Dry Eye Syndrome Preferred Practice Pattern®

Topical glaucoma medications - Possible implications on the meibomian glands

One of the most common causes of blindness on a global scale is glaucoma. There is a strong association between glaucoma and increased intraocular pressure (IOP). Because of this, adequate IOP-lowering is the most important treatment strategy, mostly through topical eyedrops. Well-functioning meibomian glands are paramount for maintaining a stable tear film, and their dysfunction is the most common cause of dry eye disease. There is a growing concern that both topical glaucoma medications themselves and their added preservatives damage the meibomian glands, and consequently, the ocular surface. Preserved topical glaucoma medications appear to cause dysfunction and atrophy of the meibomian glands. Upon comparison, preserved formulations caused more symptoms of dry eye, tear film instability, inflammatory changes and meibomian gland dropout than the preservative-free counterpart. However, although seemingly less detrimental, unpreserved alternatives may diminish glandular efficacy, and, depending on the active ingredient, lead to glandular death. This negatively impacts quality of life, adherence to treatment regimens and prognosis. In this review, we explore the available evidence regarding the effects of IOP-lowering eye drops on the meibomian glands.

Advances in artificial intelligence for meibomian gland evaluation: A comprehensive review

Meibomian gland dysfunction (MGD) is increasingly recognized as a critical contributor to evaporative dry eye, significantly impacting visual quality. With a global prevalence estimated at 35.8 %, it presents substantial challenges for clinicians. Conventional manual evaluation techniques for MGD face limitations characterized by inefficiencies, high subjectivity, limited big data processing capabilities, and a dearth of quantitative analytical tools. With rapidly advancing artificial intelligence (AI) techniques revolutionizing ophthalmology, studies are now leveraging sophisticated AI methodologies--including computer vision, unsupervised learning, and supervised learning--to facilitate comprehensive analyses of meibomian gland (MG) evaluations. These evaluations employ various techniques, including slit lamp examination, infrared imaging, confocal microscopy, and optical coherence tomography. This paradigm shift promises enhanced accuracy and consistency in disease evaluation and severity classification. While AI has achieved preliminary strides in meibomian gland evaluation, ongoing advancements in system development and clinical validation are imperative. We review the evolution of MG evaluation, juxtapose AI-driven methods with traditional approaches, elucidate the specific roles of diverse AI technologies, and explore their practical applications using various evaluation techniques. Moreover, we delve into critical considerations for the clinical deployment of AI technologies and envisages future prospects, providing novel insights into MG evaluation and fostering technological and clinical progress in this arena.

Effectiveness and safety of a novel crosslinked hyaluronate canalicular gel occlusive device for dry eye

PURPOSE

To evaluate the effectiveness and safety of a crosslinked hyaluronate (HA) canalicular filler (Lacrifill Canalicular Gel) compared with a commercially available hydrogel canalicular plug (Form Fit).

SETTING

5 sites in the United States.

DESIGN

Prospective, multicenter, controlled, double-masked, randomized 2:1 (filler:plug).

METHODS

Adults (≥22 years) with the Schirmer test (with anesthesia) ≤10 mm/5 minutes, presence of corneal staining, ocular surface disease index (OSDI) of ≥23 with ≤3 responses of "not applicable," patent lacrimal drainage system, and bilateral corrected distance visual acuity of 20/40 or better. Filler or plugs were instilled bilaterally in the inferior canaliculi. Primary effectiveness endpoint was noninferiority of the mean within subject change from baseline to month 3 in Schirmer score for patients receiving filler compared with plugs. The key secondary effectiveness endpoint was noninferiority of the proportion of patients with filler achieving improvement from baseline to month 3 in OSDI by a minimal clinically important difference. Additional endpoints included the mean change from baseline to 3 and 6 months in tear meniscus height, OSDI, corneal staining, tear breakup time, and safety.

RESULTS

157 patients were randomized; 99 patients with crosslinked HA filler and 52 patients with hydrogel plugs completed the study. Filler was noninferior to plugs in the mean Schirmer score change from baseline and in the proportion of patients achieving a clinically important improvement in OSDI.

CONCLUSIONS

Crosslinked HA filler is a safe, well-tolerated, and effective method to treat dry eye. Clinically and statistically significant improvements in signs and symptoms of dry eye were sustained through 6 months.

Empowering vision: the impact of nursing-led educational program on patients with dry eye syndrome

BACKGROUND

Dry eye syndrome (DES) is a widespread ocular condition affecting the general population. It is a complex disorder affecting the eye surface, characterized by a tear film imbalance and ocular symptoms such as eye ache, burning, irritation, dryness, blurred vision, and foreign body sensation. DES can reduce visual acuity, increase the risk of ocular infection, and significantly impact daily activities and quality of life.

AIM

Determine the impact of nursing-led educational program on the management of DES and patients' health outcomes including the intensity of DES symptoms and their influence on visual-related functions.

METHODS

The study was conducted with a quasi-experimental design. Sixty adult patients diagnosed with DES were selected using a convenience sampling method. Two tools were employed for the collection of data. Tool I: Precipitating factors of DES structured interview schedule. Tool II: Ocular surface disease index (OSDI) to assess ocular irritation symptoms associated with DES and their effect on functions related to vision.

RESULTS

A statistically significant decrease in the mean scores of OSDI in the study group two weeks after the implementation of the educational program regarding the ocular symptoms, functions associated with vision, environmental triggers, and overall score of OSDI.

CONCLUSION

Implementing an educational program for DES is effective in relieving symptoms, boosting patients' understanding of managing symptoms effectively, and maintaining eye health. Therefore, patients must be instructed on dry eye early detection and management to enhance health-related outcomes and self-care practices.

REGISTRATION

ClinicalTrials.gov: NCT06288945.

Factors predicting slow visual recovery following microkeratome-assisted myopic LASIK

PURPOSE

To identify factors predicting slow visual recovery following myopic microkeratome assisted in situ keratomileusis (LASIK).

DESIGN

Retrospective study.

METHODS

This study included consecutive patients who underwent microkeratome-assisted myopic LASIK between January 2005 and December 2019 at Care Vision Laser Center, Tel Aviv, Israel. Patients were divided into three groups according to whether they experienced normal recovery of visual acuity (1 week visit), slow visual recovery (1 month visit) or very slow recovery (>1 month). Normal visual recovery was defined as achieving an efficacy index of 0.9 or greater. Efficacy index was calculated as postoperative uncorrected visual acuity/preoperative best corrected visual acuity. A comparison of baseline and intraoperative parameters was performed.

RESULTS

Overall, 10 439 eyes were included. Mean age was 30.8 ± 8.7 years and 47.1% were females. The slower visual recovery groups (slow 11.4%, n = 1191; very slow 8.4%, n = 875) were of older age (p < 0.001), steeper preoperative steep keratometry (p = 0.002) and larger refractive astigmatism (p < 0.001). In binary logistic regression older age (p < 0.001), female gender (p = 0.001), larger astigmatism (p < 0.001) and high myopia (p < 0.001) remained significant predictors of slow visual recovery.

CONCLUSION

Slow visual recovery was observed in 19.8% of patients following myopic LASIK. Older age, female gender, larger astigmatism and high myopia were associated with slow visual recovery. Patients may be advised accordingly.

Factors Predicting Slow Visual Recovery Following Myopic Photorefractive Keratectomy

PURPOSE

To identify factors predicting slow visual recovery following photorefractive keratectomy (PRK).

METHODS

This retrospective study included consecutive patients who underwent PRK between January 2005 and December 2019 at Care Vision Laser Center, Tel Aviv, Israel. Myopic patients were divided into 2 groups according to whether they experienced normal recovery of visual acuity (within 60 days) or slow visual recovery (>60 days). Visual recovery was defined as achieving an efficacy index of 0.9 or greater. Efficacy index was calculated as postoperative uncorrected visual acuity/preoperative best corrected visual acuity. A comparison of baseline and intraoperative parameters was performed. Binary logistic regression was performed to identify potential predictors of slow visual recovery.

RESULTS

Overall, 4868 eyes were included. The mean age was 25.9 ± 7.7 years, and 53.9% were male. The slow visual recovery group (39.3%, n = 1911/4868) was older (P < 0.001) and had greater refractive astigmatism (P < 0.001) with a larger proportion of recent contact lens wearers (P = 0.002). The slow recovery group had larger optic zone treatments (P < 0.001), alcohol-assisted PRK (vs. transepithelial PRK) (P < 0.001), and greater maximum ablation depth (P < 0.001). In binary logistic regression, older age (P < 0.001), higher refractive astigmatism (P = 0.01), recent contact lens wear (P = 0.01), greater optic zone treatment (P = 0.001), and alcohol-assisted PRK (P < 0.001) remained significant predictors of slow visual recovery.

CONCLUSIONS

Slow visual recovery was observed in ∼40% of patients following myopic PRK. Older age, greater refractive astigmatism, recent contact lens wear, greater optic zone treatment, and alcohol-assisted PRK were associated with slow visual recovery.

Androgen Deprivation Therapy and the Risk of Newly Developed Dry Eye Syndrome in Patients with Prostate Cancer: A Nationwide Nested Case-Control Study in the Republic of Korea

Background: We aimed to evaluate the association between androgen deprivation therapy (ADT) and newly developed dry eye syndrome (DES) in patients with prostate cancer. Methods: A nested case-control study was conducted. From the nationwide claims database of the Republic of Korea, 125,005 patients were included in the final analysis. Cases were defined as those newly diagnosed with DES during follow-up, and 12,654 patients were identified. The cases were matched with controls in a ratio of 1:4. Odds ratios (ORs) for newly developed DES associated with ADT were estimated using conditional logistic regression. Results: After matching, 7499 cases and 29,996 controls were selected. ADT was associated with a reduced risk of newly developed DES in patients with prostate cancer compared to no ADT (OR = 0.875; 95% confidence interval, 0.825-0.927; p < 0.0001). An accumulated dose of ADT < 1 year was associated with a reduced risk of incidental DES (OR = 0.811; 95% CI, 0.751-0.875; p < 0.0001), and a duration of 1-2 years was also associated with a reduced risk (OR = 0.890; 95% CI, 0.802-0.986; p = 0.026). No association was observed with an ADT duration of ≥2 years. Conclusions: The use of ADT, especially for shorter durations (<2 years), was associated with a reduced risk of newly developed DES in S. Korean patients with prostate cancer.

Long-Term Safety and Efficacy of a Water-Free Cyclosporine 0.1% Ophthalmic Solution for Treatment of Dry Eye Disease: ESSENCE-2 OLE

PURPOSE

The ESSENCE-2 Open-Label Extension study aimed to demonstrate long-term safety, tolerability, and efficacy of a novel water-free, nonpreserved topical cyclosporine 0.1% ophthalmic solution (US brand name VEVYE) for patients with dry eye disease (DED).

METHODS

This was a Phase 3, prospective, multicenter, open-label, clinical study. All patients received cyclosporine 0.1% ophthalmic solution and dosed each eye twice a day for 52 weeks. Primary safety end points were ocular and nonocular adverse events (AEs). Secondary safety end points included visual acuity, biomicroscopy, intraocular pressure, and dilated fundoscopy. Efficacy end points, such as total corneal fluorescein staining (tCFS) score (National Eye Institute [NEI] Scale), ocular symptoms (visual analog scale [VAS]), and Schirmer tear test, were also assessed.

RESULTS

A total of 202 patients were enrolled from the ESSENCE-2 study. At week 52, 175 patients (86.6%) completed ESSENCE-2 open-label extension. A total of 55 patients (27.5%) reported 74 ocular treatment-emergent adverse events (TEAEs). The most common ocular AE was instillation site pain (6.5%), which was of mild intensity in all cases. Patients showed statistically significant improvements in all prespecified efficacy end points compared with baseline at each visit. Corneal staining improvements were early and stabilized over time while tear production improved continuously. Symptomatology improvement followed these effects with scores reaching a minimum after 1 year of treatment.

CONCLUSIONS

The water-free cyclosporine 0.1% ophthalmic solution was safe and well tolerated during long-term use. The results demonstrated sustained 1-year efficacy, in both signs and symptoms of DED, and may help understand short and long-term healing dynamics in a predominant inflammatory DED population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

United States Regulatory Approval of Topical Treatments for Dry Eye

PURPOSE

To report the heterogeneity in methodology of clinical trials submitted to the US Food and Drug Administration (FDA) for approval of topical dry eye treatments.

DESIGN

Comparative analysis of clinical trials' methods.

METHODS

We reviewed the online, publicly available FDA database, application review files, ClinicalTrials.gov registry records, and journal articles for each FDA-approved topical dry eye treatment. For each trial, we extracted information about the study, patient demographics, treatment names and doses, sample size in each arm, and the measurement instrument in a systematic fashion.

RESULTS

Fourteen trials were included that assessed 5 topical treatments for dry eye (cyclosporine 0.05%, cyclosporine 0.09%, lifitegrast 5%, and loteprednol 0.25% eye drops and varenicline 0.03-mg nasal spray). Median treatment duration was 12 weeks (range, 2-24 weeks). In all trials, treatments, including varying concentrations of the same treatment, were compared with vehicle. Twelve trials (85.7%) evaluated a primary clinician-measured clinical sign, and 10 trials (71.4%) evaluated a primary patient-reported symptom. Corneal staining was the most frequently evaluated clinical sign primary outcome, reported in half (6 of 12) of the trials, and was graded using 4 different scoring systems. Conjunctival staining, conjunctival hyperemia, and tear production were each measured using 2 different scoring systems. Ocular discomfort, the only patient-reported symptom primary outcome, was measured using 5 different instruments.

CONCLUSION

A variety of outcome measures were used in these clinical trials. Clinically meaningful dry eye outcome measures and standardized measurements can optimize the assessment of and comparison of therapeutic benefits.

Enhancing Ocular Surface in Dry Eye Disease Patients: A Clinical Evaluation of a Topical Formulation Containing Sesquiterpene Lactone Helenalin

The aim of this work was to assess the tolerability, safety, and efficacy of an ophthalmic topical formulation containing helenalin from Arnica montana and hyaluronic acid 0.4% (HA) in patients with mild-to-moderate Dry Eye Disease (DED) exhibiting positive Matrix Metalloproteinase 9 (MMP-9) test results. Tolerability and safety were evaluated in 24 healthy subjects. Participants were instructed to apply one drop of the formulation three times a day in the study eye, for 2 weeks, followed by a clinical follow-up of 21 days. Efficacy was studied in 48 DED patients randomized into Study (Group 1/receiving the studied formulation) or Control (Group 2/Receiving HA 0.4% eye lubricant) groups for 1 month. Assessments included an MMP-9 positivity test, conjunctival impression cytology (CIC), Ocular Surface Disease Index (OSDI), non-invasive film tear breakup time (NIBUT), non-invasive average breakup time (NIAvg-BUT), ocular surface staining, Schirmer's test, and meibomiography. A crossover design with an additional 1-month follow-up was applied to both groups. Healthy subjects receiving the studied formulation exhibited good tolerability and no adverse events. Regarding the efficacy study, Group 1 exhibited a statistically significant reduction in the MMP-9 positivity rate compared to Group 2 (p < 0.001). Both Group 1 and Group 2 exhibited substantial improvements in OSDI and NIBUT scores (p < 0.001). However, Group 1 demonstrated a significant improvement in NI-Avg-BUT and Schirmer's test scores (p < 0.001), whereas Group 2 did not (p > 0.05). Finally, after the crossover, the proportion of MMP-9-positive subjects in Group 1 increased from 25% to 91.6%, while Group 2 showed a significant decrease from 87.5% to 20.8%. Overall, the topical formulation containing sesquiterpene helenalin from Arnica montana and hyaluronic acid was well tolerated and exhibited a favorable safety profile. Our formulation reduces DED symptomatology and modulates the ocular surface inflammatory process; this is evidenced by the enhancement of CIC, the improvement of DED-related tear film status, and the reduction of the MMP-9 positivity rate.

Managing Dry Eye Disease with Novel Medications: Mechanism, Study Validity, Safety, Efficacy, and Practical Application

Dry eye disease (DED) is a common condition that affects mainly older individuals and women. It is characterized by reduced tear production and increased tear evaporation. Symptoms include burning, irritation, tearing, and blurry vision. This paper reviews key trials of various new DED treatments, including their mechanism of action, study outcomes, safety, and efficacy. The paper also includes a critical assessment of the trial's validity and potential pharmacy applications of these new treatments. The literature search was conducted through PubMed, the Cochrane Central Register of Controlled Trials, and Google Scholar. The keywords "Dry Eye Disease", "lifitegrast", "cyclosporine", "loteprednol etabonate", "varenicline nasal spray", and "perfluorohexyloctane" were used to identify these medications' landmark trials. The articles deemed these medications safe and efficacious, with minimal side effects. Our randomized controlled trial validity comparison found the trials robust with predominantly low bias. Cyclosporine and loteprednol are effective when artificial tears fail, while perfluorohexyloctane reduces tear film evaporation and is preservative-free. Varenicline offers drug delivery via the nasal route and is appropriate for contact lens users. In conclusion, these FDA-approved novel medications exhibit safety and efficacy in managing DED. Further research is needed on long-term outcomes, efficacy, and side-effect comparisons, and combination therapy benefits.

Utilizing visual symptoms to distinguish dry eye from glaucoma, cataract, and suspect glaucoma patients: a cross-sectional study

BACKGROUND

The diagnosis of dry eye and other common ophthalmological conditions can be supported using patient reported symptoms, which is increasingly useful in contexts such as telemedicine. We aim to ascertain visual symptoms that differentiate dry eye from cataract, glaucoma, or glaucoma suspects.

METHODS

Adults with dry eye, glaucoma, cataract, and suspected glaucoma (controls) completed a questionnaire to rate the frequency and severity of 28 visual symptoms. Univariate, followed by multivariable logistic regression with backward stepwise selection (p < 0.05), determined the individual symptoms and set of symptoms best distinguishing dry eye from each of the other conditions.

RESULTS

Mean age of 353 patients (94 glaucoma suspect controls, 79 glaucoma, 84 cataract, and 96 dry eye) was 64.1 years (SD = 14.1); 67% were female and 68% White. Dry eye patients reported more frequent light sensitivity (OR = 15.0, 95% CI = 6.3-35.7) and spots in vision (OR = 2.8, 95% CI = 1.2-6.3) compared to glaucoma suspect controls. Compared to glaucoma patients, dry eye patients experienced more frequent light sensitivity (OR = 9.2, 95% CI = 2.0-41.7), but less frequent poor peripheral vision (OR = 0.2, 95% CI = 0.06-0.7), difference in vision between eyes (OR = 0.09, 95% CI = 0.01-0.7), and missing patches of vision (OR = 0.06, 95% CI = 0.009-0.3). Compared to cataract patients, dry eye patients reported more frequent spots in vision (OR = 4.5, 95% CI = 1.5-13.4) and vision variability across the week (OR = 4.7, 95% CI = 1.2-17.7) and were less likely to report worsening vision (OR = 0.1, 95% CI = 0.03-0.4) and blindness (OR = 0.1, 95% CI = 0.02-0.8).

CONCLUSION

Visual symptoms may serve as a complementary tool to distinguish dry eye from various ocular conditions, though the symptoms that best distinguish dry eye differ across comparisons. Differentiating how patients visually perceive common eye diseases may be used in a variety of clinical settings to rule out specific conditions.

Trends in Health Service Use for Dry Eye Disease From 2017 to 2021: A Real-World Analysis of 369,755 Outpatient Visits

Purpose

We aimed to analyze the trends and patterns in outpatient health service treatment of dry eye disease (DED) using real-world data from Yinzhou District in China.

Methods

The Yinzhou Health Information System is a comprehensive database including electronic medical records from 277 medical institutions representing over 1.64 million residents. We extracted outpatient records from January 1, 2017, to December 31, 2021, that included the first diagnosis of DED according to the International Classification of Diseases, 10th Revision (H04.101, H04.103, H11.104, H16.202, or H18.803). We analyzed the trends and patterns of DED outpatient visits using the Mann-Kendall trend test and Cochran-Armitage trend test.

Results

We identified a total of 369,755 outpatient visits from 145,712 patients with DED of all ages (60.37% female; 54.10% 50 years or older). Primary medical institutions had the largest number of DED outpatient visits (42%), followed by tertiary medical institutions (35%). Over the 5-year period, the number of DED outpatient visits increased from 59,260 to 90,807 (53.23%). We observed significant consecutive annual proportion increases in females (from 61.09% to 62.01%; P = 0.001), patients 50 years or older (from 55.10% to 60.08%; P < 0.001), and outpatient visits in primary medical institutions (from 33.19% to 48.75%; P < 0.001).

Conclusions

Our study found an increase in outpatient health service use for DED in Yinzhou from 2017 to 2021, with higher proportions and increases among females, patients 50 years or older, and primary medical institutions.

Translational Relevance

The rapid growth in the prevalence of DED indicates high eye healthcare needs in patients.

Interventions for Dry Eye: An Overview of Systematic Reviews

Importance

Dry eye is a common ocular disease that can have substantial morbidity. Systematic reviews provide evidence for dry eye interventions and can be useful for patients, clinicians, and clinical guideline developers. Overviews of reviews use explicit and systematic methods to synthesize findings from multiple systematic reviews, but currently, there are no overviews of systematic reviews investigating interventions for dry eye.

Objective

To summarize the results of reliable systematic reviews of dry eye interventions and to highlight the evidence gaps identified.

Evidence Review

We searched the Cochrane Eyes and Vision US satellite database and included reliable systematic reviews evaluating dry eye interventions published from 2016 to 2022. We reported the proportion of systematic reviews that were reliable with reasons for unreliability. Critical and important outcomes from reliable systematic reviews were extracted and verified. Critical outcomes included dry eye-related patient-reported outcome measures. Results were synthesized from reliable systematic reviews to provide summaries of evidence for each intervention. Evidence for each intervention was defined as conclusive or inconclusive depending on whether high-certainty evidence across systematic reviews was available according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and whether findings reached statistical or clinical significance. Recommendations were made for further research.

Findings

Within the Cochrane Eyes and Vision US satellite database, 138 potentially relevant systematic reviews were identified, 71 were considered eligible, and 26 (37%) were assessed as reliable. Among reliable systematic reviews, no conclusive evidence was identified for any dry eye intervention. Inconclusive evidence suggested that environmental modifications, dietary modifications, artificial tears and lubricants, punctal occlusion, intense pulsed light therapy, vectored thermal pulsation therapy (Lipiflow), topical corticosteroids, topical cyclosporine A, topical secretagogues, and autologous serum may be effective. Only unreliable systematic reviews evaluated lifitegrast, oral antibiotics, and moisture chamber devices.

Conclusions and Relevance

This overview of systematic reviews found some evidence that dry eye interventions may be effective, but no conclusive evidence was available. The conduct and reporting of most systematic reviews for dry eye interventions warrant improvement, and reliable systematic reviews are needed to evaluate lifitegrast, oral antibiotics, and moisture chamber devices.

Topical diquafosol versus hyaluronic acid for the treatment of dry eye disease: a meta-analysis of randomized controlled trials

BACKGROUND

Diquafosol enhances fluid transfer and mucin secretion on ocular surface, which has been suggested as an effective treatment for dry eye disease (DED). The aim of the systematic review and meta-analysis was to compare the efficacy and safety of topical diquafosol versus hyaluronic acid (HA) for DED.

METHODS

Relevant randomized controlled trials were obtained via search of electronic including PubMed, Embase, Cochrane Library, and Web of Science. A random-effects model was used to pool the results after incorporating the influence of potential heterogeneity.

RESULTS

A total of nine RCTs involving 1295 patients with DED were included in the meta-analysis. Compared to treatment with 0.1% HA, topical treatment with 3% diquafosol significantly improved the Ocular Surface Disease Index (mean difference (MD): - 3.59, 95% confidence interval (CI): - 4.68 to - 2.50, p < 0.001; I2 = 6%), results of Schirmer's test (MD: 1.08 mm, 95% CI: 0.41 to 1.76, p = 0.002; I2 = 0%), tear breakup time (MD: 0.60 s, 95% CI: 0.20 to 0.99, p = 0.003; I2 = 63%), corneal fluorescein staining score (MD: - 0.20, 95% CI: - 0.37 to - 0.03, p = 0.02; I2 = 58%), and ocular rose bengal staining score (MD: - 0.62, 95% CI: - 0.88 to - 0.35, p < 0.001; I2 = 15%). No severe adverse events were reported. Topical use of diquafosol was associated with a higher risk of overall adverse events as compared to HA (odds ratio: 1.71, 95% CI: 1.08 to 2.71, p = 0.02; I2 = 18%).

CONCLUSIONS

Topical treatment with 3% diquafosol may be more effective than 0.1% HA for patients with DED. However, the long-term efficacy and tolerability of diquafosol still need to be determined.

[Chronic eye pain]

Numerous conditions in the field of ophthalmology are associated with pain in or around the eye. Chronic pain associated with the eye is a common finding in the daily routine of ophthalmologists and can be associated with primary ocular or extraocular diseases as well as with other conditions. Appropriate diagnostic assessment and management of people with chronic pain requires an understanding of the condition based on the biopsychosocial model in which the interactions of biological/somatic, psychological and social factors are determining pain and suffering. Beyond the ophthalmological findings,  close interdisciplinary cooperation and assessment are required. Therefore, if eye pain is insufficiently responsive to treatment or if symptoms of chronic pain are evident, pain medicine expertise should be involved. The management of chronic ocular pain is based on interdisciplinary multimodal approaches, in addition to the ophthalmologist-specific approaches. These focus on self-efficacy, patient competence and acceptance of pain as central goals of treatment rather than pain relief. Patient information, education and the development of a suitable concept by the interdisciplinary team are essential therapeutic aspects in this context.

Evaluation of Publications from the American Academy of Ophthalmology: A 5-Year Analysis of Ophthalmology Literature

Objective

To analyze recent publications in Ophthalmology, the journal of the American Academy of Ophthalmology.

Design

Retrospective review of published articles.

Participants

No human participants were involved in the study.

Methods

Articles published in Ophthalmology from January 2018 to December 2022 were reviewed and analyzed.

Main Outcome Measures

Research and review articles were included and analyzed per the following: total number of published articles based on related subspecialty area, level of evidence using the modified Oxford level of evidence, number of citations, number of listed authors, gender of the corresponding author, country of affiliation of the corresponding and contributing author(s), and involvement of consortium(s), group(s), or committee(s).

Results

A total of 965 articles were included. The mean (standard deviation) number of authors per article was 8.6 (5.7) and the majority of corresponding authors were male (665, 70.7%). The greatest number of published articles were related to retina (296, 30.7%) followed by glaucoma (172, 17.8%). The greatest number of Preferred Practice Pattern guidelines were also related to retina (7/24, 29.1%), followed by cornea/dry eye syndrome/external disease (6/24, 25%). Retina (77) had the most level 1 evidence, glaucoma (30) for level 2 evidence, and retina for levels 3 (69) and 4 (65). There were 223 articles contributed by consortia/groups/committees, with most from retina (73, 32.7%) followed by glaucoma (40, 17.9%). The mean number of citations per subspecialty article was highest in retina (45.8/article), followed by uveitis (31.7/article). The United States had the greatest number of affiliated corresponding authors (544, 56.4%), followed by the United Kingdom (68, 7.0%). There were 357 (37.0%) articles with coauthors affiliated outside the corresponding author's country of affiliation, although with a downward trend over the most recent 5-year period. There has been an increasing trend in the number of authors and consortia/group/committee involvement in publications.

Conclusions

Although team science and collaborations have increased recently, ongoing efforts to diversify individuals, groups, and subspecialties may be needed.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Poloxamer sols endowed with in-situ gelability and mucoadhesion by adding hypromellose and hyaluronan for prolonging corneal retention and drug delivery

The purpose of this study was to develop poloxamer (P407)-based in-situ thermogellable hydrogels with reducing concentration of P407 by adding hypromellose (HPMC) and with enhancing mucoadhesion of resulting hydrogels by adding hyaluronic acid (HA) for prolonging ocular delivery of hydroxypropyl-β-cyclodextrin (HPβCD)-solubilized testosterone (TES). Results demonstrated that 0.5% TES solution was successfully solubilized with adding 10% HPβCD. Non-gellable 13% P407 sol became in-situ gellable with adding 2.0-2.5% HPMC and mucoadhesibility was further imporved with adding 0.3% HA-L (low MW) or HA-H (high MW). Optimized 0.5% HPβCD-solubilized TES P407-based thermogellable hydrogels with enhancement of mucoadhesion for prolonging ocular delivery comprised 13% P407, 2.5% HPMC, and 0.3% HA-L or HA-H. Furthermore, rheological measurements under simulated eye blinking confirmed that non-thixotropic properties of optimized hydrogels could be spreaded evenly and retain a greater amount of drug-loaded hydrogels on the ocular surface for a longer period to prolong drug delivery. Compared with conventional eye drops, the prolonged residence time of optimized hydrogels from ex vivo and in vivo studies were observed, indicating relationships between rheological properties and in vivo performances. It was concluded that P407-based thermosensitive hydrogels with reducing concentration of P407 and enhancing mucoadhesion was successfully formulated by adding 2.5% HPMC and 0.3% HA in 13% P407 for potentially accomplishing effective clinical treatment of DED.

Dry eye disease: identification and therapeutic strategies for primary care clinicians and clinical specialists

Dry eye disease (DED) is a multifactorial disorder characterized by loss of tear film homeostasis with an estimated worldwide prevalence of 5% to 50%. In DED, dysfunction of the ocular structures that create and regulate the tear film components-including the lacrimal glands, meibomian glands, cornea, and conjunctiva-causes a qualitative and/or quantitative tear deficiency with resultant tear film instability and hyperosmolarity. This initiates a vicious cycle of ocular surface inflammation and damage that may ultimately impair the quality of life and vision of affected patients. Many factors can contribute to the development of DED, including ocular and systemic diseases, topical and systemic medications, and environmental conditions. Because DED is a chronic disorder, treatment is most often long term and may utilize both pharmacologic and nonpharmacologic interventions to address all etiologic components. The long-term management of DED can be challenging and most often should involve eye care specialist referral. However, primary care clinicians (PCCs) are often the first points of contact for patients with DED and importantly provide initial diagnosis and preliminary patient education about the disease process. Consideration of DED is also vital for the practice of various specialties due to the large number of comorbidities and medications that can contribute to DED pathogenesis and progression. Therefore, it is important that PCCs and clinical specialists be aware of the etiology of DED and its available therapeutic options. This manuscript provides an overview of DED pathophysiology and treatment and discusses specific considerations regarding DED management for PCCs and clinical specialists.Key messagesSuccessful management of dry eye disease often requires the use of various pharmacologic and/or nonpharmacologic therapies, as well as environmental and lifestyle modifications, to mitigate the underlying etiologies and restore tear film homeostasis.Primary care clinicians play an essential role in dry eye disease management by establishing a diagnosis, educating patients about the disorder, and providing referrals to eye care specialists for initiation of specialized treatment and long-term follow-up.Primary care clinicians and clinical specialists should consider prescribing medications with fewer ocular surface effects whenever possible in patients at risk for or with existing dry eye disease.

Characteristics and management of vascular compromise after an organ transplantation surgery of the head and neck region: Analysis of 220 submandibular glands with autologous transplantation

BACKGROUND

Microvascular submandibular gland transplantation (SMGT) for severe dry eye disease (DED) has rarely been reported in the literature. The aim of this study was to report a case series of SMGT with the special focus on monitoring and management of postoperative vascular compromise.

METHODS

Using a retrospective single-cohort study design, the investigators enrolled a sample of DED patients undergoing SMGT in a Chinese university hospital during 1999 and 2021. The main outcomes were baseline and surgical data, post-operative manifestations, and surgical results. Descriptive, uni- and bivariate statistics were computed with the significant P < 0.05.

RESULTS

During the study period, 220 DED patients (55.9% female) with a mean age of 32.66±14.47 years underwent SMGT. Vascular compromises occurred in 27 grafted glands (12.3%; 22 venous compromises and 5 arterial compromises) at a median of 27 h(range, 3.3 to 288 h) after surgery. Harden texture and swelling of the covering skin flap of the donor indicated venous compromises, while some specific sign was absent for arterial compromise. The accompanying vein of the facial artery (FAV) as a donor's vein was associated with less vascular compromise compared to the anterior facial vein (AFV). Timely reexploration was performed in 25 glands (92.6%), with a salvaged rate of 48%, and more venous compromises were salvaged compared to artery compromises (54.6% vs. 0%, P = 0.047). Temporary hypersecretion on postoperative 2-5 days was noticed in the grafted glands with no or salvaged vascular compromise (Schirmer's test, 35 mm/5 min and 37 mm/5 min, respectively, P = 0.749), while they were absent for the 15 surgically failed grands (Schirmer's test 0 mm/5 min, P<0.001).

CONCLUSIONS

Vascular compromise appears to be a common complication of SMGT. Postoperative hypersecretion of the grafted glands may indicate good circulation, and the use of FAV as the donor's vein could help to decrease the risk of vascular compromise.

Intranasal Varenicline: Review of a Novel Formulation for the Treatment of Dry Eye Disease

Objective: To examine the literature pertaining to safety and efficacy of intranasal (IN) varenicline for the treatment of dry eye disease (DED). Data Sources: A literature search of PubMed was performed (1985 to January 2022) using the following search terms: varenicline, OC-01, intranasal, and dry eye. Additional data were acquired from references of identified articles, prescribing information, government databases, and manufacturer website. Study Selection/Data Extraction: All relevant English-language studies were included in this review. Data Synthesis: IN varenicline was FDA approved for the treatment of DED in 2021. IN varenicline has demonstrated a statistically significant improvement in outcomes related to basal tear film production as measured by a Schirmer test score (STS) in data from phase 2 and 3 clinical trials. Safety data from these trials have demonstrated that IN varenicline is generally well tolerated with minimal ocular side effects. The most common side effects reported in the trials were sneezing, coughing, along with throat and nasal irritation. Relevance to Patient care and Clinical Practice: Patients suffering from DED have been traditionally treated with ophthalmic preparations; however, many patients struggle with proper administration of ophthalmic products. IN varenicline stimulates nicotinic cholinergic receptors and basal tear film production through the trigeminal parasympathetic nerve pathway (TPP). There is no evidence to support the long-term remission of DED symptoms with IN varenicline as seen with anti-inflammatory modulators. Conclusions: IN varenicline offers an effective and novel approach to management of DED for patients who desire a non-ophthalmic preparation with a favorable side effect profile.

Autoimmune Disease-Related Dry Eye Diseases and Their Placement Under the Revised Classification Systems: An Update

Dry eye disease (DED) is a chronic and progressive disorder involving the ocular surface, characterized by disturbances in tear film composition, instability of the tear film, and inflammation of the ocular surface. There are two forms of DED: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). Autoimmune diseases are systemic disorders involving multiple organs, including the eyes, and have a significant impact on DED. There have been multiple studies demonstrating the relation between autoimmune diseases and DED. This article reviews the current knowledge regarding the epidemiological characteristics, pathogenesis, and treatments of autoimmune disease-related DED.

Ocular dryness in intensive care: proposal for a new nursing diagnosis

OBJECTIVE

to analyze the concept associated with diagnostic proposition Ocular dryness in adult patients hospitalized in an Intensive Care Unit, identifying its attributes, antecedents and consequences.

METHODS

a methodological study carried out through concept analysis, operationalized by scoping review.

RESULTS

the analysis of 180 studies allowed the identification of two attributes, 32 antecedents and 12 consequences. The attributes were tear film deficiency and ocular signs and/or symptoms. The prevalent antecedents were incomplete eyelid closure (lagophthalmos) and blinking mechanism decrease. Major consequences included conjunctival hyperemia and decreased tear volume.

CONCLUSIONS

this study allowed constructing nursing diagnosis Ocular dryness, part of domain 11, class 2, with 12 defining characteristics, 12 related factors, seven populations at risk and 13 associated conditions. This problem-focused proposal may provide targeted care by promoting early detection and implementing interventions that reduce the risk of ocular damage.

Identification of Subtypes of Dry Eye Disease, Including a Candidate Corneal Neuropathic Pain Subtype Through the Use of a Latent Class Analysis

PURPOSE

In the absence of a gold-standard diagnostic test for different subtypes of dry eye disease (DED), we aimed to identify latent subtypes of DED within a well-characterized cohort.

DESIGN

This is a cross-sectional study of participants enrolled in the Sjögren International Collaborative Clinical Alliance (SICCA).

METHODS

A latent class analysis was applied to different dry eye-related signs/tests and symptoms of ocular pain (particularly those that aligned with corneal neuropathic pain) giving relative specificities and sensitivities of each diagnostic test or symptom in the SICCA population.

RESULTS

Four subtypes of DED were identified with putative designations including normal, asymptomatic dry eye, symptomatic dry eye, and corneal neuropathic pain.

CONCLUSIONS

More specific classification criteria are needed for DED. Latent class analysis applied to the signs and symptoms captured in the SICCA cohort may allow for the development and refinement of classification criteria for specific subtypes of dry eye.

The Effect of Sodium Hyaluronate Eye Drops 2, 4 or 6 Times a Day on Signs and Symptoms of Dry Eye Disease

Purpose

A randomized clinical trial was run to evaluate the effectiveness of a preservative-free 0.4% sodium hyaluronate eye drop (LOF) in different dosage schemes to alleviate signs and symptoms of dry eye disease (DED).

Methods

A total of 116 subjects with mild-to-moderate DED were included, and 111 completed the study (from which 67.6% were female and 65.3% were users of oral contraceptives). Patients were randomly assigned to instill a drop of LOF either 2 (BID), 4 (QID) or 6 (6TD) times a day (at least 3 hours apart) for 30 days. The clinical parameters and symptom endpoints were Ocular Surface Disease Index (OSDI), tear break-up time (TBUT), ocular surface staining, and conjunctival hyperemia. Other parameters evaluated were chemosis, best corrected visual acuity, and the incidence of adverse events (AE).

Results

There was a significant reduction in OSDI scores by day 30 in all groups. The recovery of the OSDI score back to normal values was observed in 51.4% of patients treated (50%, 48.6%, and 55.6% in BID, QID, and 6TD, respectively, p = 0.822). Similar improvement was observed for TBUT, 50.5% of patients increased this variable to >10 seconds (39.5%, 51.4%, and 61.1%, p = 0.175), and for ocular surface staining, ≥72% showed Grade 0. There were no significant differences among posology groups regarding ocular surface staining, conjunctival hyperemia, or any safety parameters. No overall improvement in OSDI and TBUT to normal values was noted for 31 patients (21 were female and 71.4% users of contraceptive drugs).

Conclusion

The ophthalmic use of preservative free LOF, 2, 4 or 6 times a day, may alleviate clinical parameters and symptoms in 50% of patients with mild-to-moderate DED after a one-month treatment. This improvement seemed to be less ubiquitous in patients within reproductive age and using oral contraceptives.

Trial Registration

This trial is registered at clinicaltrials.gov (NCT0704531).

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.

Case report: Utilization of a scleral lens to mitigate exposure keratopathy and associated mental health decline

PURPOSE

To report a case of acute exposure keratopathy with comorbid depression and improvement of both conditions with the use of a scleral lens (SL).

OBSERVATIONS

A 72-year-old male with a past ocular history significant for extensive basal cell carcinoma (BCC) excision of the right upper and lower eyelids presented for evaluation of exposure keratitis and consideration of a SL for the right eye. Examination was notable for post-surgical irregular lid margins with lagophthalmos, trichiasis and an Oxford Grade I staining of the central exposed cornea. Medical history was notable for chronic severe depression and anxiety with suicidal ideation. Upon treatment with a SL, the patient noted ocular comfort, and reported significantly improved affect.

CONCLUSION AND IMPORTANCE

Currently, there is no peer reviewed literature reporting on the management of exposure keratopathy in the setting of comorbid affective disorders. This case highlights the improvement in quality of life for a patient with exposure keratitis and severe depression with suicidal ideation and points to the potential utilization of a SL to mitigate the risk of mental health decompensation.

Interobserver Reliability of Tear Break-Up Time Examination Using "Smart Eye Camera" in Indonesian Remote Area

Introduction

Dry eye disease (DED) is a multifactorial disease of tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability leading to decrease of vision, productivity and quality of life, and blindness. DED diagnosis remains difficult and underdiagnosed regarding inconsistency between subjective symptoms and clinical findings. Tear break-up time (TBUT) is an objective indicator of tear film stability in diagnostic DED. A novel smartphone attachment, namely SEC (smart eye camera), could mimic conventional slit lamp to assess TBUT and beneficial in facilitating DED diagnosis. Reliability between a non and an ophthalmologist in TBUT assessment and DED diagnosis is observed in this study.

Purpose

To determine interobserver reliability of TBUT measurement for diagnosing DED using SEC.

Design

This a cross-sectional analytic study involving 99 participants (198 eyes) aged 40 years who visited Pratama Gema Santi Hospital, Nusa Penida, from September 2nd to 4th, 2022, with consecutive sampling technique.

Methods

Fluoresceined eyes were filmed using the SEC device and apps, continued by masked ophthalmologist and resident assessing TBUT based on the video. The primary outcome is interobserver reliability for TBUT measurement and DED diagnosis.

Results

The mean age of participants was 55.22±9.78 years, 48.5% male and 51.5% female. The reliability of interobserver in assessing DED based on TBUT test is 0.78 (95% CI=0.31-1.26, P-value=0.001), and interobserver reliability in diagnosing DED based on OSDI and TBUT showed good agreement (weighted kappa=0.71). Good interobserver reliability underscores that non-ophthalmologists can diagnose DED based on TBUT video using SEC.

Conclusion

SEC video has good interobserver reliability to assess TBUT for DED diagnosis. SEC can be used as one of the methods in assessing DED in limited health care facilities. The high reliability of interobserver assessment indicates that DED diagnosis using video taken with SEC may be useful for telemedicine evaluation in remote areas.

A clinical decision support system for diagnosing and determining severity of dry eye disease

INTRODUCTION

Dry eye and its related symptoms are the most common causes of referrals to the ophthalmology centers. Since people with dry eye may suffer from different levels of the disease severity, this study aimed to develop a clinical decision support system for diagnosing and determining severity of dry eye disease.

METHODS

This research was carried out in two phases in 2020. In the first phase, a questionnaire was designed to identify the most important diagnostic parameters from the cornea specialists' perspectives (n = 37). In the second phase of the research, a clinical decision support system was designed and implemented by using MATLAB software. Finally, the system was evaluated using patient data which were collected in a teaching hospital (n = 50).

RESULTS

The diagnostic parameters for dry eye disease were filamentary keratitis, meibomian gland dysfunction, score of ocular surface disease index, Schirmer's test result, tear meniscus height, tear breakup time, and fluorescein staining score. The system output variables were the diagnosis and severity of dry eye disease at four levels for the right and left eyes, separately. The results of the evaluation study showed that the accuracy, sensitivity and specificity of the system were 96.9%, 97.5%, and 93.7%, respectively.

CONCLUSION

It seems that the system designed in this study can help ophthalmologists to diagnose dry eye disease more accurately and quickly. However, it is recommended to conduct more evaluation studies and include more patients in the future research.

Detection of Subclinical Neurotrophic Keratopathy by Non-Contact Esthesiometry

Objectives

To analyze corneal sensitivity with a new noncontact and hand-held esthesiometer (Brill Engines, Spain) in patients with dry eye disease (DED) and patients on hypotensive drops, and to compare it with healthy subjects.

Methods

31 patients (57 eyes) with DED, 23 patients (46 eyes) with glaucoma and 21 healthy patients (33 eyes) were recruited. In all patients, corneal sensitivity was measured. Subsequently, a keratography test (Keratograph 5M, Oculus) was carried out to measure tear meniscus height (TMH), non-invasive break up time (NIBUT), bulbar redness (Jenvis scale) and corneal staining (CS, Oxford scale). Both corneal sensitivity and ocular surface parameters were compared between DED, glaucoma, and healthy subjects. Linear mixed models were constructed to utilize data from both eyes of patients. A 95% confidence level was considered statistically significant.

Results

The mean age was 56.1±16.1 years in DED group, 69.5±11.7 years in the glaucoma group and 36.3±10.5 years in the control group. Adjusting for age and sex, esthesiometry was significantly worse in DED and glaucoma vs control group (p = 0.02 and p = 0.009, respectively). NIBUT was lower in DED and glaucoma patients (p < 0.001 and p = 0.001, respectively). Redness and CS values were higher in DED group (p = 0.04 and p = 0.001, respectively). TMH was lower in the glaucoma patients (p = 0.03).

Conclusions

Corneal sensitivity measured with a novel noncontact esthesiometer was reduced in DED and glaucoma patients compared to controls. In clinical practice, this esthesiometer could be an easy-to-use device to evaluate for patients with subclinical neurotrophic keratopathy.

The multifunctional human ocular melanocortin system

Immune privilege in the eye involves physical barriers, immune regulation and secreted proteins that together limit the damaging effects of intraocular immune responses and inflammation. The neuropeptide alpha-melanocyte stimulating hormone (α-MSH) normally circulates in the aqueous humour of the anterior chamber and the vitreous fluid, secreted by iris and ciliary epithelium, and retinal pigment epithelium (RPE). α-MSH plays an important role in maintaining ocular immune privilege by helping the development of suppressor immune cells and by activating regulatory T-cells. α-MSH functions by binding to and activating melanocortin receptors (MC1R to MC5R) and receptor accessory proteins (MRAPs) that work in concert with antagonists, otherwise known as the melanocortin system. As well as controlling immune responses and inflammation, a broad range of biological functions is increasingly recognised to be orchestrated by the melanocortin system within ocular tissues. This includes maintaining corneal transparency and immune privilege by limiting corneal (lymph)angiogenesis, sustaining corneal epithelial integrity, protecting corneal endothelium and potentially enhancing corneal graft survival, regulating aqueous tear secretion with implications for dry eye disease, facilitating retinal homeostasis via maintaining blood-retinal barriers, providing neuroprotection in the retina, and controlling abnormal new vessel growth in the choroid and retina. The role of melanocortin signalling in uveal melanocyte melanogenesis however remains unclear compared to its established role in skin melanogenesis. The early application of a melanocortin agonist to downregulate systemic inflammation used adrenocorticotropic hormone (ACTH)-based repository cortisone injection (RCI), but adverse side effects including hypertension, edema, and weight gain, related to increased adrenal gland corticosteroid production, impacted clinical uptake. Compared to ACTH, melanocortin peptides that target MC1R, MC3R, MC4R and/or MC5R, but not adrenal gland MC2R, induce minimal corticosteroid production with fewer amdverse systemic effects. Pharmacological advances in synthesising MCR-specific targeted peptides provide further opportunities for treating ocular (and systemic) inflammatory diseases. Following from these observations and a renewed clinical and pharmacological interest in the diverse biological roles of the melanocortin system, this review highlights the physiological and disease-related involvement of this system within human eye tissues. We also review the emerging benefits and versatility of melanocortin receptor targeted peptides as non-steroidal alternatives for inflammatory eye diseases such as non-infectious uveitis and dry eye disease, and translational applications in promoting ocular homeostasis, for example, in corneal transplantation and diabetic retinopathy.

In Vitro Inhibition of Evaporation with Perfluorohexyloctane, an Eye Drop for Dry Eye Disease

Objective

Perfluorohexyloctane (PFHO) MIEBO^TM, formerly (NOV03) is a single component, water-free eye drop approved by the Food and Drug Administration in the United States for the treatment of dry eye disease. We evaluated the in vitro inhibitory effect of PFHO on the evaporation rate (R_evap) of saline.

Methods

Evaporation rates were measured gravimetrically at 25°C or 35°C. The evaporation rate (R_evap) of phosphate-buffered saline (PBS) was measured following the application of 11-200 µL PFHO or 100 µL artificial tears (Soothe XP [Bausch + Lomb, Bridgewater, New Jersey], Systane Balance [Alcon, Fort Worth, Texas], and Systane Ultra [Alcon]). The effect of PFHO on the R_evap of PBS was further evaluated following the addition of 50 mg/mL mucin to PBS and compared with that of meibum lipid collected from a 68 year-old White volunteer.

Results

At 25°C the mean (SEM) R_evap of PBS alone or PFHO alone was 4.06 (0.06) and 0.137 (0.004) µm/min, respectively. Layering 100 µL PFHO over PBS inhibited the R_evap of PBS by 81% (P < 0.0001), whereas artificial tears had no effect. The presence of mucin attenuated the inhibition of the R_evap of PBS by PFHO by 17% (P < 0.0001). At 35°C, the R_evap of PBS was inhibited by 88% when layering 100 µL PFHO over PBS and 28% when applying a single 11 µL drop of PFHO (P value < 0.0001 for both). Meibum lipid inhibited the R_evap of PBS by 8% at this temperature, whereas the combination of a drop of PFHO plus meibum inhibited the R_evap of PBS by 34%.

Conclusions

PFHO significantly inhibited the R_evap of saline in this in vitro model. The data support the idea that PHFO may form an antievaporative layer on the tear film surface and may be a functional substitute for the native tear-film lipid layer in patients with dry eye disease.

The Autoimmune Rheumatic Disease Related Dry Eye and Its Association with Retinopathy

Dry eye disease is a chronic disease of the ocular surface characterized by abnormal tear film composition, tear film instability, and ocular surface inflammation, affecting 5% to 50% of the population worldwide. Autoimmune rheumatic diseases (ARDs) are systemic disorders with multi-organ involvement, including the eye, and play a significant role in dry eye. To date, most studies have focused on Sjögren's syndrome (one of the ARDs) since it manifests as two of the most common symptoms-dry eyes and a dry mouth-and attracts physicians to explore the relationship between dry eye and ARDs. Many patients complained of dry eye related symptoms before they were diagnosed with ARDs, and ocular surface malaise is a sensitive indicator of the severity of ARDs. In addition, ARD related dry eye is also associated with some retinal diseases directly or indirectly, which are described in this review. This review also summarizes the incidence, epidemiological characteristics, pathogenesis, and accompanying ocular lesions of ARD's related dry eye, emphasizing the potential role of dry eye in recognition and monitoring among ARDs patients.

The Incidence and Risk Factors for Dry Eye After Pediatric Strabismus Surgery

INTRODUCTION

This study aimed to investigate the incidence and risk factors for dry eye after pediatric strabismus surgery.

METHODS

Children aged 5-12 years who underwent strabismus surgery were included in this single-center, prospective, cohort study. The ocular surface assessments were conducted 1 day before and 1, 4, and 8 weeks after surgery. The main outcome measures were the incidence of dry eye after strabismus surgery and associated risk factors.

RESULTS

A total of 84 eyes (48 children) that underwent strabismus surgery were included in the study. The mean age at surgery was 7.21 years. The incidence of dry eye was 47.62% at 1 week, 10.71% at 4 weeks, 0% at 8 weeks after surgery. The preoperative tear breakup time (BUT) was lower in the dry eye group than that in the non-dry eye group (P ≤ 0.01). The univariate analysis showed that preoperative BUT was significantly associated with the incidence of dry eye after pediatric strabismus surgery (odds ratio [OR] 0.647, confidence interval [CI] 0.503-0.833, P ≤ 0.01).

CONCLUSIONS

Dry eye commonly occurs after pediatric strabismus surgery. Tear film instability is more common than deficient aqueous tear production in patients with dry eye after surgery. Children with a low preoperative BUT are more likely to develop dry eye after strabismus surgery.

Effectiveness of Intranasal Tear Neurostimulation for Treatment of Dry Eye Disease: A Meta-Analysis

INTRODUCTION

To assess the effectiveness and safety of intranasal tear neurostimulation in the treatment of dry eye disease.

METHODS

We performed a meta-analysis of four databases from their inception to October 2022 without language restrictions. Randomized controlled trials and non-randomized controlled trials meeting the inclusion criteria were included in this review and were quality appraised. The risk of bias was evaluated by two independent reviewers using the Cochrane Collaboration Tool and Methodological Index for Non-Randomized Studies. The random-effect model or fixed-effect model was adopted to estimate the pooled effect sizes.

RESULTS

Fifteen published studies consisting of 17 clinical trials with a total of 901 patients were analyzed. Schirmer II test scores were significantly higher after intranasal tear neurostimulation in patients with dry eye disease (mean difference = 14.12 mm, 95% confidence intervals (8.93, 19.31), P < 0.001). Intranasal tear neurostimulation increased the meibomian gland areas (mean difference = - 251.79 μm², 95% confidence intervals (- 348.34, - 155.23), P < 0.001), but no significant difference was found in meibomian gland perimeters before and after stimulation (mean difference = 3.72 mm, 95% confidence intervals (- 22.14, 29.59), P = 0.78). All adverse events were mild or moderate, and no serious adverse events were reported.

CONCLUSIONS

This meta-analysis provides promising evidence for the controversial effectiveness of intranasal tear neurostimulation in the treatment of dry eye disease, along with useful information for guiding intranasal tear neurostimulation in future clinical trials.

TRIAL REGISTRATION

This meta-analysis was registered on the Prospective Register of Systematic Reviews (PROSPERO) (CRD42021284214).

Pre-analytical sample handling effects on tear fluid protein levels

Tear fluid is emerging as a source of non-invasive biomarkers, both for ocular and systemic conditions. Accurate quantification of tear proteins can be improved by standardizing methods to collect and process tear fluid. The aim of this study was to determine sample handling factors that may influence the tear protein biomarker profile. Tear fluid was collected using Schirmer's strips. Tear proteins were extracted by elution through centrifugation. Total protein content was determined using the bicinchoninic acid assay. Key concepts that apply to the entire sample processing cycle are tear sampling, tear storage, protein extraction and data normalization. Differences in wetting or migration length were observed between Schirmer's strips from different manufacturers, and between protein-free and protein-rich solutions. One unit of migration length (mm) did not correspond to one unit of volume (µL). A positive correlation (r = 0.6671, p < 0.0001) was observed between migration length and total tear protein content. The most beneficial storage conditions were strips that were not stored (+ 21.8%), or underwent 'wet' storage (+ 11.1%). Protein recovery was the highest in 400 µL extraction buffer and independent of protein molecular weight. This study helps to explain inter- and intra-variability that is often seen with tear biomarker research. This information is critical to ensure accuracy of test results, as tear biomarkers will be used for patient management and in clinical trials in the near future. This study also highlights the need for standardization of Schirmer's strip manufacturing, tear fluid processing and analyte concentration normalization.

Auricular Acupressure for Dry Eye Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: The purpose of this systematic review was to summarize the current evidence to examine the safety and effectiveness of auricular acupressure on dry eye diseases. Materials and Methods: Twenty databases were searched from their inception until November 2022. Only randomized controlled trials (RCTs) in which auricular acupressure was used for dry eye diseases were included. The selection process, data extraction and quantitative were conducted according to the guidelines. Results: Seven RCTs met the inclusion criteria. Meta-analysis showed that compared to artificial tears, auricular acupressure had a favorable effect on prolonging tear breakup time (TBUT), improving the Schirmer I test (SIT) score and the score of symptoms (SOS) of patients with dry eye disease (p < 0.05). Furthermore, compared to the artificial tears alone, auricular acupressure plus artificial tears had a significantly greater SIT score (p < 0.001) and response rate (p = 0.006), significantly longer TBUT (p < 0.001), and significantly lower Ocular surface disease index (OSDI) (p = 0.02) and SOS (p = 0.03). However, there was no statistically significant difference between the auricular acupressure plus artificial tears group and the artificial tears group in terms of cornea fluorescein staining (CFS) (p = 0.09). Conclusions: Auricular acupressure, as a sole intervention or in combination with artificial tears, may have a beneficial effect on dry eye disease. However, more high-quality RCTs need to be included in the future to further prove the positive effects of auricular acupressure on patients with dry eye disease.

High dupilumab levels in tear fluid of atopic dermatitis patients with moderate-to-severe ocular surface disease

BACKGROUND

The patho-mechanism of ocular surface disease (OSD) in dupilumab-treated atopic dermatitis (AD) patients remains unclear. The aim of this study is to measure dupilumab levels in tear fluid and serum, and relate these findings to the severity of OSD during dupilumab treatment in AD patients.

METHODS

This prospective study included dupilumab-treated moderate-to-severe AD patients who were seen by a dermatologist and an ophthalmologist before the start of dupilumab (baseline), and after 4 and 28 weeks of dupilumab treatment. Dupilumab levels in tear fluid and serum were measured by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Additionally, a pilot study was conducted to measure dupilumab on conjunctival epithelial cells using flow cytometry and LC-MS/MS.

RESULTS

At baseline, 89.6% (n = 43/48) of the patients had OSD, with 50.0% having moderate-to-severe OSD. After 28 weeks of dupilumab treatment, the median dupilumab tear fluid levels were 0.55 mg/L (IQR 0.35-1.31) and 0.29 mg/L (IQR 0.16-0.60) in patients with moderate-to-severe OSD and patients with no or mild OSD, respectively (p = 0.02). Dupilumab levels could be detected on conjunctival epithelial cells of 5 AD patients treated with dupilumab for 4 weeks.

CONCLUSION

Patients with moderate-to-severe OSD had higher dupilumab tear fluid levels compared to patients with no or mild OSD, indicating that dupilumab reaches the ocular surface. Dupilumab was also detected in conjunctival cell suspensions and was found to directly bind CD45-conjunctival epithelial cells. This suggests that AD-induced changes of the conjunctival epithelium may play a role in the development of OSD as well as increased local drug availability.

Matching-adjusted indirect comparison of phase 3 clinical trial outcomes of OC-01 (varenicline solution) nasal spray and lifitegrast 5% ophthalmic solution for the treatment of dry eye disease

BACKGROUND: Matching-adjusted indirect comparison (MAIC) is a methodology for cross-study comparisons after adjusting for baseline characteristic imbalances. It is a comparative analytical approach used across therapeutic areas absent head-to-head trial outcomes. OBJECTIVE: To compare the efficacy of OC-01 (varenicline solution) 0.03 mg nasal spray (OC-01 VNS) to lifitegrast 5% ophthalmic solution on tear production and patient-reported eye dryness in patients with dry eye disease (DED) using data from phase 3 clinical trials via MAIC analysis. METHODS: Individual patient data (IPD) from the phase 3 registrational trial of OC-01 VNS and aggregate data from 2 phase 3 trials of lifitegrast in the publicly available XIIDRA New Drug Application were used. Using unanchored MAIC methods, IPD were weighted on clinically relevant baseline variables (age, race, sex, baseline Schirmer's test score [STS], and Eye Dryness Score [EDS]) to produce weighted OC-01 VNS datasets matched to the same lifitegrast datasets' variables. Least-squares (LS) mean change from baseline (CFB) in STS for OC-01 VNS was calculated using the identical analysis of covariance model and covariates used to calculate the same values for lifitegrast in the XIIDRA New Drug Application and was then compared. LS mean EDS (based on a 100- point Visual Analogue Scale) was compared via analysis of covariance in the weighted OC-01 VNS and lifitegrast datasets. OC-01 VNS at 2 and 4 weeks compared to lifitegrast data at 2 and 6 weeks. RESULTS: Data from 511 subjects (n = 260 treated; 251 vehicle control [VC]) in the OC-01 VNS phase 3 trial, 588 (n = 293 treated, 295 VC) in the lifitegrast phase 3 OPUS-1 trial, and 718 (n = 358 treated, 360 VC) in the lifitegrast phase 3 OPUS-2 trial were analyzed. The LS mean STS CFB for OC-01 VNS at 2 and 4 weeks was significantly greater than that for lifitegrast at 2 and 6 weeks in OPUS-1 and OPUS-2 (P < 0.0001 for all comparisons). The LS mean EDS CFB for OC-01 VNS at 2 and 4 weeks was significantly greater than that for lifitegrast at 2 and 6 weeks in OPUS-1 (P < 0.0001 for both comparisons) and at 4 weeks vs lifitegrast at 6 weeks in OPUS-2 (P < 0.0001). CONCLUSIONS: This MAIC analysis demonstrates OC-01 VNS produced significantly greater improvement in mean STS and comparable or greater improvement in EDS compared with lifitegrast in phase 3 trials. These findings suggest a potentially greater magnitude of improvement achieved with OC-01 VNS compared with lifitegrast for the treatment of DED within the conditions of the analysis methodology. DISCLOSURES D White is a consultant for Oyster Point Pharma, Inc. L Hendrix, M Macsai, and A Gibson are employees and shareholders for Oyster Point Pharma, Inc. L Sun was an employee of COEUS, Clinical Research at the time of study conduct and received funding from Oyster Point Pharma, Inc. I Tam is an employee of COEUS, Clinical Research and received funding from Oyster Point Pharma, Inc. Oyster Point Pharma, Inc was involved in the study design, data collection, data analysis, and preparation of the manuscript and is the manufacturer/licensee of OC-01 (varenicline solution) nasal spray. Oyster Point Pharma, Inc., sponsored the phase 3 OC-01 (varenicline solution) clinical study from which analysis data were obtained.

Transcorneal but not transpalpebral electrical stimulation disrupts mucin homeostasis of the ocular surface

PURPOSE

Transcorneal electrical stimulation (TcES) is increasingly applied as a therapy for preserving and improving vision in retinal neurodegenerative and ischemic disorders. However, a common complaint about TcES is its induction of eye pain and dryness in the clinic, while the mechanisms remain unknown.

METHOD

TcES or transpalpebral ES (TpES) was conducted in C57BL6j mice for 14 days. The contralateral eyes were used as non-stimulated controls. Levels of intracellular [Ca2+] ([Ca2+]i) were assessed by Fura-2AM. The conductance resistances of the eye under various ES conditions were measured in vivo by an oscilloscope.

RESULTS

Although TcES did not affect tear production, it significantly induced damage to the ocular surface, as revealed by corneal fluorescein staining that was accompanied by significantly decreased mucin (MUC) 4 expression compared to the control. Similar effects of ES were detected in cultured primary corneal epithelium cells, showing decreased MUC4 and ZO-1 levels after the ES in vitro. In addition, TcES decreased secretion of MUC5AC from the conjunctiva in vivo, which was also corroborated in goblet cell cultures, where ES significantly attenuated carbachol-induced [Ca2+]i increase. In contrast to TcES, transpalpebral ES (TpES) did not induce corneal fluorescein staining while significantly increasing tear production. Importantly, the conductive resistance from orbital skin to the TpES was significantly smaller than that from the cornea to the retina in TcES.

CONCLUSION

TcES, but not TpES, induces corneal epithelial damage in mice by disrupting mucin homeostasis. TpES thus may represent a safer and more effective ES approach for treating retinal neurodegeneration clinically.

The LINC00852/miR-29a-3p/JARID2 axis regulates the proliferation and invasion of prostate cancer cell

Long intergenic non-coding RNA 00852 (LINC00852) has been shown to promote the progression of many different cancers including prostate cancer. However, the involved mechanism in promoting the proliferation, migration and invasion of prostate cancer cells has not been reported. In this study, we found that LINC00852 was highly expressed in the tissue of prostate cancer using quantitative reverse transcription PCR (qRT-PCR). CCK-8 assay, colony formation experiment, Transwell migration and invasion experiments were performed to prove that the up-regulation of LINC00852 could promote the proliferation, migration and invasion of prostate cancer cells in vitro. Xenograft tumors experiments in nude mice confirmed that up-regulation of LINC00852 promoted the proliferation of prostate cancer cells in vivo. Bioinformatics predictions and dual-luciferase reporter gene assay showed that miR-29a-3p binds to the 3'-untranslated region of JARID2, and the enhancement of miR-29a-3p could reverse the effect of LINC00852 overexpression in vitro. Moreover, the results of qRT-PCR and western blot showed that LINC00852 could regulate the expression of JARID2 through miR-29a-3p induction. In summary, we demonstrated that LINC00852 played a key role in promoting the prostate cancer, and LINC00852/miR-29a-3p/JARID2 axis could be used as a target for prostate cancer treatment.

Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States: A Systematic Review and Meta-analysis

Importance

Dry eye is a common clinical manifestation, a leading cause of eye clinic visits, and a significant societal and personal economic burden in the United States. Meibomian gland dysfunction (MGD) is a major cause of evaporative dry eye.

Objective

To conduct a systematic review and meta-analysis to obtain updated estimates of the prevalence and incidence of dry eye and MGD in the United States.

Data Sources

Ovid MEDLINE and Embase.

Study Selection

A search conducted on August 16, 2021, identified studies published between January 1, 2010, and August 16, 2021, with no restrictions regarding participant age or language of publication. Case reports, case series, case-control studies, and interventional studies were excluded.

Data Extraction and Synthesis

The conduct of review followed a protocol registered on PROSPERO (CRD42021256934). PRISMA guidelines were followed for reporting. Joanna Briggs Institute and Newcastle Ottawa Scale tools were used to assess risk of bias. Data extraction was conducted by 1 reviewer and verified by another for accuracy. Prevalence of dry eye and MGD were combined in separate meta-analyses using random-effects models.

Main Outcomes and Measures

Prevalence and incidence of dry eye and MGD in the United States. Summary estimates from meta-analysis of dry eye and MGD prevalence with 95% CI and 95% prediction intervals (95% PI).

Results

Thirteen studies were included in the systematic review. Dry eye prevalence was reported by 10 studies, dry eye incidence by 2 studies, and MGD prevalence by 3 studies. Meta-analysis estimated a dry eye prevalence of 8.1% (95% CI, 4.9%-13.1%; 95% PI, 0%-98.9%; 3 studies; 9 808 758 participants) and MGD prevalence of 21.2% (95% CI, 7.2%-48.3%; 95% PI, 0%-100%; 3 studies; 19 648 participants). Dry eye incidence was 3.5% in a population 18 years and older and 7.8% in a population aged 68 years and older. No studies reported MGD incidence.

Conclusions and Relevance

This systematic review and meta-analysis demonstrated uncertainty about the prevalence and incidence of dry eye and MGD in the United States. Population-based epidemiological studies that use consistent and validated definitions of dry eye and MGD are needed for higher-certainty estimates of dry eye and MGD prevalence and incidence in the United States.

Moxibustion with Walnut Shell Spectacles Could Improve the Objective Symptoms and Tear Film Stability of Patients with Dry Eye Disease: A Randomized Controlled Trial

Objectives

This study aims to evaluate the efficacy and acceptability of moxibustion with walnut shell spectacles in treating dry eye disease (DED) patients and to provide treatment options.

Methods

126 DED patients were randomly allocated into the moxibustion group (treated by moxibustion with walnut shell spectacles, 64 cases) and the artificial tears group (treated with sodium hyaluronate eye drops, 62 cases). Evaluate the changes in the ocular surface disease index (OSDI), the visual analogue scale (VAS) of ocular discomfort, the tear film break-up time (TBUT), corneal fluorescein staining (CFS), and the Schirmer I test during the trial at baseline and after 1-week, 2-week, 3-week, and 4-week treatment. Evaluate the OSDI scale and the ocular symptom VAS scale one month after the end of treatment.

Results

There were no significant differences in baseline characteristics between the two groups. For OSDI scores, the results showed that the efficacy of the moxibustion group was no less than that of the artificial tear group. For VAS of ocular discomfort, both groups significantly reduced their score compared with baseline, and for the moxibustion group, the decrease was more significant. For TBUT, FAS, and PPS, results showed that the efficacy of the moxibustion group was significant in both eyes after 4 weeks of treatment, but the right eye was in the artificial tear group. For CFS and Schirmer I test scores, there was no significant effect for both groups.

Conclusion

Moxibustion with walnut shell spectacles could improve the clinical symptoms and tear film stability of DED patients; however, it has no significant efficacy on improving corneal injury and tear secretion, just the same as sodium hyaluronate eye drops. Nevertheless, moxibustion with walnut shell spectacles may have better effects on the self-assessment of ocular discomfort than sodium hyaluronate eye drops.

Pulsed Light Therapy in the Management of Dry Eye Disease: Current Perspectives

Purpose

To review the indications and efficacy of Intense Pulsed Light (IPL) application in the treatment of Meibomian Gland Dysfunction (MGD). Its main purpose is to describe its physiology, efficacy, indications, and adverse effects.

Patients and Methods

A two database (PubMed, EMBASE) search was performed from July 2017 to July 2022 using the MeSH terms ("Intense Pulsed Light" AND ("Meibomian Gland Dysfunction" OR "Dry Eye"). We included randomized studies and systematic reviews with meta-analysis. Exclusion criteria were non-randomized trials, studies enrolling non-MGD dry eye disease, and other works older than 5 years.

Results

Current literature shows that IPL is an effective and safe treatment modality for severe dry eye. Available evidence shows improvement of symptoms and objective indicators, such as noninvasive breakup time, thickness of lipid layer, and Schirmer test. However, our review concluded that the beneficial effects of IPL may lose some efficacy at 6-months after the initial session, and subsequent sessions may be required. Thus, IPL treatment should not be considered as first-line therapy for MGD but instead as an adjuvant option to the standard of care. The optimal treatment modality remains unknown and should be tailored according to each patient's phenotype, clinician's experience, and available technology. There is evidence that IPL treatment may down-regulate pro-inflammatory markers (such as interleukin (IL) 6, IL17a, IL-1) and Prostaglandin E2 (PGE2).

Conclusion

MGD is a multifactorial disease and IPL treatment seems a promising treatment modality. Despite this, more evidence is needed to study its benefits - since this is an emerging technology, it is expected an increase in comparative studies in the following years, with longer follow-up periods, which may enable more precise conclusions about this treatment modality.

Performance and Safety of a Sodium Hyaluronate Tear Substitute with Polyethylene Glycol in Dry Eye Disease: A Multicenter, Investigator-Masked, Randomized, Noninferiority Trial

Purpose: To compare the performance and safety of 2 tear substitutes containing sodium hyaluronate (SH); one containing 0.15% SH and polyethylene glycol (PEG) 8000, and the other containing 0.18% SH. Methods: In this multicenter, randomized, investigator-masked, noninferiority trial, 83 patients with moderate or severe dry eye disease underwent a 2-week washout, and were then randomly assigned (1:1) to receive SH plus PEG tear substitute (n = 45) or comparator SH tear substitute (n = 38) 3-6 times daily for 3 months. The primary performance endpoint was the change from baseline in the ocular surface fluorescein staining (OSFS) score on day 28 in the per-protocol (PP) population, according to the 15-point Oxford Scheme, with a noninferiority margin of 2. Results: Both groups improved significantly in terms of signs and symptoms. Among the 78 patients without major protocol deviations (the PP population), the OSFS score decreased by 2.9 ± 2.0 on day 28 from 5.4 ± 1.3 at baseline in the SH plus PEG group and by 2.3 ± 2.2 from 5.2 ± 1.4 in the comparator group (95% confidence interval of the difference: -1.2 to 0.3), demonstrating noninferiority. On day 90, the improvement in OSFS scores was significantly greater in the SH plus PEG group (P = 0.0002). The safety profiles were satisfactory in both groups. Conclusion: SH plus PEG tear substitute was noninferior to SH tear substitute in the studied population and may provide additional benefits in the long term. ClinicalTrials.gov ID: NCT02975102.

Evaluation of warm compresses and topical cyclosporine treatment in meibomian gland dysfunction by confocal scanning laser microscopy

PURPOSE

The aim of our study is to confirm the utility of warm compresses (WC) and artificial tears (AT) in meibomian gland dysfunction (MGD) management and to understand if its association with topical cyclosporine A (CsA) improves outcomes.

METHODS

Patients with diagnosis of MGD-related dry eye were evaluated. In this prospective, randomized, double-masked study, patients were randomized in two treatments: AT plus WC (group A), and AT plus WC plus CsA 0.05% ophthalmic emulsion (group B). At baseline and at 1, 3, and 6 months, Ocular Surface Disease Index (OSDI) questionnaire was completed, and tear evaluation (BUT, Schirmer and osmolarity test), ocular surface evaluation (fluorescein and lissamine green staining), clinical (Shimazaki grading) and in vivo confocal microscopy (IVCM) evaluation of rete ridges (RRs) were performed.

RESULTS

A total of 40 eyes, 20 in each group, completed the study. Analysis of OSDI, tear test, ocular surface evaluation and clinical grading of MG showed significant improvement at 6 months, whereas no difference was found between the two groups at 6 months. The analysis of IVCM showed significant improvement in both groups, but significantly better results in group B were found compared to group A at 6 months.

CONCLUSION

WC performed 3 times daily during the 1st month and once daily afterwards, in addition to AT, were useful to manage the obstruction of MG and related signs and symptoms. Additional effects of CsA were visible in IVCM only at 6 months. IVCM is an effective tool to monitor treatments in MGD.

Varenicline Solution Nasal Spray: A Review in Dry Eye Disease

Increasing endogenous tear film production via pharmacological neuroactivation of the nasolacrimal reflex [NLR; also known as the trigeminal parasympathetic pathway (TPP)] is a novel therapeutic approach to treating dry eye disease (DED). An intranasal formulation of the water-soluble, small-molecule, nicotinic acetylcholine receptor (nAChR) agonist varenicline (Tyrvaya™) has been approved in the USA for the treatment of DED. Twice-daily administration of varenicline solution nasal spray resulted in rapid, statistically significant and clinically meaningful improvements in the signs and symptoms of DED over a period of 4 weeks in two pivotal studies (ONSET-1 and -2). The efficacy of varenicline solution was maintained over a longer-term period of 12 weeks in a third study (MYSTIC). Consistent with the nasal route of delivery, the most common adverse events reported by varenicline solution recipients were non-ocular in nature (mild and transient sneezing and cough). Thus, varenicline solution nasal spray is a rapidly-acting, effective and generally well tolerated treatment for DED that offers several potentially useful advantages over existing topical ocular therapies in terms of increasing endogenous tear secretion and reducing ophthalmic treatment burden.

Dry eye disease (DED) is a common, often chronic, condition characterized by symptoms, such as irritation and blurred vision, that can negatively impact on quality of life. DED occurs due to the production of insufficient or unstable tear films and is typically treated with topically applied artificial tears and medications that reduce accompanying inflammation of the ocular surface. Using an intranasal formulation of the nicotinic acetylcholine receptor (nAChR) agonist varenicline (Tyrvaya™) to enhance natural tear production represents a novel approach to DED treatment. Varenicline solution nasal spray led to fast and sustained improvements in the signs and symptoms of DED in clinical trials of up to 12 weeks’ duration. Varenicline solution was also generally well tolerated, with the most common adverse events being mild and transient sneezing and cough. Varenicline solution nasal spray is a new type of treatment for DED that may increase natural tear production, have better ocular tolerability and, for some patients, be easier and/or more convenient to use compared with traditional topical therapies.