Treatment of menopausal keratoconjunctivitis sicca with topical oestradiol

Inflammation mechanism and anti-inflammatory therapy of dry eye

Dry eye is a widespread chronic inflammatory disease that causes fatigue, tingling, burning, and other symptoms. Dry eye is attributed to rheumatic diseases, diabetes, hormone disorders, and contact lenses, which activate inflammatory pathways: mitogen-activated protein kinases (MAPK) and nuclear factor-B (NF-κB), promote macrophage inflammatory cell and T cell activation, and inflammation factors. Clinicians use a combination of anti-inflammatory drugs to manage different symptoms of dry eye; some of these anti-inflammatory drugs are being developed. This review introduces the dry eye inflammation mechanisms and the involved inflammatory factors. We also elucidate the anti-inflammatory drug mechanism and the detection limits.

A Phase II, Multicenter, Randomized, Placebo-Controlled, Double-Masked Trial of a Topical Estradiol Ophthalmic Formulation in Postmenopausal Women with Moderate-to-Severe Dry Eye Disease

INTRODUCTION

Dry eye disease (DED) is a multifactorial disorder of the ocular surface. The current phase II study was performed to assess the safety and dose regimen of a recently developed topical estradiol formulation for the treatment of DED.

METHODS

A total of 104 postmenopausal women suffering from moderate-to-severe DED were included. Topical 17-β-estradiol-3-phosphate eye drops were administered in three different dosage groups (group 1, 0.05% twice daily; group 2, 0.1% morning, vehicle in the evening; group 3, 0.1% twice daily) and vehicle twice daily as control group for a total period of 3 months. Clinical signs including Schirmer's test and corneal staining were assessed at baseline and at days 14, 30, 60, and 90. Symptoms of DED were measured using the symptom assessment in dry eye (SANDE) test at the same time points. Safety was assessed via frequency of adverse events.

RESULTS

Schirmer's test II wetting distance significantly increased in all four groups from baseline to day 90 without significant difference between groups (group 1, + 5.6 ± 6.7 mm/5 min; group 2, + 3.7 ± 4.2 mm/5 min; group 3, + 4.8 ± 4.5 mm/5 min; group 4, + 4.0 ± 5.3 mm/5 min). Statistical significance versus baseline was reached earlier in the treatment groups versus the control group. Corneal staining was significantly reduced after the 3-month treatment period with no significant difference between treatment groups. Staining of the inferior cornea, however, showed a significantly more pronounced decrease in the highest dose group compared to vehicle (p = 0.0463). Symptoms score as assessed with the SANDE test decreased at the end of the treatment period in all four groups. Estradiol eye drops showed a favorable safety profile.

CONCLUSION

Our results show that both estradiol eye drops and vehicle are safe and reduce signs and symptoms in postmenopausal women with moderate-to-severe DED. Although the study failed to reach the primary outcome to demonstrate a significant difference between the estradiol eye drops and vehicle in Schirmer's test, improvement occurred earlier in the active groups compared to the control group. The data of the current study will serve as a basis for a larger phase III study to establish a potential therapeutic effect of topical estradiol eye drops.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov registry NCT03821415.

The effect of hormone therapy on the ocular surface and intraocular pressure for postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of the study was to investigate the impact of hormone therapy (HT) on the ocular surface and intraocular pressure in postmenopausal women.

METHODS

This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. PubMed, EMBASE, Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure were searched from inception to November 2019 without language restrictions. Only randomized controlled trials that evaluated the impact of HT on the ocular surface and intraocular pressure in postmenopausal women were eligible. The trials had to report at least one of the following outcomes: break-up time, Schirmer test, corneal staining, ocular surface symptom score, and intraocular pressure. Two investigators independently extracted the information, assessed the risk of bias, and evaluated the publication bias. All data were analyzed by Review Manager V.5.3. Sensitivity analysis and subgroup analysis were performed to find the source of heterogeneity and evaluate the different effects among subgroups.

RESULTS

Nine randomized controlled trials (N = 612) were included. The HT group showed significant improvements compared with the control group in break-up time (mean difference [MD] = 2.09, 95% confidence interval [CI] 1.00-3.19, P = 0.0002), Schirmer test without anesthesia (MD = 4.17, 95% CI 1.55-6.80, P = 0.002), Schirmer test with anesthesia (MD = 1.44, 95% CI 0.71-2.18, P = 0.0001), and corneal staining scores (standardized mean difference [SMD] = -0.85, 95% CI -1.39 to -0.30, P = 0.002). Moreover, significant beneficial effects were observed on all four symptoms, including dryness (SMD = -1.21, 95% CI -1.99 to -0.44, P = 0.002), foreign body sensation (SMD = -1.02, 95% CI -1.29 to -0.76, P < 0.00001), ocular fatigue (SMD = -1.74, 95% CI -2.12 to -1.36, P < 0.00001), and burning (SMD = -0.53, 95% CI -0.78 to -0.29, P < 0.0001) after HT. Subgroup analysis revealed that, in terms of break-up time, postmenopausal women younger than 55 years achieved more improvements (MD = 0.88, 95% CI 0.16-1.59, P = 0.02) than women older than 55 years old (MD = 2.60, 95% CI -1.34 to 6.55, P = 0.20), and the estrogen subgroup received more benefits (MD = 3.11, 95% CI 0.93-5.30, P = 0.005) than the estrogen plus progestogen subgroup (MD = 0.42, 95% CI -0.02 to 0.85, P = 0.06). Sensitivity analysis and subgroup analysis suggested that the heterogeneity might derive from the methodological quality, the age of participants, and the intervention of the control group. Intraocular pressure (MD = -1.54, 95% CI -3.39 to 0.32, P = 0.10) was not evidently decreased after HT. No more specific adverse events (relative risk  = 1.66, 95% CI 0.41-6.77, P = 0.48) were found in the HT group.

CONCLUSIONS

Our study revealed that HT could improve ocular surface function in postmenopausal women effectively and safely, especially for those who were younger than 55 years, and estrogen only showed more improvements than estrogen plus progestogen. The effectiveness of HT in treating dry eye in postmenopausal women is, however, still a controversial topic. In addition, we did not find HT led to a significant reduction of intraocular pressure.

Topical Estrogen Therapy for Hyperopia Correction in Vivo

Purpose

In vitro studies found that 17β-estradiol (estrogen) modulates corneal biomechanical properties and reduces tissue stiffness. Therefore we hypothesized that topical estrogen might affect the refractive properties of the cornea, inducing a myopic shift.

Methods

Twelve female New Zealand white rabbits 16 weeks old were used. The rabbits were randomly divided to either the treatment group receiving 1.5% (w/v) estrogen eye drops or a control group receiving vehicle only (n = 6 each group). Both groups were given drops (50 µL) to the right eye every 12 hours for 35 days. Ocular examination, pachymetry, intraocular pressure (IOP), keratometry, and refraction were evaluated at baseline and on a weekly basis.

Results

No significant differences were observed between the two groups at baseline in all outcome measures. Both groups displayed corneal flattening and a hyperopic shift. However, the change rate was slower in the treatment group. Repeated measurements analysis revealed a statistically significant difference in keratometry readings between groups (P = 0.034) with steeper keratometry by up to 0.6 diopters in the treatment group. The difference between the two groups diminished and became statistically insignificant after treatment cessation. No significant changes were observed in IOP and pachymetry throughout the study period. No side effects were observed in either group.

Conclusions

Estrogen eye drops induced a myopic shift in keratometry readings. These results suggest that corneal refractive power might be manipulated pharmacologically. Further studies on the physiology behind this change are warranted to facilitate a pathway for development of novel pharmacologic treatments to correct refractive errors.

Mouse strains and sexual divergence in corneal innervation and nerve regeneration

A variety of mouse strains and sexes are used in studies of corneal wound healing and nerve regeneration. However, there is a gap of knowledge about corneal nerve density and its function in different mouse strains and sexes. In this study, we report a strain divergence of total and substance P (SP) sensory corneal nerves in uninjured mice. The BALB/c mouse showed the highest nerve density, corneal sensitivity, and tear volume followed by CFW and then C57BL/6. No differences were found in total nerves and SP-positive nerves between sexes. After injury damaged the corneal nerves, an important role for mouse strains, biologic sex, and their association to corneal nerve regeneration was identified. All female mice have a faster nerve regeneration rate than males. The molecular mechanism of this sexual divergence involves higher secretion neurotrophic factors in tears, which in turn modulate gene expression in trigeminal ganglion neurons. An important upstream signaling regulator was β-estradiol, and topical treatment with β-estradiol confirmed its function in corneal nerve regeneration. In conclusion, our study shows that the strain and sex of laboratory mice significantly affect the different indicators of corneal innervation and nerve regeneration. Researchers investigating corneal diseases should carefully consider these factors.—Pham, T. L., Kakazu, A., He, J., Bazan, H. E. P. Mouse strains and sexual divergence in corneal innervation and nerve regeneration.

Sex hormone therapy's effect on dry eye syndrome in postmenopausal women: A meta-analysis of randomized controlled trials

THE PURPOSE OF THE STUDY T: o assess the efficacy of sex hormone therapy in the treatment of dry eye syndrome in postmenopausal women.The following electronic databases were searched without language restrictions: PubMed, Embase, Cochrane, and the Chinese Biomedical Database. Two reviewers collected all the literature, which was searched for relevance in English and Chinese from January 1990 to July 2017. Both of the reviewers screened documents independently, identifying the studies that met the inclusion criteria. Then, the included studies were evaluated, and the data were extracted and conversed dependently. Finally, Review Manager 5.3 (offered by the Cochrane collaboration) was used to complete the meta-analysis. An integrated mean difference (MD) with its corresponding 95% confidence interval (CI) was calculated.A total of 358 patients with dry eye were enrolled in 7 randomized controlled trials (RCTs). We observed statistically significant improvements in the Schirmer's test scores (MD, 2.06; 95% CI, 0.74-4.46; I = 97%; P = .006) after sex hormone treatment. However, the scores for tear breakup time (TBUT) (MD, 1.28; 95% CI, -1.03 to 4.68; I = 99%; P = .21) and the ocular comfort index (OCI) (MD, -1.12; 95% CI, -4.42 to 1.98; I = 95%; P = .48) were not improved.This meta-analysis of 7 RCTs suggests that sex hormone therapy may be associated with better Schirmer's test scores. However, no significant differences were detected in the TBUT and OCI test scores. Consequently, sex hormone therapy has a potentially useful role in the effective management of postmenopausal women with dry eye syndrome.

Organ-on-a-Chip Systems for Women's Health Applications

Biomedical research, for a long time, has paid little attention to the influence of sex in many areas of study, ranging from molecular and cellular biology to animal models and clinical studies on human subjects. Many studies solely rely on male cells/tissues/animals/humans, although there are profound differences in male and female physiology, which can significantly impact disease mechanisms, toxicity of compounds, and efficacy of pharmaceuticals. In vitro systems have been traditionally very limited in their capacity to recapitulate female-specific physiology and anatomy such as dynamic sex-hormone levels and the complex interdependencies of female reproductive tract organs. However, the advent of microphysiological organ-on-a-chip systems, which attempt to recreate the 3D structure and function of human organs, now gives researchers the opportunity to integrate cells and tissues from a variety of individuals. Moreover, adding a dynamic flow environment allows mimicking endocrine signaling during the menstrual cycle and pregnancy, as well as providing a controlled microfluidic environment for pharmacokinetic modeling. This review gives an introduction into preclinical and clinical research on women's health and discusses where organ-on-a-chip systems are already utilized or have the potential to deliver new insights and enable entirely new types of studies.

Local synthesis of sex hormones: are there consequences for the ocular surface and dry eye?

Sex hormones are associated with the physiology and pathophysiology of almost all organs in the body, as well as most diseases. Interest in the associations between sex hormones and ocular tissues has increased in recent years. Androgens may have a positive effect on dry eye, whereas the effects of oestrogen on ocular conditions remain unclear. Intracrinology, the local synthesis and metabolism of hormones that is unique to humans, is of relevance to the eye and may help to explain why studies of the relationship between oestrogens and dry eye signs and symptoms are inconclusive. Knowledge of the pathways of hormone formation and metabolism is crucial to understanding the pathogenesis of ocular disease including dry eye. This review examines the mechanisms of steroidal sex hormone biosynthesis and reviews the significance of locally produced sex hormones, with a focus on ocular surface tissues. Much of the current literature is based on animal studies, which may not be transferable to humans due to the absence of intracrine production in animals. A large proportion of the human studies investigate systemic hormone levels rather than local levels. There is subsequently a need for additional studies to provide a better understanding of the local production of sex hormones within the human eye and ocular surface and to clarify the relationships between ocular levels of sex hormones and conditions including dry eye.

TFOS DEWS II Sex, Gender, and Hormones Report

One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.

Oestrogen, ocular function and low-level vision: a review

Over the past 10 years, a literature has emerged concerning the sex steroid hormone oestrogen and its role in human vision. Herein, we review evidence that oestrogen (oestradiol) levels may significantly affect ocular function and low-level vision, particularly in older females. In doing so, we have examined a number of vision-related disorders including dry eye, cataract, increased intraocular pressure, glaucoma, age-related macular degeneration and Leber's hereditary optic neuropathy. In each case, we have found oestrogen, or lack thereof, to have a role. We have also included discussion of how oestrogen-related pharmacological treatments for menopause and breast cancer can impact the pathology of the eye and a number of psychophysical aspects of vision. Finally, we have reviewed oestrogen's pharmacology and suggest potential mechanisms underlying its beneficial effects, with particular emphasis on anti-apoptotic and vascular effects.

Sex-steroid imbalance in females and dry eye

Dry eye (DE) is a multifactorial disorder of the ocular surface unit that results in eye discomfort, visual disturbance and ocular surface damage. It is one of the most common complaints in daily ophthalmic practice. The risk of DE increases with age in both sexes, while its incidence is higher among females. In addition, the condition of menopause in aging women may also contribute to DE onset or worsening as a consequence of an overall hormonal imbalance. Sex hormones play a key role in ocular surface physiology and they impact differently on ocular surface tissues. Reduced estrogen levels were historically thought to be responsible in age-related DE onset but more recent investigations have reconsidered the role of androgens that are present and exert a protective function on the ocular surface. Hormone levels themselves, withdrawal changes in hormone levels, and the changes in hormone-receptor responsiveness are all important factors but it remains to be fully elucidated how estrogen or androgen insufficiency act alone or together in a combined imbalance or interplay to raise the risk of disease. The purpose of this review is to briefly outline current scientific evidence on the influence of androgens and estrogens, on the Lachrymal and Meibomian glands and on ocular surface epithelia including conjunctival goblet cells during reproductive and menopausal periods. The role of sex steroids is also discussed in relation to the pathogenesis of different forms of DE and Sjogren's syndrome (SS). The impact of systemic hormone therapy (HT) in DE post-menopausal women still appears as a controversial issue, despite the many clinical studies. Finally, the outcomes of topical applications of steroid-based products are summarized, underlying the need for potential (tear) biomarker(s) in the rationale of DE-targeted therapy.

Dry eye disease: A review of diagnostic approaches and treatments

Dry eye (DE) is a common ocular disease that results in eye discomfort, visual disturbance and substantially affects the quality of life. It has a multifactorial etiology involving tear film instability, increased osmolarity of the tear film and inflammation of the ocular surface with potential damage to the ocular surface. This review discusses the classification, diagnostic approaches and treatments of DE.

Sex hormones and the dry eye

The greater prevalence of dry eye in women compared to men suggests that sex hormones may have a role in this condition. This review aims to present evidence for how sex hormones may affect the ocular structures involved in the production, regulation and maintenance of the normal tear film. It is hypothesised that hormone changes alter the homeostasis of the ocular surface and contribute to dry eye. Androgens impact on the structure and function of the meibomian and lacrimal glands and therefore androgen deficiency is, at least in part, associated with the aetiology of dry eye. In contrast, reports of the effects of oestrogen and progesterone on these ocular structures and on the conjunctiva are contradictory and the mechanisms of action of these female-specific sex hormones in the eye are not well understood. The uncertainty of the effects of oestrogen and progesterone on dry eye symptoms is reflected in the controversial relationship between hormone replacement therapy and the signs and symptoms of dry eye. Current understanding of sex hormone influences on the immune system suggests that oestrogen may modulate a cascade of inflammatory events, which underlie dry eye.

Estrogen negatively regulates epithelial wound healing and protective lipid mediator circuits in the cornea

Estrogen receptors (ERs) are expressed in leukocytes and in every ocular tissue. However, sex-specific differences and the role of estradiol in ocular inflammatory-reparative responses are not well understood. We found that female mice exhibited delayed corneal epithelial wound closure and attenuated polymorphonuclear (PMN) leukocyte responses, a phenotype recapitulated by estradiol treatment both in vivo (topically in male mice) and in vitro (corneal epithelial cell wound healing). The cornea expresses 15-lipoxygenase (15-LOX) and receptors for lipoxin A(4) (LXA(4)), which have been implicated in an intrinsic lipid circuit that regulates corneal inflammation and wound healing. Delayed epithelial wound healing correlated with lower expression of 15-LOX in the regenerated epithelium of female mice. Estradiol in vitro and in vivo down-regulated epithelial 15-LOX expression and LXA(4) formation, while estradiol abrogation of epithelial wound healing was completely reversed by treatment with LXA(4). More important, ERβ and ERα selectively regulated epithelial wound healing, PMN cell recruitment, and activity of the intrinsic 15-LOX/LXA(4) circuit. Our results demonstrate for the first time a sex-specific difference in the corneal reparative response, which is mediated by ERβ and ERα selective regulation of the epithelial and PMN 15-LOX/LXA(4) circuit. These findings may provide novel insights into the etiology of sex-specific ocular inflammatory diseases.

Relaxin and gonadal steroid receptors in uterosacral ligaments of women with and without pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This study evaluates the expression of estrogen receptor isoforms alpha (ERα) and beta (ERβ), progesterone receptor (PR), and relaxin receptor isoforms 1 and 2 (LGR7, LGR8) in uterosacral ligament (USL) tissue of women with pelvic organ prolapse and controls.

METHODS

Tissue samples of USL from women with and without pelvic organ prolapse (POP) were subjected to immunohistochemistry against ERα, ERβ, PR, and LGR7 proteins. The respective mRNA expression as well as of LGR8 was assessed by quantitative real-time polymerase chain reaction.

RESULTS

The cellular distribution of the receptor proteins was different due to cell types, independent of POP: ERα and PR were found in smooth muscle cells, but not in endothelial cells, whereas ERβ was found in endothelial cells, but not in connective tissue. ERα, ERβ, PR, and LGR7 mRNAs could be detected in all patients of both groups. ERα mRNA expression was significantly and ERβ mRNA borderline significantly higher in USL of patients with POP: ERα: p < 0.001, ERβ: p = 0.057.

CONCLUSIONS

Enhanced effects of estrogen via altered mRNA expression patterns of ERα and ERβ--but not those of progesterone--may exist in USL of patients affected by POP. A local effect of relaxin needs to be further clarified because of this first report of prevalent ligamental expression of LGR7.

Pharmacotherapy of dry eye

INTRODUCTION

based on data from the largest studies of dry eye to date - the Women's Health Study (WHS) and the Physicians' Health Study (PHS) - and other studies, it has been estimated that about 3.23 million women and 1.68 million men, for a total of 4.91 million Americans aged ≥ 50 years, have dry eye. Tens of millions more have less severe symptoms and probably a more episodic manifestation of the disease that is notable only during contact with some adverse contributing factor(s), such as low humidity or contact lens wear. Dry eye disease is a common yet frequently under-recognized public health problem whose etiology and management challenge clinicians and researchers involved in this field.

AREAS COVERED

advances in the understanding of the disease have been made over the past 10 years in areas of epidemiology, pathogenesis, clinical manifestation, and possible therapy. Historical aspects and recent information in relation to the use of artificial tear substitutes and anti-inflammatory agents in dry eye disease, including topical cyclosporin and corticosteroids, autologous serum, tetracyclines and systemic immunosuppressants, are covered in this review. The reader will gain insight into the recent views on the pharmacological menu of treatments for dry eyes following the recommendations of the 2007 International Dry Eye Workshop.

EXPERT OPINION

dry eye is a visually disabling disease, the treatment of which needs tailoring according to the type and severity of dry eye disease.

Immunohistochemical detection of estrogen and progesterone receptors in the human lacrimal gland

The nature and extent of estrogen and progesterone action on the lacrimal gland is not known, and neither are the targets for their action. Immunohistochemical detection of estrogen and progesterone receptors in the human lacrimal glands in both sexes in different age groups was performed in this study. Twenty human lacrimal glands from autopsies were analyzed by the immunohistochemical method of cell counting and the ?? test. Estrogen and progesterone receptors were detected in the lacrimal glands of both sexes with significantly higher total and average cell counts in females (p<0,001). Estrogen and progesterone receptors are present in human lacrimal glands with age and gender dependent expression.

Human lipocalin-1 association with 3H-testosterone and 3H-estradiol

PURPOSE

Topical androgens and estrogens have been studied for use in treating ocular conditions such as dry eye. The aim of this study was to identify proteins from normal human tears that associated with exogenously added sex steroid hormones. One of the major proteins in ocular tears is lipocalin-1. It binds a variety of lipids and other hydrophobic molecules and is proposed to function as a carrier protein or a lipid scavenger.

METHODS

Normal human tears were incubated with (3)H-testosterone or (3)H-estradiol. Labeled tear proteins were separated on a Q Sepharose Fast Flow (QFF) Hi Trap strong anion exchange column with a step gradient of NaCl. (3)H-testosterone or (3)H-estradiol was measured in aliquots of eluted fractions using scintillation counts, and the remainder of each sample was gel electrophoresed and silver stained. In separate experiments, (3)H-steroid-labeled tear proteins were electrophoresed in 15% polyacrylamide gels and excised from the gels. Tritium content of the proteins was measured in a scintillation counter. Immunoblots with antibodies to lipocalin-1 verified the migration of lipocalin-1 in the gels.

RESULTS

(3)H-steroid labeled tear proteins were found in the 0.15 M NaCl fractions of QFF strong anion exchange columns. 18 kD lipocalin-1 (among other tear proteins) eluted in the 0.15 M NaCl fraction. Excision of labeled tear proteins from 15% polyacrylamide gels indicated that radioactive label was associated with an 18 kD protein. Immunoblots verified that lipocalin-1 migrated as an 18 kD protein.

CONCLUSIONS

The sex steroid hormones testosterone and estradiol associated with 18 kD lipocalin-1 in human tears.

A novel porcine dry eye model system (pDEM) with simulated lacrimation/blinking system: Preliminary findings on system variability and effect of corneal drying

PURPOSE

To investigate inter- and intra-system variations and the effect of corneal drying using a recently developed pDEM.

METHODS

pDEM was used to simulate "normal" and "dry eye" conditions using two "lacrimation-blink" intervals (20 s and 60 s). Corneas were examined/graded with sodium fluorescein before and after the experiment. At the end of each experiment, corneas were assessed by trypan blue exclusion technique. Two duplicated pDEM systems were set up and tested to investigate reproducibility.

RESULTS

There was no significant difference in the results produced by the two pDEM systems. In the eyes under "normal" condition, there was no significant increase in the fluorescein grading. However, in eyes under "dry eye" condition, fluorescein staining increased and the number of non-viable cells in the central cornea increased.

CONCLUSIONS

This novel pDEM system provides a useful assessment tool for the study of causative factors and new treatment strategies for dry eye syndrome.

Low serum levels of sex steroids are associated with disease characteristics in primary Sjogren's syndrome; supplementation with dehydroepiandrosterone restores the concentrations

CONTEXT

Serum levels of the sex steroid prohormones dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S) decline upon aging and are reduced in primary Sjogren's syndrome.

OBJECTIVE

Our aim was to investigate: 1) effects of 50 mg oral DHEA/day on changes in serum levels of DHEA and 12 of its metabolites; 2) relationships between steroid levels and disease characteristics; and 3) whether these parameters were influenced by DHEA.

DESIGN

Twenty-three postmenopausal women with primary Sjogren's syndrome and subnormal levels of DHEA-S were included in a randomized, 9-month, controlled, double blind crossover study. Liquid chromatography/mass spectrometry (MS)/MS and gas chromatography/MS were used to measure the sex steroids. Anti-SS-A/Ro and/or anti-SS-B/La, salivary gland focus score, salivary flow rates, dry mouth and eye symptoms, and routine laboratory tests were assessed.

RESULTS

Baseline erythrocyte sedimentation rate was inversely correlated with testosterone (Testo), dihydrotestosterone, and DHEA-S (rs = -0.42, -0.45, and -0.58, respectively). Dry mouth symptoms correlated with low Testo and androstenedione, whereas dry eyes correlated with low estrogens, most strongly estrone (rs = -0.63). Presence of anti-SS-A and/or anti-SS-B was independently associated with low estradiol (area under the receiver operating characteristic curve, 0.82). All metabolites increased during DHEA but not during placebo. The relative increases were less for estrogens and Testo compared to dihydrotestosterone and glucuronidated androgen metabolites. Dry mouth symptoms decreased during DHEA therapy.

CONCLUSIONS

Disease manifestations in primary Sjogren's syndrome were associated with low sex hormone levels, dry mouth symptoms with low androgens, and dry eyes with low estrogens. Exogenous DHEA was preferentially transformed into androgens rather than into estrogens.

Tearful relationships? Sex, hormones, the lacrimal gland, and aqueous-deficient dry eye

Sex and the endocrine system exert a significant influence on the physiology and pathophysiology of the lacrimal gland. The purpose of this article is to briefly review the nature and magnitude of these interactions between sex, hormones and lacrimal tissue, and to address how they may relate to the pathogenesis of aqueous-deficient dry eye. Towards this end, this article has a 3-fold approach: first, to summarize the influence of androgens, estrogens, glucocorticoids, mineralocorticoids, retinoic acid, prolactin, alpha-melanocyte stimulating hormone, adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone, growth hormone, thyroid-stimulating hormone, arginine vasopressin, oxytocin, thyroxine, parathyroid hormone, insulin, glucagon, melatonin, human chorionic gonadotropin and cholecystokinin on the structure and function of the lacrimal gland; second, to discuss the mechanism of action of each hormone on lacrimal tissue; and third, to discuss the clinical relevance of the endocrine-lacrimal gland interrelationship, with a particular focus on each hormone's role (i.e. if relevant) in the development of aqueous-tear deficiency.

Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007)

The members of the Management and Therapy Subcommittee assessed current dry eye therapies. Each member wrote a succinct evidence-based review on an assigned aspect of the topic, and the final report was written after review by and with consensus of all subcommittee members and the entire Dry Eye WorkShop membership. In addition to its own review of the literature, the Subcommittee reviewed the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force (ITF) Delphi Panel on Dry Eye. The Subcommittee favored the approach taken by the ITF, whose recommended treatments were based on level of disease severity. the recommendations of the Subcommittee are based on a modification of the ITF severity grading scheme, and suggested treatments were chosen from a menu of therapies for which evidence of therapeutic effect had been presented.

Estrogen receptor-beta is the predominant estrogen receptor subtype in normal human synovia

OBJECTIVE

Joint pain increases after menopause with more than 50% of woman suffering from arthralgies. Since pain and inflammation of joints originate from synovial tissue, we aimed to discover whether estrogen receptors are present in the human synovia.

METHODS

This in vitro study was performed on samples of human synovial tissue, obtained from pre- (n = 8) and postmenopausal woman (n = 11) and men (n = 5) following surgery due to traumatic lesions. Fresh synovial tissue specimens were assessed for the localization as well as the presence of estrogen receptor-alpha (ER alpha) and estrogen receptor-beta (ER beta) by means of immunohistochemistry, as well as Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR), respectively.

RESULTS

ER beta protein and mRNA were found to be equally and highly expressed in synovial stroma and lining cells of all explants independent of sex or menopausal status. In contrast, weak ER alpha staining was localized in the synovial lining cells in only three of 24 explants. ER alpha protein was found to be weakly expressed in three of ten explants. ER alpha mRNA was found with highly variable amounts in seven of ten explants.

CONCLUSION

In view of our observation that ER beta but not ER alpha is expressed regularly in normal human synovia in high amounts, we propose that estrogen could play a significant role in synovial membrane function in women and men, operating preferably via the ER beta isoform.

Drug release and permeation studies of nanosuspensions based on solidified reverse micellar solutions (SRMS)

Solidified reverse micellar solutions (SRMS), i.e. mixtures of lecithin and triglycerides, offer high solubilisation capacities for different types of drugs in contrast to simple triglyceride systems [Friedrich, I., Müller-Goymann, C.C., 2003. Characterisation of SRMS and production development of SRMS-based nanosuspensions. Eur. J. Pharm. Biopharm. 56, 111-119]. Nanosuspensions based on SRMS were prepared by homogenisation close to the melting point of the SRMS matrix. In a first step the SRMS matrices of 1:1 (w/w) ratios of lecithin and triglycerides were loaded with 17beta-estradiol-hemihydrate (EST), hydrocortisone (HC) or pilocarpine base (PB), respectively, and subsequently ground in liquid nitrogen to minimise drug diffusion later on. The powder was then dispersed in a polysorbate 80 solution using high pressure homogenisation. The drug loading capacities of the nanosuspensions were very high in the case of poorly water-soluble EST (99% of total 0.1%, w/w, EST) and HC (97% of total 0.5%, w/w, HC) but not sufficient with the more hydrophilic PB (37-40% of total 1.0%, w/w, PB). These findings suggest SRMS-based nanosuspensions to be promising aqueous drug carrier systems for poorly soluble drugs like EST and HC. Furthermore, in vitro drug permeation from the different drug-loaded nanosuspensions was performed across human cornea construct (HCC) as an organotypical cell culture model. PB permeation did not differ from the nanosuspension and an aqueous solution whereas the permeation coefficients of HC-loaded nanosuspensions were reduced in comparison to aqueous and oily solutions of HC. However, the permeated amount was higher from the nanosuspensions due to a much lower HC concentration in the solution than that in the nanosuspension (solution 0.02%, w/w, versus nanosuspension 0.5%, w/w). The high drug load of the nanoparticles provides prolonged HC release. Permeated amounts of EST were reduced in comparison to HC and only detectable with an ELISA technique. The EST release from nanosuspensions and different EST-loaded systems revealed a prolonged EST release from the nanoparticulate systems in contrast to a faster release of an oily solution of an equal EST concentration. With regard to an aqueous EST suspension of similar concentration which represents a depot system the release rate from the nanosuspensions revealed the same order of magnitude which points again to a prolonged release potential of the nanosuspensions.

Menopause and dry eye. A possible relationship

The hormonal status and in particular sex steroids play a role in the ocular surface homeostasis and function, during the whole life and in both sexes, accomplished by estrogenic and androgenic receptors located on corneal and conjunctival epithelia and Meibomian gland. The ocular surface is an integrated unit and any dysfunction results in a scarce or unstable preocular tear film which produces dry eye, a chronic inflammatory condition with increasing incidence as people get older but always more frequent among females. In post-menopausal women endocrine changes join the aging effects in the pathogenesis of dry eye, but still it remains controversial whether estrogen or androgen deficiency or their imbalance impair ocular surface function. Another questionable issue concerns the efficacy of hormonal replacement therapy in the amelioration of dry eye symptoms and recovery of tear function, since the scientific literature stands in between a therapeutic or a promoting effect of eye dryness. Therapy of dry eye is usually based upon topical administration of tear substitutes; estrogen or androgen-based eye drops represents a promising innovative treatment based upon important scientific rationale.

Detection of oestrogen receptors (ER) alpha and beta in conjunctiva, lacrimal gland, and tarsal plates

PURPOSE

Lack of Oestrogen and androgen may be of importance in the pathogenesis of keratoconjunctivitis sicca (KCS). The signal of Oestrogens is transmitted via specific Oestrogen receptors (ER). It was the purpose of this study to evaluate the expression of ER alpha and ER beta in tear-producing tissues.

METHODS

Reverse transcriptase-polymerase chain reaction (RT-PCR, ER alpha + beta) and immunohistochemical evaluation (ER alpha only) were performed for ER detection and localization in tissue samples of bulbar conjunctiva (20 samples of 20 patients undergoing cataract surgery), tarsal plates (14 samples of 12 patients undergoing eye lid surgery), and lacrimal glands (20 samples of 13 cornea donors).

RESULTS

Messenger RNA ER alpha was identified via RT-PCR in all tissue samples with variable expression, ER beta predominantly in lacrimal gland tissue. Immunohistochemical staining for ER alpha was negative in most cases, probably due to the thermolability of ERs and very small sample sizes.

CONCLUSIONS

The detection of ER alpha and ER beta mRNA expression supports the concept of a receptor-based effect of Oestrogen in these tissues contributing to KCS. This may encourage therapeutical efforts including topical Oestrogen administration.

Effects of hormone replacement therapy on ocular function in postmenopause

OBJECTIVE

To evaluate the effect of hormone replacement therapy on climacteric ocular complaints, lacrimal secretion, intraocular pressure (IOP), and corneal thickness.

DESIGN

A prospective, controlled, randomized study on 50 healthy women (mean age 53.4 +/- 3.8 years) at least 1 year after spontaneous menopause. Twenty-five women (group A) were treated with transdermal 17beta-estradiol (50 microg/day) and medroxyprogesterone acetate (10 mg/day) for 12 days per cycle. Twenty-five untreated women (group B) were used as a control group. All participants underwent eye examination at the beginning of the study and after 3 and 6 months of therapy to detect ocular diseases and to measure lachrymal secretion, IOP, and corneal thickness.

RESULTS

No significant differences were observed between the two groups at the beginning of the study. After 3 and 6 months of treatment, we observed a significant reduction in the percentage of women in group A affected by ocular symptoms and in the severity of symptomatology in comparison with baseline and with group B (P < 0.01). A significant increase of both basal and stimulated lachrymal secretion was observed after 3 months of therapy in group A in comparison with baseline (P < 0.01). There was a significant decrease of IOP (P < 0.01) after 3 months of therapy in group A (P < 0.01), and a slight, nonsignificant increase of corneal thickness was observed in group A at 3 and 6 months in comparison with basal values.

CONCLUSION

Our data suggest that hormone replacement therapy may exert a beneficial effect on ocular symptomatology, increase lachrymal secretion, reduce IOP, and increase corneal thickness.

Effect of hormone replacement therapy on lacrimal fluid peroxidase activity in woman

OBJECTIVE

Lacrimal fluid peroxidase (POD) is an antioxidant and antimicrobial enzyme involved in the protection of the ocular surface. Our recent findings showed the existence of significant cyclic variations in POD activity that were positively correlated with those of 17beta-estradiol plasma levels throughout the menstrual cycle of fertile women. During the menopause, women lacrimal fluid POD activity significantly (P<0.05) decreased according to the natural oestrogen reduction. Since a possible influence of oestrogen on human POD activity was suggested, aim of the present investigation is to evaluate whether hormone replacement therapy (HRT) might influence this enzyme activity.

METHODS

Lacrimal fluid POD activities of 10 healthy postmenopausal women (mean age: 52.0) and eight healthy postmenopausal women (mean age: 53.0) treated by oral or transdermal routes containing oestrogen or oestrogen plus progestin were determined. Enzyme activity of each tear sample (5 microl) was spectrophotometrically determined by the 5,5'-dithiobis, 2-nitrobenzoic acid thiocyanate (NBS-SCN) assay; total protein content of tears was determined too. 17beta-Estradiol plasma levels were assayed by ELISA test.

RESULTS

HRT significantly (P<0.05) increased tear POD low postmenopausal levels. The significant (P<0.05) rise of 17beta-estradiol plasma levels of treated women was not strictly correlated to the enzyme activity increase in tears.

CONCLUSIONS

The suggested estrogen regulation of lacrimal fluid POD activity could be one possible cause for the female gender predilection in some ocular diseases. HRT is able to increase tear POD activity levels of postmenopausal women, probably contributing to the effective relieve of ocular surface complications occurring during menopause.

The prevalence of symptoms possibly related to the climacteric in pre- and postmenopausal women in Linköping, Sweden

BACKGROUND

Some extragenital symptoms have been suggested to be associated with the menopause and thus to be affected by estrogen status. In such case extragenital symptoms may be more frequent in postmenopausal women without hormone replacement therapy (HRT) than in premenopausal women or women using HRT.

OBJECTIVE

To assess if the prevalence of a number of extragenital symptoms is higher in postmenopausal women without than with HRT, or in premenopausal women of the same age.

MATERIAL AND METHODS

All women aged 53 and 54 years in the community of Linköping (n=1760) were sent a validated questionnaire about use of HRT, time since last menstruation and about different extragenital symptoms.

RESULTS

1298 (73.8%) women answered the questionnaire and answers from 1180 (67%) women were possible to analyze. Postmenopausal women woke up significantly more often during night than premenopausal, and those without HRT often due to hot flushes and sweating. Women with HRT reported more muscular pain than the others. We found no other significant difference in prevalence of extragenital symptoms between the three groups of women.

CONCLUSIONS

Sleeping disorders, arthralgia, xerophthalmia, xerostomia and dry skin are not more prevalent in 53 and 54 years old postmenopausal women without HRT than in women with HRT or in premenopausal women of the same age. It may still be that some of these symptoms are related to estrogen deficiency, but do not develop until some years after menopause. It may also be that women with the most severe symptoms decided to use HRT and thereby decreased symptoms to the same level as in non-users.

Tear function changes of postmenopausal women in response to hormone replacement therapy

OBJECTIVE

The goal of this study was to search the effect of hormone replacement therapy (HRT) on tear function changes in postmenopausal women.

METHODS

Following initial ophtalmic evaluation and tear sample collection, the subjects were given daily 0.625 mg conjugated estrogen, and either continuous combined or cyclic 5 mg medroxyprogesterone acetate was added. Eye examination included visual acuity, slit-lamp examination, fundus examination, tonometry, Schirmer's test, and break up time (BUT) evaluation. Six months later, control examination was done and repeat tear samples were obtained. Tear immune globulin A (IgA) and lysozyme levels were measured by gel electrophoresis. The pictures of the bands were evaluated by digital image analysis with Scion Image program.

RESULTS

Conjunctival vascular congestion, laxity and corneal desquamation did not change before and after HRT (P>0.05). A significant improvement was noted in meibomian gland inflammation (P=0.034). We have not observed any significant difference in burning, foreign body sensation, and tearing (P>0.05). In addition, no significant difference was noted in BUT (P=0.370) and Schirmer's test values (P=0.271). Though both lysozyme and IgA levels were elevated following the therapy, only IgA levels increased significantly (P=0.04).

CONCLUSION

HRT decreased meibomian gland inflammation and increased tear lysozyme and IgA levels in postmenopausal women.

Prevalence of treated dry eye disease in a managed care population

BACKGROUND

Survey studies are of limited utility in estimating the prevalence of treated dry eye. The use of claims data, which include only individuals who have a diagnosis of the disorder, provides a better estimation of the clinical significance of dry eye symptoms and appraisal of community needs.

OBJECTIVE

The purpose of this paper is to estimate the prevalence of treated dry eye disease using a nonsurvey methodology.

METHODS

Patients with dry eye diagnoses or who underwent punctal occlusion procedures were identified from PharMetrics' Integrated Outcomes database of medical claims for approximately 10 million patients enrolled in managed care plans. Prevalence estimates were calculated for 1997 and 1998.

RESULTS

The prevalence of dry eye was 0.48% in 1997 and 0.39% in 1998, representing 25,180 and 27,289 cases, respectively. Patients aged > or = 65 years were approximately 4 times as likely as those aged < 65 years to be diagnosed with keratoconjunctivitis sicca or tear film insufficiency. In 1997, dry eye was diagnosed or treated in 0.65% of women compared with 0.26% of men (P < 0.001). Rates of dry eye disease in 1998 were highest among women aged 75 to 79 years (2.02%) and men aged 80 to 84 years (1.30%). Women tended to receive a diagnosis at a younger age than did men. The most common diagnosis was tear film insufficiency (73.96% and 73.41% of dry eye patients in 1997 and 1998, respectively). The most common procedure was lacrimal punctal occlusion by plug (7.78% and 8.74% of dry eye patients in 1997 and 1998, respectively).

CONCLUSION

The prevalence of treated dry eye disease is 0.4% to 0.5% and is highest among women and the elderly.

Treatment of keratoconjunctivitis sicca with topical androgen

OBJECTIVE

Androgens have been reported to influence lipid production of sebaceous glands and even many ocular tissues. The effect of topical androgen therapy on a 54-year-old patient with keratoconjunctivitis sicca (KCS) and decreased lipid phase of the tear film is reported.

METHODS

For assessment of the lipid phase of the tear film, break up time (BUT) and lipid layer thickness (LLT) were monitored during 6 months before treatment as well as 3 months while using a daily topical androgen therapy.

RESULTS

During the topical androgen therapy the pathological lipid phase of the tear film was completely restored indicated by the normalisation of the values of BUT and LLT.

CONCLUSION

These findings are consistent with animal experiments indicating that topical administered androgen can restore the decreased lipid phase of the tear film. This may open up new therapeutic strategies for KCS.

Expression of sex steroid hormone receptors in human cornea

PURPOSE

Previously we reported the occurrence of estrogen receptor alpha (ER beta), estrogen receptor beta (ER beta) and androgen receptor (AR) in mouse corneas. The present study was designed to investigate the occurrence of various sex steroid hormone receptors, including ER alpha, progesterone receptor (PR) and AR, in human corneas.

METHODS

We used reverse transcription-polymerase chain reaction (RT-PCR) to look for sex hormone receptor mRNAs (ER alpha, PR and AR) in human corneal epithelial cells obtained at autopsy. Next, using an immunocytochemical technique, we localized these receptors in donor human corneas.

RESULTS

mRNAs encoding all receptors tested for were found in corneal epithelial cells obtained from male and female donor eyes. Immunocytochemical examination revealed that the receptors were located in the nuclei of corneal epithelial, stromal, and endothelial cells.

CONCLUSIONS

Since receptors for both male and female sex hormones are present in human corneas of both genders, we postulate that the receptors may influence the biological functions of corneal cells through direct interaction with specific hormones.

Immunohistochemical detection of estrogen and progesterone receptor in human cornea

OBJECTIVE

For treatment of postmenopausal keratoconjunctivitis sicca hormone therapy is favored by some clinicians. The likely morphological basis assessing the hormone receptor status in the human cornea has not been performed. Immunohistochemical staining methods provide the opportunity to evaluate the hormone receptor content within the histologic compartments of the cornea. The aim of our study was to assess and localize immunohistochemical hormone receptor staining in the human cornea.

METHODS

Formalin-fixed and paraffin-embedded specimens of three pre- and three postmenopausal women were assessed for localization of estrogen receptor (ER) and progesterone receptor (PR) expression with established immunohistochemical hormone receptor staining methods.

RESULTS

No nuclear staining reaction was found in the epi- and endothelial layers of the corneas. The stroma of the corneas showed no immunohistochemical staining reaction in all cases. We found cytoplasmatic PR staining of the endothelial layer in two cases.

CONCLUSIONS

We found no morphological basis in the human cornea for the use of topical steroid hormone treatment in postmenopausal keratoconjunctivitis sicca. Hormone receptor expression in the conjunctiva or in the lacrimal gland may have an impact in some patients showing relief of symptoms in postmenopausal dry eye syndrome.

Gender-specific medicine: the new profile of gynecology

The science of gynecology is undergoing a change and is swiftly turning into a holistic discipline, i.e. gender-specific medicine. The rationale for this is that the hormones of the ovary not only are responsible for reproduction but also perform a number of extragenital functions that extend far into other disciplines, giving rise to a different frequency of diseases in women than in men. For example, females are five times more likely to be affected by rheumatoid arthritis than males, the same also holding true for autoaggressive conditions. This phenomenon may be accounted for by the fact that physiological auto-aggression is involved in the reproductive process. Similarly, there is a difference between women and men with regard to the sicca phenomenon, or to such disorders as connective tissue weakness, cellulite, venous conditions or hypercholesterolemia. A cause-related treatment of such problems is now available through specific endocrine therapy. That is why gynecologists in future will increasingly have to adopt an interdisciplinary approach.