The diagnosis and management of dry eye: a twenty-five-year review

Modified Sodium hyaluronate conjugated to riboflavin (Har® 0.1 %) as lubricant eyedrops in the treatment of dry eye: A prospective randomised study

Background

This study evaluates the therapeutic efficacy of HAr® (a novel ophthalmic solution containing modified hyaluronic acid covalently linked to riboflavin) compared to hyaluronic acid eye drops in patients with dry eye disease (DED).

Methods

Sixteen consecutive patients with bilateral medium to severe DED were divided into two groups. Group 1 received HAr® 0.1 % (Ribohyal®), while Group 2 received HA 0.1 % eye drops. Parameters such as Ocular Surface Disease Index (OSDI) score, osmolarity, break-up time (BUT), non-invasive BUT (NIBUT), tear meniscus measurement, Schirmer test, and Oxford Staining were evaluated. This study has been successfully registered on ClinicalTrials.gov public (Identifier NCT06122428).

Results

The Ribohyal group showed faster improvement in OSDI scores, with a statistically significant difference at 2 h (mean classification difference: -51.75; p = 0.0003). Photophobia significantly reduced at 2 h, 4 weeks, and 8 weeks in the Ribohyal group compared to baseline (p < 0.0001). Osmolarity improved significantly after 8 weeks in both groups (p < 0.0001).

Conclusions

HAr® 0.1 % (Ribohyal®) effectively reduced DED symptoms and improved photophobia within 2 h of instillation, lasting up to 8 weeks.

Efficacy and Safety of Quantum Molecular Resonance Electrotherapy in Patients with Aqueous-Deficient, Evaporative and Mixed-Type Dry Eye: A Randomized Interventional Study

INTRODUCTION

To evaluate the efficacy and safety of Quantum Molecular Resonance (QMR) treatment in patients with severe dry eye disease (DED), as well as its effects on aqueous-deficient (ADDE), evaporative (EDE), and mixed (MDE) dry eye.

METHODS

In this prospective, interventional study, 81 patients were randomly allocated to received four treatment sessions of QMR at 1-week intervals (Rexon-Eye®, Resono Ophthalmic, Trieste, Italy) (QRM group) or tear substitute four times daily, containing 0.15% sodium hyaluronate and 3% trehalose (Thealoz Duo®, Thea Pharma, France) (SH-TH group). Outcome measures included ocular surface disease index (OSDI) questionnaire, tear meniscus height (TMH), tear breakup time (TBUT), non-invasive breakup time (NIBUT), corneal fluorescein staining (CFS), lipid layer thickness (LLT), tear film osmolarity (OSM), and meibomian gland dysfunction (MGD) grade, which were assessed at baseline and 1-month and 3-month follow-up.

RESULTS

The QMR group achieved better improvements than the SH-TH group in OSDI and SANDE questionnaires, NIBUT, LLT, and CFS. The mean differences between the groups were as follows: OSDI (- 12.4 ± 0.25 points, P = 0.01), SANDE (10.6 ± 1.7 points, P = 0.01), NIBUT (2 ± 0.25 s, P = 0.01), LLT (18.7 ± 0.7 nm, P = 0.01), and CFS (1.2 ± 0.1 points, P = 0.02). In subgroups analysis, QMR treatment demonstrated a beneficial role to improve DED symptoms and signs in ADDE, EDE, and MDE.

CONCLUSION

QMR is an effective and well-tolerated treatment that seems to improve DED symptoms and signs in patients with severe DED. However, further studies are needed to confirm this.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT06119386.

Animal Models in Eye Research: Focus on Corneal Pathologies

The eye is a complex sensory organ that enables visual perception of the world. The dysfunction of any of these tissues can impair vision. Conduction studies on laboratory animals are essential to ensure the safety of therapeutic products directly applied or injected into the eye to treat ocular diseases before eventually proceeding to clinical trials. Among these tissues, the cornea has unique homeostatic and regenerative mechanisms for maintaining transparency and refraction of external light, which are essential for vision. However, being the outermost tissue of the eye and directly exposed to the external environment, the cornea is particularly susceptible to injury and diseases. This review highlights the evidence for selecting appropriate animals to better understand and treat corneal diseases, which rank as the fifth leading cause of blindness worldwide. The development of reliable and human-relevant animal models is, therefore, a valuable research tool for understanding and translating fundamental mechanistic findings, as well as for assessing therapeutic potential in humans. First, this review emphasizes the unique characteristics of animal models used in ocular research. Subsequently, it discusses current animal models associated with human corneal pathologies, their utility in understanding ocular disease mechanisms, and their role as translational models for patients.

Evaluation of the Clinical Characteristics of Dry Eye Secondary to Different Types of Liver Diseases

INTRODUCTION

This study compares the clinical characteristics of dry eye secondary to primary biliary cholangitis (PBC), drug-induced liver injury (DILI), and viral hepatitis B(HBV) to evaluate the ocular surface damage caused by different types of liver diseases.

METHODS

Thirty healthy people were included as control group. Sixty patients with dry eye secondary to different types of liver disease were included, including 19 cases of PBC, 18 cases of DILI, and 23 cases of HBV. All patients were evaluated by the SPEED questionnaire, corneal fluorescein staining (CFS), noninvasive tear breakup time (NIBUT), Schirmer I test (SIt), tear meniscus height test (TMH), the area of meibomian glands dropout (MG dropout), partial blinking rate (PBR), lipid layer thickness (LLT), meibum expressibility, and meibum quality.

RESULTS

There are statistical differences in ophthalmic examination results between different types of liver diseases and normal people (P < 0.05). Compared with DILI and HBV groups, the CFS score of PBC group score was higher (P < 0.05), the PBR was higher (P < 0.05), and the SIt was lower (P < 0.01). The TMH of PBC and DILI groups were significantly lower than the HBV group, and the difference was statistically significant (P < 0.05). Compared with the PBC group, the LLT of the DILI group decreased (P < 0.01). The area of meibomian glands dropout of the three groups had mild-to-moderate defects, but there was no significant statistical difference between groups (P > 0.05).The Meibum quality score in the DILI group was significantly higher than the HBV group (P < 0.05).

CONCLUSIONS

The PBC group was more prone to aqueous-deficient dry eye. The DILI group was more prone to obstructive meibomian gland dysfunction (MGD).The HBV group was more prone to nonobstructive MGD. The symptoms of dry eye in the PBC group are mild-to-moderate discomfort, but the degree of corneal damage is higher, indicating that the corneal sensitivity is reduced, which may be related to the high rate of partial blinking.

Comparative Evaluation of Matrix Metalloproteinase-9 Immunoassay and Tear Osmolarity Measurement for Diagnosing Severity of Dry Eye Disease

PURPOSE

To evaluate and compare the clinical efficacy of matrix metalloproteinase-9 (MMP-9) immunoassay and tear osmolarity measurement in diagnosing dry eye severity.

METHODS

Dry eye disease (DED) patients underwent diagnostic tests including MMP-9 assay, tear osmolarity measurement, fluorescein tear breakup time, ocular surface staining, anesthetized Schirmer test, Ocular Surface Disease Index questionnaire, and slit-lamp examination. The dry eye parameters were compared according to positive MMP-9 status and increased tear osmolarity. The correlation between dry eye profiles and MMP-9 positivity and high tear osmolarity was also analyzed.

RESULTS

Those who tested positive in MMP-9 immunoassay had significantly higher corneal fluorescein staining score and worse DED severity than those who tested negative. The intensity of MMP-9 positivity showed positive correlation with the corneal staining score and DED severity. However, DED patients with high tear osmolarity above 308 mOsm/L did not show significantly different dry eye signs and symptoms compared to those with lower tear osmolarity values. Tear osmolarity was associated with ocular surface staining score in severe DED patients.

CONCLUSIONS

MMP-9 positivity was associated with ocular surface staining and worse dry eye severity. Therefore, it may be used as a useful indicator of disease severity in conjunction to other diagnostic tests.

The effect of ocular rinse volume on surface irritation after povidone-iodine preparation for intravitreal injections: a randomized controlled trial

PURPOSE

To evaluate whether the volume of wash out rinse after povidone iodine (PI) application for intravitreal injections (IVI) affects patients' ocular surface irritation.

METHODS

This was a prospective, single-masked, randomized-controlled trial consisting of 142 subjects. A total of 51, 45, and 46 patients received 3-mL, 10-mL, and 15-mL of ocular rinse respectively. Reductions in the Ocular Surface Disease Index (OSDI) and the Standardized Patient Evaluation of Eye Dryness II (SPEED II) surveys, conducted before and at 24-72 h post-injection, were analyzed.

RESULTS

There was no statistical difference in objective dry eye findings of Schirmer test (p-value = 0.788), tear break-up time (p-value = 0.403), Oxford fluorescein grade (p-value = 0.424) between the study groups prior to injections. Dry eye symptoms as measured by reductions in the OSDI and SPEEDII scores were not different between the study groups (p-value = 0.0690 and 0.6227, respectively).

CONCLUSION

There is no difference in patients' ocular surface irritation between 3-mL, 10-mL, and 15-mL post injection rinse. Given the large number of IVIs performed, modification of practice patterns based on these findings could lead to significant reduction in global cost burden for IVIs.

Ocular instillation of conditioned medium from mesenchymal stem cells is effective for dry eye syndrome by improving corneal barrier function

Dry eye syndrome (DES) is a chronic ocular disease that induces epithelial damage to the cornea by decreasing tear production and quality. Adequate treatment options have not been established for severe DES such as Sjogren's syndrome due to complicated pathological conditions. To solve this problem, we focused on the conditioned medium of human adipose-derived mesenchymal stem cells (hAdMSC-CM), which have multiple therapeutic properties. Here, we showed that hAdMSC-CM suppressed Benzalkonium Chloride (BAC)-induced cytotoxicity and inflammation in human corneal epithelial cells (hCECs). In addition, hAdMSC-CM increased the expression level and regulated the localisation of barrier function-related components, and improved the BAC-induced barrier dysfunction in hCECs. RNA-seq analysis and pharmacological inhibition experiments revealed that the effects of hAdMSC-CM were associated with the TGFβ and JAK-STAT signalling pathways. Moreover, in DES model rats with exorbital and intraorbital lacrimal gland excision, ocular instillation of hAdMSC-CM suppressed corneal epithelial damage by improving barrier dysfunction of the cornea. Thus, we demonstrated that hAdMSC-CM has multiple therapeutic properties associated with TGFβ and JAK-STAT signalling pathways, and ocular instillation of hAdMSC-CM may serve as an innovative therapeutic agent for DES by improving corneal barrier function.

Dry eye in Parkinson's disease: a narrative review

In Parkinson's disease (PD) patients, a wide range of ocular and visual disorders are present. Tear film instability, inflammation and dysfunction of the ocular surface, and the presence of symptoms of visual disturbance characterize dry eye, a multifactorial disease of the ocular surface. Based on a literature search, we discuss the frequency, pathogenesis, and influence on the quality of life of patients with dry eye in Parkinson's disease. Furthermore, we review the available means of diagnosis and management of dry eye. An improvement in awareness and recognition of dry eye is needed to provide suitable, personalized therapeutic options for PD patients, aiming to improve their quality of life, independence, and safety.

Evaluation of Therapeutic Capability of Emustil Drops against Tear Film Complications under Dry Environmental Conditions in Healthy Individuals

Background and Objectives: Dry eye disease (DED) is a multifactorial ailment of the tears and ocular surface. The purpose of this study was to assess the tear film physiology under controlled dry environmental conditions and compare the efficacy of oil-in-water emulsion drops on tear film parameters in protection and relief treatment modalities under low-humidity conditions. Emustil eye drops were used after exposure to a low-humidity environment in the relief method, whereas, in the protection method, the drops were applied before exposure to low humidity. Materials and Methods: 12 normal male subjects (mean age 34.0 ± 7.0 years) were exposed to ultra-dry environmental conditions. A number of tear film measurements were carried out under desiccating environmental conditions in a controlled environment chamber (CEC), where the chamber temperature sat at 21 °C with a relative humidity (RH) of 5%. Keeler's TearScope Plus and an HIRCAL grid were used to assess the tear break-up time and lipid layer thickness (LLT), and the evaporation rate was evaluated using a Servomed EP3 Evaporimeter. Results: LLT measurements showed that the dry environment affected LLT significantly (p = 0.031). The median grade of LLT dropped from grade 3 (50-70 nm) at 40% RH to grade 2 (13-50 nm) at 5% RH. A significant increase in LLT was seen after both modes of treatment, with a median LLT grade of 3 when the Emustil was used for both protection (p = 0.004) and relief (p = 0.016). The mean tear evaporation rate in normal environmental conditions (40%) was 40.46 ± 11.80 g/m²/h (0.11 µL/min) and increased sharply to 83.77 ± 20.37 g/m²/h (0.25 µL/min) after exposure to the dry environment. A minimal decrease in tear film evaporation rate was seen in relief; however, statistical tests showed that the decrease in tear film evaporation rate was not significant. Mean NITBUT dropped from 13.6 s at 40% RH to 6.6 s at 5% RH (p = 0.002). All NITBUT measurements at 5% RH (with or without the instillation of Emustil) were significantly lower than those at 40%. The instillation of Emustil at 5% RH resulted in a significant improvement in NITBUT for protection (p = 0.016) but this was not the case for relief (p = 0.0.56). Conclusions: A control environmental chamber (CEC) enables the analysis of tear film parameters comparable to those found in dry eye patients. This enables us to examine the capability of oil in emulsion drops to manage tear film disruption in healthy individuals. This study suggests that using Emustil oil-in-water emulsion before exposure to a dry environment should be advocated for people who work in dry environments.

Intraobserver Repeatability Assessment of the S390L Firefly WDR Slitlamp in Patients With Dry Eye Disease: Objective, Automated, and Noninvasive Measures

OBJECTIVES

To assess the intraobserver repeatability of automated, objective, and noninvasive measures obtained with the S390L Firefly WDR slitlamp.

METHODS

This cross-sectional study included 50 eyes of patients with dry eye disease with a mean age of 55.06±12.96 years. Three consecutively repeated measures of the following variables were obtained: first noninvasive break-up time (F-NIBUT), average noninvasive break-up time (A-NIBUT), tear meniscus height, tear meniscus area (TMA), nasal ciliary hyperemia (NCIH), temporal ciliary hyperemia (TCIH), nasal conjunctival hyperemia (NCOH), temporal conjunctival hyperemia (TCOH), upper loss area meibomian gland (U-LAMG), lower loss area meibomian gland (L-LAMG), upper meibomian gland dysfunction grade (U-MGD grade), and lower meibomian gland dysfunction grade (L-MGD grade). Intraobserver repeatability was estimated with coefficient of variation (CoV), intrasubject standard deviation (SD) (S w ), and Bland-Altman plots.

RESULTS

All variables showed no statistically significant differences in the repeated-measures analysis except for L-MGD grade ( P =0.045). F-NIBUT and A-NIBUT obtained the highest CoV with an average value of 0.48±0.41 [0.02-1.00] and 0.34±0.25 [0.02-1.00], respectively. The remaining variables showed CoVs between 0.04±0.11 [0.00-0.43] and 0.18±0.16 [0.00-0.75]. A-NIBUT, TMA, NCOH, and L-LAMG obtained an S w of 2.78s, 0.21 mm 2 , <0.001, and 4.11%, respectively. Bland-Altman plots showed a high level of agreement between pairs of repeated measures.

CONCLUSION

The S390L Firefly WDR slitlamp has moderate intraobserver repeatability for F-NIBUT and A-NIBUT, which suggests that F-NIBUT and A-NIBUT are tests with high variability. The remaining variables show satisfactory intraobserver repeatability.

Age-Related Differences in the Clinical Patterns of Ocular Graft-Versus-Host Disease

Objectives

To evaluate age-related differences in clinical patterns of ocular graft-versus-host disease (GVHD).

Materials and Methods

In this cross-sectional study, patients diagnosed with ocular GVHD were evaluated in two groups: Group I included those aged 18 years or younger and Group II included those over 18 years of age. Demographic and clinical information were recorded and compared between the groups.

Results

Forty eyes of 20 patients were included (11 patients were in Group I and 9 patients were in Group II). Follow-up was at least 6 months. All patients had burning, dryness, and foreign body sensation. Conjunctival hyperemia, cicatricial conjunctivitis, and limbal stem cell disease (LSCD) was observed more frequently in Group II. In addition to non-preserved artificial tears, cyclosporine A 0.05% (65%) and autologous/allogeneic serum eye drops (80%) were given and silicone plugs were inserted (28%). In Group I, an improvement in GVHD scoring and best corrected visual acuity was observed after 6 months of treatment (p<0.0005).

Conclusion

In ocular GVHD, conjunctival cicatrization and limbal stem cell deficiency might be observed more often in adults. Topical cyclosporine, autologous/allogenic serum drops, and punctal plugs are helpful in moderate or more severe cases. With early diagnosis and treatment, an improvement in clinical signs and visual acuity might be observed, particularly in younger patients.

Novel drug delivery systems for the management of dry eye

Dry eye disease (DED) is a frequently observed eye complaint, which has recently attracted considerable research interest. Conventional therapy for DED involves the use of artificial tear products, cyclosporin, corticosteroids, mucin secretagogues, antibiotics and nonsteroidal anti-inflammatory drugs. In addition, ocular drug delivery systems based on nanotechnology are currently the focus of significant research effort and several nanotherapeutics, such as nanoemulsions, nanosuspensions, microemulsions, liposomes and nanomicelles, are in clinical trials and some have FDA approval as novel treatments for DED. Thus, there has been remarkable progress in the design of nanotechnology-based approaches to overcome the limitations of ophthalmic formulations for the management of anterior eye diseases. This review presents research results on diagnostic methods for DED, current treatment options, and promising pharmaceuticals as future therapeutics, as well as new ocular drug delivery systems.

Evaluation of the Regenerative Potential of Platelet-Lysate and Platelet-Poor Plasma Derived from the Cord Blood Units in Corneal Wound Healing Applications: An In Vitro Comparative Study on Corneal Epithelial Cells

Background: Cord blood platelet lysate (CB-PL) and cord blood platelet poor plasma (CB-PPP) have been applied with success in wound healing applications. Pathologies such as Sjogrens’s Syndrome (SS) and chronic graft versus host disease (cGVHD) can lead to severe ophthalmology issues. The application of CB-PL and CB-PPP may be strongly considered for damaged cornea healing. This study aimed to the evaluation of the beneficial properties of CB-PL and CB-PPP in corneal wound healing applications. Methods: Initially, the CB-PL and CB-PPP were produced from donated cord blood units (CBUs), followed by biochemical analysis. Corneal epithelial cells (CECs) were isolated from wistar rats and then cultured with medium containing 20% v/v either of CB-PL or CB-PPP. To define the impact of CB-PL and CB-PPP, biochemical, morphological analysis, scratch-wound assays, and immunoassays in CECs were performed. Results: CB-PL and CB-PPP were characterized by good biochemical parameters, regarding their quality characteristics and biomolecule content. CECs’ morphological features did not change after their cultivation with CB-PL or CB-PPP. A scratch wound assay and molecular analysis of CECs expanded with CB-PL indicated higher migratory capacity compared to those cultured with CB-PPP. Conclusion: CB-PL and CB-PPP exhibited good properties with respect to cell migration and proliferation, and could be considered an alternative source for eye drop production, to possibly be used in cornea wound healing applications.

Psychosocial Impact of Demodex Blepharitis

Purpose

To evaluate the impact of Demodex blepharitis on patients’ daily activities and quality of life.

Patients and Methods

In this multicenter, observational, prospective, IRB-approved study, 311 Demodex blepharitis patients aged ≥18 years were included. Demodex blepharitis was diagnosed based on the presence of ≥1.0 mite per lash (upper and lower eyelids combined), >10 collarettes on the upper lashes, and at least mild lid margin erythema of the upper eyelid in at least one eye. All patients were asked to complete a questionnaire about their symptoms, daily activities, quality of life, and management approaches, and descriptive statistics were used to analyze the responses.

Results

More than half the patients had been experiencing symptoms of blepharitis for ≥4 years. The three most frequent and bothersome symptoms experienced by patients were dry eyes, itchiness, and irritation. Nearly half the patients (47%) responded that they were conscious of their eyes all day, and 23% said that they were constantly worrying about their eyes. Other activities that were negatively affected included difficulty driving at night (47%), additional time needed for daily hygiene routine (30%), and difficulty in wearing eye make-up (in 34% of females). While all subjects had objective signs of Demodex blepharitis confirmed by an eye care provider, 58% said they had never previously been diagnosed with blepharitis. The most commonly used management approaches for Demodex blepharitis were artificial tears (47%), warm compresses (32%), and lid wipes (14%).

Conclusion

Demodex blepharitis has a significant negative impact on daily activities and the mental and physical well-being of afflicted patients.

Olive Pomace Phenolic Compounds: From an Agro-Industrial By-Product to a Promising Ocular Surface Protection for Dry Eye Disease

Dry eye (DED) is a prevalent disease with immune-mediated inflammation as the principal pathophysiological etiology. Olive pomace, the major by-product of the olive oil industry, is rich in high-value polyphenols. Their anti-inflammatory and immunomodulatory activities were determined on human CD4+ T cells (hTCD4+) and in a DED animal model. The viability of hTCD4+ cells isolated from peripheral blood and activated with phytohemagglutinin-M was evaluated after treatment for 48 h with an olive pomace extract (OPT3, 0.10–0.40 mg/mL) and its major compound, hydroxytyrosol (25–100 μM). Regarding the DED animal model, 100 μM hydroxytyrosol, 0.20 mg/mL OPT3, or vehicle (borate buffer) were topically administered to 14 days-desiccating stress-exposed (constant airflow/scopolamine administration) C57BL/6 mice. Tear volume, corneal fluorescein staining (CFS), CD4+, and CD8+ T cell count in lymph nodes (flow cytometry), and IP-10 and TNF-α gene expression (qRT-PCR) in the cornea, conjunctiva, and lacrimal glands were evaluated. OPT3 (0.2–0.4 mg/mL) and hydroxytyrosol (100 μM) significantly reduced hTCD4+ proliferation. In mice, both treatments reduced lacrimal gland IP-10 gene expression. OPT3 also decreased CFS, and conjunctival IP-10 and corneal TNF-α gene expression. In lymph nodes, hydroxytyrosol reduced CD3+, OPT3, and CD8+ count. Thus, a high-value application as a promising DED protection was proposed for olive pomace.

Lacrimal gland regeneration: The unmet challenges and promise for dry eye therapy

DED (Dry eye disease) is a common multifactorial disease of the ocular surface and the tear film. DED has gained attention globally, with millions of people affected.. Although treatment strategies for DED have shifted towards Tear Film Oriented Therapy (TFOT), all the existing strategies fall under standard palliative care when addressed as a long-term goal. Therefore, different approaches have been explored by various groups to uncover alternative treatment strategies that can contribute to a full regeneration of the damaged lacrimal gland. For this, multiple groups have investigated the role of lacrimal gland (LG) cells in DED based on their regenerating, homing, and differentiating capabilities. In this review, we discuss in detail therapeutic mechanisms and regenerative strategies that can potentially be applied for lacrimal gland regeneration as well as their therapeutic applications. This review mainly focuses on Aqueous Deficiency Dry Eye Disease (ADDE) caused by lacrimal gland dysfunction and possible future treatment strategies. The current key findings from cell and tissue-based regenerative therapy modalities that could be utilised to achieve lacrimal gland tissue regeneration are summarized. In addition, this review summarises the available literature from in vitro to in vivo animal studies, their limitations in relation to lacrimal gland regeneration and the possible clinical applications. Finally, current issues and unmet needs of cell-based therapies in providing complete lacrimal gland tissue regeneration are discussed.

Lab-on-a-Contact Lens: Recent Advances and Future Opportunities in Diagnostics and Therapeutics

The eye is one of the most complex organs in the human body, containing rich and critical physiological information (e.g., intraocular pressure, corneal temperature, and pH) as well as a library of metabolite biomarkers (e.g., glucose, proteins, and specific ions). Smart contact lenses (SCLs) can serve as a wearable intelligent ocular prosthetic device capable of noninvasive and continuous monitoring of various essential physical/biochemical parameters and drug loading/delivery for the treatment of ocular diseases. Advances in SCL technologies and the growing public interest in personalized health are accelerating SCL research more than ever before. Here, the current status and potential of SCL development through a comprehensive review from fabrication to applications to commercialization are discussed. First, the material, fabrication, and platform designs of the SCLs for the diagnostic and therapeutic applications are discussed. Then, the latest advances in diagnostic and therapeutic SCLs for clinical translation are reviewed. Later, the established techniques for wearable power transfer and wireless data transmission applied to current SCL devices are summarized. An outlook, future opportunities, and challenges for developing next-generation SCL devices are also provided. With the rise in interest of SCL development, this comprehensive and essential review can serve as a new paradigm for the SCL devices.

Current trends in pharmaceutical treatment of Dry Eye Disease: A review

Dry eye disease (DED), keratoconjunctivitis sicca or dysfunctional tear syndrome, is the most prevalent ophthalmic disease which affects a substantial segment of people worldwide with increasing frequency. It is considered a multifactorial disease of the ocular surface and tear film, characterized by a variation of signs and symptoms. The symptoms range from mild to severe itching, burning, irritation, eye fatigue, and ocular inflammation that may lead to potential damage to the cornea, conjunctiva and even vision loss. Correspondingly, depending on the different manifestations and pathophysiology, the treatment must be tailored specifically to each patient by targeting the specific mechanisms implicated in their disease. Currently, there are several medical products and techniques available or under investigation for the treatment of DED. The present article focused on the pathophysiology of DED, the new diagnostic approach and the recently developed drug delivery systems or devices reducing the progress of the disease and treating the causes.

Generation of 3D lacrimal gland organoids from human pluripotent stem cells

Lacrimal glands are the main exocrine glands of the eyes. Situated within the orbit, behind the upper eyelid and towards the temporal side of each eye, they secrete lacrimal fluid as a major component of the tear film. Here we identify cells with characteristics of lacrimal gland primordia that emerge in two-dimensional eye-like organoids cultured from human pluripotent stem cells¹. When isolated by cell sorting and grown under defined conditions, the cells form a three-dimensional lacrimal-gland-like tissue organoid with ducts and acini, enabled by budding and branching. Clonal colony analyses indicate that the organoids originate from multipotent ocular surface epithelial stem cells. The organoids exhibit notable similarities to native lacrimal glands on the basis of their morphology, immunolabelling characteristics and gene expression patterns, and undergo functional maturation when transplanted adjacent to the eyes of recipient rats, developing lumina and producing tear-film proteins.

The effect of punctal plugs in reducing ocular surface irritation after povidone-iodine preparation of intravitreal injection-a randomized trial

PURPOSE

To evaluate the utility of dissolvable collagen punctal plugs (CPP) in reducing ocular surface irritation after intravitreal injections (IVI).

METHODS

Sixty-four subjects in the experimental group received CPP after intravitreal injections. Sixty-two controls did not receive CPP. Reductions in the Ocular Surface Disease Index© (OSDI) and Standardized Patient Evaluation of Eye Dryness II (SPEED II) scores were analysed.

RESULTS

Dry eye symptoms, as measured by reductions from the pre- to post-injection OSDI (p = 0.137) and SPEED II (p = 0.381) scores, did not significantly differ between the two groups. In sub-group analysis, patients with objective findings of dry eyes had significant improvement in their symptoms (p = 0.046) with CPP. The effect of CPP is not significant in those without dry eyes (p = 0.27).

CONCLUSION

CPPs were not effective in reducing post-injection ocular irritation in patients with no or only mild dry eye symptoms. CPPs improved patients' post-injection comfort levels in those who had moderate-to-severe symptoms and objective findings of dry eye. Though costly CPP could be considered in selective patients. A standardized eye rinse could be a simple, efficacious, and cost-effective way to reduce post-injection ocular irritation; however, more studies are needed.

Comparison of Different Mass Spectrometry Workflows for the Proteomic Analysis of Tear Fluid

The tear film is a multi-layer fluid that covers the corneal and conjunctival epithelia of the eye and provides lubrication, nutrients, and protection from the outside environment. Tear fluid contains a high concentration of proteins and has thus been recognized as a potential source of biomarkers for ocular disorders due to its proximity to disease sites on the ocular surface and the non-invasive nature of its collection. This is particularly true in the case of dry eye disease, which directly impacts the tear film and its components. Proteomic analysis of tear fluid is challenging mainly due to the wide dynamic range of proteins and the small sample volumes. However, recent advancements in mass spectrometry have revolutionized the field of proteomics enabling unprecedented depth, speed, and accuracy, even with small sample volumes. In this study using the Orbitrap Fusion Tribrid mass spectrometer, we compared four different mass spectrometry workflows for the proteomic analysis of tear fluid collected via Schirmer strips. We were able to establish a method of in-strip protein digestion that identified >3000 proteins in human tear samples from 11 healthy subjects. Our method offers a significant improvement in the number of proteins identified compared to previously reported methods without pooling samples.

Biophysical properties of tear film lipid layer I. Surface tension and surface rheology

Tear film lipid layer (TFLL) is the outmost layer of the tear film. It plays a crucial role in stabilizing the tear film by reducing surface tension and retarding evaporation of the aqueous layer. Dysfunction of the TFLL leads to dysfunctional tear syndrome, with dry eye disease (DED) being the most prevalent eye disease, affecting 10%-30% of the world population. To date, except for treatments alleviating dry eye symptoms, effective therapeutic interventions in treating DED are still lacking. Therefore, there is an urgent need to understand the biophysical properties of the TFLL with the long-term goal to develop translational solutions in effectively managing DED. Here, we studied the composition-function correlations of an artificial TFLL, under physiologically relevant conditions, using a novel experimental methodology called constrained drop surfactometry. This artificial TFLL was composed of 40% behenyl oleate and 40% cholesteryl oleate, representing the most abundant wax ester and cholesteryl ester in the natural TFLL, respectively, and 15% phosphatidylcholine and 5% palmitic-acid-9-hydroxy-stearic-acid (PAHSA), which represent the two predominant polar lipid classes in the natural TFLL. Our study suggests that the major biophysical function of phospholipids in the TFLL is to reduce the surface tension, whereas the primary function of PAHSA is to optimize the rheological properties of the TFLL. These findings have novel implications in better understanding the physiological and biophysical functions of the TFLL and may offer new translational insight to the treatment of DED.

Thermogels containing sulfated hyaluronan as novel topical therapeutics for treatment of ocular surface inflammation

The development of long lasting therapeutic agents is critically important for efficient treatment of chronic diseases. We herein report a rational strategy to develop a therapeutic thermogel featured with prolonged anti-inflammatory and corneal-protective effects. Specifically, a hyaluronic acid with different sulfation degrees and an amine-terminated poly(N-isopropylacrylamide) are conjugated to achieve the thermogels. In vitro studies reveal that the thermogels are highly biocompatible to statens seruminstitut rabbit cornea cells and their anti-inflammatory properties are strongly dependent on the sulfation degree. In a rabbit model of ocular inflammation, single-dose topical administration of a thermogel formulation could repair defects in corneal epithelium (∼99% thickness restored), prevent corneal cell apoptosis (∼68.3% cells recovered), and suppress ocular surface inflammation (∼4-fold decrease) for a follow-up period of 7 days. This high treatment efficacy of the thermogel can be attributed to its potent inhibition in selectin-mediated leukocyte infiltration as well as effective corneal protection. These findings show a great promise for topical treatment of ocular inflammation and advancement of ophthalmic formulations using the bioactive thermogel as a therapeutic component that is not rapidly cleared from the eye and thus considerably reduces administration times.

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Sulfated hyaluronan thermogels served as intrinsic therapeutic agents.

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Thermogels exert inhibitory effects on selectin-mediated leukocyte infiltration.

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Sulfation degree is a key to achieve superior therapeutic thermogels.

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Highly sulfated agent reveals potent anti-inflammatory/corneal-protective effects.

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Single dose reduces corneal inflammation by 4-folds at 7 days post-instillation.

Association Between Dry Eye Syndrome and Osteoarthritis Severity: A Nationwide Cross-Sectional Study (KNHANES V)

OBJECTIVE

Recently, several researchers reported an association between osteoarthritis and dry eye syndrome (DES) and suggested that they may be related to central sensitization. We investigated the association between DES, osteoarthritis pain, and radiographic severity.

DESIGN

A nationwide, cross-sectional study.

SETTING

The Fifth Korean National Health and Nutrition Examination Survey.

SUBJECTS

8,664 participants in this survey.

METHODS

Osteoarthritis-associated radiographic changes were evaluated by trained radiologists. Multivariable logistic regression was performed to examine the relationship between osteoarthritis pain, radiographic severity, and DES. The odds ratios (ORs) of DES were analyzed in accordance with the presence of osteoarthritis-associated factors.

RESULTS

Radiographic knee osteoarthritis was significantly associated with lower ORs for DES (OR = 0.80, P = 0.046, for diagnosed/self-reported DES; OR = 0.84, P = 0.034, for symptoms of DES). Knee pain or stiffness was significantly associated with higher ORs for DES (OR = 1.28, P = 0.020, for diagnosed/self-reported DES; OR = 1.29, P = 0.003, for symptoms of DES). In patients with symptomatic osteoarthritis, DES was not significantly associated with radiographic severity of osteoarthritis. In patients with nonsymptomatic radiographic osteoarthritis, DES was inversely related with radiographic severity (Ptrend = 0.012 for diagnosed/self-reported DES; Ptrend < 0.001 for symptoms of DES).

CONCLUSIONS

Radiographic osteoarthritis showed a significant association with decreased DES. Patients with less pain and severe radiographic OA were more likely to have less DES. Our results suggest that the degree of pain caused by osteoarthritis and central sensitization may be closely associated with DES.

Economic burden and loss of quality of life from dry eye disease in Canada

Objective

To describe the direct and indirect cost estimates of dry eye disease (DED), stratified by disease severity, and the impact of DED on quality of life (QoL) in Canadian patients.

Methods and analysis

A prospective, multicentre, observational, cross-sectional study was conducted at six sites across Canada. Eligible patients completed a 20 min survey on demography, general health, disease severity, QoL and direct (resource utilisation and out-of-pocket expenses for the past 3–24 months) and indirect costs (absenteeism and presenteeism based on Work Productivity and Activity Impairment questionnaire responses). Subgroup analyses were performed according to DED severity and presence of Sjögren’s syndrome.

Results

Responses from 146 of 151 participants were included in the analysis. DED was rated as moderate or severe by 19.2% and 69.2% of patients, respectively. Total mean annual costs of DED were $C24 331 (Canadian dollars) per patient and increased with patient-reported disease severity. Mean (standard deviation [SD]) indirect costs for mild, moderate and severe disease were $C5961 ($C6275), $C16 525 ($C11 607), and $C25 485 ($C22,879), respectively. Mean (SD) direct costs were $C958 ($C1216), $C1303 ($C1574) and $C2766 ($C7161), respectively. QoL scores were lowest in patients with Sjögren’s syndrome (8.2% of cohort) and those with severe DED.

Conclusion

This study provides important insights into the negative impact of DED in a Canadian setting. Severe DED was associated with higher direct and indirect costs and lower QoL compared with those with mild or moderate disease. Increased costs and poorer QoL were also evident for patients with DED plus Sjögren’s syndrome versus DED alone.

Role of the Water Gradient Structure in Inhibiting Thin Aqueous Layer Break in Silicone Hydrogel-Soft Contact Lens

Purpose

Soft contact lenses (SCLs) are effective for refractive error correction, but prolonged wear triggers discomfort and discontinuation. This study investigates whether water gradient technology of delefilcon A-based SCLs improve tear film dynamics.

Methods

This retrospective observational study included 50 asymptomatic delefilcon A or narafilcon A users. Data on thin aqueous layer break (TALB; %), noninvasive tear break-up time (NIBUT), tear meniscus height (TMH; mm), subjective dryness, and higher-order aberrations (HOAs) were collected. Measurements of the bare eye, the SCL-worn eye after 15 minutes (visit 1 [v1]) and 30 ± 5 days after v1 after SCL was worn for ≥5 hours (visit 2 [v2]) were recorded.

Results

TALB was significantly reduced in the delefilcon A group compared to the narafilcon A group (33.3% vs. 85.5% at v1; P < 0.0001 and 31.7% vs. 80.4% at v2; P < 0.0001). The NIBUT was also significantly higher in the former (4.2 ± 2.1 seconds vs. 2.9 ± 1.5 at v1; P < 0.01 and 4.1 ± 2.3 seconds vs. 2.7 ± 1.6 seconds at v2; P < 0.01) across both visits. The TMH was significantly reduced in the former in both v1 and v2. The total ocular HOAs were significantly lower in the former at v1 (P < 0.001) and v2 (P < 0.05) compared to the bare eye.

Conclusions

The water gradient technology of delefilcon A reduces TALB and increases NIBUT.

Translational Relevance

The use of water gradient technology improves tear film dynamics and alleviate pathological break-up pattern, improving lens performance.

Ocular Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is characterized by repetitive episodes of paused breathing during sleep, which in turn induces transient nocturnal hypoxia and hypercapnia. The high prevalence of OSA and its associated health consequences place a heavy burden on the healthcare system. In particular, the consequent episodic oxygenic desaturation/reoxygenation series and arousals from sleep in patients with OSA have the potential to trigger oxidative stress, elevated systemic inflammatory responses, and autonomic dysfunction with sympathetic activation. Given these adverse side-effects, OSA is highly correlated to many eye diseases that are common in everyday ophthalmic practices. Some of these ocular consequences are reversible, but they may permanently threaten a patient’s vision if not treated appropriately. Here, this article seeks to review the ocular consequences and potential pathophysiologic associations in patients with OSA. Understanding these OSA-related eye diseases may help clinicians provide comprehensive care to their patients.

Progress in the use of plasma rich in growth factors in ophthalmology: from ocular surface to ocular fundus

Introduction: The use of blood derivatives and especially Plasma rich in growth factors (PRGF), for regenerative purposes has been a common trend along the last decades in the field of oral surgery, dermatology, orthopedics, and more recently in ophthalmology.Areas covered: PRGF is a type of platelet-rich plasma that is being explored for the treatment of ocular injuries. The present review article highlights 50 ophthalmology-related publications about the application of PRGF in the treatment of acute and chronic pathologies in ophthalmology as well as most relevant challenges and future prospects.Expert opinion: PRGF technology provides a wide range of formulations that can be used therapeutically in many different acute and chronic ocular pathologies. In addition to eye drops enriched with autologous growth factors, PRGF enables the preparation of both immunologically safe and fibrin-based formulations. Recent advances in the field have promoted PRGF storage for 12 months under freezing conditions, its daily use for 7 days at room temperature and the freeze-dried formulation. The thermally treated immunosafe formulation has shown promising clinical results for the treatment of several diseases such as Sjögren syndrome, graft versus host disease or cicatrizing conjunctivitis. In addition, several fibrin formulations have been preclinically evaluated and clinically incorporated as an adjuvant to ocular surface or glaucoma surgeries, dermal fat graft procedures, limbal stem cell expansion and retinal surgeries. The present review explores the latest scientific and clinical data, current challenges, and main prospects of this technology for the treatment of several ocular injuries.

Ocular Findings of Pediatric Dry Eye Related to Graft-Versus-Host Disease

Objectives:

To evaluate the frequency and findings of dry eye associated with ocular graft-versus-host disease (GVHD) in pediatric hematopoietic stem cell transplantation (HSCT) patients.

Materials and Methods:

Retrospectively the records of pediatric patients with ocular GVHD were evaluated and ophthalmologic examination findings as well as Schirmer test results, tear film break-up time, and corneal staining grades were recorded. In severe dry eye patients topical cyclosporine-A was prescribed and the results were evaluated.

Results:

GVHD was detected in 51 (23.4%) of 218 HSCT patients, 4 of whom died during follow-up. Thirty (63.8%) of the remaining 47 patients had chronic ocular GVHD and 4 patients with severe dry eye were treated with topical cyclosporine-A with a median follow-up of 12.1 months. Severe dry eye symptoms and findings significantly improved in 2 patients. However, 1 patient had to stop treatment due to side effects.

Conclusion:

In children, chronic ocular GVHD is a common finding of GVHD after HSCT. Therefore, these patients should be examined periodically for dry eye.

Apparent time‐dependent differences in inferior tear meniscus height in human subjects with mild dry eye symptoms

PURPOSE

The aim of the study was to track the volume of tears contained in the inferior tear meniscus over the course of the day in subjects with symptoms of mild dry eye and a control asymptomatic group.

METHODS

Forty non-contact lens-wearing subjects (aged 27 +/- 6 years) were enrolled in this investigator-masked study. They were divided into 'dry eye' (DE) and 'non-dry eye' (NDE) individuals based on their responses to the Allergan Subjective Evaluation of Symptoms of Dryness (SESOD) questionnaire. Measurement of the tear meniscus height (TMH) was undertaken on the centre of the right eye at 9:00 am, noon, 3:00 pm, 6:00 pm and 9:00 pm on the lower lid using a non-contact, non-invasive optical coherence tomographer (OCT). The TMH was determined from scanned images using customised software.

RESULTS

A monotonous and significant reduction in the central TMH occurred over the course of the day in both groups (p < 0.05), with the values constantly decreasing (NDE = 0.162 to 0.125 mm; DE = 0.154 to 0.121 mm). While the TMH values in the DE group were always lower than the NDE group, these were not significantly different at any time (p > 0.05).

CONCLUSIONS

A diurnal reduction in tear volume, as assessed by evaluation of the inferior TMH, may be one of the reasons responsible for the common increase in end-of-day ocular dryness symptoms reported by many patients in clinical practice.

Efficacy, Safety, and Tolerability of a Novel Cyclosporine, a Formulation for Dry Eye Disease: A Multicenter Phase II Clinical Study

PURPOSE

The purpose of this study was to explore the efficacy, safety, and tolerability of a novel cyclosporine formulation for dry eye disease (DED).

METHODS

This is an exploratory, multicenter, single-blind, randomized, positive-controlled Phase II clinical trial between cyclosporine ophthalmic gel (CyclAGel) and an open-label comparator (Restasis, positive control). A total of 240 eligible patients with moderate to severe DED were randomized to 4 study groups: CyclAGel 0.05%/once daily (QD) (n = 59), CyclAGel 0.05%/BID (n = 60), CyclAGel 0.1%/QD (n = 60), and Restasis 0.05%/BID (n = 61). After receiving BID dosing of hypromellose eye drops during a 2-week run-in period, patients were randomized to the respective treatment group and dosed QD or BID for 12 weeks. Efficacy was assessed based on a number of sign and symptom end points, including eye dryness score (visual analog scale), 6 other parameters of symptoms for dryness (burning/stinging, itching, foreign body sensation, discomfort, sensitivity to light, and pain), and corneal fluorescein staining. The Schirmer test was used to assess dry eye symptoms (visual analog scale severity) at visit 3 (week 2), visit 4 (week 6), and visit 5 (week 12).

FINDINGS

CyclAGel showed a consistent improvement in eye dryness score and the 6 other parameters of symptoms for dryness, corneal fluorescein staining, breakup time, and Schirmer test scores compared with Restasis over the 12-week treatment period. However, there were no statistically significant differences between CyclAGel and Restasis after baseline corrections were made, and the results of the full analysis set remained consistent with those of the per-protocol set (P > 0.05). Moreover, each CyclAGel-treated group (0.05%/QD, 0.05%/BID, and 0.1%/QD) exerted better effects than the Restasis group, and CyclAGel 0.05%/QD showed the most significant improvement. The number of ocular-related treatment-emergent adverse events was low in all treatment groups, with no serious drug-related treatment-emergent adverse events.

IMPLICATIONS

CyclAGel showed excellent safety, tolerability, and comfort profiles at 2 concentrations and frequency in moderate to severe DED.

Impact of corneal refractive surgery on the precorneal tear film

Corneal refractive surgeries are one of the commonly performed procedures for correction of refractive errors. Tear film abnormality is the most common postoperative complication of corneal refractive surgeries. Consequently, these procedures represent a clinically significant cause of dry eye disease. The mechanisms which lead to dry eye disease include corneal sensory nerve dysfunction, ocular surface desiccation, glandular apoptosis and ocular surface inflammation. Although transient tear film abnormalities occur in almost all patients following surgery, patients with pre-existing dry eye symptoms or dry eye disease are at significant risk of developing more severe or long-term ocular surface disease. As such, careful patient selection and preoperative evaluation is essential to ensuring successful surgical outcomes. This is particularly important with LASIK which has the strongest association with dry eye disease. Appropriate surface lubrication and anti-inflammatory therapy remains the cornerstone treatment. Timely and effective management is important to facilitate visual rehabilitation and reduce the risk of secondary complications. In this review we describe the causes, pathophysiology, risk factors, manifestations, and management of tear film dysfunction and dry eye disease following corneal refractive surgery.

[Recurrent corneal erosion: modern view of the problem]

Recurrent corneal erosion syndrome (RCES) is a common chronic disease associated with repeated episodes of epithelial disruption and is characterized by sudden onset of sharp pain in the eye, usually at night or upon waking, as well as redness, photophobia and lacrimation. The cause of the disease is considered to be impaired adhesion of the epithelial layer to the stroma, which is a consequence of abnormal regeneration of the basement membrane of corneal epithelium. A number of biological factors, including inflammatory mediators and proteinases in high concentrations, contribute to the destruction of the formed adhesion complexes. The basis of RCES diagnosis is characteristic medical history and biomicroscopy. An area of epithelium absence can be detected under direct illumination - more often in paracentral view - mainly in the lower third of the cornea, where an area of loose and irregular epithelium with microcysts or grayish inclusions can be seen. There may also be a card-like or «fingerprint» pattern. First of all, it is necessary to differentiate RCES from infectious lesions, which require a fundamentally different treatment regimen. It is believed that the first stage of treatment should include lubricants, drugs that promote epithelialization, inhibitors of matrix metalloproteinases and lipases. The «second line» of conservative treatment can include blood derivatives. If conservative therapy is ineffective, it is advised to use phototherapeutic keratectomy (PTK) or perform diamond burr polishing of Bowman's layer. The choice of a method for treating recurrent erosion should be based on the effectiveness of drug therapy, frequency of recurrence, duration of the disease, severity of clinical symptoms, availability of specific ophthalmic equipment and experience with it.

sPLA2-IIa participates in ocular surface inflammation in humans with dry eye disease

PURPOSE

To determine the roles of secretory phospholipase A2-IIa (sPLA₂-IIa) in the inflammatory responses of the compromised ocular surface.

METHODS

Conjunctival impression cytology (IC) samples and tears were collected from patients with mild to severe non-Sjogren's dry eye disease (DED) and normal controls. The IC samples were analyzed for transcription of sPLA₂-IIa and inflammatory cytokine/chemokine genes using quantitative real-time RT-PCR (qRT²-PCR) and pathway-focus PCR-array. The tear samples were analyzed for 13 inflammatory cytokines and chemokines with Millipore 13-Plex kit. Finally, sPLA2-IIa-treated human conjunctival epithelial cell (HCjE) cultures were analyzed with a pathway-focused PCR array.

RESULTS

Transcription of sPLA2-IIa was significantly increased in severe DED patients as compared to those of mild DED patients and normal controls. The transcription of inflammatory cytokines (IL-1β, IL-4, IL-6, IL-17, TNF-α, IFN-γ), chemokines (IL-8, CXCL10, CXCL11, CXCL-14, CCR6, LTB) and matrix metalloproteinase 9 (MMP9) were simultaneously increased in the same IC samples of DED. Concentrations of IL-6 and IL-8 in tears were significantly higher in DED patients than those of the controls and positively correlated to DED severity scores. On the other hand, IL-2, IL-4, IL-10, IL-12 and IFN-γ were significantly lower in DED patients than those in the controls and inversely correlated to DEWS scores. Single treatment of sPLA2-IIa, IL-1β or TNF-α of HCjE cells induced minimal to no PGE2 production. When sPLA2-IIa was added to HCjE cells that were pre-treated with pro-inflammatory cytokines (TNF-α or IL-1β), significant stimulation of PGE2 production was observed, concurrent with the extensive transcriptional changes of many inflammatory cytokines/chemokines and their receptors.

CONCLUSION

sPLA₂-IIa activity was elevated and not only associated with inflammatory changes in DED patient samples, but was also found to cooperate with TNF- α and IL-1β to induce inflammatory response in human conjunctival epithelial cells. Understanding the roles of sPLA₂-IIa in ocular surface inflammation may lead to better strategies for the treatment of chronic inflammation associated with DED and other ocular inflammatory conditions.

Efficacy and retention of silicone punctal plugs for treatment of dry eye in patients with and without ocular graft-versus-host-disease

PURPOSE

To examine the retention rates and efficacy of silicone punctal plugs for the treatment of dry eye disease (DED) in patients with ocular graft-versus-host-disease (oGVHD) in comparison to dry eye disease due to non-oGVHD etiologies.

METHODS

We reviewed the case-records of 864 consecutive patients with DED who were symptomatic despite topical therapy and had silicone punctal plugs placed over an eight-year- period at a single academic center. We compared plug retention rates in oGVHD and non-oGVHD DED patients using Kaplan-Meier analyses. Furthermore, we analyzed changes in objective ocular surface parameters including tear breakup time (TBUT), Schirmer's test, and corneal fluorescein staining (CFS) score in plug-retaining patients at two-, six- and twelve-month follow-up.

RESULTS

Median age of dry eye patients was 58 years, and 606 (70%) of patients were women. In the cohort, 264 (31%) patients were diagnosed with oGVHD. Plug retention was significantly lower in oGVHD-DED patients compared to non-oGVHD-DED patients (p < 0.0001). We observed significant improvement in CFS scores in plug retaining-oGVHD and non-oGVHD DED patients at all time points. Tear break-up time was significantly prolonged at six- and twelve-months follow-up in non-oGVHD patients, whereas significant change in TBUT in oGVHD patients was recorded only at twelve months post plug placement. Schirmer's score improved significantly in plug retaining-non-oGVHD DED patients at six- and twelve-months follow-up, however no significant change was observed in Schirmer's score in oGVHD DED patients.

CONCLUSIONS

An improvement in ocular surface disease parameters was observed in both plug-retaining oGVHD and non-oGVHD DED patients. However, a majority of oGVHD DED patients spontaneously lost their punctal plugs within 90 days of placement. Therefore, regular follow-up after plug placement is recommended to detect plug loss and ensure adequate disease control.

Intense pulsed light for meibomian gland dysfunction: a systematic review and meta-analysis

BACKGROUND

Intense pulsed light therapy (IPL) is a new method being used to treat meibomian gland dysfunction (MGD) globally. With an increasing number of studies being published, it is necessary to consider additional factors related to treatment. This review aims to investigate the efficacy and safety of IPL for the treatment of MGD.

METHODS

The PubMed, EMBASE, Web of Science, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, and SinoMed databases were searched through February 24, 2020. Randomized clinical trials and cohort studies comparing IPL+ meibomian gland expression (MGX) or IPL alone with control groups were included. The weighted mean difference (WMD) was calculated to analyze the Ocular Surface Disease Index (OSDI) score and Standard Patient Evaluation of Eye Dryness (SPEED) score, and the standard mean difference (SMD) was calculated to analyze the tear breakup time (TBUT). Heterogeneity was quantified by the I² statistic ranging from 0 to 100%, and a random effects model was used in this meta-analysis. All analyses were performed by RevMan 5.3. All p values were calculated by the t test, and p values were regarded as statistically significant at p < 0.05. The Cochrane Collaboration's tool for assessing risk of bias was used to identify and evaluate bias in the literature.

RESULTS

Nine studies with a total of 539 patients were included. Eight studies examined TBUT, six examined OSDI scores, and four examined SPEED scores. IPL combined with MGX showed superiority regarding the TBUT (SMD 2.33, 95% CI 1.04-3.61), and OSDI scores (WMD 11.93, 95% CI - 17.10 to - 6.77), with high heterogeneity. The SPEED scores were not significantly different.

CONCLUSIONS

IPL combined with MGX may be an effective and safe treatment for MGD, but it cannot improve all symptoms. IPL alone is not superior to MGX. The efficacy is also affected by the number and average frequency of treatments. The efficacy of IPL may decrease within 6 months after the last treatment, so it should be considered a long-term adjuvant therapy combined with MGX. When patients receive 3 or 4 treatments (once every 3-4 weeks), a return visit at 6 months after the last treatment is required.

Preparation and characterization of a pterostilbene-peptide prodrug nanomedicine for the management of dry eye

In the present study, a pterostilbene-peptide amphiphile (PS-GA-RGD) that can spontaneously self-assemble into prodrug nanomedicine, was rationally designed and developed as a novel ophthalmic formulation for the potential management of dry eye. The formed PS-GA-RGD nanomedicine was characterized by dynamic latter scattering (DLS) and transmission electron microscopy (TEM). After esterase treatment, active pterostilbene (PS) sustainably released from the PS-GA-RGD nanomedicine within 48 h, as indicated by an in vitro release study. In comparison with native PS, the formed PS-GA-RGD nanomedicine caused minimal cytotoxicity towards RAW 264.7 and HCEC cells in the 0-20 μM range and did not delay wound healing of HCEC monolayer within 6 h. Furthermore, PS-GA-RGD nanomedicine effectively reduced the intracellular reactive oxygen species (ROS) level in H₂O₂ challenged RAW264.7 macrophages and remarkably suppressed the secretion of inflammatory cytokines (e.g., NO, TNF-α, and IL-6) in lipopolysaccharide (LPS) activated RAW264.7 macrophages. Ocular tolerance to the proposed PS-GA-RGD nanomedicine was good after a single instillation in in vivo ocular irritation tests. Overall, the proposed PS-GA-RGD nanomedicine had potent anti-oxidant capacity and anti-inflammatory efficacy, which may be a promising ophthalmic formulation for the management of dry eye.

Effect of rigid gas permeable contact lens on keratoconus progression: a review

The prevalence of keratoconus is 1/2000 in the general population and is high in adolescents. Keratoconus is a progressive disease, which has a great impact on patients' quality of life and mental health. It can be managed by surgical and non-surgical means, rigid gas permeable (RGP) contact lens as its main non-surgical method is widely used in clinic. The efficacy of wearing RGP contact lens has been confirmed to some extent, but some studies have found that wearing RGP contact lens has adverse effects, which may promote disease progression. In this paper, the advantages and disadvantages of RGP contact lens in controlling keratoconus were reviewed to provide more suggestions and references for the clinical application of RGP contact lens.

Acupoint selection for the treatment of dry eye: A systematic review and meta-analysis of randomized controlled trials

The effectiveness of acupuncture in the treatment of dry eye has been confirmed, but the association between acupoint selection and therapeutic effect has remained to be elucidated. In the present study, a systematic review and meta-analysis were performed to evaluate the effect of periocular acupoints and periocular acupoints plus body acupoints compared with AT for the treatment of dry eye disease (DED). The PubMed, Cochrane Library, Embase, Ovid, China National Knowledge Infrastructure and Chonqing VIP Information, Co., Ltd. databases were searched with entries until 10 July 2018 considered. Only randomized controlled trials (RCTs) were included. Meta-analyses were performed to compare the effects of acupuncture with those of conventional treatment (including AT or other non-acupuncture therapies). The primary outcomes, including tear break-up time (BUT), Schirmer's I test (SIT) result and Symptom scores were analyzed. Subgroup analysis was performed for periocular acupoints only and periocular acupoints plus body acupoints. A total of 12 studies comprising 900 participants were included. In the primary meta-analysis, a significant improvement in the BUT [n=1,209, weighted mean difference (WMD)=1.01, 95% CI: 0.56-1.84, P<0.00001], SIT result (n=1,107, WMD=1.98, 95% CI: 0.44-3.34, P<0.00001) and Symptom scores (n=402, WMD=-1.02, 95% CI: -1.33 to -0.72, P<0.00001) was obtained to evaluate the clinical efficacy of acupuncture and AT. Furthermore, periocular acupoints plus body acupoints were more effective in the treatment of DED. However, the total sample size of subjects with only periocular acupoints in the treatment of DED was too small to get any firm conclusions. Further large RCTs are warranted.

Approaches toward enhancing survival probability following deep anterior lamellar keratoplasty

The greatest advantage of deep anterior lamellar keratoplasty over full-thickness corneal transplantation is the elimination of graft failure caused by endothelial rejection. Despite this advantage, a deep anterior lamellar keratoplasty graft can fail because of several factors, such as complications related to the donor-recipient interface, graft epithelial abnormalities, graft vascularization, stromal graft rejection, and recurrence of herpetic keratitis. Increased deep anterior lamellar keratoplasty graft survival is mainly built upon optimization of the ocular surface to provide a hospitable environment for the graft. Any predisposing factors for graft epithelial abnormalities, corneal neovascularization, and preexisting vernal keratoconjunctivitis should be identified and treated preoperatively. Prompt recognition and appropriate treatment of interface-related complications and stromal graft rejection usually result in good anatomic outcomes, with no detrimental effects on vision.

Intense pulsed light therapy: A promising complementary treatment for dry eye disease

OBJECTIVE

To propose the Intense Pulsed Light (IPL) therapy as a helpful supplementary treatment in patients with dry eye disease.

MATERIAL AND METHODS

Retrospective cross sectional design. Medical records of patients in whom dry eye disease symptoms were not satisfactorily controlled with medical therapy alone and who underwent additional IPL with at least three sessions completed. Data were analyzed before therapy and 3weeks after its completion to asses improvement. Determination of symptoms, through a visual analog scale; tear film stability, through tear Break Up Time (tBUT); measurement of tear secretion, through Schirmer Test; and ocular surface staining with Van Bijsterveld score were evaluated. SPSS software and nonparametric analysis of repeated measures were used. The study was approved by the ethics committee.

RESULTS

50 eyes from 25 subjects were reviewed. There were 9 males (36%) and 16 females (64%), with a median age of 59years (IQR 52-64). The median of the symptoms scale was 8 (IQR 8-9) and 3 (IQR 2-4) before and after the therapy respectively (P<.05). The median of BUT was 4 (IQR 3-5) and 10 (IQR 8-11), Schirmer test was 13 (IQR 12-15) and 15 (IQR 13-20), and Van Bijsterveld score was 3 (RIC 3-4) and 2 (IQR 2-3) before and after the therapy respectively (P<.05, for all measurements).

CONCLUSION

IPL treatment has excellent results regarding both: dry eye disease symptoms improvement and in office objective tests such as tBUT, Schirmer test and Van Bijsterveld score; IPL could be considered as an effective adjunct for dry eye disease.

Tear-film dynamics by combining double-pass images, pupil retro-illumination, and contrast sensitivity

Tear-film dynamics were analyzed by a synchronizing recording of double-pass (DP) and pupil retro-illumination (RI) images with contrast sensitivity (CS) measurements. Simultaneous DP and RI images were acquired in three subjects wearing contact lenses while keeping the eye open. Changes in contrast sensitivity for an 18 c/deg green grating were also estimated. From the DP retinal images, the effect of the tear film is described through the objective scattering index (OSI). This presented a negative correlation with the increase in CS during tear-film deterioration (as observed by RI imaging). These results show a relationship between visual outcome degradation due to tear-film breakup and the increase in intraocular scattering. This work shows a combined methodology for the evaluation of tear-film dynamics.

Recurrent corneal erosion: a comprehensive review

Purpose

To comprehensively review the literature regarding recurrent corneal erosion (RCE) and to present treatment options and recommendations for management.

Overview

RCE usually presents with sharp, unilateral pain upon awakening, in an eye with an underlying basement membrane dystrophy, prior ocular trauma, stromal dystrophy or degeneration, or prior surgery for refractive errors, cataracts, or corneal transplantation. Making the correct diagnosis requires a careful slit-lamp examination of both eyes coupled with a high degree of suspicion. Several treatments are commonly used for RCE but new therapies have been introduced recently. Conservative treatment consists of antibiotic and preservative-free lubricating drops, with topical cycloplegics and oral analgesics to control pain. Patients who are unresponsive to these therapies may benefit from therapeutic bandage contact lenses (BCL). Newer therapies include oral matrix metalloproteinase (MMP) inhibitors, blood-derived eye drops, amniotic membrane graft application, and judicious application of topical corticosteroids. Once the epithelium is healed, a course of hypertonic saline solution and/or ointment can be used. Surgical procedures may be performed in patients who fail conservative therapy. Punctal occlusion with plugs increases the tear film volume. Epithelial debridement with diamond burr polishing (DBP), anterior stromal puncture (ASP), or alcohol delamination should be considered in selected patients. DBP can be used for patients with basement membrane dystrophies and is the preferred treatment overall due to a low recurrence rate. ASP can be used for erosions outside the central visual axis. Excimer laser phototherapeutic keratectomy is an attractive option in eyes with central RCE since it precisely removes tissue while preserving corneal transparency. In patients with RCE who are also candidates for refractive surgery, photorefractive keratectomy can be considered.

Summary

Newly introduced therapies for RCE enable therapy to be individualized and lower the recurrence rate.

Ocular Manifestations of Rheumatoid Arthritis: Implications of Recent Clinical Trials

While rheumatoid arthritis (RA) typically presents with synovitis of the small and medium joints of the hands, ocular manifestations of the disease are generally overlooked and largely underdiagnosed. These complications usually present in longstanding RA population and occasionally represents the first manifestation of the disease and generally affect the anterior chamber of the eye, leading to keratoconjunctivitis sicca, episcleritis, scleritis, peripheral ulcerative keratitis and anterior uveitis. In this review, we present the current understanding of the pathophysiologic mechanisms for ocular disease in RA, including the role of oxidative stress, cytokine imbalance, chronic inflammation, vascular permeability, immune complex deposition and the role of T-cells as well as the contribution of tear hyperosmolarity among other factors. We also discuss the clinical presentation and diagnosis of each of the ocular disease entities highlighting the latest strategies in the management of this serious disorders that could potentially lead to blindness and the implications of recently completed and ongoing clinical trials in the field. While RA disease control is the cornerstone in the management of RA-associated ocular manifestations, early recognition of ocular pathology with prompt referral to ophthalmology is of paramount importance in order to prevent blindness and improve the quality of life in this patient population.