Impaired Visual Performance in Patients with Dry Eye

Preliminary Application of a Continuous Functional Contrast Visual Acuity System in the Assessment of Visual Function in Dry Eye Patients

Purpose

To investigate the feasibility and efficacy of a continuous functional contrast visual acuity (CFCVA) system in the assessment of visual function in dry eye disease (DED).

Methods

Twenty patients with DED and 15 normal controls were recruited. Subjective symptoms were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire, and tear film stability was assessed by a noninvasive corneal topographer. Under natural blinking conditions, the custom-built CFCVA system was used to take serial visual acuity measurements at 100%, 25%, 10%, and 5% contrast for 60 seconds. A 5-minute measurement at a 100% contrast level was defined as the stress test (ST). Mean CFCVA was defined, and visual maintenance ratio (VMR) was the ratio of mean CFCVA divided by baseline visual acuity.

Results

In both groups, VMR decreased and mean CFCVA (logarithm of the minimum angle of resolution) increased with decreasing optotype contrast (from 100% to 5%). In ST, the ST VMR at the fourth and fifth minutes (VMR54 and VMR55) showed the strongest correlations with OSDI total, ocular symptoms, and vision-related function (-0.646 and -0.598, -0.688 and -0.693, and -0.599 and -0.555, respectively, P < 0.05). VMR54 and VMR55 also demonstrated the best discriminating ability for detecting DED, with areas under the curve of 0.903 and 0.867, respectively.

Conclusions

Extending the continuous measuring time was more effective for detecting vision-related functional abnormalities in patients with DED than simply decreasing the optotype contrast level.

Translational Relevance

The proposed CFCVA system and associated parameters offer a potential method for quantifying and interpreting the visual symptoms of DED in clinical care.

TFOS Lifestyle: Impact of the digital environment on the ocular surface

Eye strain when performing tasks reliant on a digital environment can cause discomfort, affecting productivity and quality of life. Digital eye strain (the preferred terminology) was defined as "the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing". Digital eye strain prevalence of up to 97% has been reported, due to no previously agreed definition/diagnostic criteria and limitations of current questionnaires which fail to differentiate such symptoms from those arising from non-digital tasks. Objective signs such as blink rate or critical flicker frequency changes are not 'diagnostic' of digital eye strain nor validated as sensitive. The mechanisms attributed to ocular surface disease exacerbation are mainly reduced blink rate and completeness, partial/uncorrected refractive error and/or underlying binocular vision anomalies, together with the cognitive demand of the task and differences in position, size, brightness and glare compared to an equivalent non-digital task. In general, interventions are not well established; patients experiencing digital eye strain should be provided with a full refractive correction for the appropriate working distances. Improving blinking, optimizing the work environment and encouraging regular breaks may help. Based on current, best evidence, blue-light blocking interventions do not appear to be an effective management strategy. More and larger clinical trials are needed to assess artificial tear effectiveness for relieving digital eye strain, particularly comparing different constituents; a systematic review within the report identified use of secretagogues and warm compress/humidity goggles/ambient humidifiers as promising strategies, along with nutritional supplementation (such as omega-3 fatty acid supplementation and berry extracts).

Multimodal-Synergistic-Modulation Neuromorphic Imaging Systems for Simulating Dry Eye Imaging

Inspired by human eyes, the neuromorphic visual system employs a highly efficient imaging and recognition process, which offers tremendous advantages in image acquisition, data pre-processing, and dynamic storage. However, it is still an enormous challenge to simultaneously simulate the structure, function, and environmental adaptive behavior of the human eye based on one device. Here, a multimodal-synergistic-modulation neuromorphic imaging system based on ultraflexible synaptic transistors is successfully presented and firstly simulates the dry eye imaging behavior at the device level. Moreover, important functions of the human visual system in relation to optoelectronic synaptic plasticity, image erasure and enhancement, real-time preprocessing, and dynamic storage are simulated by versatile devices. This work not only simplifies the complexity of traditional neuromorphic visual systems, but also plays a positive role in the publicity of biomedical eye care.

Visual ergonomics, performance and the mediating role of eye discomfort: A structural equation modelling approach

The purpose of this study was to model the visual ergonomic factors affecting the performance in human computer interaction. A cross-sectional study using structural equation modelling was performed with a sample of 200 participants. The measuring instruments included Office Lighting Survey Questionnaire, performance assessment questionnaires, visual ergonomics assessment, and an eye discomfort assessment. The hypothetical model evaluated workplace lighting status and visual ergonomics as precursors, performance as the output, and eye discomfort as a mediator. The results showed that eye discomfort directly affected performance. Visual ergonomics also had a significant direct effect on eye discomfort. The final model suggested a significant new path between the quality of lighting and visual ergonomics. Also, the quality of lighting had an indirect effect on eye discomfort and performance, and the effect of visual ergonomics on performance was the same. Improving the lighting quality and visual ergonomics can reduce eye discomfort and increase performance.

Prevalence, Severity, and Treatment Outcomes of Meibomian Gland Dysfunction in Patients With Dry Eye Symptoms at a Tertiary Care Center in South India

Background and objective

Dry eye disease (DED) is one of the most common reasons why patients seek eye care. With increasing age, widespread adoption of technology, and environmental changes, its prevalence has been on the rise, and will likely increase further. Meibomian gland dysfunction (MGD) is the most common cause of DED; however, for a variety of reasons, it is currently underrecognized. We aimed to determine the etiology of DED from a sample of patients visiting our center with dry eye symptoms and study the characteristics of those diagnosed with MGD.

Methodology

We conducted this prospective observational study from 2016 to 2018. We included patients with two or more dry eye symptoms and excluded those with systemic conditions or structural issues causing dry eye. Each patient underwent a detailed evaluation of the dry eye, including the Ocular Surface Disease Index (OSDI) questionnaire, Oxford corneal staining, Schirmer test 1, tear film break-up time (TBUT), tear meniscus height, and non-contact meibography. All patients subsequently received appropriate treatment. Patients with MGD were evaluated once again after one month.

Results

We included 250 patients in the study. Their mean (standard deviation) age was 45.3 (16.9) years, and 138 (55%) of them were males. Grittiness and itching were the most common symptoms. MGD was the most common diagnosis, seen in 100 (40%), followed by chronic allergic conjunctivitis. Patients with MGD were more likely to be elderly and had significantly worse DED parameters. Over half of all MGD cases were mild or less severe. With appropriate treatment, all DED metrics improved significantly.

Conclusions

MGD was the most common cause of DED in our sample. Patients with MGD were more likely to be elderly and had more severe DED, consistent with other studies in the literature. With specific treatment of MGD, there was a significant improvement in the patients' condition. DED is a growing ocular health issue that causes great detriment to patients’ quality of life and finances. Our findings support the need for a detailed evaluation and specific treatment of patients presenting with dry eye symptoms.

Measurements of Tear Evaporation Rate in Subjects with Refractive Errors Using a Portable Evaporimeter

Dry eye symptoms are associated with refractive errors. We aimed to measure the tear evaporation rate (TER) in subjects with refractive errors (RE) using a portable evaporimeter. This nonrandomized, case–control, and observational study included 75 subjects, including 25 subjects aged 18–38 years (28.8 ± 6.8 years) with myopia (−0.75 to −3.75 D) and 25 subjects aged 18–39 years (27.7 ± 5.5 years) with hyperopia (+0.50 to +3.75 D). In addition, a control group of 25 subjects with emmetropic eyes aged 20–30 years (23.6 ± 2.6 years) was recruited. The ocular surface disease index (OSDI) was completed, followed by the TER measurements using a portable evaporimeter. The OSDI score and TER measurements showed dry eye symptoms in 36% and 48% of myopic subjects, respectively. For hyperopic participants, dry eye was observed in 24% and 56% of the subjects based on the OSDI and TER scores, respectively. Significant differences (Mann-Whitney U test; p < 0.001) were found among the OSDI and TER scores recorded within the study (myopic and hyperopic subjects) and control groups. Significant strong positive correlations were detected between the OSDI and TER scores in both myopic (p = 0.004; r = 0.559) and hyperopic (p = 0.001; r = 0.619) subjects. The TER scores were significantly higher in subjects with RE (myopic and hyperopic) as compared with individuals with normal eyes.

Funktionelle Sehschärfe beim Trockenen Auge

Das Trockene Auge führt häufig zu Sehstörungen trotz guter Sehleistung in der Standardvisusprüfung. Die Beschwerden treten meist beim Lesen, Arbeiten am Computer und/oder beim Autofahren auf. Grund ist die schlechte optische Qualität der Augenoberfläche beim Trockenen Auge mit Zunahme von topometrischer Irregularität und Asymmetrie, Anstieg des irregulären Astigmatismus, Zunahme der kornealen und okulären Aberrationen höherer Ordnung, Abnahme der Kontrastsensitivität und Zunahme der Lichtstreuung. Die funktionelle Sehschärfe repräsentiert die Visusfunktion im Zeitverlauf und reflektiert die Visusleistung eines Individuums bei täglichen Aktivitäten. Sie ist beim Trockenen Auge signifikant reduziert im Vergleich zu Normalprobanden. Eine Vielzahl von Testmethoden zur Evaluierung der funktionellen Sehschärfe wurde beschrieben. Kein Verfahren hat sich bisher in der täglichen Praxis durchgesetzt.

Ocular Pathophysiology of Sjögren's Syndrome

The purpose of this review is to delve into the clinical and research understanding of the pathophysiology and presentation of Sjögren's-related keratoconjunctivitis sicca in order address the diagnostic and management challenge that it represents, as well as to provide a basis for appreciating the pharmacotherapies designed to treat the ophthalmic symptoms of Sjögren's disease.

Use of digital displays and ocular surface alterations: A review

Digital display use has been accepted to be implicated as a contributing factor for dry eye disease (DED). Abnormal blinking during computer operation, including a reduced blink rate and an incomplete eyelid closure, increased palpebral fissure as consequence of high visualization angles, and meibomian gland dysfunction associated to long-term display use, are behind the increased prevalence of dry eye signs and symptoms found in digital display users. Previous research reveals significant reductions in tear volume and stability, alterations in tear film composition, including increased osmolarity, inflammatory cytokines, oxidative stress markers and reduced mucin secretion, eyelid abnormalities and ocular surface damage, encompassing corneal and conjunctival staining and bulbar redness, as a direct consequence of digital display use. In this regard, individual differences in the way that the various digital displays are typically set up and used may account for differences in their effects on induced dryness signs and symptoms. Furthermore, factors such as the use of contact lenses or inappropriate working environments, usually accompanying the use of displays, may significantly increase the prevalence and the severity of induced dry eye. Other factors, such as old age and female gender are also relevant in the appearance of associated alterations. Finally, clinicians should adopt a treatment strategy based on a multidirectional approach, with various treatments being applied in conjunction.

Effect of OTX-101, a Novel Nanomicellar Formulation of Cyclosporine A, on Corneal Staining in Patients With Keratoconjunctivitis Sicca: A Pooled Analysis of Phase 2b/3 and Phase 3 Studies

Supplemental digital content is available in the text.

Keratoconjunctivitis sicca affects 5% to 33% of the population and is often accompanied by symptoms such as burning and dryness. This pooled analysis evaluated total and central corneal fluorescein staining (CFS) in patients receiving OTX-101 0.09% or vehicle in phase 2b/3 and 3 studies and whether improvements in corneal staining correlated with improved visual acuity.

Impact of Dry Eye on Prolonged Reading

SIGNIFICANCE

Patients with dry eye frequently report difficulty with reading. However, the impact of dry eye on reading has not been studied in detail. This study shows the unfavorable effect of dry eye on reading speed and offers mechanisms that may be responsible.

PURPOSE

The purpose of this study was to evaluate the impact of dry eye signs as well as symptoms on both short-duration out-loud and prolonged silent reading.

METHODS

This study included 116 patients with clinically significant dry eye, 39 patients with dry eye symptoms only, and 31 controls, 50 years or older. After the Ocular Surface Disease Index (OSDI) questionnaire, objective testing of dry eye (tear film stability studies, Schirmer's test, and ocular surface staining) was performed. Total OSDI score and two subscores (vision related and discomfort related) were calculated. A short-duration out-loud reading test and a 30-minute sustained silent reading test were performed. Reading speed for each test was calculated as words per minute (wpm) and compared across the three groups.

RESULTS

Patients with clinically significant dry eye read slower than controls measured with sustained silent reading test (240 vs. 272 wpm, P = .04), but not with short-duration out-loud reading test (146 vs. 153 wpm, P = .47). Patients with dry eye symptoms only did not have slower reading speed measured using either reading test as compared with controls. However, vision-related OSDI subscore independently was associated with slower reading speed (P = .02). Multivariable regression models demonstrated that each 1-point (between 0 and 6) increase in corneal staining score led to a 10-wpm decrease in sustained silent reading speed (P = .01).

CONCLUSIONS

This study demonstrates a significant negative impact of dry eye (particularly presence of corneal staining) on prolonged reading. Prolonged reading task may serve as an objective clinically relevant test to measure the impact of dry eye on vision-related quality of life.

[Tear film analysis and evaluation of optical quality: A review of the literature (French translation of the article)]

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

Tear film analysis and evaluation of optical quality: A review of the literature

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

Assessment of visual function and Vision-related Quality of Life in female contact lens wearers with Dry Eye Syndrome

Purpose

To assess visual function and Vision-related Quality of Life (VRQOL) in female contact lens wearers with Dry Eye Syndrome in Riyadh city, Saudi Arabia.

Methods

This was a cross sectional study. Saudi Females subjects with and without DES (contact lens wearer [CLW] and Non-contact lens wearers [NCLW]) aged between 16 and 35 years were included in this study. Subjects were recruited from female campus at King Saud University (KSU), Riyadh, KSA. Measurements include corneal topography, visual acuity (VA), autorefraction, contrast sensitivity (CS), Schirmer's test and Tear breakup test (TBUT) were performed on all subjects. In addition, corneal thickness was measured using Pentacam HR to compare between the total corneal thickness (TCT) in DES and Non-DES groups. Contact Lens Impact on Quality of Life (CLIQ) Questionnaire was used to assess VRQOL. Visual functions and VRQOL were compared between groups (contact lens (CL) and NCLW) using SPSS program version 23 (SPSS Inc, Chicago, Illinois, USA).

Results

A total of 100 subjects with DES (n = 44 including 25 CLW and 19 NCLW), and non-DES (n = 56 including 17 CLW and 39 NCLW) were included in this study. The mean age of participants with DES was 21.39 years and was 20.96 years of participants Non-DES. There were no significant different in VA, CS, and TCT between subjects DES and Non-DES (P > 0.05), which indicates that dryness have no effect on the visual function and TCT. Contact lens wearers had higher score on convince, economic and psychological items than NCLW. Within CL group, subjects with DES had higher score on convince and psychological items. Similarly, within DES group, subjects who wore CL had higher score on convince and psychological items.

Conclusion

This study provides evidence that dryness may has no effect on visual function in both CLW and NCLW. Psychological and convenience domains of VRQOL were negatively affect in Saudi female patients with DES specially who wear CL.

Topical administration of regorafenib eye drops: phase I dose-escalation study in healthy volunteers

Aim

Regorafenib is a multikinase inhibitor under investigation for use in neovascular age‐related macular degeneration. In this phase I study, regorafenib eye drops were administered to healthy volunteers to provide information on safety, tolerability and systemic exposure.

Methods

This was a single‐centre, randomized, double‐masked, parallel‐group, dose‐escalation, placebo‐controlled study. Subjects received regorafenib eye drops (30 mg ml⁻¹, 25 μl) as a 0.75 mg single dose (Cohort 1), 0.75 mg twice daily (bid) or thrice daily (tid) over 14 days (Cohorts 2 and 3, respectively), 1.5 mg tid unilaterally for 3 days, then bilaterally for up to 14 days (Cohort 4), or placebo. Plasma samples were taken to estimate systemic exposure. Safety and functional assessments were performed throughout the study.

Results

Thirty‐six subjects received regorafenib and 12 received placebo. Regorafenib was safe and well tolerated over the dose range. No pathological changes occurred in the anterior, vitreous or posterior eye compartments. Mild eyelid redness, oedema and conjunctival hyperaemia were observed across all regorafenib cohorts; these were comparable with the effects seen with placebo. Predominant symptoms were blurred vision in the active and placebo groups. Systemic safety evaluations showed no clinically relevant findings. Absolute systemic exposure after multiple administrations of regorafenib eye drops at a dose of 0.75 mg was 600–700‐fold lower than after multiple oral administration of 160 mg day⁻¹, the dose approved in cancer indications.

Conclusion

These results indicate a favourable safety and tolerability profile of regorafenib eye drops up to 30 mg ml⁻¹ tid for use in clinical studies.

Blink: Characteristics, Controls, and Relation to Dry Eyes

Blink is a complex phenomenon that is profoundly affected by diverse endogenous and exogenous stimuli. It has been studied in the context of cognition, emotional, and psychological states, as an indicator of fatigue and sleepiness, particularly in the automobile and transportation industry, in visual tasking, and finally, as it relates to tear film stability and ocular surface health. The fact that it is highly variable and has input from so many sources makes it very difficult to study. In the present review, the behavior of blink in many of these systems is discussed, ultimately returning in each instance to a discussion of how these factors affect blink in the context of dry eyes. Blink is important to ocular surface health and to an individual's optimal functioning and quality of life. Disturbances in blink, as cause or effect, result in a breakdown of tear film stability, optical clarity, and visual function.

Use of the Controlled Adverse Environment (CAE) in Clinical Research: A Review

The many internal and external factors that contribute to the pathophysiology of dry eye disease (DED) create a difficult milieu for its study and complicate its clinical diagnosis and treatment. The controlled adverse environment (CAE^®) model has been developed to minimize the variability that arises from exogenous factors and to exacerbate the signs and symptoms of DED by stressing the ocular surface in a safe, standardized, controlled, and reproducible manner. By integrating sensitive, specific, and clinically relevant endpoints, the CAE has proven to be a unique and adaptable model for both identifying study-specific patient populations with modifiable signs and symptoms, and for tailoring the evaluation of interventions in clinical research studies.

TFOS DEWS II pathophysiology report

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.

TFOS DEWS II Clinical Trial Design Report

The development of novel therapies for Dry Eye Disease (DED) is formidable, and relatively few treatments evaluated have been approved for marketing. In this report, the Subcommittee reviewed challenges in designing and conducting quality trials, with special reference to issues in trials in patients with DED and present the regulatory perspective on DED therapies. The Subcommittee reviewed the literature and while there are some observations about the possible reasons why so many trials have failed, there is no obvious single reason other than the lack of correlation between signs and symptoms in DED. Therefore the report advocates for conducting good quality studies, as described, going forward. A key recommendation for future studies is conduct consistent with Good Clinical Practice (GCP), including use of Good Manufacturing Practice (GMP) quality clinical trial material. The report also recommends that the design, treatments, and sample size be consistent with the investigational treatment, the objectives of the study, and the phase of development. Other recommendations for pivotal studies are a priori selection of the outcome measure, and an appropriate sample size.

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

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

Vision-related quality of life and psychological status in Chinese women with Sjogren's syndrome dry eye: a case-control study

Background

Sjogren’s syndrome dry eye (SSDE) mainly affects middle-aged women and can negatively affect women’s psychological and social functioning. However, little is known about the correlation between vision-related quality of life (VR-QoL) and psychological status for women with SSDE. We therefore examined VR-QoL and psychological status in two groups of Chinese women: an SSDE group and a non-SSDE group. We also explored the associations between VR-QoL scores, sociodemographic measures, ophthalmologic parameters, and psychological status in women with SSDE.

Methods

The case-control study recruited 30 female outpatients with SSDE and 30 without SSDE from the Eye and Ear, Nose, and Throat (ENT) Hospital of Fudan University. Demographic and ophthalmologic data were collected from all participants. Ophthalmologic examinations included best-corrected visual acuity (BCVA), corneal fluorescein staining (CFS), tear break-up time (TBUT) and Schirmer test. Data collected using the National Eye Institute’s Visual Function Questionnaire (NEI-VFQ) and Ocular Surface Disease Index (OSDI) survey instruments were analyzed to identify potential differences in VR-QoL between the SSDE group and the non-SSDE group. We also used the Zung Self-Rating Anxiety and Self-Rating Depression Scales (SAS and SDS) to determine psychological status in both groups.

Results

The SSDE group scored significantly lower than the non-SSDE group on the NEI-VFQ subscales of general health, general vision, and long-distance vision activities (all p < 0.05). The SSDE group achieved a significantly higher ocular symptoms score compared with the control group (p = 0.0256). The SAS and SDS scores of the SSDE group were significantly higher than the non-SSDE group (p = 0.0072 and 0.0162, respectively). The prevalence of anxiety and depression in the SSDE group was significantly higher than the non-SSDE group (p = 0.0240 and 0.0200, respectively). Nine of twelve NEI-VFQ subscales were negatively correlated with SAS/SDS scores (all p values were <0.05). The exceptions were social function, color vision and peripheral vision. The composite OSDI score and its three subscale scores for the women in the SSDE group were all positively correlated with overall SAS/SDS scores (all p values were <0.05).

Conclusions

Both VR-QoL and psychological status were significantly worse in SSDE group than in the non-SSDE group. The VR-QoL of women with SSDE had a negative correlation with their anxiety and depression levels.

A Randomized Multicenter Study Comparing 0.1%, 0.15%, and 0.3% Sodium Hyaluronate with 0.05% Cyclosporine in the Treatment of Dry Eye

Purpose: To investigate the efficacy of 0.1%, 0.15%, and 0.3% sodium hyaluronate (SH) artificial tears compared with 0.05% cyclosporine (CS) ophthalmic solution for the treatment of dry eye.

Methods: One hundred seventy-six patients were recruited and randomized to receive of 0.1%, 0.15%, and 0.3% SH and 0.05% CS. There was a primary end point which is the changes in the fluorescein corneal staining (FCS) score to determine noninferiority of 0.1%, 0.15%, and 0.3% SH. Secondary objective end points were lissamine green conjunctival staining (LGCS) scores, Schirmer test, and tear film break-up time (TBUT). Secondary subjective end point was ocular surface disease index (OSDI) score. These were evaluated before treatment and 6 and 12 weeks after start of treatment.

Results: In the primary analysis, the mean change from baseline in FCS scores verified noninferiority of 0.1% and 0.15% SH to 0.05% CS and also indicated significant improvement of all groups (P < 0.05). Values for TBUT, LGCS scores, and OSDI scores showed significant improvements in all groups (P < 0.05), although no significant intergroup difference was shown. However, Schirmer test scores in the 0.15% SH group showed a significant tendency for better improvement at week 12 compared with the other groups (P < 0.05). No serious adverse events were observed.

Conclusions: Administration of 0.1%, 0.15%, and 0.3% SH was effective in improving both the objective signs and subjective symptoms of dry eye. Those findings, in addition to the well-tolerated profile of 0.1%, 0.15%, and 0.3% SH, show that it is effective therapeutic method for dry eye.

The IMPACT study: a prospective evaluation of the effects of cyclosporine ophthalmic emulsion 0.05% on ocular surface staining and visual performance in patients with dry eye

Objective

The aim of this study was to evaluate the effects of cyclosporine ophthalmic emulsion 0.05% on ocular surface staining and visual performance in patients with dry eye.

Methods

This was a single-center, 6-month, open-label, Phase IV study. Patients with bilateral dry eye disease and a symptom score of ≥2 on the Ocular Discomfort and 4-Symptom Questionnaire, an Ocular Surface Disease Index score of >12, at least one eye with Schirmer’s score <10 mm/5 minutes, and central corneal staining graded as ≥2 on the Ora Calibra™ Corneal and Conjunctival Staining Scale were enrolled. Cyclosporine ophthalmic emulsion 0.05% (Restasis^®) was instilled twice daily in each eye. The primary efficacy endpoints were ocular surface staining and visual function at 6 months. Secondary outcome measures included Schirmer’s test, tear film breakup time, symptoms, and adverse events.

Results

A total of 40 patients with the mean age of 59.4 years (range, 40–78 years) were enrolled; 35 (87.5%) were female and 37 (92.5%) completed the study. At 6 months, inferior corneal, central corneal, total corneal, and total ocular surface fluorescein staining were significantly improved from baseline in both eyes (P<0.001). Patient responses on the Ocular Surface Disease Index showed significant improvement in blurred vision and visual function related to reading, driving at night, working with a computer or bank machine, and watching television (P≤0.041). At 6 months, 35.1% of patients achieved ≥5 mm improvement and 18.9% achieved ≥10 mm improvement in the average eye Schirmer score. Mean tear film breakup time improved by >50% in both eyes (P>0.001). Patients reported significant improvement in ocular discomfort and dry eye symptoms (P<0.001). No patients discontinued treatment because of stinging or any other ocular adverse event.

Conclusion

Dry eye patients with difficulties with day-to-day visual function demonstrated improvement in both signs and symptoms of dry eye and reported improved visual function after 6 months of treatment with cyclosporine ophthalmic emulsion 0.05%.

Vision-Related Quality of Life in Patients with Ocular Graft-versus-Host Disease

PURPOSE

To assess the vision-related quality of life (QOL) in a cohort of patients with ocular graft-versus-host disease (GVHD).

DESIGN

Prospective study.

PARTICIPANTS

Eighty-four patients diagnosed with chronic ocular GVHD.

METHODS

We assessed the vision-related QOL with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). The symptoms of ocular GVHD were assessed using the Ocular Surface Disease Index (OSDI) and Symptom Assessment in Dry Eye (SANDE) questionnaires.

MAIN OUTCOME MEASURES

We assessed vision-related QOL with the NEI-VFQ-25 and compared the scores obtained from patients with ocular GVHD with those from a healthy population. In the ocular GVHD population, we also evaluated the associations between the NEI-VFQ-25 and the dry eye symptoms measured by the OSDI and SANDE questionnaires, age, duration of disease, best-corrected visual acuity (BCVA), corneal fluorescein staining (CFS), tear break-up time, and Schirmer test.

RESULTS

The mean composite NEI-VFQ-25 score in patients with ocular GVHD was 76.5±17. Compared with healthy subjects, patients with ocular GVHD reported reduced scores on all NEI-VFQ-25 subscales (each P < 0.001) with the exception of color vision (P = 0.11). The NEI-VFQ-25 composite scores significantly correlated with OSDI (R = -0.81, P < 0.001), SANDE (R = -0.56, P < 0.001), CFS (R = -0.36, P = 0.001), and BCVA (R = -0.30, P = 0.004).

CONCLUSIONS

Patients with ocular GVHD experience measurable impairment of vision-related QOL. This study highlights the impact of ocular GVHD on the vision-related QOL, and thus the importance of comprehensive diagnosis and treatment of this condition.

Comparison on the vision-related quality of life between outpatients and general population with dry eye syndrome

PURPOSE

To compare the impact of dry eye syndrome (DES) on vision-related quality of life (VR-QoL) between outpatients and general populations.

METHODS

This cross-sectional comparative study enrolled 154 participants, 77 outpatients and 77 general participants, all of whom met the diagnostic criteria of DES. Apart from the collection of sociodemographic and clinical data, the Chinese version of 25-item National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) and Ocular Surface Disease Index Questionnaire (OSDI) were administered. Main outcome measures include the comparison on the OSDI score and VFQ-25 score between two groups, and their correlation with sociodemographic and clinical data.

RESULTS

The two groups were comparable concerning sociodemographic parameters except that the outpatients were better educated (χ(2) = 18.609, p < 0.001). The ophthalmic data related with DES did not have statistically significant differences between two groups except that the proportion of subjects with positive corneal fluorescein staining (CFS) was higher in outpatients (χ(2) = 21.296, p < 0.001). The outpatients reported significantly higher OSDI scores and lower VFQ-25 scores. The VFQ-25 composite score had negative correlation with the OSDI score of all participants or that of outpatients solely (ρ = -0.247 and -0.397, p = 0.030 and 0.000, respectively). Among outpatients, the value of Schirmer test (ST), tear film breakup time (TBUT) and CFS in the eyes with worse DES had significant correlations with the OSDI overall scores, while TBUT and CFS of both eyes correlated with the VFQ-25 composite score.

CONCLUSIONS

DES exerts more adverse impact on VR-QoL in outpatients than general patients. The impairment of VR-QoL has a significant correlation with the severity of DES.

Rethinking dry eye disease: a perspective on clinical implications

Publication of the DEWS report in 2007 established the state of the science of dry eye disease (DED). Since that time, new evidence suggests that a rethinking of traditional concepts of dry eye disease is in order. Specifically, new evidence on the epidemiology of the disease, as well as strategies for diagnosis, have changed the understanding of DED, which is a heterogeneous disease associated with considerable variability in presentation. These advances, along with implications for clinical care, are summarized herein. The most widely used signs of DED are poorly correlated with each other and with symptoms. While symptoms are thought to be characteristic of DED, recent studies have shown that less than 60% of subjects with other objective evidence of DED are symptomatic. Thus the use of symptoms alone in diagnosis will likely result in missing a significant percentage of DED patients, particularly with early/mild disease. This could have considerable impact in patients undergoing cataract or refractive surgery as patients with DED have less than optimal visual results. The most widely used objective signs for diagnosing DED all show greater variability between eyes and in the same eye over time compared with normal subjects. This variability is thought to be a manifestation of tear film instability which results in rapid breakup of the tearfilm between blinks and is an identifier of patients with DED. This feature emphasizes the bilateral nature of the disease in most subjects not suffering from unilateral lid or other unilateral destabilizing surface disorders. Instability of the composition of the tears also occurs in dry eye disease and shows the same variance between eyes. Finally, elevated tear osmolarity has been reported to be a global marker (present in both subtypes of the disease- aqueous-deficient dry eye and evaporative dry eye). Clinically, osmolarity has been shown to be the best single metric for diagnosis of DED and is directly related to increasing severity of disease. Clinical examination and other assessments differentiate which subtype of disease is present. With effective treatment, the tear osmolarity returns to normal, and its variability between eyes and with time disappears. Other promising markers include objective measures of visual deficits, proinflammatory molecular markers and other molecular markers, specific to each disease subtype, and panels of tear proteins. As yet, however, no single protein or panel of markers has been shown to discriminate between the major forms of DED. With the advent of new tests and technology, improved endpoints for clinical trials may be established, which in turn may allow new therapeutic agents to emerge in the foreseeable future. Accurate recognition of disease is now possible and successful management of DED appears to be within our grasp, for a majority of our patients.

TearLab® Osmolarity System for diagnosing dry eye

Dry eye (DE) disease is an impairment of the lachrymal unit function and one the most frequent eye problems. A major challenge is to find accurate diagnostic criteria to be able to define DE severity, as symptoms poorly correlate with clinical signs. Tear osmolarity is considered a key factor in DE onset and perpetuation; its measurement is now possible in clinical setting by an innovative electrical impedance-based lab-on-a-chip technology. This article outlines the features of DE disease and the limitations of current clinical tests. The role of tear osmolarity in DE etiopathogenesis is surveyed, and the pitfalls in measurement are discussed. Diagnostic performance, accuracy and clinical applications of the technology in focus are critically reviewed. The instrument offers the possibility to measure tear osmolarity in a rapid and reliable way in daily practice. As scientific evidence grows, it is expected in the future that it will represent an objective indicator of ocular surface health in the management of DE disease and in clinical trials.

Effects of diquafosol tetrasodium administration on visual function in short break-up time dry eye

PURPOSE

To investigate the effect of diquafosol tetrasodium on tear and visual function in short break-up time (sBUT) dry eye (DE).

METHODS

This interventional nonrandomized comparative study involved 11 eyes in 11 patients with sBUT DE (symptom-positive sBUT group) and 13 eyes in 13 volunteers with BUT values ≤5 s without DE symptoms (symptom-negative sBUT group). Tear function was assessed by measuring BUT and Schirmer values. Serial measurements were made of visual acuities (using a functional visual acuity measurement system) and higher-order aberrations (using a wavefront sensor). The parameters were compared before and 1 month after diquafosol tetrasodium instillation. Any changes in symptomatology after administration were also recorded.

RESULTS

After diquafosol tetrasodium administration, BUT values tended to increase in the symptom-positive sBUT group (P=0.07) and significantly increased in the symptom-negative sBUT group (P<0.05). LogMAR functional, minimal, and maximal visual acuities and higher-order aberrations significantly decreased after diquafosol tetrasodium administration in the symptom-positive sBUT group (P<0.05), while there were no significant changes in these values in the symptom-negative sBUT group (P>0.05). Diquafosol tetrasodium administration provided relief of DE symptoms in 75% of patients in the symptom-positive sBUT group.

CONCLUSIONS

Diquafosol tetrasodium appeared to improve tear film stability and visual function in sBUT DE.

Discomfort symptoms reduction and ocular surface parameters recovery with Artelac Rebalance treatment in mild-moderate dry eye

PURPOSE

To evaluate Artelac Rebalance® eyedrops' efficacy in symptoms reduction, ocular surface parameters recovery, and tolerability in the treatment of mild to moderate dry eye.

METHODS

Fifteen patients were enrolled. Inclusion criteria were Ocular Surface Disease Index (OSDI) score >16, tear film break-up time (TFBUT) <10 seconds, Schirmer test I >10 mm/5 min, and mild ocular surface damage (Oxford grading) ≤3. Artelac Rebalance® eyedrops were administered 3 times daily for 2 months. Patients were evaluated at enrollment, after 2 days of washout (baseline), and after 1 and 2 months of treatment. Parameters for ocular discomfort (OSDI score), tear film quality (Schirmer test I, TFBUT, tear osmolarity), ocular surface damage (fluorescein staining, conjunctival imprint cytology), and inflammation (scraping cytology and exuded serum albumin) were measured. Tolerability and satisfaction were assessed by validated questionnaires.

RESULTS

At endpoint versus baseline, all variables showed a statistically significant improvement (paired Student t test, p<0.01 for all parameters) as follows: OSDI score (21.9 ± 10.6 vs 35.8 ± 12.2), TFBUT (6.5 ± 1.1 s vs 5.2 ± 2.3 s), Oxford grading of corneal and conjunctival damage (0.56 ± 0.50 vs 1.16 ± 0.37), tear osmolarity (294.6 ± 2.1 mOsm/L vs 303.1 ± 4.6 mOsm/L), conjunctival goblet cell density/mm2 (140.8 ± 43.3 cells/mm2 vs 115.1 ± 15.8 cells/mm2), scraping cytology score (2.9 ± 1.0 vs 4.2 ± 1.3), and percentage of serum albumin in tears (9.2% ± 4.8% vs 24.1% ± 10.8%). Tolerability and satisfaction were scored high, with no adverse events reported.

CONCLUSIONS

Application of Artelac Rebalance® eyedrops for 2 months in mild to moderate dry eye resulted in a reduction of ocular inflammation parameters, ocular surface damage, and subjective discomfort symptoms, with a parallel improvement in tear film quality (measured by TFBUT and osmolarity).

Dry Eye Disease: Impact on Quality of Life and Vision

Dry eye disease (DED) is a growing public health concern causing ocular discomfort, fatigue and visual disturbance that interferes with quality of life (QoL), including aspects of physical, social, psychological functioning, daily activities and workplace productivity. This paper assesses the current understanding of the impact of DED on QoL and vision. The full impact of DED on a patient's QoL is not easily quantifiable, but several methods and techniques have been evaluated to measure the decreased quality of vision from DED, and a number of questionnaires have been developed to quantify the impact of DED on various aspects of patient QoL. We summarize available evidence on the impact of DED based on a review of published literature.