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Tzamalis A, Matsou A, Anastasopoulos E, Ziakas N. Treatment of spontaneous corneal perforation secondary to undiagnosed Sjögren's syndrome using regenerating agent and autologous serum eye drops. Eur J Ophthalmol 2019; 31:NP17-NP21. [PMID: 31137968 DOI: 10.1177/1120672119853106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to report a case of sterile corneal ulcer leading to perforation, which was treated effectively with autologous serum eye drops, topical regenerative agent (poly-carboxymethylglucose sulfate), steroids, and systemic immunosuppression in a patient with undiagnosed primary Sjögren's syndrome. METHODS A 74-year-old female presented with a month's history of gradually worsening blurry vision in her left eye. Ophthalmic examination revealed a central descemetocele with excessive corneal stromal melting and absence of signs of infection. A bandage contact lens was applied for tectonic support along with topical corticosteroid and antibiotic drops. Autoimmune screen disclosed a diagnosis of Sjögren's syndrome, and the patient was commenced on systemic immunosuppression. Forty-eight hours after presentation, the patient developed a localized corneal perforation, presenting with a flat anterior chamber. RESULTS Urgent amniotic membrane transplantation was arranged while topical dexamethasone, moxifloxacin, and autologous serum eye drops were administered. After 24 h of intensive topical treatment, a significant reforming of the anterior chamber and subsequent gradual regeneration of the corneal stroma were noted, thus postponing amniotic grafting. The patient remained under close monitoring, showing progressive clinical improvement. Regenerating agent eye drops (Cacicol20®) were also applied over the next month, with careful and slow tapering of topical dexamethasone. Further improvement of corneal thickness was observed, and visual acuity increased to 20/80. CONCLUSION This case report demonstrates the successful medical treatment of an autoimmune-related sterile corneal perforation without surgical intervention, highlighting the fact that early diagnosis and rigorous medical treatment with autologous serum and regenerating agent eye drops can effectively aid tissue regeneration and favorable visual rehabilitation.
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Affiliation(s)
- Argyrios Tzamalis
- 2nd Department of Ophthalmology, Faculty of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece.,St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Artemis Matsou
- 2nd Department of Ophthalmology, Faculty of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Eleftherios Anastasopoulos
- 2nd Department of Ophthalmology, Faculty of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Ziakas
- 2nd Department of Ophthalmology, Faculty of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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De Aracena Del Cid RM, De Espinosa Escoriaza IM. Subconjunctival application of regenerative factor-rich plasma for the treatment of ocular alkali burns. Eur J Ophthalmol 2018; 19:909-15. [DOI: 10.1177/112067210901900603] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
BACKGROUND Theoretically, autologous serum eye drops (AS) offer a potential advantage over traditional therapies on the assumption that AS not only serve as a lacrimal substitute to provide lubrication but contain other biochemical components that allow them to mimic natural tears more closely. Application of AS has gained popularity as second-line therapy for patients with dry eye. Published studies on this subject indicate that autologous serum could be an effective treatment for dry eye. OBJECTIVES We conducted this review to evaluate the efficacy and safety of AS given alone or in combination with artificial tears as compared with artificial tears alone, saline, placebo, or no treatment for adults with dry eye. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2016), Embase (January 1980 to July 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We also searched the Science Citation Index Expanded database (December 2016) and reference lists of included studies. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 July 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared AS versus artificial tears for treatment of adults with dry eye. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts and assessed full-text reports of potentially eligible trials. Two review authors extracted data and assessed risk of bias and characteristics of included trials. We contacted investigators to ask for missing data. For both primary and secondary outcomes, we reported mean differences with corresponding 95% confidence intervals (CIs) for continuous outcomes. We did not perform meta-analysis owing to differences in outcome assessments across trials. MAIN RESULTS We identified five eligible RCTs (92 participants) that compared AS versus artificial tears or saline in individuals with dry eye of various origins (Sjögren's syndrome-related dry eye, non-Sjögren's syndrome dry eye, and postoperative dry eye induced by laser-assisted in situ keratomileusis (LASIK)). We assessed the certainty of evidence as low or very low because of lack of reporting of quantitative data for most outcomes and unclear or high risk of bias among trials. We judged most risk of bias domains to have unclear risk in two trials owing to insufficient reporting of trial characteristics, and we considered one trial to have high risk of bias for most domains. We judged the remaining two trials to have low risk of bias; however, these trials used a cross-over design and did not report data in a way that could be used to compare outcomes between treatment groups appropriately. Incomplete outcome reporting and heterogeneity among outcomes and follow-up periods prevented inclusion of these trials in a summary meta-analysis.Three trials compared AS with artificial tears; however, only one trial reported quantitative data for analysis. Low-certainty evidence from one trial suggested that AS might provide some improvement in participant-reported symptoms compared with artificial tears after two weeks of treatment; the mean difference in mean change in symptom score measured on a visual analogue scale (range 0 to 100, with higher scores representing worse symptoms) was -12.0 (95% confidence interval (CI) -20.16 to -3.84; 20 participants). This same trial found mixed results with respect to ocular surface outcomes; the mean difference in mean change in scores between AS and artificial tears was -0.9 (95% CI -1.47 to -0.33; 20 participants; low-certainty evidence) for fluorescein staining and -2.2 (95% CI -2.73 to -1.67; 20 participants; low-certainty evidence) for Rose Bengal staining. Both staining scales range from 0 to 9, with higher scores indicating worse results. The mean change in tear film break-up time was 2.00 seconds longer (95% CI 0.99 to 3.01; 20 participants; low-certainty evidence) in the AS group than in the artificial tears group. Investigators reported no clinically meaningful differences in Schirmer's test scores between groups (mean difference -0.40 mm, 95% CI -2.91 to 2.11; 20 participants; low-certainty evidence). None of these three trials reported tear hyperosmolarity and adverse events.Two trials compared AS versus saline; however, only one trial reported quantitative data for analysis of only one outcome (Rose Bengal staining). Trial investigators of the two studies reported no differences in symptom scores, fluorescein staining scores, tear film break-up times, or Schirmer's test scores between groups at two to four weeks' follow-up. Very low-certainty evidence from one trial suggested that AS might provide some improvement in Rose Bengal staining scores compared with saline after four weeks of treatment; the mean difference in Rose Bengal staining score (range from 0 to 9, with higher scores showing worse results) was -0.60 (95% CI -1.11 to -0.09; 35 participants). Neither trial reported tear hyperosmolarity outcomes. One trial reported adverse events; two of 12 participants had signs of conjunctivitis with negative culture that did resolve. AUTHORS' CONCLUSIONS Overall, investigators reported inconsistency in possible benefits of AS for improving participant-reported symptoms and other objective clinical measures. There might be some benefit in symptoms with AS compared with artificial tears in the short-term, but we found no evidence of an effect after two weeks of treatment. Well-planned, large, high-quality RCTs are warranted to examine participants with dry eye of different severities by using standardized questionnaires to measure participant-reported outcomes, as well as objective clinical tests and objective biomarkers to assess the benefit of AS therapy for dry eye.
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Affiliation(s)
- Qing Pan
- Zhejiang Provincial People's Hospital, Hangzhou Medical CollegeDepartment of Ophthalmology158 Shangtang RoadHangzhouZhejiangChina
- Johns Hopkins University School of MedicineWilmer Eye Institute327 Maumenee Bldg600 N. Wolfe St.BaltimoreMarylandUSA21287‐9238
| | - Adla Angelina
- University of Mississippi School of MedicineDepartment of Pathology2500 North State StJacksonMississippiUSA39216
| | - Michael Marrone
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N Wolfe StreetBaltimoreMarylandUSA21205
| | - Walter J Stark
- Johns Hopkins University School of MedicineWilmer Eye Institute327 Maumenee Bldg600 N. Wolfe St.BaltimoreMarylandUSA21287‐9238
| | - Esen K Akpek
- Johns Hopkins University School of MedicineWilmer Eye Institute327 Maumenee Bldg600 N. Wolfe St.BaltimoreMarylandUSA21287‐9238
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Valim V, Trevisani VFM, de Sousa JM, Vilela VS, Belfort R. Current Approach to Dry Eye Disease. Clin Rev Allergy Immunol 2016; 49:288-97. [PMID: 25081064 DOI: 10.1007/s12016-014-8438-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dry eye disease (DED) is a multifactorial disease of the tears and ocular surface that causes tear film instability with potential damage to the ocular surface. The prevalence of dry eye in the world population ranges from 6 to 34 %. It is more common in those aged over 50, and affects mainly women. Since the introduction of the Schirmer's test in 1903, other tests have been developed to evaluate dry eye, such as biomicroscopy, the tear film breakup time (BUT), vital dyes (lissamine green and rose bengal), fluorescein, leaf fern test, corneal sensitivity test, conjunctiva impression cytology, optical coherence tomography (OCT), and tear osmolarity measurement. Although there is no gold standard, it is advisable to combine at least two tests. Strategies for treating DED have recently been modified and include patient education, tear substitute, corticosteroids, secretagogues, fatty acids, immunomodulators, occlusion of lacrimal puncta surgery and, tarsorrhaphy. Biological therapy and new topical immunomodulators such as tacrolimus, tofacitinib and IL-1 receptor inhibitor are being tested. In this review, the evaluation tests for dry eye are compared and the main studies on treatment are presented, with emphasis on studies in patients with Sjögren's syndrome. The authors propose an approach for the management of dry eye.
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Affiliation(s)
- Valéria Valim
- Centro de Referência de Doenças Reumáticas, Serviço de Reumatologia, Universidade Federal do Espírito Santo, Hospital Universitário Cassiano Antonio de Moraes, Rua Marechal Campos, 1468, Maruípe, Vitória, ES, Brazil, 29040-091. .,Scientific Committee on Sjögren's Syndrome, Brazilian Society of Rheumatology, Av. Brigadeiro Luís Antônio, 2466, Bela Vista, São Paulo, SP, Brazil, 01402-000.
| | - Virginia Fernandes Moça Trevisani
- Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, Universidade Federal de São Paulo, Rua Botucatu 740 Vila Clementino, São Paulo, SP, Brazil, 04023-062.,Universidade de Santo Amaro, Rua Enéas Siqueira Neto, Jardim das Embuias, São Paulo, SP, Brazil.,Scientific Committee on Sjögren's Syndrome, Brazilian Society of Rheumatology, Av. Brigadeiro Luís Antônio, 2466, Bela Vista, São Paulo, SP, Brazil, 01402-000
| | - Jacqueline Martins de Sousa
- Escola Paulista de Medicina (EPM), Departamento de Oftalmologia e Ciências Visuais, Rua Botucatu 820, Vila Clementino, São Paulo, SP, Brazil, 04023-062
| | - Verônica Silva Vilela
- Disciplina de Reumatologia, Universidade do Estado do Rio de Janeiro, Avenida 28 de Setembro 77, Vila Isabel, Rio de Janeiro, RJ, Brazil, 20551-900.,Scientific Committee on Sjögren's Syndrome, Brazilian Society of Rheumatology, Av. Brigadeiro Luís Antônio, 2466, Bela Vista, São Paulo, SP, Brazil, 01402-000
| | - Rubens Belfort
- Escola Paulista de Medicina (EPM), Departamento de Oftalmologia e Ciências Visuais, Rua Botucatu 820, Vila Clementino, São Paulo, SP, Brazil, 04023-062
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Nugent RB, Lee GA. Ophthalmic use of blood-derived products. Surv Ophthalmol 2015; 60:406-34. [PMID: 26077627 DOI: 10.1016/j.survophthal.2015.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 12/23/2022]
Abstract
There is a wide spectrum of blood-derived products that have been used in many different medical and surgical specialties with success. Blood-derived products for clinical use can be extracted from autologous or allogeneic specimens of blood, but recombinant products are also commonly used. A number of blood derivatives have been used for a wide range of ocular conditions, from the ocular surface to the retina. With stringent preparation guidelines, the potential risk of transmission of blood-borne diseases is minimized. We review blood-derived products and how they are improving the management of ocular disease.
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Affiliation(s)
| | - Graham A Lee
- City Eye Centre, Brisbane, Queensland, Australia; Department of Ophthalmology, University of Queensland, Brisbane, Queensland, Australia.
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Pan Q, Angelina A, Zambrano A, Marrone M, Stark WJ, Heflin T, Tang L, Akpek EK. Autologous serum eye drops for dry eye. Cochrane Database Syst Rev 2013; 8:CD009327. [PMID: 23982997 PMCID: PMC4007318 DOI: 10.1002/14651858.cd009327.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND =Theoretically, autologous serum eye drops (AS) have a potential advantage over traditional therapies based on the assumption that ASserve not only as a lacrimal substitute to provide lubrication, but also contain other biochemical components mimicking natural tears more closely. The application of AS in dry eye treatment has gained popularity as a second-line therapy in the treatment of dry eye.Published studies on the subject indicate that autologous serum could be an effective treatment for dry eye. OBJECTIVES To evaluate the efficacy and safety of AS compared to artificial tears for treating dry eye. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 3),Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE,(January 1950 to April 2013), EMBASE (January 1980 to April 2013), Latin American and Caribbean Literature on Health Sciences(LILACS) (January 1982 to April 2013), themetaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov(www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We also searched the Science Citation Index Expanded database (September 2013) and reference lists of included studies. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 April 2013. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which AS was compared to artificial tears in the treatment of dry eye in adults. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts and assessed full-text articles of potentially eligible trials. Two review authors extracted data and assessed the methodological quality and characteristics of the included trials.We contacted investigators for missing data. For both primary and secondary outcomes, we reported mean differences with corresponding 95% confidence intervals(CIs) for continuous outcomes. MAIN RESULTS We identified four eligible RCTs in which AS was compared with artificial tear treatment or saline in individuals (n = 72 participants)with dry eye of various etiologies (Sjögren’s syndrome-related dry eye, non-Sjögren’s syndrome dry eye and postoperative dry eye induced by laser-assisted in situ keratomileusis (LASIK)). The quality of the evidence provided by these trials was variable. A majority of the risk of bias domains were judged to have an unclear risk of bias in two trials owing to insufficient reporting of trial characteristics.One trial was considered to have a low risk of bias for most domains while another was considered to have a high risk of bias for most domains. Incomplete outcome reporting and heterogeneity in the participant populations and follow-up periods prevented the inclusion of these trials in a summary meta-analysis. For the primary outcome, improvement in participant-reported symptoms at one month, one trial (12 participants) showed no difference in participant-reported symptoms between 20% AS and artificial tears. Based on the results of two trials in 32 participants, 20% AS may provide some improvement in participant-reported symptoms compared to traditional artificial tears after two weeks of treatment. One trial also showed positive results with a mean difference in tear breakup time (TBUT) of 2.00 seconds (95% CI 0.99 to 3.01 seconds) between 20% AS and artificial tears after two weeks, which were not similar to findings from the other trials. Based on all other objective clinical assessments included in this review, AS was not associated with improvements in aqueous tear production measured by Schirmer's test (two trials, 33 participants), ocular surface condition with fluorescein (four trials, 72 participants) or Rose Bengal staining (three trials, 60 participants), and epithelial metaplasia by impression cytology compared to artificial tears (one trial, 12 participants). Data on adverse effects were not reported by three of the included studies. In one study, there were no serious adverse events reported with the collection of and treatment with AS. AUTHORS' CONCLUSIONS Overall there was inconsistency in the possible benefits of AS in improving participant-reported symptoms and TBUT and lack of effect based on other objective clinical measures. Well-planned, large, high-quality RCTs are warranted, in different severities of dry eye and using standardized questionnaires to measure participant-reported outcomes and objective clinical tests as well as objective biomarkers to assess the benefit of AS therapy for dry eye.
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Affiliation(s)
- Qing Pan
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Ophthalmology, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Adla Angelina
- Department of Pathology, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Andrea Zambrano
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Marrone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Walter J Stark
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas Heflin
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Li Tang
- Ophthalmology Department, Affiliated Hospital of Guiyang Medical College, Guiyang, China
| | - Esen K Akpek
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Effects of Topical Human Amniotic Fluid and Human Serum in a Mouse Model of Keratoconjunctivitis Sicca. Cornea 2012; 31:424-30. [DOI: 10.1097/ico.0b013e31823f0a64] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Yamada C, King KE, Ness PM. Autologous serum eyedrops: literature review and implications for transfusion medicine specialists. Transfusion 2008; 48:1245-55. [DOI: 10.1111/j.1537-2995.2008.01665.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Borzini P, Mazzucco I. Platelet-rich plasma (PRP) and platelet derivatives for topical therapy. What is true from the biologic view point? ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1751-2824.2007.00085.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
ABSTRACT Corneal ulcers can cause significant loss of vision from scarring and astigmatism, but rapid management can limit the destruction and improve outcomes. Infectious ulcers usually resolve with antimicrobial treatment. Noninfectious ulcers, however, present a diagnostic and therapeutic challenge. They can often be resolved by eliminating toxic medications and providing surface support with lubrication and collagenase inhibitors, but resistant ulcers may need more aggressive therapy with bandage contact lenses, tarsorrhaphy, or autologous serum. Ulcers impending perforation require urgent surgical management (e.g., tissue glue, conjunctival flaps, or keratoplasty). Topical steroids are useful when the ulceration is secondary to inflammatory mediators, but they are contraindicated in corneal melts with minimal inflammation, such as those associated with Sjogren syndrome. Systemic immunomodulation is required in addition to topical therapy in the presence of autoimmune disease. Understanding of the pathological processes that occur in different types of corneal ulcers is essential to formulation of a logical and effective treatment plan. Newer, more targeted treatment modalities may offer treatment options that have greater efficacy and fewer adverse effects.
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Affiliation(s)
- Sonal S Tuli
- Department of Ophthalmology and the Department of Obstetrics and Gynecology, University of Florida, Gainesville, FL USA.
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