autocatalytic dysregulation, an event that is not well-defined. To better define this event, here, we present a model providing a potential approach when homeostasis is challenged and the coping capacities have reached their limits, resulting in the stage of heterostasis, in which the dysregulated cellular stress mechanisms take over, leading to dry eye disease. The main feature of the proposed model is the concept that, prior to the initiation of the events leading to cellular stress, there is a period of intense activation of all available coping mechanisms preventing the imminent dysregulation of ocular surface homeostasis. When the remaining coping mechanisms and resilience potential have been maximally exploited and have, finally, been exceeded, there will be a transition to manifest disease with all the well-known signs and symptoms, with a shift to allostasis, reflecting the establishment of another state of balance. The intention of this review was to show that it is possibly the phase of heterostasis preceding the establishment of allostasis that offers a better chance for therapeutic intervention and optimized recovery. Once allostasis has been established, as a new steady-state of balance at a higher level of constant cell stress and inflammation, treatment may be far more difficult, and the potential for reversal is drastically decreased. Homeostasis, once lost, can possibly not be fully recovered. The processes established during heterostasis and allostasis require different approaches and treatments for their control, indicating that the current treatment options for homeostasis need to be adapted to a more-demanding situation. The loss of homeostasis necessarily implies the establishment of a new balance; here, we refer to such a state as allostasis.
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Affiliation(s)
- Gysbert-Botho van Setten
- St. Eriks Eye Hospital, 171 04 Solna, Sweden;
- Lab of DOHF and Wound Healing, Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Eugeniavägen 12/Level 6, 171 04 Solna, Sweden
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12
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Penbe A, Oklar M, Kanar HS, Bayrak MZ, Ersarı B, Talan M, Gün RD, Orçun A, Şimşek Ş. The effects of facial mask use on ocular surface parameters and tear film cytokine profile in prolonged use. Int Ophthalmol 2023; 43:2623-2632. [PMID: 36856985 PMCID: PMC9975438 DOI: 10.1007/s10792-023-02661-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/19/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To compare tear fluid levels of matrix metalloproteinase 9 (MMP-9) and IL-1ß cytokines between healthcare workers wearing facial masks and controls with correlations in clinical findings. METHODS In a prospective, controlled clinical trial tear fluid was analyzed for MMP-9 and IL-1ß levels using a commercially available test (Invitrogen; Thermo Fisher Scientific Inc. Waltham, Massachusetts, USA). Symptoms and signs of dry eye disease (DED) were evaluated using the ocular surface disease index (OSDI), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH), Oxford corneal staining, meibomiography, and clinical findings of meibomian gland dysfunction (MGD). RESULTS In the 38 eyes of healthcare workers and 30 eyes of controls, there was no statistically significant difference between the groups in terms of age and sex (p > 0.05). The mean OSDI score, daily mask wear time, meibomiography degree, and rate of positive clinical findings of MGD were higher in group 1 than in group 2, and the mean NIBUT was higher in group 2. (p > 0.05). The mean values of IL-1ß and MMP-9 were higher in group 1 (p = 0.036 and p = 0.001, respectively). The TMH and Oxford score percentages were similar between the two groups (p > 0.05). CONCLUSIONS Elevated levels of IL-1ß and MMP-9 in the basal tear fluid reveal increased ocular inflammation in healthcare professionals. Lower NIBUT values with higher OSDI and meibomian gland loss scores support ocular surface disturbance depending on regular mask use.
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Affiliation(s)
- Aysegul Penbe
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Murat Oklar
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Hatice Selen Kanar
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Müberra Zülal Bayrak
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Başak Ersarı
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Mustafa Talan
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Raziye Dönmez Gün
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Asuman Orçun
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
| | - Şaban Şimşek
- Department of Ophthalmology, Health Science University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Semsi Denizer Caddesi, E-5, 34890 Kartal Istanbul, Turkey
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13
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Adigal SS, Bhandary SV, Hegde N, Nidheesh VR, John RV, Rizvi A, George SD, Kartha VB, Chidangil S. Protein profile analysis of tear fluid with hyphenated HPLC-UV LED-induced fluorescence detection for the diagnosis of dry eye syndrome. RSC Adv 2023; 13:22559-22568. [PMID: 37501778 PMCID: PMC10369224 DOI: 10.1039/d3ra04389d] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Tear fluid contains organic and inorganic constituents, variations in their relative concentrations could provide valuable information and can be useful for the detection of several ophthalmological diseases. This report describes the application of the lab-assembled light-emitting diode (LED)-based high-performance liquid chromatography system for protein profiling of tear fluids to diagnose dry eye disease. Principal Component Analysis (PCA), match/no-match, and Artificial Neural Network (ANN) based binary classification of protein profile data were performed for disease diagnosis. Results from the match/no-match test of the protein profile data showed 94.4% sensitivity and 87.8% specificity. ANN with the leaving one out procedure has given 91.6% sensitivity and 93.9% specificity.
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Affiliation(s)
- Sphurti S Adigal
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 576104
| | - Sulatha V Bhandary
- Department of Ophthalmology, Kasturba Medical College Manipal Karnataka India 576104
| | - Nagaraj Hegde
- Ato-gear BV Schimmelt 28 5611 ZX Eindhoven Netherlands
| | - V R Nidheesh
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 576104
| | - Reena V John
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 576104
| | - Alisha Rizvi
- Department of Ophthalmology, Kasturba Medical College Manipal Karnataka India 576104
| | - Sajan D George
- Centre for Applied Nanotechnology, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 567104
| | - V B Kartha
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 576104
| | - Santhosh Chidangil
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India 576104
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14
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Jung GT, Kim M, Song JS, Kim TI, Chung TY, Choi CY, Kim HS, An WJ, Jeong SJ, Lee HS, Jeon S, Kim KP, Lee HK. Proteomic analysis of tears in dry eye disease: A prospective, double-blind multicenter study. Ocul Surf 2023; 29:68-76. [PMID: 37094778 DOI: 10.1016/j.jtos.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/19/2023] [Accepted: 04/20/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE To identify specific dry eye disease (DED) tear biomarker(s) using tear proteomic analysis, clinical parameters, and their correlations before and after DED treatment. METHODS A prospective, double-blinded, national multicenter clinical study was performed using data from 80 DED patients. The patients were treated with 0.1% cyclosporine (CsA, n = 28), 0.05% CsA (n = 26), or 3% diquafosol (DQS, n = 26) eye drops, and tear proteome changes and clinical outcomes (tear break-up time [TBUT], corneal erosion [Cor-Er], conjunctival erosion [Conj-Er], and symptom assessment in dry eye [SANDE] scores) were observed at 4, 8, and 12 weeks. For all clinical parameters, correlation analysis was performed between the three drug conditions and the differentially expressed proteins (DEPs) from the proteomic analysis. RESULTS AFM, ALCAM, CFB, H1-4, PON1, RAP1B, and RBP4 were identified in all treatment groups and were downregulated after treatment. All clinical parameters significantly improved at 12 weeks than at baseline (p-value <0.0001); however, their values were not significantly different among groups, except for Cor-Er (p-value = 0.007). Compared with the DQS group, Cor-Er score significantly improved after treatment with 0.1% and 0.05% CsA. The seven DEPs identified in all groups were not consistently correlated with the clinical parameters (p-value >0.05). CONCLUSIONS Despite differences in drug concentration and action mechanisms, the improvement levels of TBUT, Cor-Er, and SANDE scores were clinically adequate. However, useful tear protein biomarkers, clinically acceptable biomarker combinations correlating with clinical parameters, and clinically acceptable levels of specificity and sensitivity were not identified.
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Affiliation(s)
- Gun Tae Jung
- Department of Biomedical Science and Technology, Kyung Hee Medical Science Research Institute, Kyung Hee University, Seoul, Republic of Korea
| | - Minha Kim
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Suk Song
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Tae Im Kim
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Young Chung
- College of Pharmacy, Yonsei University, Seoul, Republic of Korea
| | - Chul Young Choi
- Department of Ophthalmology, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Hyun Seong Kim
- Department of Ophthalmology, Catholic University College of Medicine, Seoul, Republic of Korea
| | - Woo Ju An
- Department of Applied Chemistry, Institute of Natural Science, Global Center for Pharmaceutical Ingredient Materials, Kyung Hee University, Yongin, Republic of Korea
| | - Su Jin Jeong
- Department of Statistics Support, Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soyoung Jeon
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwang Pyo Kim
- Department of Biomedical Science and Technology, Kyung Hee Medical Science Research Institute, Kyung Hee University, Seoul, Republic of Korea; Department of Applied Chemistry, Institute of Natural Science, Global Center for Pharmaceutical Ingredient Materials, Kyung Hee University, Yongin, Republic of Korea.
| | - Hyung Keun Lee
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Republic of Korea; College of Pharmacy, Yonsei University, Seoul, Republic of Korea.
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15
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Chester T, Garg S(S, Johnston J, Ayers B, Gupta P. How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives. Clin Ophthalmol 2023; 17:1587-1604. [PMID: 37304329 PMCID: PMC10254642 DOI: 10.2147/opth.s388289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023] Open
Abstract
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.
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Affiliation(s)
| | - Sumit (Sam) Garg
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California-Irvine, Irvine, CA, USA
| | - Josh Johnston
- Georgia Eye Partners, Atlanta, GA, USA
- Southern College of Optometry, Memphis, TN, USA
| | - Brandon Ayers
- Ophthalmic Partners PC, Cornea Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Preeya Gupta
- Triangle Eye Consultants, Raleigh, NC, USA
- Department of Ophthalmology, Tulane University, New Orleans, LA, USA
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16
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Morphological alterations in corneal nerves of patients with dry eye and associated biomarkers. Exp Eye Res 2023; 230:109438. [PMID: 36933693 DOI: 10.1016/j.exer.2023.109438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/27/2023] [Accepted: 03/12/2023] [Indexed: 03/18/2023]
Abstract
The purposes of the present study were to (1) identify the relationship between dry eye symptoms and morphological changes in corneal subbasal nerves/ocular surfaces, and (2) discover tear film biomarkers indicating morphological changes in the subbasal nerves. This was a prospective cross-sectional study conducted between October and November 2017. Adults with dry eye disease (DED, n = 43) and healthy eyes (n = 16) were evaluated based on their subjective symptoms and ophthalmological findings. Corneal subbasal nerves were observed using confocal laser scanning microscopy. Nerve lengths, densities, branch numbers, and nerve fiber tortuosity were analyzed using ACCMetrics and CCMetrics image analysis systems; tear proteins were quantified by mass spectroscopy. Compared with the control group, the DED group had significantly lower tear breakup times (TBUT) and pain tolerance capacity, and significantly higher corneal nerve branch density (CNBD) and corneal nerve total branch density (CTBD). CNBD and CTBD showed significant negative correlations with TBUT. Six biomarkers (cystatin-S, immunoglobulin kappa constant, neutrophil gelatinase-associated lipocalin, profilin-1, protein S100-A8, and protein S100-A9) showed significant positive correlations with CNBD and CTBD. The significantly higher CNBD and CTBD in the DED group suggests that DED is associated with morphological alterations in corneal nerves. The correlation of TBUT with CNBD and CTBD further supports this inference. Six candidate biomarkers that correlate with morphological changes were identified. Thus, morphological changes in corneal nerves are a hallmark of DED, and confocal microscopy may help in the diagnosis and treatment of dry eyes.
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