Meibomian gland dysfunction is highly prevalent among first-time visitors at a Norwegian dry eye specialist clinic

Phospholipid Nanoemulsion-Based Ocular Lubricant for the Treatment of Dry Eye Subtypes: A Multicenter and Prospective Study

INTRODUCTION

Dry eye disease (DED) is a multifactorial condition of the ocular surface (OS) characterized by loss of tear film homeostasis, ocular discomfort, and vision disturbances. Most available ocular lubricants target the aqueous deficiency of the tear, restoring only this layer, leaving the tear lipid stratum deficient, as occurs in most patients with evaporative DED. An innovative propylene glycol-hydroxypropyl guar enriched with a phospholipid nanoemulsion (PG-HPG-PH-N) is indicated to restore deficiencies in both the lipid and aqueous layers of the tear film, and its composition was designed to increase lubricant retention on the OS. The purpose of this study was to evaluate, through the Ocular Surface Disease Index (OSDI) and clinical assessment, the treatment of patients who had DED due to aqueous deficiency arising from mixed or evaporative DED subtypes with a PG-HPG-PH-N ocular lubricant at a reduced frequency of twice a day, in a prospective, multicenter, and single-arm study.

METHODS

Patients were screened from days - 7 to 0, and from day 1 (baseline and first day of treatment) to day 28 of treatment with this lubricant. After visit 1 (screening visit, days - 7 to 0), designed as pre-treatment OS assessment, patients returned to their research center on days 14 and 28 of treatment for a complete assessment, including anamnesis, the OSDI, corrected visual acuity, tear breakup time (TFBUT), OS staining evaluation, tolerability index, and environmental exposure questionnaire.

RESULTS

Seventy patients were enrolled in this study (60 women, 10 men), with a mean age of 45 (range 27-64) years. TFBUT results showed an improvement in tear film stability as vital dyes sodium fluorescein and lysamine green showed a decrease in corneal staining after 14 and 28 days of treatment. No significant adverse events were reported, demonstrating the good tolerability of the lubricant.

CONCLUSIONS

The PG-HPG-PH-N nanoemulsion can be considered to be a safe and effective ocular lubricant for treating DED due to aqueous deficiency, both mixed and evaporative subtypes.

TRIAL REGISTRATION

Brazilian National Research Ethics Commission (ReBEC registration number 16055).

Sex Differences in the Prevalence of Meibomian Gland Dysfunction: A Mini Review

PURPOSE

In this review, we aimed to investigate the literature on sex-specific prevalence of meibomian gland dysfunction (MGD) and to determine whether women or men are more at risk for MGD.

METHODS

A search was conducted on PubMed using the terms: (Sex OR Gender OR prevalence) AND (Meibomian gland).

RESULTS

Twenty-four relevant studies on MGD prevalence were identified, including 10 population-based and 14 hospital-based studies. Among the population-based studies, five studies reported higher rates among men, three studies found no differences, and one study observed higher rates among women. In the hospital-based studies, 10 studies reported no difference, two found higher rates among men, and one found higher among women. In the reviewed literature, there was a considerable variation between studies in terms of quality, sample size, age ranges, diagnostic criteria.

CONCLUSIONS

While most of the population-based studies suggest a higher prevalence among men, the majority of clinic-based studies show no significant difference. Further research with larger samples and standardized criteria is needed to determine whether men are indeed more susceptible to MGD.

Age Associations with Dry Eye Clinical Signs and Symptoms in the Dry Eye Assessment and Management (DREAM) Study

Purpose

To evaluate how increasing age is associated with dry eye disease (DED) signs and symptoms in the Dry Eye Assessment and Management (DREAM) study. This study was undertaken to better understand how DED signs and symptoms differ across decades of life with goals to help assess detection and treatment of DED.

Design

Secondary analysis of the DREAM study.

Subjects

One hundred twenty, 140, 185, and 90 participants aged < 50, 50 to 59, 60 to 69, and ≥ 70 years, respectively.

Methods

We performed a secondary analysis of data from the DREAM study, a multicenter randomized clinical trial, to evaluate the effect of omega-3 fatty acid supplementation for the treatment of DED. At baseline, 6 months, and 12 months follow-up, participants underwent an assessment of DED symptoms and signs using Ocular Surface Disease Index, Brief Pain Inventory, tear break-up time (TBUT) (in seconds), Schirmer test with anesthesia (mm/5 minutes), conjunctival staining, corneal staining, meibomian gland dysfunction evaluation, and tear osmolarity (mOsm/l). Multivariable generalized linear regression models were used to compare DED symptoms and signs across the 4 age groups among all participants and by sex.

Main Outcome Measures

Scores of DED symptoms, individual signs, and composite scores of DED signs.

Results

Among 535 patients with DED, increasing age was significantly associated with worse TBUT (P = 0.01), corneal staining (P < 0.001), a composite severity score of DED signs (P = 0.007), and tear osmolarity (P = 0.001). Similar significant differences were found across 4 age groups of 334 women in TBUT, corneal staining score, composite severity score of DED signs, and tear osmolarity (all P < 0.05) but not in men.

Conclusion

We found that corneal staining, TBUT, tear osmolarity, and a composite severity score of DED signs were significantly more severe with increasing age in women but not in men; worsening symptoms did not increase with increasing age.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Pulsed Oral Azithromycin vs 6-Week Oral Doxycycline for Moderate to Severe Meibomian Gland Dysfunction: A Randomized Clinical Trial

Importance

The treatment of moderate to severe meibomian gland dysfunction (MGD) with oral doxycycline requires a 6-week course of treatment and has frequent adverse effects (AEs), which may be associated with poor compliance.

Objective

To determine if the AEs of a 3-week course of oral azithromycin were equivalent to the AEs of a 6-week course of oral doxycycline.

Design, Setting, and Participants

This double-masked randomized clinical trial was conducted at a referral center in Thailand from September 2018 to May 2022. Participants with moderate to severe MGD judged unresponsive to conservative management were included.

Interventions

Patients were randomized 1:1 to receive oral azithromycin (1 g once per week for 3 weeks) or oral doxycycline (200 mg daily for 6 weeks).

Main Outcomes and Measures

After initiating therapy, the study team assessed the total MGD score and Ocular Surface Disease Index (OSDI) score at the initial visit, at 6 weeks, and at 8 weeks, and assessed AEs at 6 weeks and 8 weeks. The prespecified equivalence margins for MGD score and OSDI score were set at ±2 and ±9, respectively.

Results

A total of 137 eyes from 137 patients were randomized into groups, 68 eyes in the azithromycin group and 69 eyes in the doxycycline group (female, 66.4%; mean age, 62.0 [SD, 15.1] years). The adjusted mean difference of total MGD scores between groups at week 6 and week 8 were -0.33 (95% CI, -1.70 to 1.03; P for equivalence = .01) and 0.13 (95% CI, -1.59 to 1.84; P for equivalence = .02), respectively. The adjusted mean difference of OSDI between groups score at week 6 and week 8 was -1.20 (95% CI, -5.31 to 2.91; P for equivalence  < .001) and -1.59 (95% CI, -5.73 to 2.55; P for equivalence  < .001), respectively. In addition, patients treated with azithromycin had fewer gastrointestinal AEs (4.4% vs 15.9%; risk difference, 11.5%; 95% CI 1.6%-21.4%; P = .03).

Conclusions and Relevance

These data support an equivalency of effects of azithromycin as compared with doxycycline for MGD score and OSDI score at both follow-up times. The study did not show more gastrointestinal AEs in the azithromycin group. The reduced dosing and potentially fewer gastrointestinal AEs associated with azithromycin support its use as an alternative to doxycycline for at least 6 weeks.

Trial Registration

ThaiClinicalTrials.org Identifier: TCTR20180810001.

Dry Eye Disease Associated with Meibomian Gland Dysfunction: Focus on Tear Film Characteristics and the Therapeutic Landscape

Meibomian gland dysfunction (MGD) is highly prevalent and is the leading cause of evaporative dry eye disease (DED). MGD is characterized by a reduction in meibum secretion and/or a change in meibum composition that results in the disruption of the tear film lipid layer and an increase in the tear film evaporation rate. Excessive evaporation causes tear film instability, desiccation, tear hyperosmolarity, inflammation, and apoptosis of ocular surface cells, resulting in a continuous cycle of DED. The primary treatment goal for DED associated with MGD is to restore the tear film lipid layer and decrease evaporation, thereby reducing ocular signs and symptoms. The management of MGD includes home care options (eyelid hygiene, warming eye masks, ocular lubricants) and office-based treatments (manual expression, microblepharoexfoliation, thermal pulsation, intense pulsed light, intraductal probing). Topical ophthalmic prescription medications attempt to alter various factors that may contribute to DED (e.g., inflammation, bacterial growth, inadequate tear production). In this review, clinical evidence regarding available treatments and emerging therapies from randomized studies in patients with DED associated with MGD is summarized. Although some treatment modalities have been evaluated specifically for DED patients with MGD, large-scale randomized controlled trials are needed to confirm efficacy and safety in this patient population. Currently, there are no approved prescription pharmacologic treatments specifically indicated for DED associated with MGD, and those medications approved for the treatment of DED do not target the key driver of the disease (i.e., excessive evaporation). NOV03 (perfluorohexyloctane; under review with the US Food and Drug Administration) is the most advanced emerging therapy for DED associated with MGD and has demonstrated statistically significant improvements in both signs and symptoms in randomized controlled trials. Development of novel pharmacotherapies will improve therapeutic options and allow for a more individualized approach for patients with DED associated with MGD.

The efficacy of ocular surface assessment approaches in evaluating dry eye treatment with artificial tears

This study evaluates the effectiveness of objective techniques in assessing dry eye disease (DED) treatment compared with the subjective assessment commonly used in clinical practice. Thirty subjects were recruited for two visits separated by 28(± 3) days of treatment with artificial tears. A buttery of common subjective assessment methods were accompanied by a set of objective techniques including measurement of noninvasive tear film break-up time (NIBUT), lipid layer thickness (LLT), and quantitative evaluation of tear film surface quality and dynamics (TFD). Additionally, meibography was performed. Two commercially available videokeratoscopes and a prototype of a lateral shearing interferometer were used for the measurements. Both subjective and objective techniques showed a positive effect of artificial tears in DED treatment. Statistically significant improvements were observed in subjective symptoms (from P < 0.001 for Ocular Surface Disease Index, OSDI to p = 0.019 for tearing), conjunctival redness (P = 0.022), ocular staining (P = 0.012), fluorescein tear film break-up time (P = 0.015), NIBUT (P = 0.037), LLT (P < 0.001), and TFD (P = 0.048). In general, weak or statistically insignificant correlations were observed between subjective and objective assessment methods. The apparent lack of correlation between these methods might indicate the complementary character of objective techniques that likely assess other characteristics of ocular surface health than those assessed subjectively.

Spanish Cross-Cultural Adaptation, Rasch Analysis and Validation of the Ocular Comfort Index (OCI) Questionnaire

The Ocular Comfort Index (OCI) assesses ocular surface irritation and grades the severity of dry eye disease. This study sought to adapt the OCI questionnaire into Spanish, and then to assess the psychometric performance and validity of the new adapted version (OCI-versión española, OCI_VE). The questionnaire was translated, back translated, and then cross-culturally adapted for use with Spanish-speaking individuals. The OCI_VE was completed by 450 participants, including 53 subjects that were diagnosed with dry eye disease. Through a Rasch analysis, the psychometric properties of item fit, targeting, person separation, reliability, and differential item functioning (DIF) were assessed. To test the convergent validity, we examined the correlation between the OCI_VE and the Computer Vision Symptom Scale (CVSS17). Validity was tested in a subgroup of participants with and without dry eye, and test-retest repeatability was determined in a subset of 151 individuals. We also compared, via DIF, the performance of the OCI_VE with that of the original OCI. Our Rasch analysis revealed a good model fit, high accuracy, good targeting, unidimensionality, and no DIF according to gender. The validity and repeatability were good. The OCI_VE shows comparable psychometric properties to the original English version, making it a valid tool for measuring dry eye symptoms in Spanish adults.

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.