The role of medications in causing dry eye

Association between statin use and dry eye disease in patients with hyperlipidemia: A population-based retrospective cohort study

Higher serum cholesterol levels have been associated with an increased risk of dry eye disease (DED). The relationship between statin (HMG-CoA reductase inhibitor) use and DED in patients with hyperlipidemia remains unclear. To investigate the association between statin use and the risk of DED in patients with hyperlipidemia, we conducted a population-based retrospective cohort study utilizing data from Taiwan's Longitudinal Generation Tracking Database. Patients were categorized into statin users and nonusers, with a 5-year follow-up period. The study identified patients with newly diagnosed hyperlipidemia, excluding those with prior DED diagnoses. Matching and adjustments for covariates resulted in 41,931 individuals in each group. Patients receiving statin therapy were compared with those unexposed. Cumulative exposure doses were also evaluated to assess dose-response relationships. The primary outcome was the incidence of DED diagnosed during the follow-up period. Cox proportional hazards regression models estimated the risk of DED, and conditional logistic regression analyzed the dose-response effect of statin exposure. Among 41,931 matched pairs, statin users exhibited a slightly increased risk of developing DED compared with nonusers (adjusted hazard ratio, 1.06; 95% CI, 1.02-1.11; p < 0.01). However, no dose-response relationship was observed between statin exposure and DED risk. Statin use among patients with hyperlipidemia is associated with a marginally higher risk of DED. These findings underscore the importance of regular eye examinations in this patient population to facilitate early detection and management of DED.

Demographic and lifestyle factors associated with dry eye disease in China: A cross-sectional multi-center study

PURPOSE

Associations were assessed between demographic/lifestyle factors and tear film breakup time (TBUT) defined dry eye disease (DED) in China.

METHODS

The cross-sectional study involved 50,280 subjects (54 ± 17 y) in 217 clinics (25 provinces). Data included sleep disorders; digital screen exposure; and use of cosmetics, contact lenses, and eye drops (for asthenopia). Clinical examinations included TBUT; Schirmer I test; meibomian gland plug status. TBUT-defined DED was TBUT <10 s, with TBUT ≤5 s also considered (i.e., short TBUT-type DED), either unilateral or bilateral.

RESULTS

TBUT-defined DED was present in 81.6 % overall. The highest rates were in those 71 years or older, living in the north, with chronic daily sleep disorder, or daily cosmetic application; or daily digital screen exposure for 5 years, contact lenses 4 h, or 3 months eye drops. Compared with those without TBUT-defined DED, those with TBUT-defined DED showed lower Schirmer I results and more severe meibomian gland plug status (each, P < 0.001). Independent risk factors of DED were: aging; living in the southwest; daily digital screen exposure ≥3 h; and occasional cosmetic use. Risk factors of DED TBUT ≤5 s were: living in the southwest; wearing contact lenses (>3 y); and using eye drops. Rates of unilateral and bilateral DED were comparable.

CONCLUSIONS

DED in China is more likely in the aged and those in the north/southwest. DED rates increase with digital screen exposure, and use of cosmetics, contact lenses, or eye drops for asthenopia. Unilateral DED should be treated as promptly as bilateral.

Tear film assessment before and after phacoemulsification in patients with age-related cataracts

BACKGROUND

The study aims to assess the tear film before and after phacoemulsification in patients with age-related cataracts.

METHODS

A prospective observational study of 41 age-related cataract patients undergoing phacoemulsification procedure. Tear Film Break-Up Time (TBUT), Tear Film Meniscus Height (TMH), Meibomian glands (MG), and Lipid Layer Thickness (LLT) were assessed by a non-invasive Dry Eye Diagnostic System. All measurements were taken preoperatively, one week, one month, and three months postoperatively. The Marginal homogeneity and The Cochran Q tests were used in the statistical analysis.

RESULTS

The value of Non-Invasive Break-Up Time (NITBUT) was statistically significantly lower at one week (7.15 ± 3.31), one month (7.61 ± 3.41), and three months (7.66 ± 3.36) postoperatively than preoperatively (10.71 ± 2.71), p < 0.001. The Non- Invasive Tear Meniscus Height (NITMH) was significantly lower at one week (0.18 ± 0.0), one month (0.20 ± 0.09), and three months (0.20 ± 0.09) postoperatively than preoperatively (0.30 ± 0.113) p < 0.001. By the first month, both (NITBUT) and (NITMH) improved significantly compared to the first post-operative week. There was no statistically significant difference between one month and three months. The (NITMH) improved to a healthy level of ≥ 0.2 mm by the first month through the third month. Both (NITBUT) and (NITMH) did not reach the baseline by the third month. The meibomian glands and the lipid layer thickness had the same preoperative grade distribution without changes.

CONCLUSION

Phacoemulsification surgery can cause post-operative deterioration in the tear film, which starts within a week of the procedure, followed by gradual recovery over the next weeks and months. The phacoemulsification procedure mainly affects the tear break-up time and tear meniscus height. Both the lipid layer and meibomian glands are not affected.

Quantitative Analysis of Tear Film in Patients on Atypical Antipsychotics

PURPOSE

To evaluate and compare the prevalence and severity of dry eye disease (DED) among patients on atypical antipsychotics with controls.

METHODS

This cross-sectional study was conducted on patients who were on atypical antipsychotic therapy (study group) and matched controls (control group). Prevalence of DED was assessed using tear break up time. Statistical analysis was done using SPSS. Chi-square test and t-test were used. p < 0.05 was taken as the level of statistical significance.

RESULTS

Prevalence of DED was significantly more in study group. Polytherapy group has significantly high DED compared with monotherapy. Among monotherapy, clozapine had highest prevalence of DED (p-0.013) and among the polytherapy, clozapine-quetiapine had highest prevalence of dry eye.

CONCLUSION

Prevalence of DED was higher among antipsychotics than the normal population, and in polytherapy than monotherapy group. The patients on clozapine (monotherapy) and clozapine with quetiapine (polytherapy) had highest prevalence of DED.

Association between systemic medication use and severity of dry eye signs and symptoms in the DRy eye assessment and management (DREAM) study

PURPOSE

Some systemic medications are reported to be associated with dry eye disease (DED), yet their associations with the severity of DED signs and symptoms are not well studied. To evaluate these associations, we performed a secondary analysis of data from the DRy Eye Assessment and Management (DREAM) Study.

METHODS

Participants (N = 535) were assessed for DED signs using tear break-up time (TBUT), Schirmer testing, corneal fluorescein staining, conjunctival lissamine green staining, meibomian gland dysfunction (MGD), and tear osmolarity and DED symptoms using the Ocular Surface Disease Index (OSDI). We derived a composite signs severity score from the 6 DED signs and categorized participant-reported systemic medications into antidepressants, antihistamines, aspirin, corticosteroids, diuretics, nonsteroidal anti-inflammatory drugs, proton pump inhibitors, statins, vitamin D3, and medications for diabetes mellitus, hypertension, hypothyroidism, migraine, and seizure. Generalized linear models were used to compare DED symptom and sign scores between medication users and non-users, with adjustment for factors associated with DED severity.

RESULTS

Compared to non-users, antihistamine users had lower TBUT (p = 0.01) and higher OSDI score (p = 0.02); aspirin users had lower TBUT (p = 0.02); corticosteroid users had lower TBUT (p = 0.02), lower Schirmer test scores (p = 0.03), higher cornea fluorescein staining (p = 0.01), higher composite severity score (p = 0.01), and higher OSDI score (p = 0.03); seizure medication users had higher composite severity score (p = 0.02); vitamin D3 users had lower TBUT (p = 0.001) and greater MGD (p = 0.03); and diuretic users had less MGD (p = 0.03).

CONCLUSIONS

Certain systemic medications may be associated with more severe DED. This may guide prescription practices in patients with DED.

A Preservative-Free Approach - Effects on Dry Eye Signs and Symptoms After Cataract Surgery

Purpose

To compare the effect of treatment with preservative-free dexamethasone, NSAIDs and trehalose/hyaluronic acid eye drops with the preservative benzalkonium chloride containing dexamethasone and NSAIDs after cataract surgery in dry versus non-dry eyes.

Patients and Methods

In this prospective randomized intervention study, dry eye tests were performed before and 6 weeks after cataract surgery. Patients were considered as having dry eye, SDE (sign of dry eye), if at least one of the following dry eye tests were abnormal; corneal fluorescein staining (CFS), non-invasive keratograph breakup time (NIKBUT) or tear osmolarity. Patients with SDE were randomly assigned to one of two groups. Group 1 patients were treated with dexamethasone and bromfenac eye drops with the preservative benzalkonium chloride (BAC). Group 2 patients were treated with preservative-free dexamethasone and preservative-free diclofenac, as well as a preservative-free lubricant with trehalose and hyaluronic acid both before and after surgery. Patients with normal tear film status acted as the control group (group 3) and received same treatment as group 1.

Results

A total of 215 patients were enrolled six weeks after surgery, the number of patients with SDE decreased significantly in groups 1 and 2 (p <0.001). Subjective symptoms and objective measures including osmolarity, NIKBUT, CFS, and tear film thickness (TFT) improved after surgery, tear production remained unchanged, while corneal sensitivity and meibomian gland dysfunction (MGD) parameters worsened. In the control group with normal tear-film status, SDE increased significantly after the surgery (p <0.001). There were no statistically significant differences in tear film parameters between the three groups after surgery.

Conclusion

After cataract surgery, patients with mild to moderate dry eyes may experience improved tear film status and reduced symptoms. However, we found no additional beneficial effect on dry eye parameters with treatment with preservative-free dexamethasone, NSAIDs, and lubricants compared to preservative-containing eye drops.

Ocular Surface Side Effects of Novel Anticancer Drugs

Surgery, anticancer drugs (chemotherapy, hormonal medicines, and targeted treatments), and/or radiation are common treatment strategies for neoplastic diseases. Anticancer drugs eliminate malignant cells through the inhibition of specific pathways that contribute to the formation and development of cancer. Given the ability of such pharmacological medications to combat cancerous cells, their role in the management of neoplastic diseases has become essential. However, these drugs may also lead to undesirable systemic and ocular adverse effects due to cyto/neuro-toxicity and inflammatory reactions. Ocular surface side effects are recognized to significantly impact patient's quality of life and quality of vision. Blepharoconjunctivitis is known to be a common side effect caused by oxaliplatin, cyclophosphamide, cytarabine, and docetaxel, while anastrozole, methotrexate, and 5-fluorouracil can all determine dry eye disease. However, the potential processes involved in the development of these alterations are yet not fully understood, especially for novel drugs currently available for cancer treatment. This review aims at analyzing the potential ocular surface and adnexal side effects of novel anticancer medications, trying to provide a better understanding of the underlying pharmacological processes and useful insights on the choice of proper management.

Dry eye disease: identification and therapeutic strategies for primary care clinicians and clinical specialists

Dry eye disease (DED) is a multifactorial disorder characterized by loss of tear film homeostasis with an estimated worldwide prevalence of 5% to 50%. In DED, dysfunction of the ocular structures that create and regulate the tear film components-including the lacrimal glands, meibomian glands, cornea, and conjunctiva-causes a qualitative and/or quantitative tear deficiency with resultant tear film instability and hyperosmolarity. This initiates a vicious cycle of ocular surface inflammation and damage that may ultimately impair the quality of life and vision of affected patients. Many factors can contribute to the development of DED, including ocular and systemic diseases, topical and systemic medications, and environmental conditions. Because DED is a chronic disorder, treatment is most often long term and may utilize both pharmacologic and nonpharmacologic interventions to address all etiologic components. The long-term management of DED can be challenging and most often should involve eye care specialist referral. However, primary care clinicians (PCCs) are often the first points of contact for patients with DED and importantly provide initial diagnosis and preliminary patient education about the disease process. Consideration of DED is also vital for the practice of various specialties due to the large number of comorbidities and medications that can contribute to DED pathogenesis and progression. Therefore, it is important that PCCs and clinical specialists be aware of the etiology of DED and its available therapeutic options. This manuscript provides an overview of DED pathophysiology and treatment and discusses specific considerations regarding DED management for PCCs and clinical specialists.Key messagesSuccessful management of dry eye disease often requires the use of various pharmacologic and/or nonpharmacologic therapies, as well as environmental and lifestyle modifications, to mitigate the underlying etiologies and restore tear film homeostasis.Primary care clinicians play an essential role in dry eye disease management by establishing a diagnosis, educating patients about the disorder, and providing referrals to eye care specialists for initiation of specialized treatment and long-term follow-up.Primary care clinicians and clinical specialists should consider prescribing medications with fewer ocular surface effects whenever possible in patients at risk for or with existing dry eye disease.

Dry Eye Symptoms in Jazan University Lecturers During the COVID-19 Pandemic Using Ocular Surface Disease Index (OSDI)

Background Dry eye disease (DED) is a disease of the ocular surface charac-terized by instability of the tear film, which causes ocular surface inflamma-tion and damage that leads to ocular symptoms, discomfort, and visual disturbance. Dry eye is a common ocular condition and a major reason for ophthalmologist visits. Compulsory e-learning has arisen in colleges and schools with the coronavirus disease 19 (COVID-19) pandemic as a tool for new teaching and learning. DED is an emerging threat to public health and is directly proportional to digital screen viewing length. DED diagnosis flowchart begins with history-taking of associated risk factors and a screening test by Ocular Surface Disease Index (OSDI). Therefore, we aim to assess the prevalence and the severity of DED among Jazan University lecturers and to identify the associated risk factors. Methods  A total of 150 participants were recruited for this descriptive, observational study. Participants completed an online questionnaire that contained questions about sociodemographics, electronic devices they used, the average number of hours of use in a day as well as the distance and posture while reading, and factors that may influence visual symptoms such as the use of glasses, frequent changes in glasses prescription and DED symptoms. Results The results showed that the prevalence of DED was high, with 23% of participants having mild DED, 12% having moderate DED, and 29% having severe DED. DED was associated with a number of sociodemographic and clinical factors, including younger age, female gender, occupation as a lecturer, and use of digital devices. Conclusion This study highlights the need to develop strategies to prevent and control DED among high-risk groups, such as university lecturers. Future research should focus on identifying more effective ways to prevent DED and to improve the management of DED symptoms.

Effects of Punctal Occlusion on Ocular Itching and Conjunctival Redness Associated with Allergic Conjunctivitis

PURPOSE

Punctal occlusion using punctal plugs has been successfully used to treat the signs and symptoms of dry eye disease. However, the effects of punctal occlusion on the symptoms of allergic conjunctivitis (AC) have been less well documented. There is some concern among clinicians that punctal occlusion may make signs/symptoms of allergic conjunctivitis worse by trapping allergens on the eye. The objective of this post hoc analysis was to address this question and thus assess the effect of punctal occlusion alone on ocular itching and conjunctival redness associated with AC.

METHODS

This was a pooled post hoc analysis of three randomized, double-blind, placebo insert-controlled clinical trials in subjects with AC. Enrolled subjects were generally healthy adults with ocular allergies and a positive skin test reaction to perennial and/or seasonal allergens. The study used a modified version of the traditional conjunctival allergen challenge (CAC) model, which included multiple, repeated allergen challenges following placement of the intracanalicular insert. Subjects were rechallenged on Days 6, 7 and 8; Days 13, 14 and 15; and Days 26, 27 and 28.

RESULTS

The data set included 128 subjects that were administered placebo. Baseline mean (SD) ocular itching and conjunctival redness scores were 3.52 (0.44) and 2.97 (0.39), respectively. On post-insertion Days 7, 14 and 28, mean itching scores were 2.62, 2.26 and 1.91, respectively, representing 26%, 36% and 46% itching reductions, respectively (p < 0.001). On Days 7, 14 and 28, mean conjunctival redness scores were 1.98, 1.90, and 2.08, respectively, representing 33%, 36%, and 30% redness reductions, respectively (p < 0.001).

CONCLUSIONS

Based on this post hoc pooled analysis, punctal occlusion with a resorbable hydrogel intracanalicular insert did not worsen ocular itching or conjunctival redness in this patient population.

Possible Strategies to Mitigate Placebo or Vehicle Response in Dry Eye Disease Trials: A Narrative Review

Many candidate drugs for dry eye disease (DED) have been assessed over the years in pursuit of demonstrating efficacy in both signs and symptoms. However, patients with DED have very limited treatment options for management of both signs and symptoms of DED. There are several potential reasons behind this including the placebo or vehicle response, which is a frequent issue observed in DED trials. A high magnitude of vehicle response interferes with the estimation of a drug's treatment effect and may lead to failure of a clinical trial. To address these concerns, Tear Film and Ocular Surface Society International Dry Eye Workshop II taskforce has recommended a few study design strategies to minimize vehicle response observed in DED trials. This review briefly describes the factors that lead to placebo/vehicle response in DED trials and focuses on the aspects of clinical trial design that can be improved to mitigate vehicle response. In addition, it presents the observations from a recent ECF843 phase 2b study, wherein the study design approach consisted of a vehicle run-in phase, withdrawal phase, and masked treatment transition, and led to consistent data for DED signs and symptoms and reduced vehicle response post randomization.

French national diagnostic and care protocol for Sjögren's disease

Sjögren's disease (SD), also known as Sjögren's syndrome (SS) or Gougerot-Sjögren's syndrome in France, is a rare systemic autoimmune disease in its primary form and is characterised by tropism for the exocrine glandular epithelia, particularly the salivary and lacrimal glands. The lymphocytic infiltration of these epithelia will clinically translate into a dry syndrome which, associated with fatigue and pain, constitutes the symptom triad of the disease. In about one third of patients, SD is associated with systemic complications that can affect the joints, skin, lungs, kidneys, central or peripheral nervous system, and lymphoid organs with an increased risk of B-cell lymphoma. SD affects women more frequently than men (9/1). The peak frequency is around the age of 50. However, the disease can occur at any age, with paediatric forms occurring even though they remain rare. SD can occur alone or in association with other systemic autoimmune diseases. In its isolated or primary form, the prevalence of SD is estimated to be between 1 per 1000 and 1 per 10,000 inhabitants. The most recent classification criteria were developed in 2016 by EULAR and ACR. The course and prognosis of the disease are highly variable and depend on the presence of systemic involvement and the severity of the dryness of the eyes and mouth. The current approach is therefore to identify at an early stage those patients most at risk of systemic complications or lymphoma, who require close follow-up. On the other hand, regular monitoring of the ophthalmological damage and of the dental status should be ensured to reduce the consequences.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Ex vivo analysis of ketotifen content in an antihistamine-eluting contact lens worn up to 5 hours

Aim: This study characterized ex vivo release of ketotifen from etafilcon A contact lenses worn over 5 h. Materials & methods: 14 participants, 21 to 59 years, wore lenses with 19 μg ketotifen over 8 visits, for 1 min to 5 h. Residual ketotifen was measured using high-performance liquid chromatography (HPLC) compared with unworn lenses from the same lots to determine percent ketotifen remaining. Results: Residual ketotifen ranged from 16.19 μg ± 0.44 (84.1%) [1 minute] to 0.20 μg ± 0.07 (1.1%) [5 h]. No adverse events or clinically significant biomicroscopy changes were observed. Conclusion: The ketotifen-releasing etafilcon A lenses were well-tolerated with an acceptable safety profile in the population studied. The release of ketotifen from study lenses over 5 h was consistent with a diffusion-controlled system.

Managing Severe Evaporative Dry Eye with Intense Pulsed Light Therapy

INTRODUCTION

This study assessed the efficacy and safety of intense pulsed light (IPL) therapy in participants with severe evaporative dry eye disease (DED).

METHODS

This randomized, controlled, single-center study included 49 adult participants (≥ 18 years) with severe evaporative DED who received either IPL therapy (n = 56 eyes) or sham therapy (n = 42 eyes) three times. The primary efficacy parameters were ocular surface disease index (OSDI) score, non-invasive tear breakup time (NITBUT), tear film lipid layer (TFLL), conjunctivocorneal staining score (CS), MG Score, meibomian gland (MG) quality, and MG expression score.

RESULTS

The mean ages for the IPL group and the control group were 28.05 ± 3.41 years (57.1% female) and 28.14 ± 3.53 years (52.4% female), respectively. Comparison between the IPL group and the control group found significant differences in the mean OSDI score (22.16 ± 6.08 vs. 42.38 ± 6.60; P < 00.01), NITBUT (6.27 ± 0.84 vs. 3.86 ± 0.68; P < 0.001), TFLL (2.14 ± 0.44 vs. 3.45 ± 0.50; P < 0.001), MG Score (1.34 ± 0.55 vs. 1.88 ± 0.33; P < 0.001), MG quality (1.59 ± 0.07 vs. 2.67 ± 0.08), and MG expression (1.54 ± 0.57 vs. 2.45 ± 0.55) at 12 weeks follow-up; however, there was no significant difference in CS (3.32 ± 1.11 vs. 3.74 ± 1.04; P = 0.063).

CONCLUSION

The findings suggest that IPL therapy is clinically beneficial in ameliorating the signs and symptoms of severe evaporative dry eye disease.

Rodent models for dry eye syndrome: Standardization using benzalkonium chloride and scopolamine hydrobromide

Dry eye disease is a highly prevalent ocular condition that significantly affects the quality of life and presents a major challenge in ophthalmology. Animal models play a crucial role in investigating the pathophysiology and developing effective treatments. The goal of this study was to compare and standardize two dry eye disease rodent models and explore their recovery aspects. We have standardized benzalkonium chloride and scopolamine-induced dry eye disease models which represents two different classes of the dry eye i.e., evaporative dry eye and aqueous deficient dry eye, respectively. After the development of dry eye conditions, a self-recovery period of seven days was granted to assess the reversal of the induced changes. The dry eye condition was assessed by measuring tear volume, corneal slit lamp imaging, and histological examination of the cornea, the lacrimal and the harderian gland. The study indicated the development of chronic inflammation of the cornea and lacrimal gland in the case of benzalkonium after five days of the treatment, while the scopolamine treated group showed chronic inflammation of the lacrimal gland after five days and corneal inflammation after seven days of administration. The recovery study suggested that after discontinuation of inducing agent, the dry eye symptoms were still persistent suggesting the utility of the model in evaluating dry eye treatments. The study highlights the comparative changes in both models along with recovery which can serve as a base for drug discovery and development against dry eye disease.

Clinical relationship between dry eye disease and uveitis: a scoping review

This scoping review examined the relationship between Dry Eye Disease (DED) and Uveitis. We searched Pubmed, Embase, and LILACS databases for articles in which at least one patient had DED and uveitis concomitantly. The search produced 2381 records, and 24 studies were included in the qualitative synthesis. We concluded that DED and uveitis of any etiology could appear concomitantly in patients of any age. However, both diseases seem to coexist more frequently in middle-aged women and cases of anterior uveitis. Therefore, it is crucial that ophthalmologists actively look for the coexistence of ocular surface abnormalities, especially in patients with these characteristics. Future studies should establish and quantify the risk factors and pathophysiological mechanisms of this coexistence to achieve an early diagnosis of both etiologies and comprehensive management of these patients.

The Potential Role of Regulated Cell Death in Dry Eye Diseases and Ocular Surface Dysfunction

The research on new treatments for dry eye diseases (DED) has exponentially grown over the past decades. The increased prevalence of dry eye conditions, particularly in the younger population, has received much attention. Therefore, it is of utmost importance to identify novel therapeutical targets. Regulated cell death (RCD) is an essential process to control the biological homeostasis of tissues and organisms. The identification of different mechanisms of RCD stimulated the research on their involvement in different human pathologies. Whereas apoptosis has been widely studied in DED and included in the DED vicious cycle, the role of RCD still needs to be completely elucidated. In this review, we will explore the potential roles of different types of RCD in DED and ocular surface dysfunction. Starting from the evidence of oxidative stress and inflammation in dry eye pathology, we will analyse the potential therapeutic applications of the following principal RCD mechanisms: ferroptosis, necroptosis, and pyroptosis.

Lacrimal Gland Insufficiency in Aqueous Deficiency Dry Eye Disease: Recent Advances in Pathogenesis, Diagnosis, and Treatment

BACKGROUND

Aqueous deficiency dry eye disease is a chronic and potentially sight-threatening condition, that occurs due to the dysfunction of the lacrimal glands. The aim of this review was to describe the various recent developments in the understanding, diagnosis and treatment of lacrimal gland insufficiency in aqueous deficiency dry eye disease.

METHODS

A MEDLINE database search using PubMed was performed using the keywords: "dry eye disease/syndrome", "aqueous deficient/deficiency dry eye disease", "lacrimal gland" and "Sjogren's syndrome". After scanning through 750 relevant abstracts, 73 eligible articles published in the English language from 2016 to 2021 were included in the review.

RESULTS

Histopathological and ultrastructural studies have revealed new insights into the pathogenesis of cicatrising conjunctivitis-induced aqueous deficiency, where the lacrimal gland acini remain uninvolved and retain their secretory property, while significant ultrastructural changes in the gland have been observed. Recent advances in diagnosis include the techniques of direct clinical assessment of the lacrimal gland morphology and secretion, tear film osmolarity, tear film lysozyme and lactoferrin levels, tear film interferometry and lacrimal gland confocal microscopy. Developments in the treatment of aqueous deficiency dry eye disease, apart from the nanoparticle-based tear substitutes, include secretagogues like diquafosol tetrasodium and rebamipide, anti-inflammatory topical agents like nanomicellar form of cyclosporine and lifitegrast, scleral contact lenses, neurostimulation, and acupuncture for increasing the amount of tear production, minor salivary gland transplantation, faecal microbial transplantation, lacrimal gland regeneration and mesenchymal stem cell therapy.

CONCLUSIONS

Significant advances in the understanding, diagnosis and management of lacrimal gland insufficiency and its role in aqueous deficiency dry eye disease have taken place within the second half of the last decade. Of which, translational breakthroughs in terms of newer drug formulations and regenerative medicine are most promising.

Statin Use Is Associated With a Lower Risk of Blepharitis: A Population-Based Study

Background

Blepharitis is a common eye disorder that may be overlooked by patients and clinical practitioners. The symptoms of blepharitis often manifest as irritation, a burning sensation, grittiness, and itchiness and may decrease visual acuity if not treated promptly. Meibomian gland dysfunction (MGD), a common cause of blepharitis, is believed to be associated with increased inflammatory marker levels that may disrupt the composition of lipids produced by the sebaceous glands in the eyelids and ultimately cause tear film instability.

Methods

This is a retrospective, population-based study using National Health Insurance Research Database (NHIRD) data from a 14-year period (2000–2015). Pearson chi-squared and Student's t-tests were used to assess the differences in categorical and continuous variables, respectively, between statin users and non-statin users. Univariate and multivariate Cox regression analyses were performed to calculate the hazard ratios (HRs) after adjusting for confounders. Kaplan-Meier analysis was used to assess the cumulative risk of blepharitis between the two cohorts.

Results

A total of 67,014 patients who used statins were enrolled as the study cohort, and 268,056 patients who did not use statins were enrolled as the comparison cohort. The incidence of blepharitis was 3.04% with statin treatment and 3.72% without statin treatment (p < 0.001). Patients who used statins had a lower risk of developing blepharitis [adjusted hazard ratio (aHR): 0.746, p < 0.001] than those who did not. In addition, diabetes mellitus (DM), hypertension, coronary heart disease (CHD), stroke, chalazion, rosacea, Sjogren syndrome, psoriasis and atopy were found to be possible risk factors for blepharitis.

Conclusion

Statin use can decrease the risk of developing blepharitis. However, further prospective studies are needed to evaluate statin treatment for various subtypes of blepharitis and to identify the associated mechanism.

Effects of wearing swimming goggles on non-invasive tear break-up time in a laboratory setting

PURPOSE

The use of swimming goggles (SG) has demonstrated to alter different ocular parameters, however, the impact of wearing SG on the tear film stability remain unknown. The main objective of this study was to determine the short-term effects of wearing SG on tear film surface quality break-up time (TFSQ-BUT).

METHODS

Twenty-eight young healthy adults (14 men and 14 women) wore a drilled SG, and TFSQ-BUT was measured before, during and after SG use. Dynamic-area high-speed videokeratoscopy was used for the non-invasive assessment of TFSQ-BUT.

RESULTS

TFSQ-BUT was significantly reduced while SG wear in comparison to the baseline measurement (4.8 ± 4.5 s vs. 8.8 ± 6.9 s; corrected p-value = 0.017, d = 0.57, mean difference = 4.0 [0.6, 7.3]; 45% reduction). Immediately after SG removal, TFSQ-BUT rapidly recovered baseline levels (8.2 ± 5.9 s vs. 8.8 ± 6.9 s; corrected p-value = 0.744). The impact of wearing SG on TFSQ-BUT were independent of the gender of the participants (p = 0.934).

CONCLUSION

The use of SG induces a TFSQ-BUT reduction, with these changes returning to baseline levels immediately after SG removal. These data may be of relevance for the management of dry eye patients, who need to avoid circumstances that exacerbate tear film instability. Nevertheless, these results must be interpreted with caution since the experiment did not entirely mimic real-life conditions (e.g., eye cup piece drilled, time of exposure, environmental conditions). Future studies should consider the inclusion of dry eye patients and older individual in order to explore the generalizability of these findings.

Is dry eye disease the same in young and old patients? A narrative review of the literature

Advanced age is one of the most evident risk factors for dry eye disease (DED), with male/female sex, chronic drug consumption, and prolonged device use. This article aims to review the literature about the changes of the ocular surface associated with DED in the elderly and patients < 40 years. The pathophysiologic changes of the ocular surface responsible for eye dryness are linked with inflammation and neurosensory abnormalities and may occur with a different feature in young patients compared with elders. Peculiar treatment strategies may be needed for young and older subjects with DED.

Ocular benzalkonium chloride exposure: problems and solutions

Preservatives in multidose formulations of topical ophthalmic medications are crucial for maintaining sterility but can be toxic to the ocular surface. Benzalkonium chloride (BAK)-used in approximately 70% of ophthalmic formulations-is well known to cause cytotoxic damage to conjunctival and corneal epithelial cells, resulting in signs and symptoms of ocular surface disease (OSD) including ocular surface staining, increased tear break-up time, and higher OSD symptom scores. These adverse effects are more problematic with chronic exposure, as in lifetime therapy for glaucoma, but can also manifest after exposure as brief as seven days. Multiple strategies are available to minimize or eliminate BAK exposure, among them alternative preservatives, preservative-free formulations including sustained release drug delivery platforms, and non-pharmacological therapies for common eye diseases and conditions. In this paper, we review the cytotoxic and clinical effects of BAK on the ocular surface and discuss existing and emerging options for ocular disease management that can minimize or eliminate BAK exposure.

Estimated Annual Economic Burden of Dry Eye Disease Based on a Multi-Center Analysis in China: A Retrospective Study

Purpose: To conduct a multi-center analysis and assess the economic burden due to dry eye disease (DED) in China. Design: A retrospective and cross-sectional study. Methods: Patients (n = 598) with diagnosed DED were recruited from 3 eye centers (in central, southeast, and northeast China) from 1 January 2018 to 31 December 2018. Data were collected regarding the examination, pharmacological therapy, and non-pharmacological therapy fees. Sub-group analyses were stratified by eye center, DED severity, types of DED, number of visits to physicians, and residential area. A logistic regression analysis was conducted to investigate the variables influencing total costs. Results: The per capita costs devoted to DED at the 3 centers were 422.6, 391.3, and 265.4 USD, respectively. The costs of non-pharmacological therapy accounted the largest part in three centers (75.6, 76.4, 76.5%, respectively). Patients with severe DED sustained the largest economic burden. Patients with mixed type of DED spent the most comparing to patients with either evaporative or aqueous-deficient types of DED. Patients spent more during the first visit compared with subsequent visits. Patients living in urban areas spent significantly more than did those living in rural areas (P = 0.001). The logistics regression analysis showed that total costs were significantly influenced by DED severity, number of visits to physicians, and area of residence (beta = 2.83, 0.83, 1.48; P < 0.0001). Conclusions: DED is a chronic ocular disease that timely non-cost counseling, early diagnosis, and efficacious treatment can reduce its economic burden on patients and the society.

Human meibomian gland epithelial cell culture models: Current progress, challenges, and future directions

The widely used immortalised human meibomian gland epithelia cell (iHMGEC) line has made possible extensive studies of the biology and pathophysiology of meibomian glands (MG). Tissue culture protocols for iHMGEC have been revised and modified to optimise the growth conditions for cell differentiation and lipid accumulation. iHMGEC proliferate in serum-free medium but require serum or other appropriate exogenous factors to differentiate. Several supplements can enhance differentiation and neutral lipid accumulation in iHMGEC grown in serum-containing medium. In serum-free medium, rosiglitazone, a peroxisome proliferator activator receptor-γ (PPARγ) agonist, is reported to induce iHMGEC differentiation, neutral lipid accumulation and expression of key biomarkers of differentiation. iHMGEC cultured in serum-containing medium under hypoxia or with azithromycin increases DNAse 2 activity, a biomarker of terminal differentiation in sebocytes. The production of lipids with composition similar to meibum has not been observed in vitro and this remains a major challenge for iHMGEC culture. Innovative methodologies such as 3D ex vivo culture of MG and generation of MG organoids from stem cells are important for further developing a model that more closely mimics the in vivo biology of human MG and to facilitate the next generation of studies of MG disease and dry eye.

Assessment of Ocular Surface Disease in Glaucoma Patients in Ghana

PRECIS

Dry eye disease (DED) observed in this study is associated with ocular surface abnormalities as shown by specific dry eye tests. Changes in tear quality may be responsible for dry eye symptoms among the participants.

PURPOSE

This study sought to evaluate DED in glaucoma patients in Ghana.

MATERIALS AND METHODS

This was a hospital-based descriptive cross-sectional study involving glaucoma patients on topical glaucoma treatment for at least 6 months. The medical records of participants were thoroughly reviewed for information on demographics, ocular history, medical history, number of topical antiglaucoma medications used within the last 6 months, and any other ophthalmic medications used by the participants. An Ocular Surface Disease Index (OSDI) questionnaire was administered to each participant, after which Schirmer test and tear break-up time (TBUT) were performed on each participant in a controlled environment.

RESULTS

A total of 100 individuals participated in the study. The mean±SD age of participants was 60.44±14.05 years. The majority (60.0%) of the participants were females and 55.0% of participants used 2 or more topical antiglaucoma medication. Of the participants, 81.0% reported subjective dry eye symptoms. Schirmer test and TBUT showed that 55.0% and 87.0% of the participants had decreased tear production and abnormal tear quality, respectively. Multiple logistic regression showed a significant association between age and abnormal OSDI (P=0.037), Schirmer test (P=0.003), and TBUT (P=0.042); the number of topical glaucoma medications and OSDI (P=0.016) and Schirmer test (P=0.009). The prevalence of DED was 23.0%. Increasing age was associated with an ∼7 times higher odds of having DED (P=0.0019), using >2 glaucoma medications with ∼4.5 times higher odds of having DED (P=0.001), 5 or more years of glaucoma medication use with ∼4 times higher odds of DED (P=0.009), and both benzalkonium chloride and sodium chlorite as preservative was associated with ∼3.5 times higher odds of DED (P=0.047).

CONCLUSION

DED is prevalent among glaucoma patients in Ghana and is associated with age, duration of glaucoma medication, type of preservatives, and number of topical glaucoma medications.

The ocular surface immune system through the eyes of aging

Since the last century, advances in healthcare, housing, and education have led to an increase in life expectancy. Longevity is accompanied by a higher prevalence of age-related diseases, such as cancer, autoimmunity, diabetes, and infection, and part of this increase in disease incidence relates to the significant changes that aging brings about in the immune system. The eye is not spared by aging either, presenting with age-related disorders of its own, and interestingly, many of these diseases have immune pathophysiology. Being delicate organs that must be exposed to the environment in order to capture light, the eyes are endowed with a mucosal environment that protects them, the so-called ocular surface. As in other mucosal sites, immune responses at the ocular surface need to be swift and potent to eliminate threats but are at the same time tightly controlled to prevent excessive inflammation and bystander damage. This review will detail how aging affects the mucosal immune response of the ocular surface as a whole and how this process relates to the higher incidence of ocular surface disease in the elderly.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients' quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients' QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

Evidence of Polyphenols Efficacy against Dry Eye Disease

Dry eye disease is a multifactorial pathology compromising the quality of life of patients, resulting in significant damage of the ocular surface and discomfort. The current therapeutical strategies are not able to definitively resolve the underlying causes and stop the symptoms. Polyphenols are promising natural molecules that are receiving increasing attention for their activity/effects in counteracting the main pathologic mechanisms of dry eye disease and reducing its symptoms. In the present review, a deep literature search focusing on the main polyphenols tested against dry eye disease was conducted, analyzing related in vitro, in vivo, and clinical studies to provide a comprehensive and current review on the state of the art. Polyphenols present multiple effects against dry eye diseases-related ocular surface injury. In particular, the observed beneficial effects of polyphenols on corneal cells are the reduction of the pathological processes of inflammation, oxidative stress, and apoptosis and modulation of the tear film. Due to numerous studies reporting that polyphenols are effective and safe for treating the pathological mechanisms of this ocular surface disease, we believe that future studies should confirm and extend the evidence of polyphenols efficacy in clinical practice against dry eye disease and help to develop new ophthalmic drug(s).

Iatrogenic corneal diseases or conditions

Any prescribed or self-administered therapy carries inherent risks of secondary adverse events. While the volume of treatments being administered through healthcare systems has been increasing, scientific advancements in our understanding of the mechanisms of pharmaceutical side effects and complications from procedures now allow us to reduce the risk of non-intentional damage to ocular health. This review summarizes the most common and leading causes of iatrogenic visual impairment, corneal diseases, and conditions that present in a general ophthalmologic practice, including a comprehensive analysis of their pathophysiology and recommendations for management and prophylaxis.Iatrogenic corneal diseases and conditions can arise from topical drugs, contact lens use, eye surgeries and procedures, systemic drugs, non-ophthalmological events, and cosmetic procedures. Topical and systemic drugs may disturb tear film homeostasis or result in ocular surface deposits. The use of ill-fitted contact lenses can trigger eye discomfort and poor hygiene conditions that can predispose to severe infections. Procedures to the eye may result in a variety of anatomical and functional complications that ophthalmologists should be aware of how to avoid or at least be prepared to manage if they occur. Even non-ophthalmological events such as non-invasive ventilation, radiation therapies and, immune-based conditions, or cosmetic procedures such as eyelash growth and fillers, can result in unwanted damage to the ocular surface.

Efficacy of 0.1% crosslinked hyaluronic acid, coenzyme Q10 and vitamin E in the management of dry eye disease in menopause patients receiving antidepressants

PURPOSE

The purpose of this study is to test non-inferiority of a lower dose of crosslinked hyaluronic acid (CLHA) to a higher dose of carmellose eye drop in menopause patients receiving antidepressant treatments.

METHODS

This prospective, double-blind, single-center study enrolled sixty female patients. Mean age was 63.25 ± 9.13 years. We examined patients with Schirmer I, breakup time (TBUT) and the ocular surface disease index (OSDI) at the first visit. Tear A eyedrops were formulated with crosslinked hyaluronic acid, coenzyme Q10 and vitamin E. Control tear B was formulated with carmellose sodium. Posology was two and five times, respectively.

RESULTS

After 2 months of treatment, the tear A obtained 14.12 ± 7.47 score points for OSDI (t = 11.74, p < 0.01), and tear B obtained 19.46 ± 10.03 score points (t = 7.59, p < 0.01). The tear A obtained 13.77 ± 7.78 score points for Schirmer test (t = 0.88, p > 0.05), and tear B obtained 14.20 ± 8.62 score points (t = 2.92, p < 0.01). The tear A obtained 8.30 ± 2.08 s for TBUT (t = 15.50, p < 0.01), and tear B obtained 7.23 ± 2.40 s (t = 8.79, p < 0.01).

CONCLUSION

Lower total daily dose of crosslinked hyaluronic acid eyedrops obtained similar efficacy results in terms of tear stability and subjective dry eye sensation than higher carmellose total daily dose. A lower total daily dose of crosslinked eyedrops was sufficient to achieve better dry eye disease management compared to carmellose.

Extended multi-item gamma Poisson shrinker methods based on the zero-inflated Poisson model for postmarket drug safety surveillance

Bayesian signal detection methods, including the multiitem gamma Poisson shrinker (MGPS), assume a Poisson distribution for the number of reports. However, the database of the adverse event reporting system often has a large number of zero-count cells. A zero-inflated Poisson (ZIP) distribution can be more appropriate in this situation than a Poisson distribution. Few studies have considered ZIP-based models for Bayesian signal detection. In addition, most studies on Bayesian signal detection methods include simulation studies conducted assuming a gamma distribution for the prior. Herein, we extend the MGPS method using the ZIP model and apply various prior distributions. We evaluated the extended methods through an extensive simulation using more varied settings for the model and prior than existing methods. We varied the total number of reports, the number of true signals, the relative reporting rate, and the probability of observing a true zero. The results show that as the probability of observing a zero count increased, methods based on the ZIP model outperformed the Poisson model in most cases. We also found that using the mixture log-normal prior resulted in more conservative detection than other priors when the relative reporting rate is high. Conversely, more signals were found when using the mixture truncated normal distributions. We applied the Bayesian signal detection methods to data from the Korea Adverse Event Reporting System from 2012 to 2016.

Efficacy and tolerability of nortriptyline in the management of neuropathic corneal pain

PURPOSE

Neuropathic corneal pain (NCP) is a recently acknowledged disease entity. However, there is no consensus in potential treatment strategies, particularly in patients with a centralized component of pain. This study aims to assess the efficacy and tolerability of the tricyclic antidepressant, nortriptyline, among NCP patients.

METHODS

Patients with clinically diagnosed NCP and a centralized component of pain, treated with oral nortriptyline, who had recorded pain scores as assessed by the ocular pain assessment survey at the first and last visit were included. Patients were excluded if they had any other ocular pathology that might result in pain or had less than 4 weeks of nortriptyline use. Demographics, time between visits, concomitant medications, systemic and ocular co-morbidities, duration of NCP, side effects, ocular pain scores, and quality of life (QoL) assessment were recorded.

RESULTS

Thirty patients with a mean age of 53.1 ± 18.5 were included. Male to female ratio was 8:22. Mean ocular pain in the past 24 h improved from 5.7 ± 2.1 to 3.6 ± 2.1 after 10.5 ± 9.1 months (p < 0.0001). Twelve patients (40.0%) had equal to or more than 50% improvement, 6 patients (20.0%) had 30-49% improvement, 6 patients (20.0%) had 1-29% improvement, 4 patients (13.3%) did not improve, while 2 patients (6.7%) reported increase in pain levels. Mean QoL improved from 6.0 ± 2.5 to 4.3 ± 2.4 (p = 0.019). Eight patients (26.6%) discontinued treatment due to persistent side effects, despite improvement by 22.4%.

CONCLUSION

Nortriptyline was effective in relieving NCP symptoms in patients with centralized component and insufficient response to other systemic and topical therapies who tolerated the drug for at least 4 weeks. Nortriptyline may be used in the management of patients with NCP.

Dry Eyes, Ocular Lubricants, and Use of Systemic Medications Known or Suspected to Cause Dry Eyes in Residents of Aged Care Services

Ocular issues are common, burdensome, and under-researched among residents of aged care services. This study aims to investigate the prevalence of dry eyes or use of ocular lubricants among residents, and the possible association with systemic medications known or suspected to cause dry eyes. A cross-sectional study of 383 residents of six aged care services in South Australia was conducted. Data were extracted from participants' medical histories, medication charts, and validated assessments. The main exposure was systemic medications known to cause, contribute to, or aggravate dry eyes. The primary outcome was documented dry eyes or regular administration of ocular lubricants. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between systemic medications and dry eyes/use of ocular lubricants. Dry eyes were documented for 53 (13.8%) residents and 98 (25.6%) residents were administered ocular lubricants. Overall, 116 (30.3%) residents had documented dry eyes/used ocular lubricants. Of these, half (n = 58) were taking a medication known to cause, contribute to, or aggravate dry eyes. Taking one or more medications listed as known to cause dry eyes was associated with having dry eyes/use of ocular lubricants (OR 1.83, 95% CI 1.15-2.94). In sub-analyses, no individual medication was associated with dry eyes/use of ocular lubricants. Dry eyes and use of ocular lubricants are common in residential aged care. Our hypothesis generating findings suggest the need for further research into the clinical significance of systemic medications as a possible cause of dry eyes.

The Carbonic Anhydrase Inhibitor Dorzolamide Stimulates the Differentiation of Human Meibomian Gland Epithelial Cells

PURPOSE

Clinical studies have indicated that the long-term use of topical antiglaucoma drugs, such as carbonic anhydrase inhibitors (CAIs), may lead to meibomian gland dysfunction (MGD). We hypothesize that these adverse effects involve a direct influence on human MG epithelial cells (HMGECs). The purpose our present investigation was to test our hypothesis and determine whether exposure to dorzolamide, a CAI, impacts the proliferation, intracellular signaling and differentiation of HMGECs.

MATERIALS AND METHODS

We cultured immortalized (i) HMGECs with vehicle or various concentrations of dorzolamide for 6 days. Cells were enumerated with a hemocytometer, and examined for their morphology, Akt signaling activity, accumulation of neutral lipids, phospholipids and lysosomes, and the expression of protein biomarkers for lipogenesis regulation, lysosomes and autophagosomes.

RESULTS

Our results show that a high, 500 µg/ml concentration of dorzolamide causes a significant decrease in Akt signaling and the proliferation of iHMGECs. However, the high dose of dorzolamide also promotes the differentiation of iHMGECs. This response features increases in the number of lysosomes, the accumulation of phospholipids, and the expression of the light chain 3A biomarker for autophagosomes. In contrast, the therapeutic amount (50 µg/ml) of dorzolamide has no impact on the proliferative or differentiative abilities of iHMGECs.

CONCLUSIONS

Our results support our hypothesis and demonstrate that the CAI dorzolamide does exert a direct influence on the proliferation and differentiation of iHMGECs. However, this effect is elicited only by a high, and not a therapeutic, amount of dorzolamide. Abbreviations: AKT: phosphoinositide 3-kinase-protein kinase B; BPE: bovine pituitary extract; CAD: cationic amphiphilic drug; DED: dry eye disease; DMEM/F12: 1:1 mixture of Dulbecco's modified Eagle's medium and Ham's F-12; EGF: epidermal growth factor; FBS: fetal bovine serum; iHMGECs: immortalized human meibomian gland epithelial cells; KSFM: keratinocyte serum-free medium; LAMP-1: lysosomal-associated membrane protein 1; LC3A: light chain 3A; MGD: meibomian gland dysfunction; SREBP-1: sterol regulatory element-binding protein 1.

The Efficacy and Safety of Qiming Granule for Dry Eye Disease: A Systematic Review and Meta-Analysis

Background

Dry eye disease (DED) is a common complication in clinical practice. Qiming granule, a traditional Chinese patent medicine, is widely used in treating DED in China. However, its effect is still largely unknown.

Objectives

This research aims to evaluate the efficacy and safety of QG on DED.

Methods

Three English database and four Chinese databases without restriction on language and publication bias were searched. Qualified literature was selecting according to inclusion and exclusion criteria, extracted the data, and conducted a meta-analysis.

Results

A total of 11 articles were included in this meta-analysis. The methodological quality of included studies was low. The results showed that QG was effective for DED (RR:1.26, 95%CI:1.12 to 1.41, P=0.0001). The results combined with random effects model showed that QG could significantly prolong the tear film break up time (MD: 2.93, 95% CI: 2.22 to 3.65, P < 0.00001), increase the amount of tears in patients with DED (MD: 2.94, 95% CI: 1.83 to 4.04, P < 0.00001) and repair the corneal defects in patients (MD: -0.71, 95% CI: -1.25 to -0.17, P < 0.00001).

Conclusions

This study found that despite of the apparently positive results of some outcomes, it is premature to confirm the efficacy of QG in treating DED. More high-quality studies are still needed in the future to further confirm the efficacy and safety.

Improvement of conjunctival cytological grade and tear production in Ankylosing Spondylitis patients under TNF inhibitors: a long-term follow-up

Dry eye disease can compromise the patient’s quality of life. Few studies assessed the ocular surface (OS) in Ankylosing Spondylitis (AS) patients. This study aimed to evaluate the clinical and cytological findings of the OS in patients with AS, classify dry eye disease (DED) severity grade and conjunctival impression cytology (IC), and the effects of TNF inhibitors (TNFi) in a one-year follow-up. A baseline (BL) evaluation included 36 AS patients and 39 healthy controls. They fulfilled the Ocular Surface Index Disease questionnaire and underwent the Schirmer I test, break-up time, vital staining, and conjunctival IC. A DED severity grade, as well as IC rating, was applied. Fourteen of these patients received TNFi and analysis of ocular and systemic AS disease parameters occurred at BL and three months (3 M), and 12 months (12 M) after treatment. The AS patients presented a higher frequency of DED (p = 0.01), a worse score of severity (p = 0.001), and a higher frequency of altered IC (p = 0.007) when compared to controls. The 14 patients under TNFi presented an improvement in all the clinical disease activity parameters throughout the one-year treatment (p < 0.05) even as a concomitant increase in the Schirmer test (p = 0.04), and a significant amelioration in the altered IC to a normal IC (p = 0.006). DED is a frequent and under-diagnosed ocular disease in AS patients. The long-term parallel improvement of disease activity and OS parameters in AS patients receiving TNFi suggests that the OS can be an additional target of systemic inflammation in AS.

Polygonum cuspidatum stem extract (PSE) ameliorates dry eye disease by inhibiting inflammation and apoptosis

[Purpose]

Here, we aimed to determine the effect of Polygonum cuspidatum stem extract (PSE) on exorbital lacrimal gland-excised rat models and hyperosmotic stress-stimulated human conjunctival cells (HCCs).

[Methods]

Seven week old male Wistar rats were divided into six groups. Only the rats in the control group (NOR, n=5) did not undergo surgery. Three days after the surgery, the exorbital lacrimal gland-excised rats were randomly allocated to five groups: (1) vehicle-treated dry-eyed rats (DED, n=5); (2) PSE (10 mg/kg) treated DED rats (PSE-10, n=5); (3) PSE (100 mg/kg) treated DED rats (PSE-100, n=5); and (4) PSE (250 mg/kg) treated DED rats (PSE-250, n=5). In addition, the HCC line was co-treated with hyperosmolar media (528 mOsm) and PSE (1-100 μg/ml).

[Results]

PSE treatment restored the tear volume and goblet cell density by inhibiting severe corneal irregularities and damage. The treatment with PSE significantly attenuated the hyperosmolar stress-induced inflammation and cell death through the suppression of mRNA expression levels of Tumor necrosis factor-α (TNF-α), Interleukin-6 (IL-6), Interleukin-1β (IL-1β), and Interferon-γ (IFN-γ), and the expression of Bcl-2-associated X protein (Bax) as well as the activation of caspase-3 in vitro.

[Conclusion]

The inhibitory effects of PSE treatment on dry eye disease indicate the potential of nutritional intervention by PES against inflammatory diseases without adverse effects.

Comorbidities and Prescribed Medications in Patients With or Without Dry Eye Disease: A Population-Based Study

PURPOSE

To assess the proportion of comorbidities in patients with dry eye disease (DED) compared with matched patients without DED in a comprehensive US population.

DESIGN

Retrospective case-control study.

METHODS

Healthcare records for insurance claims data, detailing medical services incurred by military personnel and their families and dependents in military and civilian facilities across the United States from January 1, 2003, to March 31, 2015, were obtained from the Department of Defense (DOD) Military Health System (MHS). Diagnostic and procedural codes related to DED from selected International Classification of Diseases, Ninth Revision (ICD-9) Current Procedural Terminology codes and prescriptions for cyclosporine A ophthalmic emulsion were used to identify patients with newly diagnosed and prevalent DED in the MHS database. Age, sex, and geographically matched patients without DED were also identified from healthcare claims records. Medication use and comorbidities in these patient populations were assessed and compared.

RESULTS

In both the newly diagnosed and prevalent DED samples, the most common comorbidities were hypertension, cataracts, thyroid disease, type 2 diabetes, and glaucoma. All comorbidities were significantly higher in the DED vs non-DED groups (P < .001). Medication use (including, but not limited to, ophthalmic agents and drugs to treat comorbidities) was also significantly higher in the DED than in the non-DED groups (P < .001).

CONCLUSIONS

The high proportions of patients with DED with a range of comorbidities and prescribed medications highlight the need for a multidisciplinary approach to the management of these patients.

Dry Eye Disease: Consideration for Women's Health

Dry eye disease (DED) is a multifactorial disorder of the ocular surface and tear homeostasis that can result in discomfort, pain, and visual disturbance. Untreated, DED can become chronic, progressive, and significantly affect an individual's quality of life. Women are disproportionately affected by DED, are diagnosed at a younger age, and experience more severe symptoms compared with men. DED is associated with a wide range of comorbid conditions; there is a strong association between DED and autoimmune disorders, especially those that affect women at many times the rate of men. Treatment response questionnaires indicate women respond better to a wellness model of treatment for DED than men. Furthermore, women's health care-seeking behaviors provide opportunities for general practitioners, specialists, and women's health centers to help identify women with DED or at risk for DED for referral to an eye care specialist. This review of the prevalence of DED in women, and gender and sex-specific aspects of DED, highlight a significant opportunity for action. Earlier diagnosis and treatment of this common but burdensome condition could significantly improve a woman's quality of life.

Dry Eye Disease in Routine Rheumatology Practice

Dry eye disease (DED) is one of the most frequent ophthalmological conditions, with a major impact on patients’ quality of life. Tear film instability and tear hyperosmolarity are considered to play a crucial role in the vicious cycle of dry eye disease. They occur as a result of, either a reduced lacrimal secretion or an excessive evaporation from the tear film. There is a well-known association of DED, not only with autoimmune diseases but also with other systemic diseases and medication. Early diagnosis is important and it is based on the presence of classical symptoms and signs of dry eye in combination with specialized methods. The comprehension of the pathophysiology is significant, as different approaches can be taken to treat DED, depending on the cause and primary source of the disease, as well as on disease severity.

Immune Relevant Models for Ocular Inflammatory Diseases

Ocular inflammatory diseases, such as dry eye and uveitis, are common, painful, difficult to treat, and may result in vision loss or blindness. Ocular side effects from the use of antiinflammatory drugs (such as corticosteroids or nonsteroidal antiinflammatories) to treat ocular inflammation have prompted development of more specific and safer medications to treat inflammatory and immune-mediated diseases of the eye. To assess the efficacy and safety of these new therapeutics, appropriate immune-relevant animal models of ocular inflammation are needed. Both induced and naturally-occurring models have been described, but the most valuable for translating treatments to the human eye are the animal models of spontaneous, immunologic ocular disease, such as those with dry eye or uveitis. The purpose of this review is to describe common immune-relevant models of dry eye and uveitis with an overview of the immuno-pathogenesis of each disease and reported evaluation of models from small to large animals. We will also review a selected group of naturally-occurring large animal models, equine uveitis and canine dry eye, that have promise to translate into a better understanding and treatment of clinical immune-relevant ocular disease in man.

Effect of brimonidine, an α2 adrenergic agonist, on human meibomian gland epithelial cells

We recently discovered that the anti-glaucoma pharmaceuticals timolol, a β adrenergic antagonist, and pilocarpine, a cholinergic compound, negatively influence the morphology, proliferative capacity and survival of human meibomian gland epithelial cells (HMGECs). We hypothesize that another class of anti-glaucoma drugs, the α2 adrenergic agonists, also acts directly on HMGECs to affect their structure and function. We tested this hypothesis. Immortalized (i) HMGECs were cultured with brimonidine, as well as clonidine (α2 agonist), phenylephrine (α1 agonist), RX821002 (inverse α2 agonist) and MK912 (neutral α2 agonist) for up to 7 days. Cells were counted with a hemocytometer, and evaluated for morphology, signaling pathway activity, protein biomarker expression, and the accumulation of neutral lipids, phospholipids and lysosomes. Our findings demonstrate that brimondine treatment induces a dose-dependent decrease in Akt signaling and proliferation of iHMGECs. In contrast, brimonidine also promotes a dose-dependent differentiation of iHMGECs, including an increase in neutral lipid, phospholipid and lysosome levels. These effects were paralleled by an inhibition of p38 signaling, and duplicated by cellular exposure to clonidine, but not phenylephrine. Brimonidine also enhanced the cellular content of sterol regulatory binding protein-1, a master regulator of lipid synthesis. Of particular interest, the putative α2 antagonists, RX821002 and MK912, did not interfere with brimonidine action, but rather stimulated IHMGEC differentiation. Our results support our hypothesis and demonstrate that α2 adrenergic agonists act directly on iHMGECs. However, these compounds do not elicit an overall negative effect. Rather, the α2 agonists promote the differentiation of iHMGECs.

Influence of Pilocarpine and Timolol on Human Meibomian Gland Epithelial Cells

PURPOSE

Investigators have discovered that topical antiglaucoma drugs may induce meibomian gland dysfunction. This response may contribute to the dry eye disease commonly found in patients with glaucoma taking such medications. We hypothesize that drug action involves a direct effect on human meibomian gland epithelial cells (HMGECs). To test this hypothesis, we examined the influence of the antiglaucoma drugs, pilocarpine and timolol, on the morphology, survival, proliferation, and differentiation of HMGECs.

METHODS

Immortalized (I) HMGECs (n = 2-3 wells/treatment/experiment) were cultured with multiple concentrations of pilocarpine or timolol for up to 7 days. Experiments included positive controls for proliferation (epidermal growth factor and bovine pituitary extract) and differentiation (azithromycin). Cells were enumerated using a hemocytometer and evaluated for morphology, neutral lipid staining, and lysosome accumulation.

RESULTS

Our results demonstrate that pilocarpine and timolol cause a dose-dependent decrease in the survival of IHMGECs. The clinically used concentrations are toxic and lead to cell atrophy, poor adherence, or death. By contrast, drug levels that are known to accumulate within the conjunctiva, adjacent to the meibomian glands, do not influence IHMGEC survival. These latter concentrations also have no effect on IHMGEC proliferation or differentiation, and they do not interfere with the ability of azithromycin to stimulate cellular neutral lipid and lysosome accumulation. This dose of pilocarpine, though, did suppress the epidermal growth factor+bovine pituitary extract-induced proliferation of IHMGECs.

CONCLUSIONS

Our results support our hypothesis and demonstrate that these antiglaucoma drugs, pilocarpine and timolol, have direct effects on HMGECs that may influence their morphology, survival, and proliferative capacity.