The Dry Eye Assessment and Management (DREAM) extension study - A randomized clinical trial of withdrawal of supplementation with omega-3 fatty acid in patients with dry eye disease

Enhancing Meibography Image Analysis Through Artificial Intelligence-Driven Quantification and Standardization for Dry Eye Research

Purpose

This study enhances Meibomian gland (MG) infrared image analysis in dry eye (DE) research through artificial intelligence (AI). It is comprised of two main stages: automated eyelid detection and tarsal plate segmentation to standardize meibography image analysis. The goal is to address limitations of existing assessment methods, bridge the curated and real-world dataset gap, and standardize MG image analysis.

Methods

The approach involves a two-stage process: automated eyelid detection and tarsal plate segmentation. In the first stage, an AI model trained on curated data identifies relevant eyelid areas in non-curated datasets. The second stage refines the eyelid area in meibography images, enabling precise comparisons between normal and DE subjects. This approach also includes specular reflection removal and tarsal plate mask refinement.

Results

The methodology achieved a promising instance-wise accuracy of 80.8% for distinguishing meibography images from 399 DE and 235 non-DE subjects. By integrating diverse datasets and refining the area of interest, this approach enhances meibography feature extraction accuracy. Dimension reduction through Uniform Manifold Approximation and Projection (UMAP) allows feature visualization, revealing distinct clusters for DE and non-DE phenotypes.

Conclusions

The AI-driven methodology presented here quantifies and classifies meibography image features and standardizes the analysis process. By bootstrapping the model from curated datasets, this methodology addresses real-world dataset challenges to enhance the accuracy of meibography image feature extraction.

Translational Relevance

The study presents a standardized method for meibography image analysis. This method could serve as a valuable tool in facilitating more targeted investigations into MG characteristics.

Evaluating Moisture Migration in Schirmer Test Strips: Exploring Brand-Specific Variations and Introducing Calibration and Conversion Methods

PURPOSE

Schirmer test results are widely used for ocular surface disease assessment, but Schirmer strips are not standardized. We compare the characteristics and tear volume with millimeter moisture migration in different brands of Schirmer strips and introduce methods for volume-based, brand-independent calibration.

METHODS

Physical parameters of Haag-Streit, EagleVision, TearFlo, Contacare, and MIPL/A6 Schirmer strip brands were compared. Schirmer strip millimeter moisture migration distances were assessed 5 minutes after application of incremental microliter volumes of human tears. Linear regression analysis of data points from each Schirmer strip brand was performed, and the root-mean-square deviation of data points to the best-fit linear regression was calculated. Calibration correction was performed by converting migration distance to the corresponding tear volume. A reference table and calibration method formulas were created.

RESULTS

Schirmer strips differed in design, shape, and manufacturing precision. Strip width, weight, and length were different between the 5 brands ( P < 0.05). A wide range of Schirmer strip moisture migration values for identical tear volumes was observed among brands. Statistical measurement resulted in a root-mean-square deviation of 2.9 mm for all data points from all brands. Millimeter to volume and weight to volume-based calibration correction methods resulted in a 2.2- and 3.1-fold measurement error reduction, respectively.

CONCLUSIONS

Our findings highlight the lack of standardization among different brands of Schirmer strips, raising concerns about potential sources of unintentional measurement errors. We propose volume-based Schirmer strip calibration methods and conversion of millimeter to microliter results to achieve brand-independent results and improve Schirmer test accuracy.

British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease

Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.

Two-Year Progression of Dry Eye Disease in Dry Eye Assessment and Management Study

PURPOSE

The purpose of this study was to evaluate the progression of dry eye disease (DED) symptoms and signs over 2 years through a secondary analysis of data collected from the Dry Eye Assessment and Management study.

METHODS

Participants who were assigned to omega-3 fatty acid in the first year were rerandomized in the second year to either continue with omega-3 fatty acid or switch to placebo. At baseline, 3, 6, 12, 18, and 24 months, DED symptoms were evaluated by using the Ocular Surface Disease Index and the Brief Ocular Discomfort Index (BODI). DED signs were assessed using conjunctival staining, corneal staining, tear break-up time, Schirmer testing, and keratography measures. Medication usage was documented at each visit. Because the treatment and placebo groups displayed no statistical differences in both signs and symptoms, data from the 43 participants were combined to assess longitudinal changes in symptoms and signs.

RESULTS

At 3 months after omega-3 fatty acid treatment, there were significant improvements from baseline in Ocular Surface Disease Index and Brief Ocular Discomfort Index scores (all P ≤ 0.002) and less use of artificial tears or gel (P = 0.02), but between 3 and 24 months, no significant changes in symptoms and treatments were observed (P ≥ 0.06). Except for a significant improvement in conjunctival staining score over 2 years (P = 0.001), there were no significant sign changes in corneal staining (P = 0.32), tear break-up time (P = 0.43), Schirmer test (P = 0.09), and additional measures (all P ≥ 0.07).

CONCLUSIONS

We did not observe a progression of DED signs or symptoms over a 2-year period, except for a probable placebo response in symptoms in the first 3 months and an improvement in conjunctival staining score.

Leger AJ, Galor A. Living with your biome: how the bacterial microbiome impacts ocular surface health and disease

Introduction

Microbiome research has grown exponentially but the ocular surface microbiome (OSM) remains an area in need of further study. This review aims to explore its complexity, disease-related microbial changes, and immune interactions, and highlights the potential for its manipulation as a therapeutic for ocular surface diseases.

Areas Covered

We introduce the OSM by location and describe what constitutes a normal OSM. Second, we highlight aspects of the ocular immune system and discuss potential immune microbiome interactions in health and disease. Finally, we highlight how microbiome manipulation may have therapeutic potential for ocular surface diseases.

Expert Opinion

The ocular surface microbiome varies across its different regions, with a core phyla identified, but with genus variability. A few studies have linked microbiome composition to diseases like dry eye but more research is needed, including examining microbiome interactions with the host. Studies have noted that manipulating the microbiome may impact disease presentation. As such, microbiome manipulation via diet, oral and topical pre and probiotics, and hygienic measures may provide new therapeutic algorithms in ocular surface diseases.

Update on Dry Eye Disease Treatment: Evidence From Randomized Controlled Trials

ABSTRACT

Although the ultimate goal of dry eye disease (DED) management is to restore the ocular surface and tear film homeostasis and address any accompanying symptoms, addressing this is not an easy task. Despite the wide range of current treatment modalities targeting multiple aspects of DED, the available DED management literature is quite heterogeneous, rendering evaluation or comparison of treatment outcomes hard or almost impossible. There is still a shortage of well-designed, large-scale, nonsponsored, randomized, controlled trials (RCTs) evaluating long-term safety and efficacy of many targeted therapies individually or used in combination, in the treatment of identified subgroups of patients with DED. This review focuses on the treatment modalities in DED management and aims to reveal the current evidence available as deduced from the outcomes of RCTs.

Efficacy of Omega-3 Intake in Managing Dry Eye Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To explore the efficacy of omega-3 fatty acids (FAs) on patients suffering from dry eye disease (DED), a complex inflammatory condition, we reviewed data from PubMed, Embase, ClinicalTrials.gov, Web of Science, and Cochrane CENTRAL in the past 10 years (2013 to 2023). These sources provided randomized clinical trials (RCTs) that examined the efficacy of omega-3 FAs on DED patients with accessible pre- and post-intervention data, excluding trials with overlapping participants, without omega-3 supplementation, or those lacking placebo control or quantitative assessments. Two independent reviewers extracted data related to dry eye symptom scores, tear break-up time (TBUT), Schirmer's tests, osmolarity, and corneal fluorescein staining (CFS), and the results were analyzed by Comprehensive Meta-Analysis software version 4. We incorporated 19 related RCTs assessed by the Cochrane Risk of Bias tool, encompassing 4246 DED patients with various etiologies. Patients given omega-3 treatment demonstrated more significant improvements in dry eye symptoms (Hedges' g = -1.047; p < 0.001), TBUT [standardized mean difference (SMD) = -0.939; p < 0.001], scores from the Schirmer test (SMD = -0.372; p < 0.001), CFS (SMD = -0.299; p = 0.037), and osmolarity (SMD = -0.721; p < 0.001) compared to those on a placebo regimen. In the meta-regression analysis of DED symptoms, the daily dose of omega-3 (coefficient = -0.0005, p = 0.002), duration of omega-3 intake (coefficient = -0.1399, p = 0.021), and percentage of eicosapentaenoic acid (EPA) (coefficient = -0.0154, p < 0.001) exhibited a significant positive correlation with a reduction in dry eye symptom scores. Apart from CFS, similar trends were noted in TBUT, Schirmer tests, and osmolarity scores. Based on the evidence, omega-3 FAs effectively reduce DED symptoms, especially in high doses, for a long duration, and with increased EPA levels. However, given the heterogeneity in study results and diverse patient characteristics, caution is needed in generalizing these findings. In conclusion, omega-3 FA supplementation is still recommended for DED management in clinical settings.

Greater adherence to a mediterranean diet is associated with lower C-reactive protein (CRP) levels, but not to lower odds of having dry eye disease

PURPOSE

To investigate the hypothesis that a Mediterranean diet is associated with a lower risk of having dry eye disease (DED) in the general population.

METHODS

DED was assessed using the Women's Health Study (WHS) dry eye questionnaire in 58,993 participants from the Dutch Lifelines Cohort with complete available dietary data (20-94 years, 60% female). Level of adherence to a traditional Mediterranean diet was assessed using the modified Mediterranean Diet Score (mMDS). High-sensitivity C-reactive Protein (hsCRP) was included as a marker of whole-body inflammation. Logistic regressions were used to examine the relationship between WHS-defined DED and mMDS, corrected for age, sex, BMI, education, income, and 48 potentially confounding comorbidities. The association between mMDS and hsCRP, and hsCRP and DED, was further explored in separate regressions.

RESULTS

Of all participants, 9.1% had DED. In contrast to the hypothesis, higher mMDS levels were associated with greater odds of DED, corrected for demographics, smoking status, BMI, and comorbidities (OR 1.034, 95%CI: 1.015 to 1.055, P = 0.001). Moreover, there was a highly significant relationship between increasing mMDS and lower circulating hsCRP levels; however, there was no significant relationship between hsCRP and DED.

CONCLUSIONS

Stronger adherence to a Mediterranean diet does not appear to be associated with lower odds of having DED in the general population. Furthermore, there was no association between hsCRP and DED in this study. However, the previously described link between a Mediterranean diet and lower hsCRP was confirmed in this large population-based study.

Recent advances in drug treatments for dry eye disease

INTRODUCTION

Dry eye disease (DED) is a common ocular condition with a significant impact on patients' quality of life. Conventional treatments include behavioral changes, tear substitutes, and anti-inflammatory agents; however, recent advances in the understanding of DED pathogenesis have opened the way to the development of novel treatment strategies able to target several pathways involved in the onset and persistence of DED.

AREAS COVERED

Literature search was conducted on PubMed and Scopus around the term 'dry eye disease' and others involving its pathophysiology and therapeutic strategy. The primary focus was on recent drugs approved by FDA or under investigation in phase 3 clinical trials. Google and ClinicalTrials.gov were used for obtaining information about the status of FDA approval and ongoing clinical trials.

EXPERT OPINION

Due to its multifaced pathogenesis, DED management is often challenging, and patients' needs are frequently unmet. Recently, several novel treatments have been either FDA-approved or studied in late-phase trials. These novel drugs target-specific biological components of the ocular surface and reduce inflammation and ocular pain. Additionally, new drug delivery systems allow for increased bioavailability, improve effective dosing, and minimize ocular side effects. These advances in drug therapies show real promise for better management of DED patients.

Possible Strategies to Mitigate Placebo or Vehicle Response in Dry Eye Disease Trials: A Narrative Review

Many candidate drugs for dry eye disease (DED) have been assessed over the years in pursuit of demonstrating efficacy in both signs and symptoms. However, patients with DED have very limited treatment options for management of both signs and symptoms of DED. There are several potential reasons behind this including the placebo or vehicle response, which is a frequent issue observed in DED trials. A high magnitude of vehicle response interferes with the estimation of a drug's treatment effect and may lead to failure of a clinical trial. To address these concerns, Tear Film and Ocular Surface Society International Dry Eye Workshop II taskforce has recommended a few study design strategies to minimize vehicle response observed in DED trials. This review briefly describes the factors that lead to placebo/vehicle response in DED trials and focuses on the aspects of clinical trial design that can be improved to mitigate vehicle response. In addition, it presents the observations from a recent ECF843 phase 2b study, wherein the study design approach consisted of a vehicle run-in phase, withdrawal phase, and masked treatment transition, and led to consistent data for DED signs and symptoms and reduced vehicle response post randomization.

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.

NLRP3 Inflammasome as a Potential Therapeutic Target in Dry Eye Disease

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

Anti-Inflammatories in the Treatment of Dry Eye Disease: A Review

Inflammation is an important driver of dry eye disease (DED) pathogenesis. An initial insult that results in the loss of tear film homeostasis can initiate a nonspecific innate immune response that leads to a chronic and self-sustaining inflammation of the ocular surface, which results in classic symptoms of dry eye. This initial response is followed by a more prolonged adaptive immune response, which can perpetuate and aggravate inflammation and result in a vicious cycle of chronic inflammatory DED. Effective anti-inflammatory therapies can help patients exit this cycle, and effective diagnosis of inflammatory DED and selection of the most appropriate treatment are therefore key to successful DED management and treatment. This review explores the cellular and molecular mechanisms of the immune and inflammatory components of DED, and examines the evidence base for the use of currently available topical treatment options. These agents include topical steroid therapy, calcineurin inhibitors, T cell integrin antagonists, antibiotics, autologous serum/plasma therapy, and omega-3 fatty acid dietary supplements.

Polymorphisms in Lymphotoxin-Alpha as the "Missing Link" in Prognosticating Favourable Response to Omega-3 Supplementation for Dry Eye Disease: A Narrative Review

Elements of inflammation are found in almost all chronic ocular surface disease, such as dry eye disease. The chronicity of such inflammatory disease speaks to the dysregulation of innate and adaptive immunity. There has been a rising interest in omega-3 fatty acids to attenuate inflammation. While many cell-based (in vitro) studies verify the anti-inflammatory effects of omega-3, different human trials report discordant outcomes after supplementation. This may be due to underlying inter-individual differences in inflammatory cytokine metabolism (such as tumor necrosis factor alpha (TNF-α)), in which genetic differences might play a role, such as polymorphisms in the lymphotoxin alpha (LT-α) gene. Inherent TNF-α production affects omega-3 response and is also associated with LT-α genotype. Therefore, LT-α genotype might predict omega-3 response. Using the NIH dbSNP, we analyzed the relative frequency of LT-α polymorphisms among various ethnicities, each weighted by the genotype's probability of positive response. While the probability of response for unknown LT-α genotypes are 50%, there is greater distinction in response rates between various genotypes. Hence, there is value in genetic testing to prognosticate an individual's response to omega-3.

A comparative review of evaporative dry eye disease and meibomian gland dysfunction in dogs and humans

Dry eye disease is a complex ophthalmic disorder that consists of two main subtypes, aqueous deficient dry eye (ADDE) and evaporative dry eye disease (EDED). Due to the complex underlying physiology, human dry eye disease can be difficult to model in laboratory animal species. Thus, the identification and characterization of a spontaneous large animal model of dry eye disease is desirable. Dogs have been described as an ideal spontaneous model of ADDE due to the similar pathophysiology between dogs and humans. Recently, EDED and meibomian gland dysfunction (MGD) have been increasingly recognized and reported in dogs. These reports on EDED and MGD in dogs have identified similarities in pathophysiology, clinical presentations, and diagnostic parameters to humans with the comparable disorders. Additionally, the tests that are used to diagnose EDED and MGD in humans are more easily applicable to dogs than to laboratory species due to the comparable globe sizes between dogs and humans. The reported response of dogs to EDED and MGD therapies are similar to humans, suggesting that they would be a valuable preclinical model for the development of additional therapeutics. Further research and clinical awareness of EDED and MGD in dogs would increase their ability to be utilized as a preclinical model, improving the positive predictive value of therapeutics for EDED and MGD in both humans and dogs.

Glaucoma and Ocular Surface Disease: More than Meets the Eye

Understanding the association between ocular surface disease and glaucoma is important for improving adherence to treatment and introducing practical solutions. While topical antihypertensive medications for glaucoma are well tolerated according to short-term studies, there is little evidence on their long-term effects. Since they are often required for many years, the effects of these drops on the ocular surface become important in regard to quality of life and adherence. In this nonsystematic review performed in April 2022, we summarize what is known about the relationship between glaucoma and ocular surface disease. Specifically, we examine how each class of topical glaucoma drops affects the ocular surface. We then review the treatment of ocular surface disease for patients on topical glaucoma therapy. Finally, we discuss treatments that may reduce or eliminate the burden of topical medications.

Topical Omega-3 Fatty Acids Eyedrops in the Treatment of Dry Eye and Ocular Surface Disease: A Systematic Review

Dry eye is a common inflammatory condition of the ocular surface. While oral omega-3 supplementation for its treatment has been extensively studied, recent large-scale studies have cast doubt on their efficacy. However, efficacy of topical omega-3 has yet to be reviewed. We performed a systematic search of PubMed, Embase, and Cochrane databases for all studies evaluating topical omega-3 in dry eye. Five human and five animal studies were included. Of the five human studies, two were on dry eye disease (DED), one was on contact lens discomfort, and two were on patients undergoing corneal collagen crosslinking. In humans, there is promising evidence for improved ocular surface staining and tear break-up time compared to controls, equivocal evidence for improvements to ocular surface symptoms and meibomian gland dysfunction, and no effect on increasing tear production. Data from animal models largely agree with these findings, and further reveal decreased inflammatory cytokines and monocyte infiltration. Our review suggests that topical omega-3 is a promising treatment for dry eye, but also points to the paucity of evidence in this field. Further trials in humans are required to characterize effects of topical omega-3 and optimize its dosage.

Updates in diagnostics, treatments, and correlations between oral and ocular manifestations of Sjogren's syndrome

Sjogren's syndrome (SS) is characterized as an autoimmune disorder targeting secretory glands, including the lacrimal and salivary glands, causing dry eye and dry mouth predominantly in women over the age of 40. In this review, we summarize recent advancements in SS diagnostics, treatments, and our understanding of correlations between oral and ocular manifestations of SS. Google Scholar and PubMed databases were utilized to search peer-reviewed papers since 2016 on SS diagnosis, treatment, and correlations between oral and ocular manifestations. For diagnostics, we discuss the updated SS classification criteria by the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR), new biomarkers, and compare studies of current diagnostic methods with alternative technologies. For treatments, we discuss topical, systemic, and surgical treatment developments in the management of oral and ocular symptoms of SS as there is still no cure for the disorder. Finally, we report studies that directly suggest correlations between the ocular surface disease and oral disease in SS, as well as shared abnormalities in the microbiome and cytokine expression that may be correlated. We conclude by stating limitations to our review as well as paths moving forward. Elucidating correlations between oral and ocular manifestations may be the key to furthering our understanding of SS pathogenesis as well as defining new standards for diagnosis and treatment.

Placebo administration for dry eye disease: a level I evidence based systematic review and meta-analysis

Background

The efficacy of various common treatment options for dry eye disease (DED) has been investigated against placebo. However, the potential beneficial effect of placebo in the management of DED is still unclear.

Aim

This meta-analysis investigated the impact of placebo administration in DED in Ocular Surface Disease Index (OSDI), Schirmer I test (SIT), tear breakup time (TBUT), corneal staining, and complications.

Method

This meta-analysis and systematic review was conducted according to the 2020 PRISMA guidelines. In March 2022, Pubmed, Web of Science, Google Scholar, and Embase were accessed. All the randomised clinical trials which investigated any active treatment against a placebo control group were considered. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), corneal staining.

Results

Data from 56 studies (12,205 patients) were retrieved. Placebo administration is not effective in improving TBUT (P = 0.3), OSDI (P = 0.2), SIT (P = 0.1) and corneal staining (P = 0.1) from baseline to last follow-up. Active treatment led to a higher TBUT and SIT compared to placebo administration (P < 0.0001). The active treatment resulted in a lower OSDI compared to placebo administration (P = 0.0005). Five studies reported data on the corneal staining. No difference was found between placebo administration and active treatment (P = 0.8).

Conclusion

Placebo administration does not impact symptoms of DED and can be successfully employed to evaluate the efficacy of active treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01439-y.

The Protective Effect of Polyunsaturated Fatty Acids against Dry Eye Disease: A Literature Review

Dry eye disease (DED) is a common disease, and have an adverse effect the physical, functional, and psychological quality of life. It is a multifactorial disorder characterized by the loss of tear film homeostasis, in which self-perpetuating vicious cycle leads to deterioration of function and inflammation of the lacrimal functional unit. Hence, treatment strategies should be aimed at the interruption of the vicious inflammatory cycle and alleviation of ocular surface inflammation. Anti-inflammatory therapies have been shown to improve the signs and symptoms of the disease. Evidence indicates that polyunsaturated fatty acids (PUFAs) may contribute to reinforcement of innate anti-inflammatory mechanisms, and systemic and topical administration of PUFAs may help modulate ocular surface inflammation. In the present review, the authors will introduce the results of clinical and experimental studies to elucidate the mechanism, efficacy, and safety of systemic and topical supplementation with PUFAs as an alternative therapeutic strategy for DED. This review will also include discussion regarding current perspectives, including evidence-based recommendations and possible side effects of PUFAs supplementation. The review of the literature suggests that PUFAs supplementation can be a viable option for the treatment of DED, although further studies are needed for establishment of treatment guidelines.

An Evidence-Based Strategic Approach to Prevention and Treatment of Dry Eye Disease, a Modern Global Epidemic

Dry eye disease (DED) is an emerging health concern causing significant visual, psychological, social, and economic impact globally. In contrast to visual rehabilitation undertaken at late stages of DED, measures instituted to prevent its onset, establishment, or progression can alter its natural course and effectively bring down the associated morbidity. This review attempts to present the available literature on preventive strategies of DED at one place, including strategies for risk assessment and mitigation, targeting a wide range of population. A literature search was conducted using PubMed and an extensive literature review on preventive strategies for DED was compiled to put forth a holistic and strategic approach for preventing DED. This can be undertaken at various stages or severity of DED directed at different tiers of the health care system. Conclusion: This review intends to put emphasis on preventive strategies being adopted as an integral part of routine clinical practice by general ophthalmologists and specialists to tackle the burden of DED and improve the quality of the lives of the patients suffering from it.

Contact Lens Wear and Dry Eye: Beyond the Known

Contact lens wear is one of the relevant risk factors for dry eye, and the coexistence of dry eye poses a serious challenge in patients wearing contact lenses. The Tear Film and Ocular Surface Society Workshop addressed issues around the topic of discomfort in contact lens wear, which is a major cause for discontinuation of contact lens wear, and termed this condition as contact lens discomfort. With the rapid advances in contact lens technology and pharmacological agents and deeper understanding of this field, updating the "new normal" beyond what is known as standard is essential. This review aims to summarize the latest topics in contact lens and dry eye that would be useful for clinicians and contact lens practitioners.

Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians

Primary care presentations of dry eye disease (DED) are common and pose a diagnostic challenge due to the variety of symptoms and the absence of certainty for family practitioners. While there are many published articles on the topic, the 2017 Tear Film and Ocular Surface Society Dry Eye Workshop was a landmark report in distinguishing multifactorial differences. Redefined terms clarified the DED disorder. The ocular surface—the tear/air interface—is the primary refractive component of the eye, which is why DED is so significant and impacts vision. There is a high prevalence of DED in the community, ranging from 5% to 30% of people across multiple studies. Elderly patients have up to 75% increased risk of DED and receive more intensive treatment than younger age groups. DED is also more common in women than men, occurring in 9.8% of postmenopausal women. The causes of DED span defective lacrimal apparatus and systemic disorders. Despite its prevalence, up to one-half of patients with confirmed DED do not receive proper alleviating treatment. Risk factors on functional and environmental bases follow. Tools to elicit a diagnosis more confidently are outlined using the Ocular Surface Disease Index (OSDI) and the Symptom Assessment in Dry Eye questionnaires (SANDE). Lacritin, lutein, vitamin A, and balanced nutrition are essential contributors to maintaining healthy eyes with appropriate management and treatment. The authors hope that this paper will prompt a more accurate and expedient diagnosis of DED in primary care practice and an earlier recognition of specialist referrals.

Dry eye disease (DED) poses a diagnostic challenge to primary care physicians. The condition involves the tear/air interface, at the corneal (ocular) surface, where light enters the eye. Any change in light refraction affects regular sight. Symptoms of DED include itching, grittiness, foreign body sensation, redness, excessive tearing, and visual blurring, the lattermost being the most common presentation. Ultimately, the untreated disease leads to continued discomfort and visual deficit, but when severe, it can result in blindness. Up to 30% of the population suffers from DED, with the elderly, particularly women, more affected. Unfortunately, up to 50% of those affected have inadequate treatment. Questionnaires help in diagnosis. Simple office tests can indicate the severity of eye problems. Technology with smartphone photography can take high-resolution images, which are useful in education and teaching. A multitude of conditions cause DED, including blepharitis, an infection of the eyelids. Environmental risks also abound. Proper nutrition is essential in maintaining eye health. Intermittent eye symptoms are likely to be underrated by the public, by purchasing over-the-counter products such as artificial tears rather than seeking a proper medical check. Newer prescription medications are now available for DED relief before advancing to debility requiring specialist treatment.

Efficacy of omega-3 fatty acids and punctal plugs in the prevention of isotretinoin-associated ocular surface disease

PURPOSE

To investigate the effects of omega-3 fatty acids and punctal plugs on tear film and ocular surface parameters in patients receiving systemic isotretinoin therapy.

METHODS

This is a prospective randomized study that included 180 eyes of 90 patients who had systemic isotretinoin therapy (120-150 mg/kg for at least 4-6 months). Exclusion criteria: DED according to the diagnostic criteria of TFOS DEWS II. Patients were assigned into three groups; (1) O3FAs/PPs group: A soft preloaded silicone plug was inserted in the inferior punctum of both eyes and received oral O3FAs two capsules twice daily total daily dose of 1040 mg/day for 6 months. (2) PPs group: A soft preloaded silicone plug was inserted in the inferior punctum of both eyes and received oral placebo. (3) Isotretinoin group: No intervention was done. At baseline, 1 week, 1, 3, and 6 months of study, Ocular surface evaluation tests were done in following order: OSDI, tear osmolarity, Schirmer's I test, TBUT, ocular surface staining score, and meibomian gland expression.

PRIMARY OUTCOME MEASURES

The changes in measurement of ocular surface evaluation tests including ocular surface disease index (OSDI), tear film breakup time (TFBUT), corneal staining, tear osmolarity, and meibomian gland expression at 6 months.

RESULTS

There are significant changes between all groups at 6 months follow-up. The ocular surface parameters were better for the PPs and O3FAs/PPs groups than the isotretinoin group. The isotretinoin group showed worsening of ocular surface parameters including a significant decrease of FTBUT and an increase of OSDI score, corneal staining score, tear osmolarity, and meibomian expression score. There was no significant difference in ST1 throughout the whole study in all groups. At 6 months follow-up, there were no statistically significant differences between PPs and O3FAs/PPs groups except meibomian expression score which showed a significant increase in PPs group.

CONCLUSION

Our cohort highlights the beneficial effects of the combination of O3FAs supplementation with PPs in the prevention of isotretinoin-associated OSD in this sample study.

Association of meibomian gland architecture and body mass index in a pediatric population

PURPOSE

To determine if meibomian gland architecture in a pediatric population is impacted by body mass index (BMI).

METHODS

Prospective evaluation of 175 eyes of 175 pediatric patients from two clinics. Demographic and clinical information were reviewed. Symptoms of dry eye were assessed with the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. Meibography was performed and grading of images was performed by a masked rater using a previously validated 5-point meiboscale (0-4) for gland atrophy and a 3-point score (0-2) for gland tortuosity.

RESULTS

175 eyes of 175 participants aged 4-17 years (11.6 ± 3.7 years) were imaged. The mean meiboscore was 0.82 ± 0.94 (range 0-4) and the mean gland tortuosity score was 0.53 ± 0.70 (range 0-2). Ninety-six patients (56%) showed evidence of gland atrophy (meiboscore greater than 0) and the majority of patients (n=50, 29%) had a gland tortuosity score of 1. The mean BMI was 20.5 ± 4.86 kg/m² with 39.4% of patients (n = 69) above the 85th percentile. BMI percentile was not found to be a significant predictor of a meiboscore greater than 0 (odds ratio (OR) 1.004 95% confidence interval (CI) (0.99-1.10, p = 0.41). However, BMI percentile was found to be a significant predictor of gland tortuosity score (OR 1.01 95% CI (1.00-1.02), p = 0.02). Patients with BMI percentiles between 41 and 60 were 3.79 times more likely to have a gland tortuosity score of greater than 0 than patients with BMI percentiles between 0 and 20 (OR 3.789 CI (1.17-12.24)). No significant associations were found between age, race, or sex and meiboscore or tortuosity. There was a trend towards reduction in lipid layer thickness with increasing BMI percentile (p = 0.028, r² = 0.04).

CONCLUSION

In this pediatric population, there was an association between meibomian gland tortuosity and higher percentiles of BMI. Future studies are needed to elucidate the pathogenesis of meibomian gland tortuosity and atrophy in pediatric patients.

Current State of Knowledge on Primary Sjögren's Syndrome, an Autoimmune Exocrinopathy

Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune rheumatic disease characterized by lymphoplasmacytic infiltration of the salivary and lacrimal glands, whereby sicca syndrome and/or systemic manifestations are the clinical hallmarks, associated with a particular autoantibody profile. pSS is the most frequent connective tissue disease after rheumatoid arthritis, affecting 0.3-3% of the population. Women are more prone to develop pSS than men, with a sex ratio of 9:1. Considered in the past as innocent collateral passive victims of autoimmunity, the epithelial cells of the salivary glands are now known to play an active role in the pathogenesis of the disease. The aetiology of the "autoimmune epithelitis" still remains unknown, but certainly involves genetic, environmental and hormonal factors. Later during the disease evolution, the subsequent chronic activation of B cells can lead to the development of systemic manifestations or non-Hodgkin's lymphoma. The aim of the present comprehensive review is to provide the current state of knowledge on pSS. The review addresses the clinical manifestations and complications of the disease, the diagnostic workup, the pathogenic mechanisms and the therapeutic approaches.

Omega-3 and omega-6 polyunsaturated fatty acids for dry eye disease

BACKGROUND

Polyunsaturated fatty acid (PUFA) supplements, involving omega-3 and/or omega-6 components, have been proposed as a therapy for dry eye. Omega-3 PUFAs exist in both short- (alpha-linolenic acid [ALA]) and long-chain (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) forms, which largely derive from certain plant- and marine-based foods respectively. Omega-6 PUFAs are present in some vegetable oils, meats, and other animal products.

OBJECTIVES

To assess the effects of omega-3 and omega-6 polyunsaturated fatty acid (PUFA) supplements on dry eye signs and symptoms.

SEARCH METHODS

CENTRAL, Medline, Embase, two other databases and three trial registries were searched in February 2018, together with reference checking. A top-up search was conducted in October 2019, but the results have not yet been incorporated.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) involving dry eye participants, in which omega-3 and/or omega-6 supplements were compared with a placebo/control supplement, artificial tears, or no treatment. We included head-to-head trials comparing different forms or doses of PUFAs.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 34 RCTs, involving 4314 adult participants from 13 countries with dry eye of variable severity and etiology. Follow-up ranged from one to 12 months. Nine (26.5%) studies had published protocols and/or were registered. Over half of studies had high risk of bias in one or more domains. Long-chain omega-3 (EPA and DHA) versus placebo or no treatment (10 RCTs) We found low certainty evidence that there may be little to no reduction in dry eye symptoms with long-chain omega-3 versus placebo (four studies, 677 participants; mean difference [MD] -2.47, 95% confidence interval [CI] -5.14 to 0.19 units). We found moderate certainty evidence for a probable benefit of long-chain omega-3 supplements in increasing aqueous tear production relative to placebo (six studies, 1704 participants; MD 0.68, 95% CI 0.26 to 1.09 mm/5 min using the Schirmer test), although we did not judge this difference to be clinically meaningful. We found low certainty evidence for a possible reduction in tear osmolarity (one study, 54 participants; MD -17.71, 95% CI -28.07 to -7.35 mOsmol/L). Heterogeneity was too substantial to pool data on tear break-up time (TBUT) and adverse effects. Combined omega-3 and omega-6 versus placebo (four RCTs) For symptoms (low certainty) and ocular surface staining (moderate certainty), data from the four included trials could not be meta-analyzed, and thus effects on these outcomes were unclear. For the Schirmer test, we found moderate certainty evidence that there was no intergroup difference (four studies, 455 participants; MD: 0.66, 95% CI -0.45 to 1.77 mm/5 min). There was moderate certainty for a probable improvement in TBUT with the PUFA intervention relative to placebo (four studies, 455 participants; MD 0.55, 95% CI 0.04 to 1.07 seconds). Effects on tear osmolarity and adverse events were unclear, with data only available from a single small study for each outcome. Omega-3 plus conventional therapy versus conventional therapy alone (two RCTs) For omega-3 plus conventional therapy versus conventional therapy alone, we found low certainty evidence suggesting an intergroup difference in symptoms favoring the omega-3 group (two studies, 70 participants; MD -7.16, 95% CI -13.97 to -0.34 OSDI units). Data could not be combined for all other outcomes. Long-chain omega-3 (EPA and DHA) versus omega-6 (five RCTs) For long-chain omega-3 versus omega-6 supplementation, we found moderate certainty evidence for a probable improvement in dry eye symptoms (two studies, 130 participants; MD -11.88, 95% CI -18.85 to -4.92 OSDI units). Meta-analysis was not possible for outcomes relating to ocular surface staining, Schirmer test or TBUT. We found low certainty evidence for a potential improvement in tear osmolarity (one study, 105 participants; MD -11.10, 95% CI -12.15 to -10.05 mOsmol/L). There was low level certainty regarding any potential effect on gastrointestinal side effects (two studies, 91 participants; RR 2.34, 95% CI 0.35 to 15.54).

AUTHORS' CONCLUSIONS

Overall, the findings in this review suggest a possible role for long-chain omega-3 supplementation in managing dry eye disease, although the evidence is uncertain and inconsistent. A core outcome set would work toward improving the consistency of reporting and the capacity to synthesize evidence.