The economic burden of dry eye disease in the United States: a decision tree analysis

Cornea Classic: Bron, Evans, and Smith, "Grading of Corneal and Conjunctival Staining in the Context of Other Dry Eye Tests" (2003)

ABSTRACT

Dry eye is an increasingly common ocular condition with significant impact on quality of life due to eye discomfort and blurred vision complaints. In addition, the financial burden of dry eye on both patients and society is substantial. Although there has been a recent explosion of research in the field since 2002 with the approval of the first prescription topical treatment (Restasis, Allergan Inc, Irvine CA), dry eye lags behind other ophthalmic conditions where clinically meaningful outcome measures are closely tied with the metrics by which their therapeutics are evaluated. Unfortunately, current practice is such that physicians largely rely on patient symptoms to evaluate dry eye, and these do not always correlate with objective ocular surface and tear film parameters. In patients with severe dry eye, the patient-reported symptoms are likely dampened because of the neurotrophic state of the ocular surface, which accompanies any long-standing inflammatory ocular condition. Therefore, staining of the corneal and conjunctival surface using vital dyes is an invaluable dry eye test to provide information normally not visible during routine slit-lamp examination. The landmark article by Bron, Evans, and Smith published in Cornea in 2003 provides excellent guidance to clinicians to highlight and quantify ocular surface parameters in patients with dry eye. Validation studies correlating conjunctival or corneal staining with tangible quality-of-life parameters and metrics to measure those are needed to verify ocular surface staining as a clinically meaningful dry eye outcome to be used in clinical practice and clinical trials.

The topical azithromycin meibomian gland dysfunction survey: The effect of topical azithromycin on signs and symptoms of meibomian gland dysfunction

INTRODUCTION

The aim of this study was to assess the long-term effects of topical azithromycin on signs, symptoms and self-management of meibomian gland dysfunction (MGD).

METHODS

Forty participants were assessed for MGD and its effect on the fluorescein tear break-up time (FTBUT). Participants were treated with topical azithromycin twice daily for 2 weeks and then once daily for a further 2 weeks. One year after treatment, 31 participants completed a survey assessing pre- and post-treatment effect on symptoms, lifestyle and self-treatment methods.

RESULTS

Following treatment, there was a significant reduction in MGD grading from a median of grade 2 to grade 0 (z = 4.40, p < 0.0001) and an increase in FTBUT from a median of 3-8 s (z = 4.75, p < 0.0001). One year afterwards, the survey showed a significant improvement in symptoms (sensitivity to light, grittiness, burning, blurred vision, all p < 0.03) and reduction in required self-treatments (lid wipes, tear substitutes, both p < 0.03). There was also a reduced impact on lifestyle (reading, night driving, computer use and watching television, all p < 0.0001) and in all environmental conditions (all p < 0.0001).

CONCLUSIONS

This study confirms the positive effect of topical azithromycin on MGD and shows it has a long-term impact on symptoms, self-treatment methods and lifestyle. This has implications for both chair time and healthcare costs when managing patients with MGD. Pending further clinical trials in a larger population with different demographics, topical azithromycin should be considered by all eyecare practitioners as a viable pharmacological treatment when managing MGD.

An Assessment of the Ocular Toxicity of Two Major Sources of Environmental Exposure

The effect of airborne exposure on the eye surface is an area in need of exploration, particularly in light of the increasing number of incidents occurring in both civilian and military settings. In this study, in silico methods based on a platform comprising a portfolio of software applications and a technology ecosystem are used to test potential surface ocular toxicity in data presented from Iraqi burn pits and the East Palestine, Ohio, train derailment. The purpose of this analysis is to gain a better understanding of the long-term impact of such an exposure to the ocular surface and the manifestation of surface irritation, including dry eye disease. In silico methods were used to determine ocular irritation to chemical compounds. A list of such chemicals was introduced from a number of publicly available sources for burn pits and train derailment. The results demonstrated high ocular irritation scores for some chemicals present in these exposure events. Such an analysis is designed to provide guidance related to the needed ophthalmologic care and follow-up in individuals who have been in proximity to burn pits or the train derailment and those who will experience future toxic exposure.

Sutureless Dehydrated Amniotic Membrane (Omnigen) Application Using a Specialised Bandage Contact Lens (OmniLenz) for the Treatment of Dry Eye Disease: A 6-Month Randomised Control Trial

Background and Objectives: Dry Eye Disease (DED) is a chronic condition characterised by tear film instability and ocular surface disruption, significantly impacting patients' quality of life. This study aimed to provide top-level clinical evidence for the long-term efficacy of dehydrated amniotic membrane (dAM, Omnigen®) delivered via a specialised bandage contact lens (sBCL, OmniLenz) for managing moderate-to-severe DED. Materials and Methods: This randomised controlled trial (NCT04553432) involved 93 participants with moderate-to-severe DED, randomised to receive a 1-week bilateral treatment of either dAM (17 mm diameter with 6 mm central 'window') applied under a sBCL or sBCL alone. Participants were assessed at baseline and followed up at 1, 3, and 6 months post-treatment. Outcomes included changes in symptomatology, tear film and ocular surface measurements, and in vivo confocal microscopy imaging of corneal nerve parameters and corneal dendritic cell (CDC) counts. Results: The dAM-sBCL group demonstrated a 65% reduction in OSDI scores at 6 months (p < 0.001), with 88% of participants showing improvement at 1 month. Corneal staining was significantly reduced in both groups. dAM-sBCL provided significant improvements in corneal nerve parameters at 1 month, with sustained positive trends at 3 months. Additionally, dAM-sBCL significantly reduced mature CDC counts, suggesting an anti-inflammatory effect. Conclusions: Treatment with dAM-sBCL for just 1 week significantly and rapidly improved dry eye symptoms as well as ocular surface signs for at least 3 months. It also enhanced corneal nerve health while reducing activated/mature corneal inflammatory cell numbers, presenting a safe and promising new treatment for moderate-to-severe DED.

Health Care Use for Eye Pain

Importance

National estimates regarding the frequency of presentations and patterns of care for eye pain are unknown. This information could guide research and clinical efforts to optimize outcomes.

Objective

To estimate eye pain visits in the US in the outpatient and emergency department (ED) settings.

Design, Setting, and Participants

This retrospective cross-sectional study of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data (2008-2019) analyzed a population-based sample of visits to outpatient clinics and EDs. The sample consisted of patients presenting with eye pain. Data were analyzed from September 2023 to April 2024.

Main Outcomes and Measures

Weighted sample data estimated outpatient and ED eye pain presentations including patient and clinician characteristics, diagnoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]), and disposition.

Results

From 2008 through 2019, 4.6 million (95% CI, 3.9 million to 5.3 million) outpatient and 1.0 million (95% CI, 0.8 million to 1.1 million) ED eye pain visits occurred annually. Patients were predominantly women (63.2% [95% CI, 59.4%-67.0%]) and older than 60 years (46.6% [95% CI, 42.4%-51.0%]) in the outpatient setting. Patients presenting to the ED were more often men (51.8% [95% CI, 48.7%-55.0%]) and aged younger than 45 years (aged <15 years: 16.4% [95% CI, 13.9%-18.8%]; 15-24 years: 19.2% [95% CI, 16.6%-21.7%]; and 25-44 years: 35.6% [95% CI, 32.7%-38.5%]). In nearly half of outpatient eye pain visits, the major problem was classified as nonacute (2.0 million [95% CI, 1.6 million to 2.3 million]). Eye pain was the primary reason for the visit (RFV) in 42.0% (95% CI, 37.8%-46.2%) of outpatient visits and 66.9% (95% CI, 62.9%-70.9%) of ED eye pain visits. It was the only RFV in 18.3% (95% CI, 15.0%-21.7%) of outpatient and 32.7% (95% CI, 29.0%-36.4%) of ED eye pain encounters. Ophthalmologists evaluated the largest number of outpatient visits (45.3% [95% CI, 38.8%-51.7%). The primary diagnosis was non-vision threatening for most outpatient (78.5% [95% CI, 56.8%-100%]) and ED (69.9% [95% CI, 62.1%-77.7%]) visits when eye pain was the primary RFV. Additional follow-up was scheduled in 89.4% (95% CI, 86.2%-92.6%) of visits.

Conclusions and Relevance

More than 5 million eye pain visits occur annually; the largest percentage are outpatient with ophthalmologists. Most diagnoses were non-vision threatening in both the outpatient and ED setting and resulted in additional care. Expanding therapeutic approaches to treat the causes of eye pain may reduce the burden on the health care system and optimize outcomes.

The Aging Lacrimal Gland of Female C57BL/6J Mice Exhibits Multinucleate Macrophage Infiltration Associated With Lipid Dysregulation

Purpose

Loss of function of the lacrimal gland (LG), which produces the aqueous tear film, is implicated in age-related dry eye. To better understand this deterioration, we evaluated changes in lipid metabolism and inflammation in LGs from an aging model.

Methods

LG sections from female C57BL/6J mice of different ages (young, 2-3 months; intermediate, 10-14 months; old,  ≥24 months) were stained with Oil Red-O or Toluidine blue to detect lipids. Quantitative real-time polymerase chain reaction (qRT-PCR) analysis and western blotting of LG lysates determined differences in the expression of genes and proteins related to lipid metabolism. A photobleaching protocol to quench age-related autofluorescence was used in LG sections to evaluate changes in immunofluorescence associated with NPC1, NPC2, CTSL, and macrophages (F4/80, CD11b) with age using confocal fluorescence microscopy.

Results

Old LGs showed increased lipids prominent in basal aggregates in acinar cells and in extra-acinar sites. LG gene expression of Npc1, Npc2, Lipa, and Mcoln2, encoding proteins involved in lipid metabolism, was increased with age. NPC1 was also significantly increased in old LGs by western blotting. In photobleached LG sections, confocal fluorescence microscopy imaging of NPC1, NPC2, and CTSL immunofluorescence showed age-associated enrichment in macrophages labeled to detect F4/80. Although mononuclear macrophages were detectable in LG at all ages, this novel multinucleate macrophage population containing NPC1, NPC2, and CTSL and enriched in F4/80 and some CD11b was increased with age at extra-acinar sites.

Conclusions

Lipid-metabolizing proteins enriched in F4/80-positive multinucleated macrophages are increased in old LGs adjacent to sites of lipid deposition in acini.

Patient-Reported Dry Eye Treatment and Burden of Care

OBJECTIVES

Dry eye is a common condition that can decrease the quality of life. This survey-based study of persons with dry eye investigated self-reported treatments (initial, current), out-of-pocket expenses, time spent on self-management, sources of care, and sources of information about their condition.

METHODS

Online dry eye newsletters and support groups were emailed a link to an electronic survey asking members to participate. Survey respondents were not required to answer every question.

RESULTS

In total, 639 persons with self-reported dry eye responded (86% women, 14% men [n=623]; mean ± SD age, 55 ± 14 years [n=595]). Artificial tears were the most reported intervention (76% initially, 71% currently). The median (interquartile range) out-of-pocket treatment cost annually was $500 ($200-$1,320 [n=506]). In addition, 55% (n=544) estimated 5 to 20 min daily on self-management; 22% spent an hour or more. Ophthalmologists provided most dry eye care (67%, n=520). Only 48% (n=524) reported that their primary source of dry eye information came from their eye care clinician.

CONCLUSIONS

Artificial tears are the primary treatment for dry eye. Ophthalmologists provide most dry eye care, but half of patients report that their eye care provider is not their primary source of information. Almost one fourth of patients spend an hour or more daily on treatments.

Efficacy of RCI001 as a therapeutic candidate of dry eye disease in a modified mixed dry eye model

BACKGROUND

To evaluate the therapeutic effects of topical RCI001 (RCI) and compare its efficacy with that of 1% prednisolone acetate (PDE) and 5% Lifitegrast in a modified mixed dry eye disease (DED) model.

METHODS

The environmental DED model was induced in BALB/c mice in a dry chamber with scopolamine. The eyes of the mice were treated topically with phosphate buffered saline (PBS), PDE, Lifitegrast or RCI twice daily for 1 week. Ocular surface staining (OSS), tear secretion, inflammatory cytokines in the ocular surface and lacrimal gland, and immunofluorescence staining in the conjunctiva and cornea(CC) were assessed.

RESULTS

The RCI group demonstrated better improvement of OSS and tear secretion than the PBS group (OSS, PBS: 13.0 ± 1.6, RCI: 9.4 ± 3.0; tear secretion, PBS: 5.0 ± 0.4 mm, RCI: 7.0 ± 0.3 mm, each P < 0.001) and better clinical efficacy than PDE and Lifitegrast groups on Day 7 (improvement rate of OSS, RCI: 32.45%, Lifitegrast: 13.13%, PDE: 12.25%). The RCI group resulted in significantly lower expression of oxidative stress markers in the CC than the PBS group (4-HNE, NOX2, and NOX4 in the conjunctiva; NOX2 in the cornea, each P < 0.05). However, the PDE and Lifitegrast groups did not show significant differences compared with the PBS group. There were no significant differences of inflammatory cytokines in the ocular surface and lacrimal gland between all groups.

CONCLUSION

Topical RCI001 showed excellent therapeutic effects in environmental DED models by stimulating tear secretion, modulating oxidative stress and improving corneal epithelial healing compared to 1% PDE and 5% Lifitegrast.

Bilateral Sutureless Application of Human Dehydrated Amniotic Membrane with a Specialised Bandage Contact Lens for Moderate-to-Severe Dry Eye Disease: A Prospective Study with 1-Month Follow-Up

Purpose

To assess changes in symptoms and ocular surface signs following a bilateral sutureless treatment of dehydrated amniotic membrane (dAM) under a specialised bandage contact lens (sBCL) in patients with moderate-to-severe dry eye disease (DED).

Patients and Methods

In this prospective pre-post interventional study, 35 patients diagnosed with moderate-to-severe DED, with an Ocular Surface Disease Index (OSDI) score >30 on current treatment, were enrolled. Assessments were conducted at baseline (day -30), after 30 days run-in with no additional treatment (day 0 - control), and 30 days post sBCL+dAM treatment (day 30 - treatment). Intervention involved two successive bilateral 4-5 day sutureless applications of dAM (17mm diameter, with a 6 mm central aperture, Omnigen® VIEW) under an 18mm sBCL (OmniLenz®). Symptomatology and ocular signs were measured using OSDI, Dry Eye Questionnaire-5 (DEQ-5), Symptom Assessment iN Dry Eye (SANDE), and other ocular surface health indicators including non-invasive breakup time, corneal and conjunctival staining, and lid wiper epitheliopathy length and width (LWE).

Results

While symptomatology remained stable during the 30-day no-treatment run-in, 1-month post-dAM treatment, there was a significant reduction in OSDI scores (from 55.8 to 32.3, p<0.001), DEQ-5 (from 14.6 to 10.0, p<0.001), SANDE frequency (from 65.2 to 43.6, p<0.001), and SANDE severity (from 59.8 to 41.1, p<0.001). Additionally, there was a notable decrease in the width of LWE staining, from grade 2 (50-75% of the lid wiper) to grade 1 (25-50% of the lid wiper) (p=0.011).

Conclusion

A bilateral 8-10-day treatment duration with dAM applied with sBCL demonstrated a 31 to 42% improvement in symptomatology and a decrease in ocular surface signs of mechanical stress. This innovative bilateral treatment approach offers a promising treatment modality for patients with refractory moderate-to-severe DED.

Comprehensive dry eye therapy: overcoming ocular surface barrier and combating inflammation, oxidation, and mitochondrial damage

BACKGROUND

Dry Eye Disease (DED) is a prevalent multifactorial ocular disease characterized by a vicious cycle of inflammation, oxidative stress, and mitochondrial dysfunction on the ocular surface, all of which lead to DED deterioration and impair the patients' quality of life and social functioning. Currently, anti-inflammatory drugs have shown promising efficacy in treating DED; however, such drugs are associated with side effects. The bioavailability of ocular drugs is less than 5% owing to factors such as rapid tear turnover and the presence of the corneal barrier. This calls for investigations to overcome these challenges associated with ocular drug administration.

RESULTS

A novel hierarchical action liposome nanosystem (PHP-DPS@INS) was developed in this study. In terms of delivery, PHP-DPS@INS nanoparticles (NPs) overcame the ocular surface transport barrier by adopting the strategy of "ocular surface electrostatic adhesion-lysosomal site-directed escape". In terms of therapy, PHP-DPS@INS achieved mitochondrial targeting and antioxidant effects through SS-31 peptide, and exerted an anti-inflammatory effect by loading insulin to reduce mitochondrial inflammatory metabolites. Ultimately, the synergistic action of "anti-inflammation-antioxidation-mitochondrial function restoration" breaks the vicious cycle associated with DED. The PHP-DPS@INS demonstrated remarkable cellular uptake, lysosomal escape, and mitochondrial targeting in vitro. Targeted metabolomics analysis revealed that PHP-DPS@INS effectively normalized the elevated level of mitochondrial proinflammatory metabolite fumarate in an in vitro hypertonic model of DED, thereby reducing the levels of key inflammatory factors (IL-1β, IL-6, and TNF-α). Additionally, PHP-DPS@INS strongly inhibited reactive oxygen species (ROS) production and facilitated mitochondrial structural repair. In vivo, the PHP-DPS@INS treatment significantly enhanced the adhesion duration and corneal permeability of the ocular surface in DED mice, thereby improving insulin bioavailability. It also restored tear secretion, suppressed ocular surface damage, and reduced inflammation in DED mice. Moreover, it demonstrated favorable safety profiles both in vitro and in vivo.

CONCLUSION

In summary, this study successfully developed a comprehensive DED management nanosystem that overcame the ocular surface transmission barrier and disrupted the vicious cycle that lead to dry eye pathogenesis. Additionally, it pioneered the regulation of mitochondrial metabolites as an anti-inflammatory treatment for ocular conditions, presenting a safe, efficient, and innovative therapeutic strategy for DED and other inflammatory diseases.

Local administration of myeloid-derived suppressor cells prevents progression of immune-mediated dry eye disease

Myeloid derived suppressor cells (MDSCs) are a heterogenous population of immature hematopoietic precursors with known immunoregulatory functions. The immunosuppressive role of MDSCs has been highlighted in several inflammatory ophthalmic disorders; however, their therapeutic application in suppressing the immune-mediated changes in dry eye disease (DED) has not been studied. We observed significant reduction in antigen presenting cell (APC) frequencies and their maturation in the presence of MDSCs. Moreover, co-culturing MDSCs with T helper 17 cells (Th17) resulted in reduced Th17 frequencies and their IL-17 expression. On the contrary, MDSCs maintained regulatory T cell frequencies and enhanced their function in-vitro. Furthermore, we delineated the role of interleukin-10 (IL-10) secreted by MDSCs in their immunoregulatory functions. We confirmed these results by flow cytometry analysis and observed that treatment with MDSCs in DED mice effectively suppressed the maturation of APCs, pathogenic Th17 response, and maintained Treg function and significantly ameliorated the disease. The results in this study highlight the potential therapeutic application of MDSCs in treating refractory DED.

Social Determinants of Dry Eye in the United States: A Systematic Review

PURPOSE

To conduct a systematic review to summarize current evidence on associations between social determinants of health (SDOH) indicators and dry eye in the United States.

DESIGN

Systematic review.

METHODS

We followed a protocol registered on Open Science Framework to include studies that examined associations between SDOH indicators and dry eye. We mapped SDOH indicators to 1 of the 5 domains following the Healthy People 2030 framework and categorized dry eye measures into "dry eye diagnosis and care," "dry eye symptoms," or "ocular surface parameters." We summarized the direction of association between SDOH indicators and dry eye as worsening, beneficial, or null. We used items from the Newcastle Ottawa Scale to assess risk of bias.

RESULTS

Eighteen studies reporting 51 SDOH indicators, mostly mapped to the neighborhood and built environment domain, were included. Thirteen studies were judged at high risk of bias. Fifteen of 19 (79%) associations revealed an increase in the diagnosis of dry eye or delayed specialty care for it. Thirty-four of 56 (61%) associations unveiled exacerbated dry eye symptoms. Fifteen of 23 (65%) found null associations with corneal fluorescein staining. Ten of 22 (45%) associations revealed an increased tear break up time (45%) whereas another 10 (45%) showed null associations.

CONCLUSIONS

Most SDOH indicators studied were associated with unfavorable dry eye measures, such as a higher disease burden, worse symptoms, or delayed referral, in the United States. Future investigations between SDOH and dry eye should use standardized instruments and address the domains in which there is an evidence gap.

Aquaporins in the Cornea

The cornea is an avascular, transparent tissue that allows light to enter the visual system. Accurate vision requires proper maintenance of the cornea's integrity and structure. Due to its exposure to the external environment, the cornea is prone to injury and must undergo proper wound healing to restore vision. Aquaporins (AQPs) are a family of water channels important for passive water transport and, in some family members, the transport of other small molecules; AQPs are expressed in all layers of the cornea. Although their functions as water channels are well established, the direct function of AQPs in the cornea is still being determined and is the focus of this review. AQPs, primarily AQP1, AQP3, and AQP5, have been found to play an important role in maintaining water homeostasis, the corneal structure in relation to proper hydration, and stress responses, as well as wound healing in all layers of the cornea. Due to their many functions in the cornea, the identification of drug targets that modulate the expression of AQPs in the cornea could be beneficial to promote corneal wound healing and restore proper function of this tissue crucial for vision.

New advances in medical management of dry eye: optimizing treatment strategies for enhanced relief

PURPOSE

Dry eye disease (DED) is a prevalent ocular surface disease that is conventionally characterized by tear film hyperosmolarity and instability. This review presents a summarized classification of DED, followed by a comprehensive discussion of the most recent topical and systemic medications and clinical recommendations for selecting the most appropriate option for each patient.

METHODS

An extensive literature search was conducted on electronic databases, such as PubMed, Scopus, and Web of Science, using keywords including "dry eye syndrome," "ocular surface disease," "medical management," "artificial tears," "topical immunomodulators," and "meibomian gland dysfunction."

RESULTS

The underlying reasons for DED can range from insufficient aqueous tear production to increased tear evaporation. Recent literature has provided a more in-depth understanding of the pathophysiology of DED by examining the tear film's lipid, aqueous, and mucin layers. However, despite these advancements, medical management of patients with symptomatic DED has not fully reflected this modernized knowledge of its pathophysiology.

CONCLUSION

To develop a rationalized strategy for treating DED, it is crucial to have updated knowledge of therapeutic options, their mechanisms of actions, and indications based on the DED type and underlying causes.

Patient barriers and facilitators for making environmental and behavioral modifications for dry eye in the United States

BACKGROUND

Managing dry eye disease (DED) is expensive. Often, prescribed treatments improve clinical signs but not patient-reported symptoms. In large surveys, clinicians and patients ranked environmental and behavioral modifications among the most important DED-related research priorities. Our purpose was to investigate the barriers to and facilitators of use of these modifications by patients with DED in the United States and how their use may be impacted by socioeconomic status (SES).

METHODS

Using Qualtrics, we conducted an anonymous online survey of adults with DED living in the United States in August to September 2022. Patients were identified through the Dry Eye Foundation, Sjögren's Foundation, and a DED clinic in Colorado. We used an established index for classifying respondent SES based on education, household income, and employment. Outcomes included use of environmental and behavioral modifications and barriers to and facilitators of their use.

RESULTS

We included 754 respondents (SES: 382 low, 275 high, and 97 unclear). Most were aged 18 to 49 years (67%), female (68%), and White (76%) and reported dealing with DED for ≤5 years (67%). The most frequent modifications were taking breaks to rest eyes (68%), increasing water intake (68%), and using hot/cold compresses (52%). For these three, the biggest facilitators were as follows: belief that the modification works (27 to 37%), being recommended it (24 to 26%), and ease of use/performance (21 to 32%). Across modifications, the biggest barriers were difficulty of use (55%), lack of family/employer/social/community support (33%), and lack of awareness (32%). The data do not suggest discernible patterns of differences in barriers or facilitators by SES.

CONCLUSIONS

Greater emphasis should be placed on explaining to patients how environmental and behavioral modifications might mitigate DED. Employers and members of patients' support systems should be guided regarding how best to support patients in managing DED symptoms.

A comparison between hyaluronic acid and other single ingredient eye drops for dry eye, a review

Dry eye disease (DED) is a highly prevalent and debilitating condition. Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan that has a long history as a safe and effective DED treatment. HA is frequently used as a comparator when assessing other topical DED treatments. This study aims to summarise and critically evaluate the literature describing all isolated active ingredients that have been directly compared with HA in the treatment of DED. A literature search was conducted in Embase using Ovid on the 24th of August 2021 and in PubMed including MEDLINE on the 20th of September 2021. Twenty-three studies met the inclusion criteria, 21 of which were randomised controlled trials. Seventeen different ingredients representing six treatment categories were compared with HA treatment. Most measures showed no significant difference between treatments, suggesting either equivalency of treatments or that studies were underpowered. Only two ingredients were represented in more than two studies; carboxymethyl cellulose treatment appears equivalent to HA treatment, while Diquafosol treatment appears superior to HA treatment. Drop-frequency varied from one to eight drops daily. No single study explained the choice of drop frequency. Nine studies used a HA concentration of 0.1% which may be below therapeutic levels. Nine studies reported using preserved formulations, six of them with differences in preservatives between the compared groups. Thirteen studies were financially linked to industry. No major complications were reported. Studies were not designed to find differences in treatment effects for different types or severities of DED. HA is a good comparator treatment when assessing other DED treatments, although consensus after decades of use is still lacking for best choice of concentration, molecular weight and drop tonicity. Well-designed studies are needed to determine an evidence-based standard for HA treatment to be used as comparator.

United States Regulatory Approval of Topical Treatments for Dry Eye

PURPOSE

To report the heterogeneity in methodology of clinical trials submitted to the US Food and Drug Administration (FDA) for approval of topical dry eye treatments.

DESIGN

Comparative analysis of clinical trials' methods.

METHODS

We reviewed the online, publicly available FDA database, application review files, ClinicalTrials.gov registry records, and journal articles for each FDA-approved topical dry eye treatment. For each trial, we extracted information about the study, patient demographics, treatment names and doses, sample size in each arm, and the measurement instrument in a systematic fashion.

RESULTS

Fourteen trials were included that assessed 5 topical treatments for dry eye (cyclosporine 0.05%, cyclosporine 0.09%, lifitegrast 5%, and loteprednol 0.25% eye drops and varenicline 0.03-mg nasal spray). Median treatment duration was 12 weeks (range, 2-24 weeks). In all trials, treatments, including varying concentrations of the same treatment, were compared with vehicle. Twelve trials (85.7%) evaluated a primary clinician-measured clinical sign, and 10 trials (71.4%) evaluated a primary patient-reported symptom. Corneal staining was the most frequently evaluated clinical sign primary outcome, reported in half (6 of 12) of the trials, and was graded using 4 different scoring systems. Conjunctival staining, conjunctival hyperemia, and tear production were each measured using 2 different scoring systems. Ocular discomfort, the only patient-reported symptom primary outcome, was measured using 5 different instruments.

CONCLUSION

A variety of outcome measures were used in these clinical trials. Clinically meaningful dry eye outcome measures and standardized measurements can optimize the assessment of and comparison of therapeutic benefits.

Prevalence of dry eye and Meibomian gland dysfunction in Central and South America: a systematic review and meta-analysis

BACKGROUND

Dry eye is one of the most common ophthalmic conditions and can significantly impact quality of life. Meibomian gland dysfunction (MGD) is a major cause of evaporative dry eye. We sought to conduct a systematic review and meta-analysis to estimate the prevalence and incidence of dry eye and MGD in Central and South America and to identify factors associated with disease burden.

METHODS

Data sources Ovid MEDLINE and Embase.

STUDY SELECTION

A search conducted on August 16, 2021, identified studies published between January 1, 2010, and August 16, 2021, with no restrictions regarding participant age or language of publication. Case reports, case series, case-control studies, and interventional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

The review was based on a protocol registered on PROSPERO (CRD42021256934). Risk of bias was assessed in duplicate using a risk of bias tool designed for the purposes of descriptive epidemiological studies. Data were extracted by one investigator and verified by another for accuracy. Prevalence of dry eye and MGD were grouped based on study participant characteristics.

MAIN OUTCOMES AND MEASURES

Prevalence and incidence of dry eye and MGD in Central and South America. Summary estimates from meta-analysis with 95% confidence intervals (CI).

RESULTS

Fourteen studies (11,594 total participants) were included. The population prevalence of dry eye was 13% (95% CI, 12%-14%) in Brazil and 41% (95% CI, 39%-44%) in Mexico based on one study each. Meta-analyses suggested that dry eye prevalence was 70% among indoor workers (95% CI, 56%-80%; I2, 82%; 3 studies), 71% among students (95% CI, 65%-77%; I2, 92%; 3 studies), and 83% in general ophthalmology clinics (95% CI, 77%-88%; I2, 88%; 2 studies). MGD prevalence ranged from 23% among indoor workers (95% CI, 16%-31%; 1 study) to 68% in general ophthalmology clinics (95% CI, 62%-72%; 1 study). No studies reported incidence of dry eye or MGD.

CONCLUSIONS

This systematic review and meta-analysis demonstrated considerable variation in the published prevalence of dry eye and MGD among the general population and subpopulations in Central and South America. Local and subpopulation estimates of dry eye disease burden may be valuable to assist needs assessments and implementation of measures to mitigate the condition.

Review of clinical outcomes of a cationic emulsion tear substitute in patients with dry eye disease

First-line options for the treatment of dry eye disease (DED) rely on artificial tears (ATs), among which cationic emulsion (CE)-based ATs have been developed in order to mimic the healthy tear film for an improved restoration of the ocular surface homeostasis. In this review, we describe the outcomes reported in several studies, assessing the mode of action, ocular tolerance and clinical performance of a CE-based AT. Pilot studies have revealed that CE-based ATs can increase the volume and stability of the tear film while limiting its evaporation rate. Larger studies have demonstrated that CE-based ATs play a significant role in the improvement of both objective and subjective DED parameters, including superior efficacy on DED symptoms compared to several other available AT formulation types. Concomitantly, CE-based ATs have been shown to help patients to prevent or recover from corneal defects associated with refractive surgery. These positive outcomes on ocular surface epithelia are likely due to the combination of unique rheological behaviour and intrinsic anti-inflammatory properties. Based on all clinical findings, CE-based ATs represent a valuable treatment option for patients with various etiologies of DED including evaporative forms and would deserve evaluation of benefits in other surgical intervention types triggering DED.

Efficacy of topical 0.05% cyclosporine A and 0.1% sodium hyaluronate in post-refractive surgery chronic dry eye patients with ocular pain

BACKGROUND

The management of post-refractive surgery dry eye disease (DED) can be challenging in clinical practice, and patients usually show an incomplete response to traditional artificial tears, especially when it is complicated with ocular pain. Therefore, we aim to investigate the efficacy of combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate treatment in post-refractive surgery DED patients with ocular pain unresponsive to traditional artificial tears.

METHODS

We enrolled 30 patients with post-refractive surgery DED with ocular pain who were unresponsive to traditional artificial tears. Topical 0.05% cyclosporine A and 0.1% sodium hyaluronate were used for 3 months. They were evaluated at baseline and 1 and 3 months for dry eye and ocular pain symptoms and objective parameters, including Numerical Rating Scale (NRS), Neuropathic Pain Symptom Inventory modified for the Eye (NPSI-Eye), tear break-up time (TBUT), Schirmer I test (SIt), corneal fluorescein staining (CFS), corneal sensitivity, and corneal nerve morphology. In addition, tear levels of inflammatory cytokines and neuropeptides were measured using the Luminex assay.

RESULTS

After 3 months of treatment, patients showed a statistically significant improvement in the ocular surface disease index (OSDI), TBUT, SIt, CFS, and corneal sensitivity (all P < 0.01) using linear mixed models. As for ocular pain parameters, the NRS and NPSI-Eye scores were significantly reduced (both P < 0.05) and positively correlated with the OSDI and CFS scores. Additionally, tear IL-1β, IL-6, and TNF-α levels were improved better than pre-treatment (P = 0.01, 0.03, 0.02, respectively).

CONCLUSION

In patients with post-refractive surgery DED with ocular pain, combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate treatment improved tear film stability, dry eye discomfort, and ocular pain, effectively controlling ocular inflammation.

TRIAL REGISTRATION

Registration number: NCT06043908.

Trends in Health Service Use for Dry Eye Disease From 2017 to 2021: A Real-World Analysis of 369,755 Outpatient Visits

Purpose

We aimed to analyze the trends and patterns in outpatient health service treatment of dry eye disease (DED) using real-world data from Yinzhou District in China.

Methods

The Yinzhou Health Information System is a comprehensive database including electronic medical records from 277 medical institutions representing over 1.64 million residents. We extracted outpatient records from January 1, 2017, to December 31, 2021, that included the first diagnosis of DED according to the International Classification of Diseases, 10th Revision (H04.101, H04.103, H11.104, H16.202, or H18.803). We analyzed the trends and patterns of DED outpatient visits using the Mann-Kendall trend test and Cochran-Armitage trend test.

Results

We identified a total of 369,755 outpatient visits from 145,712 patients with DED of all ages (60.37% female; 54.10% 50 years or older). Primary medical institutions had the largest number of DED outpatient visits (42%), followed by tertiary medical institutions (35%). Over the 5-year period, the number of DED outpatient visits increased from 59,260 to 90,807 (53.23%). We observed significant consecutive annual proportion increases in females (from 61.09% to 62.01%; P = 0.001), patients 50 years or older (from 55.10% to 60.08%; P < 0.001), and outpatient visits in primary medical institutions (from 33.19% to 48.75%; P < 0.001).

Conclusions

Our study found an increase in outpatient health service use for DED in Yinzhou from 2017 to 2021, with higher proportions and increases among females, patients 50 years or older, and primary medical institutions.

Translational Relevance

The rapid growth in the prevalence of DED indicates high eye healthcare needs in patients.

Interventions for Dry Eye: An Overview of Systematic Reviews

Importance

Dry eye is a common ocular disease that can have substantial morbidity. Systematic reviews provide evidence for dry eye interventions and can be useful for patients, clinicians, and clinical guideline developers. Overviews of reviews use explicit and systematic methods to synthesize findings from multiple systematic reviews, but currently, there are no overviews of systematic reviews investigating interventions for dry eye.

Objective

To summarize the results of reliable systematic reviews of dry eye interventions and to highlight the evidence gaps identified.

Evidence Review

We searched the Cochrane Eyes and Vision US satellite database and included reliable systematic reviews evaluating dry eye interventions published from 2016 to 2022. We reported the proportion of systematic reviews that were reliable with reasons for unreliability. Critical and important outcomes from reliable systematic reviews were extracted and verified. Critical outcomes included dry eye-related patient-reported outcome measures. Results were synthesized from reliable systematic reviews to provide summaries of evidence for each intervention. Evidence for each intervention was defined as conclusive or inconclusive depending on whether high-certainty evidence across systematic reviews was available according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and whether findings reached statistical or clinical significance. Recommendations were made for further research.

Findings

Within the Cochrane Eyes and Vision US satellite database, 138 potentially relevant systematic reviews were identified, 71 were considered eligible, and 26 (37%) were assessed as reliable. Among reliable systematic reviews, no conclusive evidence was identified for any dry eye intervention. Inconclusive evidence suggested that environmental modifications, dietary modifications, artificial tears and lubricants, punctal occlusion, intense pulsed light therapy, vectored thermal pulsation therapy (Lipiflow), topical corticosteroids, topical cyclosporine A, topical secretagogues, and autologous serum may be effective. Only unreliable systematic reviews evaluated lifitegrast, oral antibiotics, and moisture chamber devices.

Conclusions and Relevance

This overview of systematic reviews found some evidence that dry eye interventions may be effective, but no conclusive evidence was available. The conduct and reporting of most systematic reviews for dry eye interventions warrant improvement, and reliable systematic reviews are needed to evaluate lifitegrast, oral antibiotics, and moisture chamber devices.

Using machine learning model explanations to identify proteins related to severity of meibomian gland dysfunction

Meibomian gland dysfunction is the most common cause of dry eye disease and leads to significantly reduced quality of life and social burdens. Because meibomian gland dysfunction results in impaired function of the tear film lipid layer, studying the expression of tear proteins might increase the understanding of the etiology of the condition. Machine learning is able to detect patterns in complex data. This study applied machine learning to classify levels of meibomian gland dysfunction from tear proteins. The aim was to investigate proteomic changes between groups with different severity levels of meibomian gland dysfunction, as opposed to only separating patients with and without this condition. An established feature importance method was used to identify the most important proteins for the resulting models. Moreover, a new method that can take the uncertainty of the models into account when creating explanations was proposed. By examining the identified proteins, potential biomarkers for meibomian gland dysfunction were discovered. The overall findings are largely confirmatory, indicating that the presented machine learning approaches are promising for detecting clinically relevant proteins. While this study provides valuable insights into proteomic changes associated with varying severity levels of meibomian gland dysfunction, it should be noted that it was conducted without a healthy control group. Future research could benefit from including such a comparison to further validate and extend the findings presented here.

Overview of CFTR activators and their recent studies for dry eye disease: a review

The cystic fibrosis transmembrane conductance regulator (CFTR) gets activated via the cAMP signaling pathway and is present in various secretory epithelial cells, including conjunctival and corneal epithelial cells. Activation of CFTR leads to fluid secretion in both mouse and human ocular surfaces. Dry eye disease is a significant health problem for which limited therapeutic options are available. In this review, on the one hand, small molecule CFTR activators with different chemical structures are summarized, and on the other hand, the pharmacological activity test and structural optimization of small molecule CFTR activators in the treatment of dry eye are outlined. The purpose of this review is to highlight the important role of CFTR activators in the treatment of dry eye disease and their potential as a new strategy for the treatment of dry eye disease.

Berberine ameliorate inflammation and apoptosis via modulating PI3K/AKT/NFκB and MAPK pathway on dry eye

BACKGROUND

Dry eye disease (DED) is a multifactorial disease in ocular surface, and inflammation plays an etiological role. Berberine (BBR) has shown efficacy in treating inflammatory diseases. Yet, there was no adequate information related to the therapeutic effects of BBR for DED.

PURPOSE

To detect the effects and explore the potential mechanisms of BBR on DED.

STUDY DESIGN

In vitro, in vivo study and network pharmacology analysis were involved.

METHOD

The human corneal epithelium cells viability was evaluated with different concentrations of BBR. Dry eye murine model was established by exposing to the desiccating stress, and Ciclosporin (CSA), BBR eye drops or vehicle were topical administration for 7 days. The phenol red cotton tests, Oregon-green-dextran staining and Periodic acid-Schiff staining were performed and evaluated the dry eye after treatment. Inflammation and apoptosis levels of ocular surface were quantified. The potential targets related to berberine and dry eye were collected from databases. The Protein-Protein interaction network analysis and GO & KEGG enrichment analysis were realized by STRING database, Metascape platform and Cytoscape software to find core targets and signaling pathways. The SchrÖdinger software was used to molecular docking and PyMOL software to visualization. Finally, the levels of PI3K/AKT/NFκB and MAPK pathways were detected.

RESULT

The data revealed BBR could rescue impaired HCE under hyperosmotic conditions. In addition, BBR eye drops could ameliorate dry eye. And BBR eye drops suppressed the inflammatory factors and CD4+T cells infiltration in conjunctiva. Besides, BBR eye drops protected ocular surface by avoiding the severe apoptosis and decreasing the level of MMP-3 and MMP-9. 148 common targets intersection between BBR and dry eye were found via network pharmacology analysis. Core proteins and core pathways were identified through PPI and GO&KEGG enrichment analysis. Molecular docking displayed excellent binding between BBR and those core targets. Finally, in vivo study verified that BBR eye drops had a therapeutic effect in dry eye by inhibiting PI3K/AKT/NFκB and MAPK pathways.

CONCLUSION

The research provided convincing evidence that BBR could be a candidate drug for dry eye.

Potential benefits of Malva sylvestris in dry-eye disease pathology in vitro based on antioxidant, wound-healing and anti-inflammatory properties

Dry eye disease (DED) is a common chronic ocular surface disease. Available therapies are effective but often associated with side effects. This study investigates the potential of a Malva sylvestris L. flower extract and two defined preparations, a mucilage and a polyphenol rich fraction, on cells that are essential for the DED pathology. Furthermore, single compounds were isolated and characterised out of the polyphenol fraction. The M. sylvestris extract and its two fractions reduced reactive oxygen species (ROS) in an ultraviolet-induced model and promoted wound healing capacity of HCE-T cells, but only the polyphenol fraction and the flower extract exhibited significant radical scavenging activity. The flower extract and the polyphenol fraction inhibited cytokine secretion (IL-6, TNF-α, IL-8) from HCE-T cells and THP-1 cells. In contrast, the mucilage fraction led to an increase in mediator secretion. The NF-κB activity and calcium influx in THP-1 and Jurkat cells, respectively was decreased by treatment with the flower extract and the polyphenol fraction, whereas the mucilage fraction had no influence on these parameters. Moreover, the flower extract and the mucilage fraction at low concentration could stimulate meibomian gland cells' lipid accumulation. The isolated single compounds showed no effect on analysed parameters, except a coumarin derivative and malvin which showed ROS inhibition effects.

Update on Dry Eye Disease Treatment: Evidence From Randomized Controlled Trials

ABSTRACT

Although the ultimate goal of dry eye disease (DED) management is to restore the ocular surface and tear film homeostasis and address any accompanying symptoms, addressing this is not an easy task. Despite the wide range of current treatment modalities targeting multiple aspects of DED, the available DED management literature is quite heterogeneous, rendering evaluation or comparison of treatment outcomes hard or almost impossible. There is still a shortage of well-designed, large-scale, nonsponsored, randomized, controlled trials (RCTs) evaluating long-term safety and efficacy of many targeted therapies individually or used in combination, in the treatment of identified subgroups of patients with DED. This review focuses on the treatment modalities in DED management and aims to reveal the current evidence available as deduced from the outcomes of RCTs.

Association between dyslipidaemia and dry eye disease: a systematic review and meta-analysis

PURPOSE

To report a systematic review and meta-analysis of the association between dry eye disease (DED) and dyslipidaemia.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were systematically searched from January 2000 to December 2021. We included observational studies to assess the correlation of DED with meibomian gland dysfunction and dyslipidaemia without any language restrictions. The pooled OR with 95% CI was calculated in Stata V.15.

RESULTS

Of 6727 identified studies, 18 studies (21 databases) with a total of 2 663 126 patients were analysed in our meta-analysis. The results showed that DED risk was associated with dyslipidaemia (OR=1.53, 95% CI: 1.41 to 1.66, p=0.001), especially elevated total cholesterol levels (OR=1.57, 95% CI: 1.25 to 1.99, p<0.001), elevated low-density lipoprotein cholesterol levels (OR=1.13, 95% CI: 1.06 to 1.20, p<0.001) and high-density lipoprotein cholesterol levels (OR=1.06, 95% CI: 1.01 to 1.11, p<0.001), but not with serum triglyceride levels. Moreover, having a history of lipid-lowering drug use (OR=1.41, 95% CI: 1.19 to 1.67, p<0.001) was also found to be positively associated with DED risk.

CONCLUSIONS

The findings suggested that dyslipidaemia and lipid-lowering drug use might be associated with an increased risk of DED. More evidence is needed to confirm the findings by prospective studies.

PROSPERO REGISTRATION NUMBER

CRD42022296664.

Real Life Impact of Dry Eye Disease

Dry Eye Disease (DED) is an increasingly common condition that affects between 5% and 50% of the global population. Even though DED is most frequently diagnosed in older people, it has also been diagnosed in young adults and adolescents more frequently in recent years (employees, gamers). People can experience different types of symptoms and find it challenging to read, watch TV, cook, climb stairs, and meet friends. Mild and severe dry eye can reduce quality of life similarly to mild psoriasis and moderate-to-severe angina. Furthermore, DED patients experience serious difficulties driving vehicles, especially at night, and show a decrease in work productivity, which, when combined with the relevant indirect cost that this condition produces, poses a serious challenge in our days. In addition, DED patients are more likely to develop depression and suicidal ideations and experience frequent sleep disorders. Finally, it is discussed how lifestyle changes, such as increased physical activity, blinking exercises, and a proper diet, have positive implications for the management of this condition. Our aim is to draw attention to the negative effects of dry eye in real life, which are unique to each patient, especially as they relate to the non-visual symptoms experienced by DED patients.

Prolonged facemask wearing among hospital workers and dry eye - a mixed-methods study

BACKGROUND

Prolonged facemask wearing may have negatively affected essential workers with dry eye. We conducted a mixed-methods study to examine and understand the associations of the ocular surface, periocular environment, and dry eye-related symptoms among hospital workers across the job spectrum with prolonged facemask use.

METHODS

We recruited clinical and non-clinical hospital workers with self-reported symptoms of dry eye and prolonged facemask use. We measured symptoms using the 5-item Dry Eye Questionnaire and the Ocular Surface Disease Index (OSDI). Objective ocular signs included corneal and conjunctival staining, fluorescein tear break up time (TBUT), meibography, tear film interferometry, and periocular humidity. We compared symptoms and signs across levels of periocular humidity, dry eye severity, facemask type, and job type. Participants with moderate or severe dry eye symptoms (OSDI > = 23) were invited for a semi-structured, one-on-one interview.

RESULTS

We enrolled 20 clinical and 21 non-clinical hospital workers: 27% were 40 years or older, 76% were female, 29% reported a race other than White, and 20% were Hispanic. Seventeen individuals participated in the semi-structured interviews. From the quantitative analyses, we found that 90% of participants reported worsened severity of dry eye at work due to facemasks. Although wearing facemasks resulted in higher periocular humidity levels compared with not wearing facemasks, 66% participants reported increased airflow over their eyes. Findings from the qualitative interviews supported the finding that use of facemasks worsened dry eye symptoms, especially when facemasks were not fitted around the nose. The data did not suggest that non-clinical hospital workers experienced a greater impact of dry eye than clinical workers.

CONCLUSIONS

Healthcare providers and patients with dry eye should be educated about the discomfort and the ocular surface health risks associated with inadequately fitted facemasks. Wearing a fitted facemask with a pliable nose wire appears to mitigate the upward airflow.

Comparison of RCI001 and corticosteroid on the effects on intraocular pressure in mice

Purpose

RCI001, a novel therapeutic candidate for the treatment of ocular inflammatory diseases, have demonstrated remarkable anti-inflammatory and antioxidant effects in various ocular experimental models. This study was to evaluate the effects of RCI001 on intraocular pressure (IOP) and compare them with those of corticosteroids in experimental mouse models.

Methods

Experimental mice were randomly divided into naïve, phosphate-buffered saline (PBS), 0.1% dexamethasone (DEX-1), and 1% RCI001 (RCI) groups, and each reagent was pipetted into the right eye of the mouse at 10 μL thrice daily for 5 weeks. In addition, 20 μL of 0.1% dexamethasone was injected subconjunctivally into the right eye once weekly for 5 weeks in the DEX-2 group. The IOP was measured under anesthesia at baseline and twice weekly for 5 weeks. The △IOP (%) was defined as the change in IOP from baseline [△IOP (%) = (IOPweek5-IOPbaseline)/IOPbaseline × 100%]. The anterior segments were clinically and histologically examined.

Results

There was no significant increase in IOP and △IOP (%) [values by week 3 (day 21) in any of the groups]. However, IOP and △IOP (%) in the DEX-2 group tended to increase slightly after day 10 compared with baseline. Compared with baseline IOP values, the DEX-1 group showed a statistically significant increase in IOP at weeks 4 and 5, and the DEX-2 group at week 5. The △IOP (%) of the DEX-1 and DEX-2 groups (%) at week 5 were 38.2% ± 5.8% and 38.4 ± 4.6%, respectively. However, the IOP in the RCI group did not increase significantly until week 5. The RCI group did not show notable corneal changes, such as epithelial defects or stromal opacities, at week 5. In addition, hematoxylin and eosin (H&E) staining of corneas in the RCI group revealed healthy corneal epithelial, stromal, and endothelial integrity.

Conclusion

Long-term use of RCI001 did not induce significant IOP elevation or ocular surface changes, whereas topical corticosteroids significantly increased the IOP. Therefore, RCI001 may be an effective anti-inflammatory agent with a low risk of drug-induced IOP elevation.

Racial and Ethnic Disparities in Dry Eye Diagnosis and Care

PURPOSE

To investigate health disparities in racial and ethnic minorities with dry eye.

METHODS

Medical records were reviewed for demographics, socioeconomic factors, treatments, and objective dry eye parameters. Race/ethnicity was self-reported as delineated by the U.S. Census. The reference group comprised of randomly selected White patients, with number equal to the largest minority group.

RESULTS

The study included 465 patients (157 Black, 157 White, 85 Asian, and 66 Hispanic). Compared to White (3.2%) patients, larger proportion of minorities used Medicaid or lacked health insurance (Black 8.3%, P = .054; Asian 10.6%, P = .019; Hispanic 18.2%, P < .001). Black and Hispanic patients had lower estimated median household income than Whites (White $98,472, Black $75,554, P < .001; Asian $105,503, P = .088; Hispanic $86,839, P = .030). Prior to presentation, fewer minority patients received prescription treatments or procedures (White 61.8%; Black 30.6%, P < .001; Asian 43.5%, P = .006; Hispanic 43.9%, P = .014). Although at baseline visit minorities had worse mean conjunctival (White, 1.7; Black 2.2, P = .136, Asian 2.4, P = .022; Hispanic 2.6, P = .005) and corneal staining scores (White, 1.6; Black 2.5, P < .001; Asian 2.3, P = .003; Hispanic 2.4, P = .001), no differences were noted at final visit.

CONCLUSION

Minorities presented with worse objective dry eye parameters, and less prior dry eye care. Income and health care access may not fully explain the observed undertreatment at presentation. Differential management by eye care providers and patient attitudes warrant further investigation.

Mesenchymal stem cell therapy in aqueous deficient dry eye disease

ENGLISH SUMMARY

Dry eye disease (DED) is characterized by ocular dryness, irritation and blurred vision and has a significant impact on the patient's quality of life. This condition can be particularly severe in patients with aqueous deficient dry eye disease (ADDE) due to Sjögren's syndrome (SS), an autoimmune disease that affects the lacrimal and salivary glands. Current treatments for ADDE are often limited to symptomatic relief. A literature review was conducted to explore the current surgical interventions used or tested in humans with ADDE (I). These interventions include procedures involving the eyelids and tear ducts, transplantation of amniotic membrane or salivary glands, injections around the tear ducts and cell-based injections into the lacrimal gland (LG). Each treatment has its advantages and disadvantages; however, treating dry eyes in patients with SS presents a particular challenge due to the systemic nature of the disease. Moreover, there is a need for new therapeutic options. Mesenchymal stem cells (MSCs) are a type of stem cell that have shown promise in regenerating damaged tissue and reducing inflammation in various diseases. Previous studies in animal models have suggested that MSCs could be effective in treating ADDE. Thus, this thesis aims to investigate the safety and efficacy of injecting MSCs into the LG as a treatment option for patients with ADDE secondary to SS. The study also aims to see this treatment in light of existing and novel investigational treatment options. The clinical studies conducted for this thesis are the first of their kind in humans. MSCs derived from healthy donors' adipose tissue (ASCs) were cultured in a laboratory, frozen and thawed ready for use. In the safety study, we performed the first human trial involving the administration of a single injection of ASCs into the LG of one eye in seven patients suffering from severe ADDE (II). The primary objective was to test the safety of this treatment, while the secondary objective was to assess improvements in subjective and objective signs of dry eye. The results of the trial showed no serious side effects within 4 months of follow-up after treatment. On average, there was a 40% reduction in dry eye symptoms assessed with the Ocular Surface Disease Index (OSDI) questionnaire. Additionally, in the treated eye, there was a significant decrease in tear osmolarity, an increase in tear film stability and an increase in tear production. To further investigate the efficacy of this treatment, our research group performed a clinical, randomized study aiming to compare the ASC injection into the LG with the injection of a vehicle (the excipient in which the ASCs are dissolved) and observation (no intervention) (III). The study involved 20 subjects receiving ASC injection, 20 subjects receiving vehicle injection and 14 patients being observed without intervention. The subjects were examined to assess the outcomes with a 12-month follow-up after treatment. Both intervention groups showed a significant reduction in subjective dry eye symptoms of approximately 40%. This improvement was evident at the 1-week follow-up and persisted until the 12-month follow-up. The observation group did not experience any change in OSDI score. The ASCs group exhibited a significant mean increase in non-invasive tear break-up time (NIKBUT) of 6.48 s (149%) at the four-week follow-up, which was significantly higher than that in the vehicle group (p = 0.04). Moreover, the ASCs group showed a significant increase in NIKBUT compared to that in the observation group at the 12-month follow-up (p = 0.004). In both the ASCs and vehicle group, a significant increase in Schirmer test scores at the 4-month follow-up and the 12-month follow-up was observed. In conclusion, this thesis contributes valuable findings with a new treatment option for patients with dry eye disease. Injection of ASCs into the LG was shown to be safe and to improve subjective dry eye symptoms and specifically the tear film stability in patients with ADDE due to SS. Compared to other treatment modalities of ADDE, this treatment has greater potential, as ASCs could potentially be used as an anti-inflammatory therapeutic option for managing DED of other causes as well. RESUMÉ (DANISH SUMMARY): Tørre øjne, karakteriseret ved tørhedsfornemmelse og irritation af øjnene samt sløret syn, har en betydelig indvirkning på patientens livskvalitet. Denne tilstand kan vaere saerligt alvorlig hos patienter med nedsat tåreproduktion (ADDE) som følge af Sjögrens syndrom (SS), en autoimmun sygdom, der påvirker tårekirtlerne og spytkirtlerne. Nuvaerende behandlinger for ADDE er ofte begraenset til symptomlindring. Vi gennemførte en litteraturgennemgang for at undersøge, hvilke nuvaerende kirurgiske behandlingsmetoder, der anvendes eller testes hos patienter med ADDE (I). Disse interventioner inkluderer procedurer, der involverer øjenlåg og tårekanaler, transplantation af amnionhinde eller spytkirtler, injektioner omkring tårekanalerne samt cellebaserede injektioner i tårekirtlen. Hver behandling har sine fordele og ulemper, men behandling af tørre øjne hos patienter med SS udgør en saerlig udfordring på grund af sygdommens systemiske udbredning, og der er behov for nye behandlingsmuligheder. Mesenkymale stamceller (MSCs) er en type stamcelle, der har vist lovende resultater med hensyn til at regenerere beskadiget vaev og reducere inflammation i forskellige sygdomme. Tidligere undersøgelser i dyremodeller har indikeret, at MSCs kan vaere en effektiv behandling af ADDE. Denne afhandling har til formål at undersøge sikkerheden og effekten af injektion af MSCs i tårekirtlen som en mulig behandling til patienter med ADDE som følge af SS. Afhandlingen sigter også mod at sammenligne denne behandling med andre eksisterende, kirurgiske behandlingsmuligheder af ADDE. Som led i dette projekt udførte vi de første kliniske forsøg af sin art i mennesker. MSCs fra raske donorers fedtvaev (ASCs) blev dyrket i et laboratorium, frosset ned og er optøet klar til brug. Det første mål var at teste sikkerheden ved denne behandling og sekundaert at undersøge behandlingens effekt. For at undersøge dette modtog syv forsøgspersoner med svaer ADDE én injektion med ASCs i tårekirtlen på det ene øje (II). Resultaterne af forsøget viste ingen alvorlige bivirkninger inden for fire måneders opfølgning efter behandlingen. I gennemsnit fandt vi yderligere en 40% reduktion i symptomer på tørre øjne vurderet med et spørgeskema, og en markant stigning i tåreproduktionen og af tårefilmens stabilitet i det behandlede øje. For yderligere at undersøge effekten af denne behandling udførte vi et klinisk, randomiseret forsøg med det formål at sammenligne injektion af ASCs i tårekirtlen med injektion af en kontrolopløsning (vaesken, hvor stamcellerne var opløst) og observation (ingen intervention) (III). Studiet omfattede 20 forsøgspersoner, der modtog ASC-injektion, 20 forsøgspersoner, der modtog injektion af kontrolopløsningen, og 14 forsøgspersoner i observationsgruppen. Forsøgspersonerne blev undersøgt med en opfølgningstid på 12 måneder efter behandling. Begge interventionsgrupper viste en betydelig reduktion på ca. 40% i subjektive symptomer på tørre øjne. Denne forbedring var betydelig allerede ved opfølgning efter en uge og varede ved 12 måneder efter behandling. Observationsgruppen oplevede ingen betydelig aendring i symptomer. ASCs gruppen viste desuden en signifikant stigning i tårefilmsstabiliteten (NIKBUT) på 6,48 sekunder (149%) ved opfølgning efter fire uger, hvilket var markant højere end efter injektion af kontrolopløsning (p = 0,04). Desuden viste ASCs gruppen en betydelig stigning i NIKBUT sammenlignet med observationsgruppen ved opfølgning efter 12 måneder (p = 0,004). Både injektion af ASCs og kontrolopløsning medførte en betydelig stigning i tåreproduktionen ved opfølgning fire måneder og 12 måneder efter behandling. Denne afhandling bidrager med vigtige resultater inden for en ny behandlingsmulighed af tørre øjne. Injektion af ASCs i tårekirtlen viste sig at vaere sikker, forbedrede subjektive symptomer på tørre øjne og øgede saerligt tårfilmens stabilitet hos patienter med ADDE på grund af SS. Sammenlignet med andre behandlingsmuligheder for ADDE har denne behandling vist et stort potentiale. ASCs kan muligvis også bruges som en anti-inflammatorisk behandling af tørre øjne af andre årsager i fremtiden.

Greater adherence to a mediterranean diet is associated with lower C-reactive protein (CRP) levels, but not to lower odds of having dry eye disease

PURPOSE

To investigate the hypothesis that a Mediterranean diet is associated with a lower risk of having dry eye disease (DED) in the general population.

METHODS

DED was assessed using the Women's Health Study (WHS) dry eye questionnaire in 58,993 participants from the Dutch Lifelines Cohort with complete available dietary data (20-94 years, 60% female). Level of adherence to a traditional Mediterranean diet was assessed using the modified Mediterranean Diet Score (mMDS). High-sensitivity C-reactive Protein (hsCRP) was included as a marker of whole-body inflammation. Logistic regressions were used to examine the relationship between WHS-defined DED and mMDS, corrected for age, sex, BMI, education, income, and 48 potentially confounding comorbidities. The association between mMDS and hsCRP, and hsCRP and DED, was further explored in separate regressions.

RESULTS

Of all participants, 9.1% had DED. In contrast to the hypothesis, higher mMDS levels were associated with greater odds of DED, corrected for demographics, smoking status, BMI, and comorbidities (OR 1.034, 95%CI: 1.015 to 1.055, P = 0.001). Moreover, there was a highly significant relationship between increasing mMDS and lower circulating hsCRP levels; however, there was no significant relationship between hsCRP and DED.

CONCLUSIONS

Stronger adherence to a Mediterranean diet does not appear to be associated with lower odds of having DED in the general population. Furthermore, there was no association between hsCRP and DED in this study. However, the previously described link between a Mediterranean diet and lower hsCRP was confirmed in this large population-based study.

3-month post-procedural evaluation of a combined intense pulsed light and photo-biomodulation system in the treatment of meibomian gland dysfunction

PURPOSE

Meibomian gland dysfunction (MGD) is the leading cause of dry eye syndrome. It is a frequent and underdiagnosed condition with a significant socioeconomic impact. We propose here the evaluation of a platform combining intense pulsed light and photo-biomodulation in the treatment of Meibomian gland dysfunction.

METHODS

We conducted a retrospective study at Brest University Hospital analyzing a cohort of 74 eyes (37 patients) at 1 month and 3 months after a protocol of 3 Eye-Light® (Espansione Group, Italy) sessions 14 days apart between January 2019 and April 2020. The primary outcome was the change in OSDI quality of life score. Secondary outcomes were the SPEED questionnaire score; tear break-up time (BUT), Oxford score, non-invasive break-up time (NIBUT), lipid layer thickness, lacrimal meniscus height and Meibomian gland atrophy rate. Tolerance of the treatment was also evaluated.

RESULTS

We found a significant improvement in OSDI scores at 1 month (-17.32; 95% CI (-25.84; -8.79), P<0.0001) and 3 months (-16.95; 95% CI (-25.26; -8.64), P<0.0001). The SPEED score, BUT, Oxford score, Meibomian gland atrophy and NIBUT were also statistically significantly improved. Tolerance to treatment was very good despite two cases of herpetic keratitis, which resolved on treatment.

CONCLUSION

Treatment with the Eye-Light® in three sessions every two weeks significantly reduced symptoms and ocular surface damage in patients with MGD. This data suggests that the use of Eye-Light® may represent a good option for patients with MGD.

Culture of primary human meibomian gland cells from surgically excised eyelid tissue

Meibomian gland dysfunction is one of the most common ocular diseases, with therapeutic treatment being primarily palliative due to our incomplete understanding of meibomian gland (MG) pathophysiology. To progress in vitro studies of human MG, this study describes a comprehensive protocol, with detailed troubleshooting, for the successful isolation, cultivation and cryopreservation of primary MG cells using biopsy-size segments of human eyelid tissue that would otherwise be discarded during surgery. MG acini were isolated and used to establish and propagate lipid-producing primary human MG cells. The primary cell viability during culture procedure was maintained through the application of Rho-associated coiled-coil containing protein kinase inhibitor (Y-27632, 10 μM) and collagen I from rat tails. Transcriptomic analysis of differentiated primary human MG cells confirmed cell origin and revealed high-level expression of many lipogenesis-related genes such as stearoyl-CoA desaturase (SCD), ELOVL Fatty Acid Elongase 1 (ELOVL1) and fatty acid synthase (FASN). Primary tarsal plate fibroblasts were also successfully isolated, cultured and cryopreserved. Established primary human MG cells and tarsal plate fibroblasts presented in this study have potential for applications in 3D models and bioengineered tissue that facilitate research in understanding of MG biology and pathophysiology.

Rapid detection of tear lactoferrin for diagnosis of dry eyes by using fluorescence polarization-based aptasensor

Differentiating dry eye disease (DED) from allergic or viral conjunctivitis rapidly and accurately is important to ensure prompt diagnosis and treatment. Tear lactoferrin (LF), a multi-functional glycoprotein found in tears, decreases significantly in patients with DED, and has been considered as a DED diagnostic biomarker. Measuring tear LF level, however, takes time and requires the use of bulky instruments. Herein, a homogeneous carbon nanostructure-based aptasensor with high sensitivity and selectivity has been developed by applying fluorescence polarization (FP) technology. The FP of carbon dots (CDs) bioconjugated with LF aptamers (CDs-aptamer) is 21.2% higher than that of CDs, which can be further amplified (1.81 times) once interacting with graphene oxide nanosheets (GONS). In the presence of LF, GONS separates from CDs-aptamer because of the stronger binding affinity between CDs-aptamer to LF, resulting in the decrease of FP value. A linear relationship is observed between FP value and LF concentration in spiked tear samples from 0.66 to 3.32 mg/mL. The selectivity of the aptasensor has been investigated by measuring other proteins. The results indicate that the FP-based aptasensor is a cost-effective method with high sensitivity and selectivity in detection of tear LF.

Recent advances of smart materials for ocular drug delivery

Owing to the variety and complexity of ocular diseases and the natural ocular barriers, drug therapy for ocular diseases has significant limitations, such as poor drug targeting to the site of the disease, poor drug penetration, and short drug retention time in the vitreous body. With the development of biotechnology, biomedical materials have reached the "smart" stage. To date, despite their inability to overcome all the aforementioned drawbacks, a variety of smart materials have been widely tested to treat various ocular diseases. This review analyses the most recent developments in multiple smart materials (inorganic particles, polymeric particles, lipid-based particles, hydrogels, and devices) to treat common ocular diseases and discusses the future directions and perspectives regarding clinical translation issues. This review can help researchers rationally design more smart materials for specific ocular applications.

Localized Heat Treatment for Meibomian Gland Dysfunction: A Single-Center Retrospective Analysis of Efficacy over Time

SIGNIFICANCE

Meibomian gland dysfunction (MGD) can produce a myriad of symptoms. The effective treatment of MGD can reduce the burden of this condition. Although several studies have indicated that TearCare (Sight Sciences, Menlo Park, CA) is an effective treatment for MGD, no studies currently provide information regarding the duration of efficacy.

PURPOSE

The purpose of this analysis was to determine the duration of efficacy of symptom relief and improvement of signs (as measured by gland function) for a treatment consisting of controlled heating of the meibomian glands using SmartLids (Sight Sciences) combined with manual expression of the liquefied meibum by a physician.

METHODS

This study involved retrospective analysis of data gathered from a single-center ophthalmology/optometry practice. Symptoms were assessed using the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and the signs were assessed using the meibomian gland expression (MGE) scores before and at several time points (8 weeks, 6 months, 12 months, and 18 months). Further analysis evaluating the efficacy in subgroups based on age, race, and sex was performed.

RESULTS

There were 78 patients included in this study. The mean baseline SPEED score decreased from 14 to 7.9 at 8 weeks. The mean SPEED scores at 6 and 12 months were maintained at 7.7 and 7.9, respectively, and at 18 months went to 8.9. At baseline, the mean MGE was 4.9 in the right eye and 4.8 in the left eye. In both eyes, the mean MGE increased to 9.0 in both eyes at 8 weeks. At 6 months, the mean MGE score was maintained at 8.6 in the right and 8.2 in the left and remained consistent at 12 months with 7.8 in the right and 7.8 in the left. At 18 months, the MGE score went to 6.8 in the right eye and 7.0 in the left eye.

CONCLUSIONS

A single TearCare treatment effectively reduced both the symptoms and signs of MGD and maintained its effects for 12 months.

The environment and dry eye-manifestations, mechanisms, and more

Dry eye disease (DED) is a multifactorial condition that often presents with chronic symptoms of pain (that can be characterized as "dryness," "burning," and "irritation," to name a few) and/or fluctuating or poor-quality vision. Given its multifactorial nature, several pathophysiologic mechanisms have been identified that can underlie symptoms, including tear film, ocular surface, and/or corneal somatosensory nerve abnormalities. Research has focused on understanding how environmental exposures can increase the risk for DED flares and negatively impact the tear film, the ocular surface, and/or nerve health. Given that DED is a common condition that negatively impacts physical and mental functioning, managing DED requires multiple strategies. These can include both medical approaches and modulating adverse environmental conditions, the latter of which may be a cost-effective way to avoid DED flares. Thus, an understanding of how environmental exposures relate to disease is important. This Review summarizes research on the relationships between environmental exposures and DED, in the hope that this information will engage healthcare professionals and patients to consider environmental manipulations in their management of DED.

Impacts of air pollution and meteorological conditions on dry eye disease among residents in a northeastern Chinese metropolis: a six-year crossover study in a cold region

The purpose of this study is to explore the associations among dry eye disease (DED), air pollution, and meteorological conditions in the cold region of a northeastern Chinese metropolis (i.e., Changchun). Data on ambient air pollutants and meteorological parameters as well as diagnosed DED outpatients during 2015-2021 were collected. The associations between DED and environmental factors were analysed at multiple time scales using various statistical methods (i.e., correlation, regression and machine learning). Among the 10,809 DED patients (21,617 eyes) studied, 64.60% were female and 35.40% were male. A higher frequency of DED was observed in March and April, followed by January, August and October. Individual and multiple factor models showed the positive importance of particles with aerodynamic diameters <10 μm (PM₁₀), carbon monoxide (CO), and ozone (O₃) among normal air pollutants and air pressure (AP), air temperature (AT) and wind speed (WS) among normal meteorological parameters. Air pollutants (PM₁₀, nitrogen dioxide: NO₂) and meteorological parameters (AT, AP) have combined impacts on DED occurrence. For the first time, we further explored the associations of detailed components of atmospheric particles and DED, suggesting potential emission sources, including spring dust from bare soil and roads and precursor pollutants of summer O₃ formation from vehicles and industry in Northeast China. Our results revealed the quantitative associations among air pollutants, meteorological conditions and DED outpatients in cold regions, highlighting the importance of coordinated policies in air pollution control and climate change mitigation.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

1,5-Dicaffeoylquinic acid from Pseudognaphalium affine ameliorates dry eye disease via suppression of inflammation and protection of the ocular surface

PURPOSE

Pseudognaphalium affine (P. affine), a medicinal plant, has long been used to treat various diseases due to its astringent and vulnerary effects. These therapeutic benefits are largely attributed to high contents of phytochemicals, such as flavonoids and polyphenols, that have anti-inflammatory and tissue-protective activities. Herein, we investigated the potential of dicaffeoylquinic acids (diCQAs), polyphenols from P. affine, as a novel treatment for dry eye disease (DED).

METHODS

We isolated 1,5-, 3,4-, 3,5- and 4,5-diCQAs from the P. affine methanol extract, and tested the effects of diCQA isomers in cultures of human corneal epithelial cells (CECs) under desiccating hyperosmolar stress and in two mouse models for DED: desiccating environmental stress-induced DED and the NOD.B10-H2b mouse model of ocular Sjögren's syndrome.

RESULTS

Initial screening showed that, among the diCQAs, 1,5-diCQA significantly inhibited apoptosis and enhanced viability in cultures of CECs under hyperosmolar stress. Moreover, 1,5-diCQA protected CECs by promoting proliferation and downregulating inflammatory activation. Subsequent studies with two mouse models of DED revealed that topical 1,5-diCQA administration dose-dependently decreased corneal epithelial defects and increased tear production while repressing inflammatory cytokines and T cell infiltration on the ocular surface and in the lacrimal gland. 1,5-diCQA was more effective in alleviating DED, as compared with two commercially-available dry eye treatments, 0.05% cyclosporine and 0.1% sodium hyaluronate eye drops.

CONCLUSIONS

Together, our results demonstrate that 1,5-diCQA isolated from P. affine ameliorates DED through protection of corneal epithelial cells and suppression of inflammation, thus suggesting a novel DED therapeutic strategy based on natural compounds.

Prevalence and Risk Factors of Dry Eye Disease among Adults in Saudi Arabia

Background

Environmental and epidemiological factors increase the risk of dry eye in Saudi Arabia, but most studies have limited generalizability.

Objective

To determine the prevalence of dry eye disease (DED) among adults across Saudi Arabia and the associated risk factors. The secondary objective was to estimate the economic burden of DED by calculating lubricant usage and its annual costs.

Methods

This cross-sectional study invited adults from across Saudi Arabia to complete a questionnaire that collected data regarding demographics, symptoms related to DED, previous diagnosis of DED, use of contact lenses, and use of eye lubricants.

Results

A total of 2042 responses were received, of which 784 (38.4%) respondents had previously been diagnosed with DED and 752 (36.8%) were symptomatic but undiagnosed. Between the DED diagnosed and symptomatic-undiagnosed groups, a significant difference was found in terms of age (P < 0.001), gender (P = 0.002), presence of diabetes mellitus (P = 0.004), smoking status (P = 0.007), duration of electronic screen use (P = 0.05), number of ocular complaints (P < 0.001), and frequency of lubricants use (P < 0.001). Between the DED-diagnosed and non-DED groups, significant differences were found in terms of age (P < 0.001), gender (P < 0.001), presence of diabetes mellitus (P = 0.001), allergy (P = 0.001), autoimmune disease (P = 0.005), smoking status (P < 0.001), and history of refractive surgery (P < 0.001). The mean estimated annual cost of using lubricating agents was SAR 328.2 ± 210.3 (USD 87.5 ± 56.1), and this was significantly higher in the diagnosed group (P = 0.01) than the symptomatic-undiagnosed group.

Conclusions

The prevalence of DED is high among adults in Saudi Arabia. High-risk population include elderly, female, and using electronic screens for >2 hours/day.

Current uses of artificial intelligence in the analysis of biofluid markers involved in corneal and ocular surface diseases: a systematic review

Corneal and ocular surface diseases (OSDs) carry significant psychosocial and economic burden worldwide. We set out to review the literature on the application of artificial intelligence (AI) and bioinformatics for analysis of biofluid biomarkers in corneal and OSDs and evaluate their utility in clinical decision making. MEDLINE, EMBASE, Cochrane and Web of Science were systematically queried for articles using AI or bioinformatics methodology in corneal and OSDs and examining biofluids from inception to August 2021. In total, 10,264 articles were screened, and 23 articles consisting of 1058 individuals were included. Using various AI/bioinformatics tools, changes in certain tear film cytokines that are proinflammatory such as increased expression of apolipoprotein, haptoglobin, annexin 1, S100A8, S100A9, Glutathione S-transferase, and decreased expression of supportive tear film components such as lipocalin-1, prolactin inducible protein, lysozyme C, lactotransferrin, cystatin S, and mammaglobin-b, proline rich protein, were found to be correlated with pathogenesis and/or treatment outcomes of dry eye, keratoconus, meibomian gland dysfunction, and Sjögren's. Overall, most AI/bioinformatics tools were used to classify biofluids into diseases subgroups, distinguish between OSD, identify risk factors, or make predictions about treatment response, and/or prognosis. To conclude, AI models such as artificial neural networks, hierarchical clustering, random forest, etc., in conjunction with proteomic or metabolomic profiling using bioinformatics tools such as Gene Ontology or Kyoto Encylopedia of Genes and Genomes pathway analysis, were found to inform biomarker discovery, distinguish between OSDs, help define subgroups with OSDs and make predictions about treatment response in a clinical setting.

Psychiatric aspects of ophthalmic disorders: A narrative review

Ophthalmic disorders have psychiatric aspects associated with them at various levels. Psychological factors have a well-documented role in the causation, aggravation, and maintenance of various ophthalmic conditions, including glaucoma, central serous retinopathy, dry eye disease, and retinitis pigmentosa. Many ophthalmic conditions, including blindness, have psychological manifestations as well, which need to be addressed, in addition to the ophthalmic pathology. There is also significant overlap in the treatment of the two disciplines in many ways. For instance, many ophthalmic drugs have psychiatric side effects. Even ophthalmological surgeries have psychiatric aspects associated with them, which primarily include black patch psychosis and anxiety in the operation theater. This review will be useful for psychiatrists and ophthalmologists, for their clinical practice and research. Future research should focus on this interface to give it its well-deserved attention.

Features and influences on the normal tear evaporation rate

Tear evaporation is a normal physiological phenomenon that has an important role in regulating blink activity and tear production. An altered tear evaporation rate (TER) is a defining characteristic of evaporative dry eye disease (DED), and the measurement of tear evaporation is a useful clinical test for diagnosis. Reported values for a normal TER cover a broad range, which may be due to the influence of ocular, environmental, and systemic factors. For improved disease diagnosis, a fuller understanding of the normal TER range is essential. This paper reports on a literature review of the current knowledge of these normal influences on TER.

The work-related burden of dry eye

PURPOSE

To investigate the relationship between dry eye disease (DED) and work functioning, unemployment, absenteeism, and worry about job loss.

METHODS

DED and unemployment, absenteeism, and 'worry about job loss' were assessed in 71,067 subjects (18-65 years, 60% female) from the Dutch population-based Lifelines cohort using the Women's Health study questionnaire and single-item questions, respectively. Work functioning was assessed in 32,475 participants using the Work role functioning questionnaire 2.0. The relationships between DED and work measures were assessed with logistic regression models, corrected for age, sex, BMI, income, educational level, smoking, and 48 comorbidities.

RESULTS

8.3% of participants had DED and had more impaired work functioning compared to those without DED (49.2% vs 41.1%, OR 1.21, 95% CI 1.10-1.32, corrected for demographics, smoking and 48 comorbidities). DED carried a similar risk of impaired work functioning as rheumatoid arthritis. For participants with highly symptomatic dry eye impaired work functioning was even higher (59.1%) and similar to that of depression. The impaired work functioning seen with increasing symptoms were greater in undiagnosed subjects versus diagnosed subjects (P = 0.03). After correction for comorbidities, DED remained tied to absenteeism and increased worry about job loss, but not unemployment.

CONCLUSION

DED was linked to impaired work functioning and absence, but not unemployment. DEDs impact on work functioning is comparable to that of other severe chronic disorders, and undiagnosed subjects may be more affected. This highlights the importance of recognizing DED as a severe disorder and of screening for dry eye in the workplace to aid with diagnosis and treatment.

The effect of non-ablative thermomechanical skin treatment (Tixel®) on dry eye disease: A prospective two centre open-label trial

PURPOSE

To determine the effects of a thermo-mechanical action-based peri-orbital fractional skin treatment (Tixel®) on dry eye disease.

METHODS

This prospective, controlled, open labelled study was conducted at two study centres: Midland Eye, Solihull, UK, and Vallmedic Vision, Andorra. Participants were screened at the baseline visit (visit-1), received three Tixel® treatments at 2-weeks intervals including further assessment (visits 2, 3 and 4). Participants were followed up for three months post-treatment (visit 5). Vision, intraocular pressure (IOP), dry eye symptomatology were assessed, including the Ocular Surface Disease Index (OSDI) questionnaire, non-invasive tear break-up time (NIBUT) and tear osmolarity as well as detailed ophthalmic assessments.

RESULTS

Seventy-four participants (41 in Birmingham and 33 in Andorra) with periorbital wrinkles and moderate to severe dry eye disease (DED) were enrolled. The mean age was 59.3 ± 13.3 years and 57 were females. No adverse events, no change in vision (p = 0.310) or IOP (p = 0.419) were observed. Tixel treatment was associated with clinically and statistically significant improvement in the DED symptoms, which was supported by a reduction of 21.40 ± 15.08 (P < 0.001) of the OSDI index. Non-invasive tear break-up time improved by 2.10 ± 0.91 s (p < 0.001) in the Birmingham cohort and 6.60 ± 2.13 s (p < 0.001) in the Andorra cohort. Tear osmolarity reduced from 299.8 ± 13.3 mOsm/L to 298.8 ± 15.6 mOsm/L following the Tixel treatment (p = 0.271).

CONCLUSIONS

Thermo-mechanical action-based peri-orbital fractional skin treatment Tixel® could be an attractive, safe and effective treatment for DED. This treatment is associated with high clinical and statistically significant improvement in DED signs and symptoms with no adverse events.