Assessment of Bulbar Redness with a Newly Developed Keratograph

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.

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.

Efficacy and Safety of Plasma Rich in Growth Factor in Patients with Congenital Aniridia and Dry Eye Disease

Congenital aniridia is a rare bilateral ocular malformation characterized by the partial or complete absence of the iris and is frequently associated with various anomalies, including keratopathy, cataract, glaucoma, and foveal and optic nerve hypoplasia. Additionally, nearly 50% of individuals with congenital aniridia experience symptoms of ocular dryness. Traditional treatment encompasses artificial tears and autologous serum. This study aimed to assess the effectiveness and safety of using platelet rich in growth factors (PRGF) plasma in patients with congenital aniridia and ocular dryness symptoms.

METHODS

The included patients underwent two cycles of a 3-month PRGF treatment. At 6 months, symptomatology was evaluated using the OSDI and SANDE questionnaires, and ocular surface parameters were analyzed.

RESULTS

The OSDI and SANDE values for frequency and severity demonstrated statistically significant improvements (p < 0.05). Ocular redness, corneal damage (corneal staining), and tear volume (Schirmer test) also exhibited statistically significant improvements (p < 0.05). No significant changes were observed in visual acuity or in the grade of meibomian gland loss.

CONCLUSION

The use of PRGF in patients with congenital aniridia and ocular dryness symptoms led to significant improvements in symptomatology, ocular redness, and ocular damage. No adverse effects were observed during the use of PRGF.

Improvement of objective ocular redness measured with Keratograph 5M in glaucoma patients after instilling brimonidine drops

OBJECTIVE

To compare objective ocular redness measured using OCULUS Keratograph 5 M before and after 0.2% brimonidine instillation in glaucoma patients under topical hypotensive treatment.

METHODS

60 eyes from 60 subjects diagnosed with glaucoma or ocular hypertension under hypotensive ocular topical treatment were analyzed. Basal Ophthalmological examination was performed.Outcome variables were OCULUS Keratograph 5 M redness scores (RS) before and after 0.2% brimonidine instillation; overall, bulbar temporal (BT), bulbar nasal (BN), limbar temporal (LT), and limbar nasal (LN); non-invasive average tear film breakup time (Nia-BUT), non-invasive first tear film breakup time (Nif-BUT) and meibography. In addition, the following clinical data were collected: intraocular pressure, type, duration, amount, and preservatives/or not of hypotensive treatment, fluorescein corneal staining score and lower tear meniscus height.

RESULTS

All eyes were under topical medication. All redness scores were reduced after brimonidine instillation, mean RS differences were BT 0.82 ± 0.62, BN hyperemia 1.03 ± 0.55, LN hyperemia 0.84 ± 0.49, LT hyperemia 0.71 ± 0.50 and total hyperemia 0.91 ± 0.52 (all p < 0.001). 30 min after brimonidine instillation mean overall RS reduction was 47.97 ± 12.39% (p < 0.001) and after 1 h there was a persistent reduction of overall RS of 45.92 ± 14.27% (p < 0.001). Hyperemia reduction was significant and comparable between preservative and preservative-free group 0.12 ± 0.14 (p > 0.392) and between patient with combination therapy and monotherapy 0.16 ± 0.14 (p > 0.258).

CONCLUSION

A significant reduction of conjunctival hyperemia was objectively found in glaucoma patients under topical hypotensive treatment before and after brimonidine instillation. Its fast and long-lasting effect may be useful preoperatively in glaucoma patients to reduce intraoperative bleeding and associated complications.

Application of three-dimensional visualization technology in phacoemulsification benefits the dry eye symptoms of patients after cataract surgery

Purpose

To investigate the effects of the three-dimension visualization system on dry eye in patients after cataract phacoemulsification.

Methods

Seventy-one patients (104 eyes) were enrolled in this study and assigned to the conventional microscopic group (CM group) or three-dimension group (3D group). Ocular Surface Disease Index, The Schirmer I test (SIt), lipid layer thickness (LLT), noninvasive tear breakup time (NIBUT) and other factors associated with dry eye were recorded before and 1 week and 1 month after surgery. The operation time and intraoperative light intensity (ILI) were also recorded.

Results

The ILI in the 3D group was significantly lower than that in the CM group (33% vs. 60%, p < 0.01). There was an interaction (group and time) effect for first NIBUT (NIBUT-F), average NIBUT (NIBUT-Ave), tear meniscus height (TMH) and the score of eye redness (Pinteraction < 0.05). The main effects of group on SIt, LLT, NIBUT-F, NIBUT-Ave and the score of eye redness were significant (Pgroup < 0.05). In the CM group, SIt, LLT, NIBUT-F, NIBUT-Ave, TMH were lower than those of the 3D group, the score of eye redness was higher than that of the 3D group at 1 week and 1 month after surgery (all p < 0.05). The changes in NIBUT-F and NIBUT-Ave between before surgery and 1 week after surgery showed negative correlations with ILI (p < 0.01).

Conclusion

Compared with microscopic surgery, the 3D visualization system can provide better tear film stability for patients after cataract surgery.

Anterior segment inflammation and its association with dry eye parameters following myopic SMILE and FS-LASIK

PURPOSE

To evaluate dry eye and anterior segment inflammation after small incision lenticule extraction (SMILE) and femtosecond laser-assisted in situ keratomileusis (FS-LASIK), and investigate their association.

METHODS

This prospective and observational study included 96 eyes from 48 myopic patients. The evaluation was performed at baseline, postoperative day 1, week 1, month 1 and month 3. Outcome measures included anterior chamber flare, bulbar redness (BR), limbal redness (LR), ocular surface disease index (OSDI), tear meniscus height (TMH), the first and average noninvasive breakup time (NIBUT-1, NIBUT-a), fluorescein breakup time (FBUT), corneal fluorescein staining (CFS), and Schirmer I. Generalized estimating equations (GEEs) were applied to explore the correlation between flare and ocular surface parameters.

RESULTS

Flare increased significantly in both groups at day 1 and week 1 and then returned to baseline at month 1. In both groups, BR decreased on day 1 and then gradually increased towards the baseline. In FS-LASIK, LR was lower than baseline at day 1 and month 3. An increase in OSDI was found in the SMILE group on day 1, and in the FS-LASIK group at day 1 to month 1. NIBUT-1 and NIBUT-a decreased significantly on day 1 in both groups. At month 3, NIBUT-a did not return to baseline in FS-LASIK. CFS increased significantly at week 1 in both groups. All parameters were comparable between SMILE and FS-LASIK except for OSDI and NIBUT-a. Time and spherical equivalent showed a correlation with flare.

CONCLUSIONS

Both SMILE and FS-LASIK induced elevated anterior chamber flare and dry eye. However, flare might not be considered a factor determining perioperative dry eye.Key MessagesDry eye disease is common after corneal refractive surgery. Signs and symptoms of dry eye disease persist longer after FS-LASIK compared with SMILE.Both FS-LASIK and SMILE transiently disrupted blood-aqueous barrier integrity, leading to anterior segment inflammation.Anterior chamber flare might not be considered a factor explaining perioperative dry eye, other biomarkers remain for future exploration.

Effect of a single warm compress prior to ophthalmic surgery on ocular surface and intraoperative visibility: a randomised controlled study

PURPOSE

We investigated the effects of a warm compress immediately before surgery on the ocular surface and intraoperative visibility during surgery.

METHODS

A randomised controlled quasi-experiment at Saitama Medical University Hospital. From November 2020 to September 2021, 200 patients scheduled for endophthalmic surgery were randomly assigned to a group that received a hot compress with a spontaneously heating eye mask (HM group) or a group that received only an eye mask (control group). The eye masks were applied for 20 min from 2 hours before surgery, and before and after mask application in the non-invasive tear break-up time (NIBUT), tear meniscus height (TMH) and obstruction score of the meibomian gland (meiboscore) were evaluated. The time from wetting to dry blurring of the corneal surface (corneal blurring time, CBT) was also compared before and after the warm compress.

RESULTS

We enrolled 100 patients in the HM group (mean age 69.0±13.3 years) and 99 patients in the control group (mean age 69.5±16.2 years). In the control group, there were no significant changes in the NIBUT, meiboscore or TMH before and after eye mask use, whereas in the HM group, the NIBUT increased from 6.7±5.1 to 9.5±5.6 s (p<0.001), the meiboscore improved from 0.71±0.93 to 0.63±0.96 (p=0.03) and the TMH significantly improved from 0.22±0.08 to 0.24±0.08 mm (p<0.001). The CBT was longer the HM group than control group (33.5±13.4 s, 25.7±14.9 s, respectively, p=0.01).

CONCLUSIONS

The condition of the ocular surface and intraoperative visibility improved after a single warm compress.

TRIAL REGISTRATION NUMBER

UMIN R000047286.

Impact of Plasma Rich in Growth Factors (PRGF) Eye Drops on Ocular Redness and Symptomatology in Patients with Dry Eye Disease

Background and Objectives: Dry eye disease (DED) is a common and very symptomatic pathology that affects normal daily activity. The aim of the study was to evaluate the efficacy of plasma rich in growth factors (PRGF) added to one routine treatment protocol for DED (artificial tears substitutes, lid hygiene, and anti-inflammatory therapy). Materials and Methods: Patients were divided into two groups of treatment: standard treatment group (n = 43 eyes) and PRGF group (n = 59). Patients' symptomatology (inferred from OSDI and SANDE questionnaires), ocular inflammation, tear stability, and ocular surface damage were analyzed at baseline and after 3 months of treatment. Results: OSDI test scores were significantly lower in both groups (p < 0.001). SANDE frequency test scores also improved statistically, with differences between groups (p = 0.0089 SANDE frequency and p < 0.0119 SANDE severity). There was a greater reduction in ocular redness (ocular inflammation) in the PRGF group (p < 0.0001) and fluorescein tear break-up time was significantly improved in the PRGF group (p = 0.0006). No significant changes were found in terms of ocular surface damage. No adverse events were obtained in either group. Conclusions: The addition of PRGF to the standard treatment of DED, according to the results obtained, proved to be safe and produced an improvement in ocular symptomatology and signs of inflammation, particularly in moderate and severe cases, when compared to standard treatment.

The effects of breaks on digital eye strain, dry eye and binocular vision: Testing the 20-20-20 rule

PURPOSE

To evaluate the benefits on the eyes of taking breaks based on the 20-20-20 rule.

METHODS

Bespoke computer software using the laptop webcam to assess user breaks, eye gaze and blinking, and emitting personalized reminders of breaks based on the 20-20-20 rule, was downloaded onto the laptops of 29 symptomatic computer users. Digital eye strain (DES), binocular vision and dry eye were assessed before and after two weeks of using the reminders and one week after the discontinuation of the strategy. Binocular measurements included visual acuity, accommodative posture, stereopsis, fixation disparity, ocular alignment, accommodative facility, positive/negative vergences and near point of convergence. Symptoms were evaluated using the computer vision syndrome questionnaire, ocular surface disease index (OSDI), and symptom assessment in dry eye questionnaire (SANDE) versions one and two. Dry eye signs were assessed by measuring tear meniscus height, conjunctival redness, blink rate and incomplete blinking, lipid layer thickness, non-invasive keratograph break-up time, corneal and conjunctival staining and lid wiper epitheliopathy.

RESULTS

A decrease in the duration of computer work and the duration of breaks, along with an increase in the number of breaks taken per day was observed as a result of the 20-20-20 rule reminders (p ≤ 0.015). No changes on any binocular parameter were observed after the management period (p ≥ 0.051), except for an increase in accommodative facility (p = 0.010). Dry eye symptoms and DES decreased with the rule reminders (p ≤ 0.045), although this improvement was not maintained one week after discontinuation (p > 0.05). No changes on any ocular surface and tear film parameter were observed with the rule reminders (p ≥ 0.089).

CONCLUSIONS

The 20-20-20 rule is an effective strategy for reducing DES and dry eye symptoms, although 2 weeks was not enough to considerably improve binocular vision or dry eye signs.

Conjunctival T Cell Profile in Allogeneic Hematopoietic Stem Cell Transplant Patients after Instilling Topical Cyclosporine-A 0.1% Cationic Emulsion

INTRODUCTION

To profile conjunctival T cell populations in allogeneic hematopoietic stem cell transplant (HSCT) patients after instillation of daily topical cyclosporine-A (CsA) 0.1% cationic emulsion (Ikervis), and to evaluate patients' tolerance to these eye drops.

METHODS

Nineteen participants were prescribed Ikervis prophylaxis once daily to both eyes from 3-5 weeks pre-HSCT to 12 months post-HSCT. The outcome measure was conjunctival T cell proportions from flow cytometry after impression cytology. Covariates included visual acuity, intraocular pressure, slit lamp and fundal examination, dry eye (SPEED) and quality of life questionnaires, non-invasive keratograph tear break-up time (NIKBUT), conjunctival redness, meibography, lipid thickness, Schirmer test, tear cytokines, fluorescein staining, tear osmolarity, and meibomian gland expressibility.

RESULTS

The conjunctival T cell analysis showed either stable or decreased proportions of conjunctival CD4 T cells at the last visit from baseline in compliant patients. CD4 proportions were increased in non-compliant patients and in the single patient who developed ocular graft-versus-host disease (GVHD). All patients were tolerant to Ikervis but 6/19 were not compliant. In the majority of patients, vision did not affect activities of daily living. Pre- and post-HSCT up to the last study visit, there was no statistically significant change in clinical covariates. Only one participant developed ocular GVHD at 9 months post-HSCT.

CONCLUSION

Superficial conjunctival T cell profile reflects compliance to daily topical Ikervis eye drops and clinical ocular surface parameters in allogenic HSCT patients. Tolerance is comparable to other formulations of topical CsA in the first 12 months.

CLINICALTRIALS

GOV IDENTIFIER

NCT04636918. URL: https://clinicaltrials.gov/ct2/show/NCT04636918?cond=ocular+Graft+Versus+Host+Disease&cntry=SG&draw=2&rank=2 .

Developing a Deep Learning Model to Evaluate Bulbar Conjunctival Injection with Color Anterior Segment Photographs

The present research aims to evaluate the feasibility of a deep-learning model in identifying bulbar conjunctival injection grading. Methods: We collected 1401 color anterior segment photographs demonstrating the cornea and bulbar conjunctival. The ground truth was bulbar conjunctival injection scores labeled by human ophthalmologists. Two convolutional neural network-based models were constructed and trained. Accuracy, precision, recall, F1-score, Kappa, and the area under the curve (AUC) were calculated to evaluate the efficiency of the deep learning models. The micro-average and macro-average AUC values for model grading bulbar conjunctival injection were 0.98 and 0.98, respectively. The deep learning model achieved a high accuracy of 87.12%, a precision of 87.13%, a recall of 87.12%, an F1-score of 87.07%, and Cohen's Kappa of 0.8153. The deep learning model demonstrated excellent performance in evaluating the severity of bulbar conjunctival injection, and it has the potential to help evaluate ocular surface diseases and determine disease progression and recovery.

Prevalence of Dry Eye Disease Among Individuals Scheduled for Cataract Surgery in a Norwegian Cataract Clinic

Purpose

To determine the prevalence of dry eye disease (DED) in patients scheduled for cataract surgery in a Norwegian eye clinic.

Patients and Methods

218 patients scheduled for cataract surgery were examined for DED in one randomly selected eye and questioned regarding symptoms and risk factors. Patients were diagnosed with DED if they fulfilled the DEWS II criteria with symptom score >12/100 with Ocular Surface Disease Index (OSDI) questionnaire, and the presence of any of the three signs: tear osmolarity >307 mOsm/L in either eye or a difference in osmolarity between the two eyes of >8 mOsm/L, corneal fluorescein staining (CSF) ≥ grade 2 and non-invasive tear film breakup time (NIKBUT) of <10 seconds. Additional tests were the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, tear meniscus height (TMH), Schirmer 1, tear film thickness (TFT), corneal sensitivity and meibography (meiboscore). Dry eye test outcomes were correlated with risk factors for DED.

Results

The prevalence of DED was 55.5% according to the DEWS II criteria. The abnormal osmolarity percentage was 66.5, while 29.8% had shortened NIKBUT and 19.7% exhibited CFS ≥2. 57% had Schirmer 1 ≤ 10 mm/5 min, and 81.1% had a meiboscore of ≥1. 71.2% of subjects scored positive for DED symptoms using the OSDI questionnaire and 69.3% using SPEED. Logistic regression analysis showed that higher age correlated with a lower OSDI symptom score, reduced corneal sensitivity and increased meibomian gland atrophy. Female sex was associated with higher odds of having DED, abnormal NIKBUT and abnormal CFS. Ocular tests for DED did not correlate with OSDI symptom scores when assessed with Spearman`s rank analysis.

Conclusion

The prevalence of DED in an elderly Norwegian population scheduled for cataract surgery is high and associated with female sex. There was a lack of correlation between signs and symptoms of DED.

Tear Proteomics Approach to Distinguishing Primary from Secondary Sjögren's Syndrome for Dry Eye Patients with Long-Term Instillation of Eyedrops

The diagnosis and monitoring of Sjögren syndrome (SS) is often difficult, requiring a multidisciplinary approach with invasive procedures. Our aim is to elucidate the tear protein alterations of dry eye disease (DED) with primary SS (pSS) and secondary SS (sSS) with the long-term instillation of eyedrops. We collected clinical demographics and tear fluid (TF) samples from DED patients with no autoimmune diseases (non-SS-DED), pSS-DED, and sSS-DED patients, followed by TF screening with tandem mass tagging-labeling gel-free proteomics assay. Bioinformatic analysis via Ingenuity Pathway Analysis was used to identify functional pathways and interacting networks. Validation of candidate proteins with enzyme-linked immunosorbent assay on the tear samples was done. The top functional pathways of the two comparisons (sSS-DED vs. pSS-DED and sSS-DED vs. non-SS-DED) were both associated with inflammation and stress-related signaling. After constructing an interaction network model with the selected candidate proteins, five proteins were identified. A Disintegrin and Metalloproteinase domain-containing protein 10 (ADAM10) was found to be an important candidate biomarker in all groups, followed by epidermal growth factor (EGF) in TF. This study revealed novel DED markers, ADAM10 and EGF, in differentiating between primary and secondary SS patients from tears by in-depth proteomic analysis.

Use of Artificial Tears in Patients Undergoing Treatment with Anti-VEGF Intravitreal Injections

Purpose

To analyze the use of artificial tears in patients undergoing treatment with anti-vascular endothelial growth (anti-VEGF) intravitreal injections.

Methods

Thirty-four eyes undergoing anti-VEGF treatment were analyzed. Each patient underwent a subjective and objective evaluation of the ocular surface, using the Ocular Surface Disease Index (OSDI), Dry Eye Questionnaire (DEQ)-5, tear meniscus height (TMH), first and average non-invasive Keratograph Break-Up Time (NIKBUT), bulbar conjunctival redness, meibography and the Vision Break-Up Time (VBUT). Patients attended 5 visits (days 0, 7, 30, 37, and 60). All patients continued with their intravitreal injection treatment during the study (days 0, 30, and 60). Patients did not receive any artificial tear treatment during the first month of the study, and at the baseline visit they were randomly assigned to one of two study groups to receive either the Systane Hydration or the Viscofresh 10mg/mL formulation. Patients were instructed to instill one drop of the assigned study treatment 3 times a day for 30 days during the second month of the study.

Results

According to the Mixed Models for Repeated Measures analysis, there is not enough statistical evidence for any of the parameters examined to determine significant differences between being treated with artificial tears and not being treated (p > 0.05). There is, however, a tendency toward improved outcomes in some parameters when artificial tears were used. OSDI, DEQ-5, TMH, and meibography were not affected by either the type of artificial tear used or by the time (from day 30 to day 60; p > 0.05), but the NIKBUT and VBUT values increased over time during this period regardless of which treatment the patient was receiving.

Conclusion

The use of artificial tears may help to keep the tear film stable Future studies with larger samples should be conducted to elucidate whether the tendency reported in our study becomes significant.

Determining the Best Management Strategy for Preventing Short-Term Effects of Digital Display Use on Dry Eyes

OBJECTIVES

To assess and compare the effectiveness of four main management strategies for preventing short-term effects of digital display use on dry eye signs and symptoms.

METHODS

The ocular surface, tear film, and visual fatigue of 47 healthy individuals were assessed before and after reading on a laptop computer for 20 min under five different experimental conditions: control, instillation of artificial tears, taking a brief break, using a blue light screen filter, and blink control. Measurements included the Ocular Surface Disease Index (OSDI) Questionnaire, 5-item Dry Eye Questionnaire (DEQ-5), tear meniscus height (TMH), noninvasive keratograph break-up time (NIKBUT), bulbar conjunctival redness, and pupil size.

RESULTS

Worse results were obtained after the control and blue light filter conditions in all variables (P≤0.037). A higher post-task DEQ-5 score (P=0.013) and TMH (P<0.0005) were obtained when taking a brief break compared with pretask, although the increase in symptoms was significantly smaller than that observed in the nonmanagement control condition (P≤0.036). Similarly, a smaller increase in OSDI and DEQ-5 was obtained with the use of artificial tears and blink control in comparison with the control condition (P≤0.008), whereas a greater increase in DEQ-5 and decrease in NIKBUT was obtained for the blue light filter condition in comparison with the instillation of artificial tears (P=0.017) or blink control (P=0.008), respectively. Finally, a significantly lower post-task pupil size was obtained for all the conditions (P≤0.027).

CONCLUSIONS

The instillation of artificial tears and blink control were the best management strategies for preventing short-term effects of digital display use on dry eyes. Conversely, using a blue light filter did not offer any benefits.

Dry eye disease and tear film assessment through a novel non-invasive ocular surface analyzer: The OSA protocol

We describe the role of OSA as a new instrument in the study of dry eye, and we recommend a protocol for conducting the tests as well as describe the advantages and disadvantages compared with other instruments. A comparison with other ocular surface devices (Tearscope Plus, Keratograph 5M, anterior-segment ocular coherence tomography, Easy Tear View-Plus, LipiView, IDRA, and LacryDiag) were presented due to manual or automatic procedure and objective or subjective measurements. The purpose of this study was to describe the OSA as new non-invasive dry eye disease diagnostic device. The OSA is a device that can provide accurate, non-invasive and easy-to-use parameters to specifically interpret distinct functions of the tear film. This OSA protocol proposed a lesser to higher non-invasive ocular surface dry eye disease tear film diagnostic methodology. A complete and exhaustive OSA and OSA Plus examination protocol was presented within the subjective questionnaire (Dry Eye Questionnaire 5, DEQ5), limbal and bulbar redness classification (within the Efron grade Scale, interferometry lipid layer thickness (LLT) (according to Guillon pattern), tear meniscus height (manually or automatic), first and mean non-invasive break up time (objective and automatic) and meibomian gland (MG) dysfunction grade and percentage (objective and automatic). The OSA and OSA Plus devices are novel and relevant dry eye disease diagnostic tools; however, the automatization and objectivity of the measurements can be increased in future software or device updates. The new non-invasive devices supposed represent a renewal in the dry eye disease diagnosis and introduce a tendency to replace the classic invasive techniques that supposed less reliability and reproducibility.

Autologous Platelet‐Rich Plasma Drops for Evaporative Dry Eye Disease from Meibomian Gland Dysfunction: A Pilot Study

Purpose

To evaluate the effects of autologous platelet‐rich plasma (PRP) drops for evaporative dry eye (EDE) disease from meibomian gland dysfunction (MGD).

Methods

This is a retrospective, consecutive case series of 20 eyes of 10 patients with EDE from MGD treated with PRP drops from November 2020 to November 2021 at a single outpatient clinic in Ontario, Canada. PRP drops were prepared from whole blood using a two-step centrifugation method. Patients were instructed to instill these drops six times daily for 4 weeks. The Canadian Dry Eye Assessment (CDEA) questionnaire score, patient subjective assessment (PSA) score, first and average non-invasive break-up times (f/a NIBUT), tear meniscus height (TMH), bulbar redness (BR), and meibograph grade (MG) were measured before and after the treatment course.

Results

Significant improvements in dry eye symptoms and tear film parameters were observed. Dry eye symptoms significantly improved as per the CDEA (mean difference (MD) = −5.45, 95% confidence interval (CI) = [−7.9, −3.1], p<0.001) and PSA (MD = −2.6, 95% CI = [−3.9, −1.2], p<0.001). There were significant improvements in tear film parameters including fNIBUT (MD = 3.85s, 95% CI = [1.2, 6.8], p=0.006), aNIBUT (MD = −6.81s, 95% CI = [5.7, 11.1], p<0.001) and TMH (MD = 0.08, 95% CI = [0.003, 0.2], p=0.045). There was an improvement in conjunctival injection as measured by BR (MD = −0.36, 95% CI = [−0.4, −0.15], p=0.373). Five eyes experienced a one-grade improvement in MG (p=0.453), and none experienced worsening in MG with treatment. No temporary or permanent adverse effects were noted.

Conclusion

Four weeks of PRP therapy resulted in significant functional improvements in dry eye symptoms and tear film quality and quantity. Improvements in conjunctival injection and microstructural improvements in meibomian glands were also observed in some eyes. Overall, PRP is a promising treatment option for patients with EDE from MGD refractory to conventional treatments.

Impact of Bariatric Surgery-Induced Weight Loss on Anterior Eye Health in Patients with Obesity

The aim of the present research was to assess the effect of bariatric surgery-induced weight loss on the tear film and ocular surface of patients with obesity. A total of 29 participants with obesity (aged 47.2 ± 10.1 years, 8 male) were measured at baseline and followed up one year after Roux-en-Y gastric bypass (RYGB) surgery. General anthropometric data, as well as serum lipid markers of cholesterol, were assessed in all individuals. Bilateral anterior eye measurements of tear meniscus height (TMH), non-invasive tear breakup time, bulbar and limbal redness and infrared meibography were captured using the Keratograph K5M (Oculus) and ocular surface damage was evaluated using fluorescein sodium and lissamine green staining. Bariatric surgery resulted in significant loss of weight (body mass index p < 0.001) and an improvement in the blood lipid profile (p < 0.01) in all participants. However, there were no statistically significant differences between the baseline and one-year follow-up for any of the measured clinical ocular surface and tear film variables (all p > 0.05). Although there were trends for a reduced TMH and a decrease in meibomian gland dropout after bariatric surgery, these differences were also insignificant (p > 0.05). In conclusion, weight reduction through bariatric surgery did not have an effect on the tear film or ocular surface in unselected patients with obesity.

Digital display use and contact lens wear: Effects on dry eye signs and symptoms

PURPOSE

To assess the potential additive effects of short-term display use and contact lens (CL) wear on the ocular surface and tear film.

METHODS

Thirty-four healthy volunteers (20.87 ± 2.33 years old) participated in this study. Participants' dry eye symptoms, ocular surface, tear film and pupil size were assessed before and after executing a 20-min reading task on a computer and a smartphone with and without CL wear, or with CL wear and artificial tear instillation. Measurements included the Ocular Surface Disease Index (OSDI) questionnaire; 5-item Dry Eye Questionnaire (DEQ-5); tear meniscus height (TMH); noninvasive keratograph break-up time (NIKBUT); bulbar conjunctival redness (BR) and pupil size.

RESULTS

Higher symptoms were reported after reading on both displays with and without CLs (p ≤ 0.001) for short periods. BR was higher and NIKBUT shorter after reading on the computer regardless of wearing CLs (p ≤ 0.02 and p ≤ 0.02, respectively), while TMH increased for all conditions (p ≤ 0.02) except for CL computer reading (p = 0.23). Reading with CLs did not lead to greater signs of dry eye (BR, NIKBUT) and symptoms compared with reading unaided (p > 0.05), although a smaller increase in TMH was observed when reading on the computer with CLs (p = 0.005). Artificial tear instillation during CL wear led to a smaller increase in symptoms (p ≤ 0.02), a smaller increase in BR (p ≤ 0.04) and a decrease in NIKBUT (p = 0.02) compared to reading without correction.

CONCLUSIONS

Disposable CL wear had no additive effects on signs and symptoms of dry eye when using digital devices for short periods. The instillation of artificial tears is an effective strategy for reducing the impact of display use in CL wearers.

Ocular surface predisposing factors for digital display-induced dry eye

CLINICAL RELEVANCE

The use of digital displays is recognised as a consistent risk factor for dry eye disease.

BACKGROUND

To identify ocular parameters contributing to the impact of computer use on dry eye.

METHODS

The ocular surface of 82 undergraduate students with a mean age of 22.8 ± 2.1 years was assessed at baseline and after reading on a computer for 30 minutes. Measurements included the ocular surface disease index (OSDI) questionnaire, 5-item dry eye questionnaire (DEQ-5), tear meniscus height, non-invasive keratograph break-up time (NIKBUT), conjunctival bulbar redness, meibomian gland dropout percentage, spontaneous blink rate and percentage of incomplete blinks. Multiple linear regressions and generalised linear mixed models were conducted to explore the associations between baseline parameters and pre-task - post-task differences and to predict the impact of computer use, respectively.

RESULTS

Greater dry eye symptoms (p < 0.0005), higher tear meniscus height and conjunctival bulbar redness (p < 0.0005 and p = 0.012, respectively) and shorter NIKBUT (p = 0.03) were obtained after reading on the computer for 30 minutes. The baseline score obtained with the OSDI and DEQ-5 was positively associated with the increase in symptoms with computer use (p < 0.0005), while the change in conjunctival redness and pre-task NIKBUT were associated with the change in NIKBUT (p ≤ 0.005). No ocular surface parameter revealed an association with tear meniscus height changes. Having a positive OSDI score at baseline increased the odds of painful and sore eyes (p = 0.012), while a higher pre-task NIKBUT increased the odds of a reduction in tear stability (p = 0.038).

CONCLUSIONS

Participants with greater dry eye symptoms were more likely to experience a greater increase in symptomatology with computer operation, while the participants with longer NIKBUT and greater conjunctival redness were more likely to suffer a greater reduction in tear stability.

Validation of a new objective method to assess lipid layer thickness without the need of an interferometer

PURPOSE

This study aimed to develop and validate new metrics to objectively assess the lipid layer thickness (LLT) through the analysis of grey intensity values obtained from the Placido disk pattern reflected onto the tear film.

METHODS

Ocular surface parameters were measured using Oculus Keratograph 5 M in 94 healthy volunteers (43.8 ± 26.8 years). Subjects' LLT was subjectively classified into 4 groups using an interferometry-based grading scale. New metrics based on the intensity of the Placido disk images were calculated and compared between groups. The repeatability of the new metrics and their diagnostic ability was analysed through receiver operating characteristics (ROC) curves. The level of agreement between the new objective tool and the existing subjective classification scale was analysed by means accuracy, weighted Kappa index and F-measure.

RESULTS

Mean pixel intensity, median pixel intensity and relative energy at 5.33 s after blinking achieved the highest performance, with a correlation with LLT between r = 0.655 and 0.674 (p < 0.001), sensitivity between 0.92 and 0.94, specificity between 0.79 and 0.81, area under the ROC curve between 0.89 and 0.91, accuracy between 0.76 and 0.77, weighted Kappa index of 0.77 and F-measure between 0.86 and 0.87.

CONCLUSION

The analysis of grey intensity values in videokeratography can be used as an objective tool to assess LLT. These new metrics could be included in a battery of clinical tests as an easy, repeatable, objective and accessible method to improve the detection and monitoring of dry eye disease and meibomian gland dysfunction.

Advances in the Noninvasive Diagnosis of Dry Eye Disease

Dry eye disease (DED) is a multifactorial disease that represents one of the most common ophthalmologic conditions encountered in everyday clinical practice. Traditional diagnostic tests for DED, such as subjective questionnaires, tear film break-up time and the Schirmer test, are often associated with poor reproducibility and reliability, which make the diagnosis, follow-up, and management of the disease challenging. New advances in imaging technologies enable objective and reproducible measurements of DED parameters, thus making the diagnosis a multimodal imaging-based process. The aim of this review is to summarize all the current and emerging diagnostic tools available for the diagnosis and monitoring of DED, such as non-invasive tear breakup time, thermography, anterior segment optical coherence tomography, meibography, interferometry, in vivo confocal microscopy, and optical quality assessment. Although there is not a gold standard imaging technique, new multi-imaging-integrated devices are precious instruments to help clinicians to better cope with the diagnostic complexity of DED.

Safety and Efficacy of BroadBand Intense Pulsed Light Therapy for Dry Eye Disease with Meibomian Gland Dysfunction

Background

BroadBand light intense pulsed light (BBL-IPL) therapy has shown to reduce hordeolum and blepharitis frequency. This study aims to evaluate the efficacy and safety of BBL-IPL therapy in patients with dry eye disease (DED) from meibomian gland dysfunction (MGD).

Methods

This is a retrospective, consecutive case series of 48 patients with DED from MGD who underwent BBL-IPL therapy from October 2016 to January 2019 at a single, outpatient clinic in Ontario, Canada. Clinical outcomes included first and average non-invasive keratograph tear break-up times (NIKBUT), bulbar redness (BR) scores, tear meniscus heights (TMH), visual acuity (VA) and meibograph grades. Patient-reported outcomes included the Canadian dry eye assessment (CDEA) questionnaire and patient subjective assessment (PSA) scores. Outcomes were measured at baseline and after completion of 4 monthly BBL-IPL sessions.

Results

The mean severity of dry eye symptoms as measured by the CDEA and PSA decreased significantly from 19.78 ± 9.62 to 12.08 ± 7.40 (p<0.001) and from 7.65 ± 1.74 to 4.77 ± 2.03 (p<0.001), respectively. Twenty-five percent of patients reported no dry eye symptoms after treatment. The meibograph grade improved significantly in both eyes (p<0.001). Approximately 71.0% and 80.1% of patients had an improved meibograph grade in the right and left eye, respectively. Near-significant improvements were observed for BR scores and VA. There was also a trend towards improved first/average NIKBUT and TMH scores. No adverse events were noted.

Conclusion

BBL-IPL appears to be an effective and safe treatment modality in improving dry eye symptoms and meibomian gland function in patients with DED from MGD.

Ocular Surface Disease in Glaucoma Patients Randomized to Benzalkonium Chloride-Containing Latanoprost and Preservative-Free Bimatoprost

Purpose: To investigate the influence of benzalkonium chloride (BAK) on ocular surface disease (OSD) in glaucoma patients receiving ocular-hypotensive agent. Methods: Patients were randomized to receive BAK-containing latanoprost (Xalatan) or preservative-free bimatoprost (Lumigan PF). Intraocular pressure (IOP), basal Schirmer's test, noninvasive keratograph tear-breakup time (TBUT), conjunctival redness score (R score), OSD index (OSDI), and corneal Oxford staining were recorded and compared between the 2 groups at 1-month and 4-month visits. The influence of BAK was analyzed by a generalized estimating equation model. Results: We enrolled 74 and 76 eyes treated with latanoprost and bimatoprost, respectively. The IOP decreased in both groups, although greater reduction was observed for latanoprost (13.95 vs. 15.42 mmHg, P = 0.0264). There was a significantly negative association between tear flow and latanoprost use (β = -0.763, P = 0.0243). The first and average TBUT did not show intergroup differences, but the area with unstable tear film increased with latanoprost use and showed marginal significance at 4-month visit (9.33% vs. 5.94% P = 0.055). In both groups, OSDI decreased, whereas Oxford stain increased over time, and R scores showed improvement after transient increase in the first month. The bimatoprost group had significantly worse conjunctival hyperemia, whereas a negative association with conjunctival hyperemia was revealed for latanoprost use (R score-bulbar nasal: β = -0.045, P = 0.0423). Conclusions: BAK-containing latanoprost was associated with decreased tear secretion and may be associated with tear-film instability, whereas bimatoprost was associated with worse conjunctival hyperemia. Ocular surface side effects should be considered when prescribing BAK-containing medication to glaucoma patients.

Diagnostic Capability of a New Objective Method to Assess Meibomian Gland Visibility

SIGNIFICANCE

The diagnosis of dry eye disease and meibomian gland dysfunction (MGD) is challenging. Measuring meibomian gland visibility may provide an additional objective method to diagnose MGD.

PURPOSE

This study aimed to evaluate the ability of new metrics to better diagnose MGD, based on measuring meibomian gland visibility.

METHODS

One hundred twelve healthy volunteers (age, 48.3 ± 27.5 years) were enrolled in this study. Ocular surface parameters were measured using the Oculus Keratograph 5M (Oculus GmbH, Wetzlar). Subjects were classified according to the presence or absence of MGD. New metrics based on the visibility of the meibomian glands were calculated and later compared between groups. The diagnostic ability of ocular surface parameters and gland visibility metrics was studied through receiver operating characteristic curves. Logistic regression was used to obtain the combined receiver operating characteristic curve of the metrics with the best diagnostic ability.

RESULTS

Statistically significant differences were found between groups for all ocular surface parameters and new gland visibility metrics, except for the first noninvasive keratograph breakup time and gland expressibility. New gland visibility metrics showed higher sensitivity and specificity than did current single metrics when their diagnostic ability was assessed without any combination. The diagnostic capability increased when gland visibility metrics were incorporated into the logistic regression analysis together with gland dropout percentage, tear meniscus height, dry eye symptoms, and lid margin abnormality score (P < .001). The combination of median pixel intensity of meibography gray values and the aforementioned ocular surface metrics achieved the highest area under the curve (0.99), along with excellent sensitivity (1.00) and specificity (0.93).

CONCLUSIONS

New meibomian gland visibility metrics are more powerful to diagnose MGD than current single metrics and can serve as a complementary tool for supporting the diagnosis of MGD.

Are there Clinical Ways to Assess Inflammation in Dry Eye Disease?

In the diagnostic process of dry eye disease, the detection of inflammatory activity is critical in order to evaluate the risk of progression and immunologic shift of the disease, to predict patient response to treatment, and to design an efficient therapeutic strategy, including artificial tear replacement, punctal occlusion or anti-inflammatory therapy.Even if it is difficult to quantify, some indicators of the presence of inflammation are collectible during the examination of the ocular surface in a first-line clinical setting. This review presents and critically discusses the assessment of inflammation in dry eye disease in clinical practice.

Ocular redness - I: Etiology, pathogenesis, and assessment of conjunctival hyperemia

The translucent appearance of the conjunctiva allows for immediate visualization of changes in the circulation of the conjunctival microvasculature consisting of extensive branching of superficial and deep arterial systems and corresponding drainage pathways, and the translucent appearance of the conjunctiva allows for immediate visualization of changes in the circulation. Conjunctival hyperemia is caused by a pathological vasodilatory response of the microvasculature in response to inflammation due to a myriad of infectious and non-infectious etiologies. It is one of the most common contributors of ocular complaints that prompts visits to medical centers. Our understanding of these neurogenic and immune-mediated pathways has progressed over time and has played a critical role in developing targeted novel therapies. Due to a multitude of underlying etiologies, patients must be accurately diagnosed for efficacious management of conjunctival hyperemia. The diagnostic techniques used for the grading of conjunctival hyperemia have also evolved from descriptive and subjective grading scales to more reliable computer-based objective grading scales.

An Emerging Method to Assess Tear Film Spread and Dynamics as Possible Tear Film Homeostasis Markers

Purpose: This study aims to assess the performance of an analysis method to measure in vivo the movement speed of tear film particles post-blink as a measure of tear film spreading.Materials and methods: Ocular surface parameters and the recording of tear film particles' spreading post-blink were assessed in eighty-one healthy volunteers (43.7 ± 27.0 years) using Keratograph 5 M. The developed software automatically decomposed the video into frames to manually track particles' position for 1.75 seconds after a blink. The following tear film-dynamic metrics were automatically calculated: mean, median, maximum, and minimum particles' speed at different times after blinking and time for particle speed to decrease to <1.20 mm/second. Repeatability of each tear film-dynamic metric and its correlations with ocular surface signs and symptoms were analyzed. Binomial logistic regression was performed to assess the predictability of new metrics to ocular parameters.Results: Repeatability tended to be lower just after blinking (variability of 12.24%), whereas the metrics from 0.5 s onwards had acceptable repeatability (variability below 10%). Tear film-dynamic metrics correlated positively with Non-Invasive Break-Up Time (NIKBUT) while negatively with meibomian gland drop-out. Binomial logistic regression analysis revealed that tear film-dynamic metrics were able to predict NIKBUT. Nevertheless, no statistically significant association was found with gland drop-out. This means that higher particle speed is related to larger NIKBUT. The metric "time for particle speed to decrease to <1.20 mm/second" can be considered the best metric to assess the quality of the tear film, since it was more strongly correlated with NIKBUT (r = 0.42, p = .004), it was more strongly associated in the binomial logistic regression analysis with NIKBUT and showed good repeatability (variability = 5.49%).Conclusions: Tear film-dynamic metrics are emerging homeostasis parameters for assessing indirectly the tear film quality in natural conditions with acceptable repeatability.

Bulbar Redness and Dry Eye Disease: Comparison of a Validated Subjective Grading Scale and an Objective Automated Method

SIGNIFICANCE

In this study, assessments of conjunctival redness were performed to evaluate whether patients with or without dry eye disease (DED) could be discriminated based on this measure. Our findings suggest that subjectively grading redness by quadrant, as opposed to automated en face measurements, may be more suitable for this purpose.

PURPOSE

This study aimed to quantify bulbar redness using the validated bulbar redness (VBR) grading scale and an automated objective method (Oculus Keratograph 5M; K5M) in participants with DED and non-DED controls.

METHODS

Participants with DED (Ocular Surface Disease Index score ≥20 and Oxford scale corneal staining ≥2) and controls (Ocular Surface Disease Index score ≤10 and corneal staining ≤1) attended two study visits. In part 1A of visit 1, baseline bulbar redness was graded with the VBR scale in each conjunctival quadrant of both eyes, followed by automated measurements of temporal and nasal redness with the K5M. This was immediately followed by part 1B, during which a topical vasoconstrictor was instilled into both eyes. Redness assessments were repeated 5 and 30 minutes after instillation with both instruments. Participants returned 14 days later for visit 2, where the same assessments as for visit 1A were repeated.

RESULTS

Seventy-four participants (50 DED and 24 controls) completed the study. There were statistically significant differences in redness between the DED and control groups when assessed with the VBR scale (14/16 comparisons; all, P < .05), whereas no significant differences in K5M-derived redness between the DED and non-DED groups were found at any location or time point. Both subjective and objective instruments detected statistically significant reductions in redness 5 and 30 minutes after instillation of the vasoconstrictor (all, P < .01).

CONCLUSIONS

Although both subjective and objective instruments were sensitive to detecting changes in redness induced by vasoconstriction, statistically significant differences in redness between DED and control groups were only found using the VBR scale.

Assessment of ocular surface disease in glaucoma patients with benzalkonium chloride-preserved latanoprost eye drops: a short-term longitudinal study

PURPOSE

To prospectively evaluate the effect of benzalkonium chloride (BAK)-preserved latanoprost on ocular surface damage and identify the associated risk factors among treatment-naive glaucoma patients.

METHODS

The basal Schirmer's test results, corneal Oxford staining score, non-invasive keratograph tear-breakup time, oculus hyperemia index score (objective metrics), and ocular surface disease index (OSDI) questionnaire (subjective metric) were evaluated at baseline, 1 month, and 4 months after receiving latanoprost eye drops. Associated risk factors were assessed by multivariate linear regression.

RESULTS

Seventy-four eyes (44 patients) were enrolled. Basal Schirmer's test tear-flow and Oxford scores gradually deteriorated (β = -0.14, P = 0.001 and β = 0.1, P < 0.001, respectively). The percentage of unstable tear-film (breakup time < 10 s) increased significantly at 4 months (6.21% vs 9.11%, P = 0.042). Hyperemic scores increased significantly at 1 month and normalized at 4 months (P = 0.01 and P = 0.16, respectively); total OSDI scores tended to improve (β = -0.76, P = 0.06). Older age was associated with additional corneal Oxford staining (P = 0.005); female sex was associated with increased unstable tear-film scores (P = 0.01). Artificial tear use was associated with a smaller decrease in basal Schirmer's test values (P = 0.01) and a smaller increase in unstable tear-film scores (P = 0.02).

CONCLUSIONS

Preserved latanoprost eye drops affected ocular surface changes in glaucoma patients through decreased basal tear secretion. Artificial tears represent an early intervention in vulnerable glaucoma patients with reduced tear secretion and impaired tear-film stability.

Tear Proteomics Study of Dry Eye Disease: Which Eye Do You Adopt as the Representative Eye for the Study?

Most studies about dry eye disease (DED) chose unilateral eye for investigation and drew conclusions based on monocular results, whereas most studies involving tear proteomics were based on the results of pooling tears from a group of DED patients. Patients with DED were consecutively enrolled for binocular clinical tests, tear biochemical markers of DED, and tear proteome. We found that bilateral eyes of DED patients may have similar but different ocular surface performance and tear proteome. Most ocular surface homeostatic markers and tear biomarkers were not significantly different in the bilateral eyes of DED subjects, and most clinical parameters and tear biomarkers were correlated significantly between bilateral eyes. However, discrepant binocular presentation in the markers of ocular surface homeostasis and the associations with tear proteins suggested that one eye’s performance cannot represent that of the other eye or both eyes. Therefore, in studies for elucidating tear film homeostasis of DED, we may lose some important messages hidden in the fellow eye if we collected clinical and proteomic data only from a unilateral eye. For mechanistic studies, it is recommended that researchers collect tear samples from the eye with more severe DED under sensitive criteria for identifying the more severe eye and evaluating the tear biochemical and proteomic markers with binocular concordance drawn in prior binocular studies.

Comparison and Evaluation of Prelens Tear Film Stability by Different Noninvasive in vivo Methods

Purpose

Prelens tear film stability of soft contact lens (SCL) play an important role for contact lens discomfort. In this study, we investigated the association between two types of noninvasive methods and evaluated the tear film stability with SCL using the methods.

Patients and Methods

In experiment 1, images of ring mire were recorded with a keratograph after focusing the pigment located at the front or back of the SCL. Interferometry and videokeratoscopy were used for the assessment of tear film stability in the right eye of 10 women, with two different cosmetic daily disposable SCLs: polymacon and etafilcon A with polyvinylpyrrolidone. Time to first distortion by noninvasive keratograph break up time (NIKBUT-first) was compared to noninvasive interferometry break up time (NIBUT). In experiment 2, ten normal females wore two different daily disposable SCLs: samfilcon A and narafilcon A. NIKBUT-first and NIBUT were compared between the lenses after 8 hours of SCL wearing.

Results

In experiment 1, NIBUT-first without SCL was significantly correlated to NIBUT without SCL (r=0.445, P=0.0488, Pearson’s correlation coefficients). However, NIKBUT-first with SCL was not significantly correlated with NIBUT with SCL. In experiment 2, although NIKBUT-first was not significantly different between SCLs, samfilcon A had significantly longer NIBUT than narafilcon A (P=0.0315, paired t-test).

Conclusion

NIKBUT-first with SCL could be related to tear film stability between the lens and the corneal surface, but not to prelens tear film stability. NIIBUT could be a suitable method to evaluate prelens tear stability.

Comparative analysis of ocular redness score evaluated automatically in glaucoma patients under different topical medications

PURPOSE

To compare ocular redness score calculated automatically between glaucoma patients and healthy controls, and to assess the associations between this score and both demographical and clinical characteristics.

METHODS

Glaucoma patients under different topical medications and matched controls were enrolled in this observational cross-sectional study. The Keratograph 5M (Oculus Optikgeräte GmbH) was used to automatically measure 5 redness scores: global; nasal bulbar; temporal bulbar; nasal limbal; temporal limbal. The Student t and ANOVA tests were used to compare continuous variables between groups. A multiple linear regression analysis was performed to evaluate the associations between redness scores and the use of different active principles.

RESULTS

One hundred two glaucoma patients and 32 controls were included. Ocular redness scores were significantly higher in glaucoma patients compared to controls (always p < 0.001). The number of active principles was significantly associated with all the redness scores (always p < 0.05). The use of carbonic anhydrase inhibitors (CAIs) was the strongest predictor of overall redness, followed by prostaglandin analogs (PAs) and alpha-adrenergic agonists (AAAs) (respectively, β = 0.400, p = 0.002; β = 0.330, p = 0.013; β = 0.311, p = 0.044). The post hoc analysis measuring the effect of different PAs on redness scores showed that overall redness and bulbar nasal redness scores were significantly lower in patients using tafluprost and latanoprost compared to those using travoprost and bimatoprost 0.01% (respectively, p = 0.025 and p = 0.024).

CONCLUSION

Ocular redness was significantly higher in patients with glaucoma compared to control subjects. The number of active principles and the use of PAs, CAIs and AAAs were associated with higher redness scores.

Analysis of tear film spatial instability for pediatric myopia under treatment

In Taiwan, the prevalence of myopia in children between 6 and 18 years old is over 80%, and high myopia accounts for over 20%, which turned out to be in the leading place worldwide. Orthokeratology and low-dose atropine are proven treatments to reduce myopia progression, though the potential corneal disturbances remain an issue in young populations. The alteration of the tear film is widely discussed but there is no consensus to date, so we aim to investigate the tear film spatial instability in children with myopia control using atropine or orthokeratology. Thirty-eight treatment-naïve participants and 126 myopic children under treatments were enrolled. The ocular surface homeostasis, spatial distribution of tear break-up, and high-order aberrations (HOAs) of the corneal surface were assessed. We found out that myopic children treated with either atropine or orthokeratology showed ocular surface homeostasis similar to that in treatment-naïve children. Nevertheless, children treated with orthokeratology presented higher HOAs (p < 0.00001) and a tendency of the first tear break-up zone at the inner half of the cornea (p = 0.04). This unique spatial instability of the tear film associated with myopia treatment might provide a more focused way of monitoring the pediatric tear film instability.

Improved Tear Film Stability in Patients with Dry Eye After Hyaluronic Acid and Galactoxyloglucan Use

Purpose

Artificial tears only provide transient relief for dry eye. To the best of our knowledge, this is the first study to objectively compare treatment with artificial tears with Keratograph 5M, which allows accurate and objective investigation of dry eye and artificial tear treatment. We aimed to evaluate whether a preservative-free combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan can improve dry eye using the new topographer, Keratograph 5M.

Patients and Methods

This prospective longitudinal, single-arm interventional cohort study was performed at a tertiary referral center and involved 20 patients with dry eye (40 eyes). Preservative-free artificial tears were administered every 3 h. The participants underwent clinical and instrumental evaluations at baseline, 15, 30, 60, 90 and 120 min after instillation and 1 week and 1 month after treatment. Baseline values were considered as the controls. All patients were assessed with Keratograph 5M for non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time, conjunctival hyperemia, and tear meniscus height. Ocular surface staining with fluorescein was evaluated using the slit-lamp and fluorescein break-up time examinations, and the Ocular Surface Disease Index score was recorded for each patient.

Results

The signs and symptoms improved after 1 month of preservative-free 0.4% hyaluronic acid and 0.2% galactoxyloglucan treatment. There was a significant increase in the non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time at 15, 30, 60, and 90 min, and 1 week and 1 month (P < 0.05) and a decrease in hyperemia, corneal staining, and Ocular Surface Disease Index scores after 1 week and 1 month (P < 0.05). No treatment-related adverse event was observed.

Conclusion

A combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan artificial tears seems effective for treating dry eye. Keratograph 5M can objectively detect these changes during the follow-up period.

Awareness of treatment: A source of bias in subjective grading of ocular complications

PURPOSE

Bias has been described as one important obstacle in scientific research. The aim of this study was to explore "awareness of treatment" as a possible source of bias in subjective grading of ocular complications.

METHODS

Thirty subjects with similar, basic experience with grading scales participated in the study. The Efron grading scales were used to grade 24 images of three different ocular conditions (eight images each of bulbar hyperaemia, limbal vascularization and corneal staining). Three consecutive, two weeks apart, grading sessions were scheduled, in which the same images were graded, although in the third session images were deceptively labelled as either "treated" or "untreated". Grading results from the first and second sessions were compared to determine grading reliability and discrepancies with the third session informed of grading bias originating from "awareness of treatment".

RESULTS

Moderate to good test-retest reliability was found for all conditions, with median intraclass correlation values of 0.80 (0.62-0.84) for bulbar hyperaemia, 0.68 (0.65-0.77) for limbal vascularization and 0.68 (0.66-0.74) for corneal staining. Grading values from the first and third sessions evidenced negative and positive systematic errors (bias) for "treated" and "untreated" conditions, respectively. Statistically significant differences were found between the average grading discrepancies of session 1 and session 2 and those of session 1 and session 3 (all p<0.001).

CONCLUSIONS

"Awareness of treatment" may be considered a source of bias of subjective grading of ocular complications, although the actual effect of bias is unlikely to be of clinical significance.

Neutrophil extracellular traps (NETs) contribute to pathological changes of ocular graft-vs.-host disease (oGVHD) dry eye: Implications for novel biomarkers and therapeutic strategies

PURPOSE

To investigate the role of neutrophil extracellular traps (NETs) and NET-associated proteins in the pathogenesis of oGVHD and whether dismantling of NETs with heparin reduces those changes.

METHODS

Ocular surface washings from oGVHD patients and healthy subjects were analyzed. Isolated peripheral blood human neutrophils were stimulated to generate NETs and heparinized NETs. We performed in vitro experiments using cell lines (corneal epithelial, conjunctival fibroblast, meibomian gland (MG) epithelial and T cells), and in vivo experiments using murine models, and compared the effects of NETs, heparinized NETs, NET-associated proteins and neutralizing antibodies to NET-associated proteins.

RESULTS

Neutrophils, exfoliated epithelial cells, NETs and NET-associated proteins (extracellular DNA, Neutrophil Elastase, Myeloperoxidase, Oncostatin M (OSM), Neutrophil gelatinase-associated lipocalin (NGAL) and LIGHT/TNFSF14) are present in ocular surface washings (OSW) and mucocellular aggregates (MCA). Eyes with high number of neutrophils in OSW have more severe signs and symptoms of oGVHD. NETs (and OSM) cause epitheliopathy in murine corneas. NETs (and LIGHT/TNFSF14) increase proliferation of T cells. NETs (and NGAL) inhibit proliferation and differentiation of MG epithelial cells. NETs enhance proliferation and myofibroblast transformation of conjunctival fibroblasts. Sub-anticoagulant dose Heparin (100 IU/mL) dismantles NETs and reduces epithelial, fibroblast, T cell and MG cell changes induced by NETs.

CONCLUSION

NETs and NET-associated proteins contribute to the pathological changes of oGVHD (corneal epitheliopathy, conjunctival cicatrization, ocular surface inflammation and meibomian gland disease). Our data points to the potential of NET-associated proteins (OSM or LIGHT/TNFSF14) to serve as biomarkers and NET-dismantling biologics (heparin eye drops) as treatment for oGVHD.

Tear Proteomics Approach to Monitoring Sjögren Syndrome or Dry Eye Disease

Sjögren syndrome (SS) or dry eye disease (DED) is one of the most complicated ocular surface diseases. The goal of this study is to elucidate the relationship of the changes in clinical indices of tear film (TF) homeostasis with respect to tear components to allow for SS-DED monitoring and avoid stably controlled SS-DED patients from re-entering a vicious cycle. This prospective case-control study compared stable SS-DED patients with non-SS-DED control from several aspects, including clinical indices for TF homeostasis, 2 DED diagnostic biomarkers (MMP-9 and lactoferrin), and the proteome of flush tears. Compared with non-SS-DED controls, stably controlled SS-DED subjects had less tear secretion and higher ocular surface inflammation, a higher concentration ratio of tear MMP-9/lactoferrin, a more diverse tear proteome, and lower spectral intensities of lipocalin-1, lacritin, and prolactin-inducible protein among the abundant tear proteins. For stable SS-DED patients, the concentration ratio of tear MMP-9/lactoferrin and the corrected lipocalin-1 signal was positively correlated with ocular inflammation and TF stability, respectively. MMP-9 released from stressed ocular surface epithelium and lipocalin-1 secreted from the energetic lacrimal gland are two tear biomarkers responding well to TF homeostasis. The tear proteomics approach through flush tears is a promising method for monitoring SS-DED patients with a standardized sampling procedure and lactoferrin-corrected analysis.

Assessment of Tear Film and Bulbar Redness by Keratograph 5M in Pediatric Patients After Orthokeratology

OBJECTIVES

To assess the tear meniscus height (TMH), noninvasive tear breakup time (NITBUT), and bulbar redness in pediatric patients after orthokeratology (OK).

METHODS

Pediatric patients who underwent overnight OK between December 2014 and November 2017 were retrospectively investigated. According to the time of wearing, subjects were divided into three groups: 1-week, 1-month, and over 1-year. Age-matched subjects were recruited as a control group. Keratograph 5M was used to assess TMH, NITBUT-first, NITBUT-average, and bulbar redness score.

RESULTS

A total of 106 subjects aged from 7 to 15 years were included. Compared with control group, NITBUT-first was significantly lower in 1-week group (P=0.036) and NITBUT-average was significantly lower in 1-month group (P=0.019). Compared with over 1-year group, NITBUT-first was significantly lower in 1-week and 1-month groups (P=0.014, P=0.035, respectively), and NITBUT-average was significantly lower in 1-month group (P=0.022). Bulbar redness score was significantly lower in 1-month group than 1-week group (P=0.004). No significant difference in TMH was found between all groups. Significant correlation was found between NITBUT-first and NITBUT-average in all subjects (R=0.812, P<0.001). No other significant correlations were found between variables included TMH, NITBUT, bulbar redness score, or target correction.

CONCLUSIONS

As a noninvasive method, Keratograph 5M was easily to be applied on pediatric patients. The OK lens did not induce significant tear deficiency or bulbar redness, but might affect tear film stability in a short term after wearing.

Objective ocular surface tolerance in patients with glaucoma treated with topical preserved or unpreserved prostaglandin analogues

Purpose:

Preservatives in glaucoma medications have been associated with ocular toxicity. We compared ocular signs and symptoms in patients with open-angle glaucoma or ocular hypertension treated in monotherapy with preserved or preservative-free prostaglandin analogues.

Methods:

Observational cross-sectional clinical study in real life. 82 patients treated for at least 6 months with prostaglandin analogue were assessed for intraocular pressure, ocular symptoms and ocular signs including conjunctival hyperaemia, tear break-up time and tear meniscus height measured using objective and non-invasive methods (OCULUS Keratograph 5M). Patients presenting with symptoms of ocular toxicity with preserved prostaglandin analogues were switched to preservative-free latanoprost, and a second assessment was processed 6 months after.

Results:

At inclusion, 30 (36.6%) patients were treated with preservative-free latanoprost, 25 (30.5%) with preserved latanoprost, 16 (19.5%) with preserved travoprost and 11 (13.4%) with preserved bimatoprost. Patients treated with preservative-free latanoprost reported significantly less ocular symptoms upon instillation (mainly burning) and between instillations than patients treated with preserved prostaglandin analogues. The mean conjunctival hyperaemia (limbal + bulbar) was significantly lower with preservative-free latanoprost (2.08 ± 0.55) compared to preserved latanoprost (2.50 ± 0.7, p = 0.0085), preserved travoprost (2.67 ± 0.82, p = 0.0083) and preserved bimatoprost (2.68 ± 0.67, p = 0.0041). There were no relevant between-group differences in mean tear meniscus height and break-up time. Ocular symptoms and conjunctival hyperaemia improved when preserved prostaglandin analogues were switched to preservative-free latanoprost for 6 months while intraocular pressure reduction was maintained.

Conclusion:

Overall, this study suggests a better subjective and objective ocular tolerance when patients were treated with preservative-free latanoprost than with other preserved prostaglandin analogues monotherapy. Switching to preservative-free latanoprost maintained intraocular pressure at the same level as preservative prostaglandin analogue, but improved ocular surface tolerance.

Assessment of ocular redness measurements obtained with keratograph 5M and correlation with subjective grading scales

OBJECTIVE

To examine correlations between ocular redness scores provided by the Keratograph 5M and those determined using two image-based grading scales.

METHODS

Observational prospective cross-sectional study. Two hundred and twenty six eyes of two hundred and twenty six participants (175 patients using anti-glaucoma eye drops and 51 subjects untreated). All subjects were scored automatically using the keratograph 5M. These redness scores (RS) were then correlated with the gradings provided by the Efron and McMonnies/Chapman-Davies scale (MC-D) scales (two observers).

RESULTS

Excellent reproducibility was observed for both the Efron (weighted K=0.897, 95% CI 0.823-0.904) and MC-D (weighted K=0.783, 95% CI 0.752-0.795) scales. Keratograph RS and the scores obtained with both Efron (Spearman's Rho=0.43, P<0.001) and MC-D (Spearman's Rho=0.48, P<0.001) scales were significantly correlated. RS for the bulbar and limbal - nasal and temporal quadrants also correlated moderately with the two subjective scales. Through Bland Altman analysis, poor agreement was detected between the objective and subjective methods: agreement values for the Efron scale or MC-D scale (matching scorers between observers) versus overall RS showed high biases (-15.58 and -22.05 respectively) and wide limits of agreement (LOA) (-46.169 to 15.005 and -52.534 to 8.19 respectively). Lowest bias was observed between temporal limbal RS and Observer 2 Efron score (-0.04).

CONCLUSIONS

Although it emerged as a reliable objective method, the keratograph 5M overestimated the scores compared with the subjective grading scales when used to grade the degree of ocular redness. Therefore, they should not be interchangeable methods.

A new scale for the assessment of conjunctival bulbar redness

PURPOSE

Current scales for assessment of bulbar conjunctival redness have limitations for evaluating digital images. We developed a scale suited for evaluating digital images and compared it to the Validated Bulbar Redness (VBR) scale.

METHODS

From a digital image database of 4889 color corrected bulbar conjunctival images, we identified 20 images with varied degrees of redness. These images, ten each of nasal and temporal views, constitute the Digital Bulbar Redness (DBR) scale. The chromaticity of these images was assessed with an established image processing algorithm. Using 100 unique, randomly selected images from the database, three trained, non-physician graders applied the DBR scale and printed VBR scale. Agreement was assessed with weighted Kappa statistics (Kw).

RESULTS

The DBR scale scores provide linear increments of 10 from 10-100 when redness is measured objectively with an established image processing algorithm. Exact agreement of all graders was 38% and agreement with no more than a difference of ten units between graders was 91%. Kw for agreement between any two graders ranged from 0.57 to 0.73 for the DBR scale and from 0.38 to 0.66 for the VBR scale. The DBR scale allowed direct comparison of digital to digital images, could be used in dim lighting, had both temporal and nasal conjunctival reference images, and permitted viewing reference and test images at the same magnification.

CONCLUSION

The novel DBR scale, with its objective linear chromatic steps, demonstrated improved reproducibility, fewer visualization artifacts and improved ease of use over the VBR scale for assessing conjunctival redness.

Intraocular light scatter in patients on topical intraocular pressure-lowering medication

PURPOSE:

To quantify ocular light scattering in patients under treatment with intraocular pressure-lowering eye-drops.

METHODS:

In this prospective, observational, cross-sectional case series study, 160 eyes of 160 patients with primary open angle glaucoma or primary ocular hypertension were consecutively recruited from our Glaucoma Department over 7 months. In total, 46 eyes of 46 healthy volunteers matched for age and sex served as the control group. The variables recorded in a single visit were as follows: drug and number of drops per day, treatment duration, OXFORD corneal staining grade, lower tear meniscus height as measured by spectral domain optical coherence tomography, ocular redness and non-invasive tear breakup time measured with the Oculus Keratograph 5M, ocular surface disease index questionnaire score and objective scatter index through a double-pass technique (Optical Analysis System II).

RESULTS:

Objective scatter index was higher in the patient group (3.1, interquartile range = 1.8-5.47) than in the control group (1.95; interquartile range = 0.7-5; p = 0.017). In a multiple linear regression model, non-invasive tear breakup time was identified as the most influential variable on light scatter (mean ratio = -1.015; p = 0.003; 95% confidence interval = -1.025 to -1.005). No correlation with objective scatter index was observed for number of daily eye-drops, preservative concentration or treatment duration.

CONCLUSION:

Participants on anti-glaucoma medication showed a significantly higher objective scatter index than control group individuals. In the treated patient group, a lower non-invasive tear breakup time was associated with a higher objective scatter index. This suggests that lubricating eye-drops to improve tear breakup time could also improve vision quality in these patients by diminishing light scattering.