Effects of postoperative cyclosporine ophthalmic emulsion 0.05% (Restasis) following glaucoma surgery

Managing the ocular surface after glaucoma filtration surgery: an orphan topic

BACKGROUND

Ocular surface (OS) disorders before glaucoma filtration surgery (GFS) have been considered to play a crucial role influencing the surgical outcome. Conversely, the impact of surgery itself on the OS is almost completely overlooked, though evidence suggest that ocular surface disease (OSD) may be induced in patients by GFS. This review analyzes the determinants involved in the OSD development after GFS, the clinical features and related consequences, the main diagnostic hallmarks, as well as the therapeutic strategies for its management.

METHODS

The PubMed database was utilized for the literature examination. Keywords that were searched included ocular surface disease, glaucoma filtration surgery, filtration bleb, post-surgical management, and quality of life.

RESULTS

After GFS, OSD is promoted by peri- and post-operative factors, such as the filtration bleb (FB) development, combined surgical approach with phacoemulsification, the use of antifibrotic agents and the reintroduction of antiglaucoma medications. This particular form of OSD that present similar clinical features to mild to moderate dry eye, can be named as post-glaucoma surgery-OSD (PGS-OSD). PGS-OSD may negatively affect the FB functionality, thus potentially hindering the disease control, and significantly worsen the patient quality of life (QOL).

CONCLUSIONS

Clinicians are encouraged to routinely include the OS evaluation after GFS and to consider proper management when the occurrence of PGS-OSD worsen the patient's QOL or exert negative effects to the FB functionality. An outline summarizing the main risk factors and the most appropriate therapeutic options to mitigate the PGS-OSD was proposed to support the routine practice.

A randomized controlled trial involving college student: Comparing 0.15% hyaluronic acid with 0.05% cyclosporine A and 3% diquafosol sodium in the Treatment of Dry Eye

BACKGROUND

To compare the efficacy of 0.15% hyaluronic acid (HA), 0.05% cyclosporine A (CsA) and 3% diquafosol sodium (DQS) ophthalmic solution for the treatment of moderate-to-severe dry eye disease (DED) in college students and the effect on inflammatory factors in tears.

METHODS

This was a prospective, randomized, multicenter trial. A total of 282 college students diagnosed with moderate-to-severe DED between October 2, 2022 and March 1, 2023 were included. A total of 282 patients were randomized to treatment in the group of 0.15% HA or 0.05% CsA or 3% DQS in a 1:1:1 assignment. There was a main end point which is the variations in the corneal staining score to determine non-inferiority of 0.15% HA. Secondary target end points were ocular surface disease index score, Schirmer test, tear meniscus height and tear film breakup time. In addition, the inflammatory factor levels of Interleukin-1β, Interleukin-6, transforming growth factor-β1 in tears were measured. Effectiveness was assessed at baseline, 4- and 12-weeks.

RESULTS

In our analysis, the average change from baseline in corneal staining score confirmed non-inferiority of 0.15% HA to 0.05% CsA and 3% DQS and manifested obvious improvement of all groups as well (P < .05). Values for ocular surface disease index score, Schirmer test, tear meniscus height and tear film breakup time showed obvious improvements in all groups (P < .05), however, the difference intergroup was not statistically significant. Value for inflammatory factor was significant improvement across all groups, although inflammatory factor scores in the 0.05% CsA group showed a clear trend of better improvement at 12 weeks compared with 0.15% HA groups (P < .01). No serious adverse reactions were observed.

CONCLUSIONS

College students taking 0.15% HA had clinically and statistically significant improvement in corneal staining score and other indicators, but it was inferior to 0.05% CsA in anti-inflammatory therapy for moderate to severe DED. However, 0.15% HA is still an effective, safe and well-tolerated treatment option that may offer additional benefits in terms of convenience and compliance.

PLA-PEG Implant as a Drug Delivery System in Glaucoma Surgery: Experimental Study

Excessive postoperative scarring halts the effectiveness of glaucoma surgery and still remains a challenging problem. The purpose of this study was to develop a PLA-PEG-based drug delivery system with cyclosporine A or everolimus for wound healing modulation. Methods: PLA-PEG implants saturation with cyclosporine A or everolimus as well as their further in vitro release were analyzed. Anti-proliferative activity and cytotoxicity of the immunosuppressants were studied in vitro using human Tenon’s fibroblasts. Thirty-six rabbits underwent glaucoma filtration surgery with the application of sham implants or samples saturated with cyclosporine A or everolimus. The follow-up period was six months. A morphological study of the surgery area was also performed at seven days, one, and six months post-op. Results: PLA-PEG implants revealed a satisfactory ability to cumulate either cyclosporine A or everolimus. The most continuous period of cyclosporine A and everolimus desorption was 7 and 13 days, respectively. Immunosuppressants demonstrated marked anti-proliferative effect regarding human Tenon’s fibroblasts without signs of cytotoxicity at concentrations provided by the implants. Application of PLA-PEG implants saturated with immunosuppressants improved in vivo glaucoma surgery outcomes. Conclusions: Prolonged delivery of either cyclosporine A or everolimus by means of PLA-PEG implants represents a promising strategy of wound healing modulation in glaucoma filtration surgery.

Improved accuracy of intraocular lens power calculation by preoperative management of dry eye disease

Background

To evaluate the effects of pretreatment for dry eye disease (DED) on the accuracy of intraocular lens (IOL) power calculation.

Methods

Patients who underwent uneventful cataract surgery were included in the study. IOL power was determined using the SRK/T and Barrett Universal II (Barrett) formulas. The patients were divided into non-pretreatment and pretreatment groups, and those in the pretreatment group were treated with topical 0.5% loteprednol etabonate and 0.05% cyclosporin A for 2 weeks prior to cataract surgery. Ocular biometry was performed in all groups within 2 days before surgery. The mean prediction error, mean absolute error (MAE), and proportions of refractive surprise were compared between the non-pretreatment and pretreatment groups at 1 month postoperatively. Refractive surprise was defined as MAE ≥ 0.75D.

Results

In a total of 105 patients, 52 (52 eyes) were in the non-pretreatment group and 53 (53 eyes) in the pretreatment group. The MAE was 0.42 ± 0.33, 0.38 ± 0.34 (SRK/T, Barrett) and 0.23 ± 0.19, 0.24 ± 0.19 in the non-pretreatment and pretreatment groups, respectively (p < 0.001/=0.008). The number of refractive surprises was also significantly lower in the pretreatment group. [non-pretreatment/pretreatment: 9/2 (SRK/T); 8/1 (Barrett); p = 0.024/0.016]. Pretreatment of DED was related to a reduction in postoperative refractive surprise. [SRK/T/Barrett: OR = 0.18/0.17 (95% CI: 0.05–0.71/0.05–0.60), p = 0.014/0.006].

Conclusions

The accuracy of IOL power prediction can be increased by actively treating DED prior to cataract surgery.

The control of conjunctival fibrosis as a paradigm for the prevention of ocular fibrosis-related blindness. "Fibrosis has many friends"

The processes involved in ocular fibrosis after disease or ocular tissue injury, including surgery play an important part in the development or failure of treatment of most blinding diseases. Ocular fibrosis is one of the biggest areas of unmet need in ophthalmology. Effective anti-scarring therapies could potentially revolutionise the management of many diseases like glaucoma worldwide. The response of a quiescent or activated conjunctiva to glaucoma surgery and aqueous flow with different stimulatory components and the response to different interventions and future therapeutics is a paradigm for scarring prevention in other parts of the eye and orbit. Evolution in our understanding of molecular and cellular mechanisms in ocular fibrosis is leading to the introduction of new and re-purposed therapeutic agents, targeting a wide range of key processes. This review provides current and futures perspectives on different approaches to conjunctival fibrosis following glaucoma surgery and highlights the challenges faced in implementing these therapies with maximal effect and minimal side effects.

Ocular Surface Disease and Glaucoma Medications: A Clinical Approach

OBJECTIVES

Ocular surface disease frequently coexists with glaucoma and may be initiated or exacerbated by topical glaucoma medications. We performed a review of current literature to assess the prevalence, causes, and treatment of ocular surface disease in glaucoma patients, specifically those on topical therapy.

METHODS

A Pubmed database search was conducted. A total of 720 articles published from 1972 to 2018 were found in relation with ocular surface disease, glaucoma, and glaucoma medications. Of these, 102 articles were included in this analysis. We included primary and empirical studies for patients on topical glaucoma medications. Exclusion criteria included case reports, non-English studies, and articles unrelated to the primary subject of this review.

RESULTS

Ocular surface disease among normal and glaucomatous eyes was evaluated based on diagnostic testing including clinical examination and questionnaires to determine visual function and quality of life. Glaucoma medications can be associated with toxicities to the ocular surface, most often due to the nature of the preservative included in the medication; however, the incidence of toxicity can be mitigated by the use of preservative free medications, decreased preservative medications, or treatment of dry eye disease. Treatment of glaucoma with laser trabeculoplasty or minimally invasive glaucoma surgeries that spare the conjunctiva and the cornea may avoid or decrease reliance on topical glaucoma medications, potentially avoiding the initiation or progression of ocular surface disease.

CONCLUSIONS

Recognition and treatment of ocular surface disease in glaucoma patients may improve patient quality of life and medication adherence. This may ultimately improve glaucoma treatment outcomes.

Clinical efficacy of combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate in the dry eyes with meibomian gland dysfunction

AIM

To investigate the efficacy of combined topical 0.05% cyclosporine A (CsA; Restasis^®, Allergan pharmaceuticals, USA) and 0.1% sodium hyaluronate treatment in dry eyes with meibomian gland dysfunction (MGD).

METHODS

In a retrospective analysis, 53 patients (106 eyes) with MGD were enrolled and performed lid warm massage for 10min daily and be instilled preservative free sodium hyaluronate 0.1% eye drops 4 times daily. Patients were divided into subjects treated with topical 0.05% CsA and preservative free sodium hyaluronate vehicle (experimental group, n=74 eyes) and subjects treated with the preservative free sodium hyaluronate vehicle (control group, n=32 eyes). They were evaluated at baseline and 1, 2, and 3mo for subjective symptoms and objective signs including tear film break-up time (tBUT), Schirmer test, corneal staining (CS) score, lid margin telangiectasia (LMT), meibomian gland secretion (MGS), and conjunctival injection (CI).

RESULTS

In the short-term treatment, the experimental group showed a statistically significant improvement in the ocular surface disease index (OSDI; P<0.001), tBUT (P=0.004), Schirmer test score (P=0.008) and LMT (P=0.021) by repeated measure ANOVA. Additionally, mean changes from baseline in OSDI (P<0.001), tBUT (P=0.001), Schirmer test score (P=0.029), CS score (P=0.047), LMT (P=0.002), CI (P=0.030) were improved better in the experimental group than in the control group at 3mo. However, there was no significant difference between the two groups in MGS (P=0.67).

CONCLUSION

In dry eyes with MGD, 0.05% CsA improves the tear film stability as well as subjective ocular discomfort, and is effective in controlling lid margin inflammation.

A Randomized Multicenter Study Comparing 0.1%, 0.15%, and 0.3% Sodium Hyaluronate with 0.05% Cyclosporine in the Treatment of Dry Eye

Purpose: To investigate the efficacy of 0.1%, 0.15%, and 0.3% sodium hyaluronate (SH) artificial tears compared with 0.05% cyclosporine (CS) ophthalmic solution for the treatment of dry eye.

Methods: One hundred seventy-six patients were recruited and randomized to receive of 0.1%, 0.15%, and 0.3% SH and 0.05% CS. There was a primary end point which is the changes in the fluorescein corneal staining (FCS) score to determine noninferiority of 0.1%, 0.15%, and 0.3% SH. Secondary objective end points were lissamine green conjunctival staining (LGCS) scores, Schirmer test, and tear film break-up time (TBUT). Secondary subjective end point was ocular surface disease index (OSDI) score. These were evaluated before treatment and 6 and 12 weeks after start of treatment.

Results: In the primary analysis, the mean change from baseline in FCS scores verified noninferiority of 0.1% and 0.15% SH to 0.05% CS and also indicated significant improvement of all groups (P < 0.05). Values for TBUT, LGCS scores, and OSDI scores showed significant improvements in all groups (P < 0.05), although no significant intergroup difference was shown. However, Schirmer test scores in the 0.15% SH group showed a significant tendency for better improvement at week 12 compared with the other groups (P < 0.05). No serious adverse events were observed.

Conclusions: Administration of 0.1%, 0.15%, and 0.3% SH was effective in improving both the objective signs and subjective symptoms of dry eye. Those findings, in addition to the well-tolerated profile of 0.1%, 0.15%, and 0.3% SH, show that it is effective therapeutic method for dry eye.

Ocular surface toxicity from glaucoma topical medications and associated preservatives such as benzalkonium chloride (BAK)

INTRODUCTION

This review discusses the evidence concerning the effect of topical medications and their preservatives on the ocular surface in glaucoma patients. The role of topical anti-glaucoma medication remains critical in the management of chronic glaucoma worldwide but the beneficial effects of treatment are counterbalanced by the adverse effects of corneal and conjunctival toxicity. Areas covered: This article covers the effect of topical ocular drops and preservatives, particularly benzalkonium chloride, on the cornea and conjunctiva. Both basic science and clinical evidence will be presented. The first part reviews the relationship between ocular surface disease and benzalkonium chloride and the evidence from non-benzalkonium chloride preserved drops. The second part discusses the effects of benzalkonium chloride on the histopathology of the conjunctiva and its impact on clinical care as well as quality of life. Expert opinion: Topical anti-glaucoma medication will continue to be used in the management of this blinding disease for the foreseeable future. Treatment outcomes will benefit from minimized exposure to benzalkonium chloride. The development of alternative preservatives, preservative-free topical options, and non-drop therapeutics such as drug-eluting systems for the delivery of ocular medications, will be very helpful in the care of glaucoma patients.

Safety of treatments for primary Sjögren's syndrome

INTRODUCTION

Primary Sjögren's syndrome (pSS) is a disabling auto-immune disease, affecting exocrine glands and several organs.

AREAS COVERED

In this review we analyze the safety of therapies used in pSS. Symptomatic treatment is widely applied due to the good supportive effect and good safety profile. Systemic stimulation of tears and saliva can be successful in pSS. However, cumbersome adverse events can influence the tolerability of this therapy. Evidence for the effectiveness of synthetic DMARDs therapies in pSS is limited, while there is a risk of adverse events. Several studies on biologic DMARD treatment of pSS patients have shown promising efficacy and safety results.

EXPERT OPINION

The safety of symptomatic treatment of pSS is very good. However, systemic therapy is necessary to achieve long-term relieve and prevention of organ-damage. Synthetic DMARDs have not shown much efficacy in earlier studies, and their benefits do not weigh up to the possible harms, while biologic DMARDs show promising results regarding efficacy and cause mostly mild adverse events. Many questions remain unanswered regarding safety of DMARDs in pSS. There is a need for well designed studies, in which safety should be evaluated in a uniform manner to be able to compare the results between studies.

P-glycoprotein Blockers Augment the Effect of Mitomycin C on Human Tenon's Fibroblasts

PURPOSE

Mitomycin C (MMC), which induces apoptosis in human Tenon's fibroblasts (HTF), is frequently used to retard wound healing after glaucoma surgery. The aim of this in vitro study was to examine whether adjunctive Verapamil and Cyclosporine could augment the cytotoxic effect of MMC on HTF.

METHODS

Fibroblast cell lines were established by explant culture from human tissue biopsy samples obtained during trabeculectomy procedures. Cells were exposed to MMC at varying concentrations (0.01-0.4 mg/ml) for 3 minutes, prior to washing in the presence or absence of the following drugs: Staurosporine (0.003mg/ml), Verapamil (2.5-0.25 mg/ml), or Cyclosporine (50-0.5 mg/ml). Following exposure, cells were cultured for 6 hours and surviving cells quantitated by haemocytometer counts.

RESULTS

Both Verapamil and Staurosporine exhibited mild toxic effects on their own, but greatly enhanced the apoptotic effect of MMC. Staurosporine is too toxic to be considered clinically, so its augmentive effect on the activity of MMC was not studied further here. Doses as low as 0.25 mg/ml of Verapamil continued to show significant augmentation of the apoptotic effect of MMC Cyclosporine at a clinically used concentration (5 mg/ml) exhibited modest augmentation of the effect of MMC.

CONCLUSIONS

Verapamil and Cyclosporine in clinically acceptable concentrations potentiate the effect of MMC and may obviate the need for high dose antimetabolites in trabeculectomy; however, further preclinical study is required.

TRANSLATIONAL RELEVANCE

Adjunctive Verapamil or Cyclosporine may allow lower dose MMC to be used in glaucoma filtration surgery while maintaining the same antifibrotic effects.