Electrical and mechanical office-based neuromodulation

Novel Extranasal Tear Stimulation: Pivotal Study Results

Purpose

To evaluate the efficacy and safety of iTEAR, a novel, portable, sonic external neuromodulation device, for the treatment of dry eye disease (DED).

Methods

This was a multicenter, open-label, single-arm clinical trial that included adult patients with DED with a Schirmer score of ≤10 mm in at least one eye. Enrolled subjects were instructed to apply the study device at least twice per day for 30 seconds bilaterally to the external nasal nerve. After the initial baseline visit, patients were followed up at days 3, 14, 30, 90, and 180. The primary efficacy endpoint was the Schirmer index (change from unstimulated to stimulated tear production as measured by the Schirmer test) at day 30. The major secondary endpoint was the change in symptoms of DED at day 30 evaluated using the Ocular Surface Disease Index (OSDI).

Results

A total of 101 subjects evaluated at day 30 had a mean Schirmer index of 9.4 mm (95% confidence interval [CI], 7.4–11.3), and the baseline OSDI improved by an average of 14.4 (95% CI, 11.1–17.7). Both endpoints were highly statistically and clinically significant at all time points. There were two mild unanticipated adverse events definitely related to the device.

Conclusions

The safety and efficacy of the iTEAR device observed in this study support its indication for treating DED.

Translational Relevance

Neurostimulation has the potential to improve signs and symptoms of DED.

Effectiveness of transcutaneous electrical stimulation combined with artificial tears for the treatment of dry eye: A randomized controlled trial

There is currently no available cure or universally effective treatment for dry eye (DE). The aim of the present study was to investigate the clinical efficacy of transcutaneous electrical stimulation (TES) combined with artificial tears in treating DE. Patients diagnosed with DE were referred for therapy with TES combined with sodium hyaluronate (SH)-containing artificial tears. A total of 52 patients (104 eyes) with DE were enrolled in this randomized controlled trial. The patients were randomized 1:1 to the TES + SH or SH group. The patients in the TES + SH group were treated with 20 sessions (5 sessions per week for 4 weeks), and each session lasted for 20 min. The treatment was continued for 4 weeks in all cases. The Ocular Surface Disease Index (OSDI), tear film breakup time (BUT), Schirmer's I test and corneal fluorescein scores were used to assess treatment efficacy. A total of 90 eyes of 45 patients completed all aspects of the study: 22 patients (44 eyes) in the TES + SH group and 23 patients (46 eyes) in the SH group. There was no statistically significant difference in sex, age or course between the two groups. The mean OSDI scores, BUT, Schirmer's I test and corneal fluorescein scores exhibited a significant improvement in the TES + SH group compared with the SH group after treatment. No serious adverse events were recorded during TES treatment. In conclusion, TES combined with artificial tears appeared to be an effective treatment for DE. Therefore, TES may represent a new therapeutic option with promising potential applications.

Electrical neuromodulation in the management of lower urinary tract dysfunction: evidence, experience and future prospects

Lower urinary tract dysfunction (LUTD) is common and causes a spectrum of morbidity and decreased quality of life (QoL) for patients. LUTD can range from urinary retention to urge incontinence, and includes a variety of syndromes, with the most common and widely recognized being overactive bladder (OAB). The classic treatments of LUTD and OAB comprise different strategies including behavioral therapies, medications and minimally invasive or invasive surgical procedures. Generally, once patients have tried behavioral modifications and oral medical therapy, and have not experienced adequate relief of their symptoms, the next step is to consider minimally invasive therapies. In the last two decades since FDA approval, sacral nerve stimulation (SNS) has become an accepted intervention, with increasing use and evidence of effectiveness for LUTD, specifically OAB and non-obstructive urinary retention. SNS has shown both objective and subjective improvement in voiding symptoms in several randomized controlled trials (RCTs) when compared to sham or standard medical therapy. The main limitations for more extensive use include relatively high cost, implantation of a device and possibly reoperation secondary to adverse events (AE). Percutaneous tibial nerve stimulation (PTNS) is a less invasive, less direct and less expensive method for neuromodulation, which has also shown effectiveness in several randomized and non-randomized trials, including comparable improvement rates to anticholinergics in OAB management. However, the efficacy of PTNS is only maintained for a short period after the stimulation is delivered. This technique has a much lower rate of AE compared to SNS, but with the inconvenience of weekly visits for stimulation, although implantable devices are on the horizon. In this article we review the mechanism of action, indications, effectiveness and complications related to SNS and PTNS therapy for LUTD.

Geriatric Urinary Incontinence

Urinary incontinence (UI) is an international problem, affecting a high percentage of geriatric women. Nurses caring for geriatric women of all ages should be aware of the problem of UI and familiarize themselves with the potential treatment options for these patients. This article focuses on the prevalence, burden, clinical application, and management recommendations for the different types of UI.

A nonrandomized, open-label study to evaluate the effect of nasal stimulation on tear production in subjects with dry eye disease

Background

Dry eye disease (DED), a chronic disorder affecting the tear film and lacrimal functional unit, is a widely prevalent condition associated with significant burden and unmet treatment needs. Since specific neural circuits play an important role in maintaining ocular surface health, microelectrical stimulation of these pathways could present a promising new approach to treating DED. This study evaluated the efficacy and safety of nasal electrical stimulation in patients with DED.

Methods

This prospective, open-label, single-arm, nonrandomized pilot study included 40 patients with mild to severe DED. After undergoing two screening visits, enrolled subjects were provided with a nasal stimulation device and instructed to use it at home four times daily (or more often as needed). Follow-up assessments were conducted up to day 180. The primary efficacy endpoint was the difference between unstimulated and stimulated tear production quantified by Schirmer scores. Additional efficacy endpoints included change from baseline in corneal and conjunctival staining, symptoms evaluated on a Visual Analog Scale, and Ocular Surface Disease Index scores. Safety parameters included adverse event (AE) rates, visual acuity, intraocular pressure, slit-lamp biomicroscopy, indirect ophthalmoscopy, and endoscopic nasal examinations.

Results

Mean stimulated Schirmer scores were significantly higher than the unstimulated scores at all visits, and corneal and conjunctival staining and symptom scores from baseline to day 180 were significantly reduced. No serious device-related AEs and nine nonserious AEs (three device-related) were reported. Intraocular pressure remained stable and most subjects showed little or no change in visual acuity at days 30 and 180. No significant findings from other clinical examinations were noted.

Conclusion

Neurostimulation of the nasolacrimal pathway is a safe and effective means of increasing tear production and reducing symptoms of dry eye in patients with DED.