Impact of Glaucoma and Dry Eye on Text-Based Searching

Risk factors as glaucoma predictors in myopic students

Purpose: identification of early risk factors — predictors of POAG development in students with myopic refraction based on questionnaire and functional test data and the effects of fractal photostimulation (FS). Material and methods. The study involved two clinical groups: the main group of 24 students (48 eyes) with mild to moderate myopia, averagely aged 21.3 ± 0.7 years, and the comparison group (according to FS effects) of 29 patients (58 eyes) with an established diagnosis of stage I–III POAG, averagely aged 58 ± 18 years, and a control group consisting of 66 people (132 eyes, mean age 21.2 ± 1.3 years). The case history of patients and typical complaints were found in questionnaire data. For the two clinical groups, the impact of 10 low-intensity FS sessions was evaluated. Results. A set of features viewed as risk factors for POAG development was determined using the data of the questionaries filled in by the main and comparison groups. The changes in mean IOP values measured before and after an FS course were found to be greater in POAG patients than in myopic students. FS was shown to contribute to IOP stabilization in patients with pre-existing morphological and functional glaucoma changes and the occurrence of accompanying pathologies such as vasospasm, blood pressure fluctuations, and migraine-like pain. After a course of FS, overall photosensitivity increased significantly as compared with the baseline in students with mild and moderate myopia (p < 0.05). Also, a positive effect of an FS course on MD indices in patients with stages IIa and IIIa POAG was confirmed. Conclusion. The research results confirm the need to identify clinical and functional predictors of POAG with a progressive glaucomatous process in students with myopic refraction.

Functional Field of View Determined by Crowding, Aging, or Glaucoma Under Divided Attention

Purpose

Parafoveal or peripheral vision is important for various everyday activities. This is particularly relevant to those who suffer from visual field defects. Here we quantified the effect of visual crowding, normal aging, and glaucoma on the spatial extent of the functional field of view (FFV) under divided attention.

Methods

Unlike visual acuity measured by single-letter recognition or visual perimetry measured by light spot detection, we measured the FFV using a target letter presented either alone or in letter triplets appearing across the visual field. A subject's task was to report whether the target letter was the same as the letter displayed concurrently at the central fixation region (i.e., divided attention task). Over the trials, a plot of the proportion correct for letter recognition versus target location was constructed, resulting in a visual field map.

Results

The results obtained from three subject groups—normal young adults, normal older adults, and patients with glaucoma—showed that on average the central 20° visual field was relatively robust to uncrowded target recognition under divided attention. However, the FFV shrunk down to the central 10° visual field when the target appeared in clutter, suggesting a strong crowding effect on FFV. An additional shrinkage of the FFV occurred in the presence of aging and glaucoma.

Conclusions

Using a quantitative method, we demonstrate that crowding, aging, and glaucoma independently decrease the spatial extent of FFV under divided attention and that crowding seems to be the major contributor limiting FFV.

Translational Relevance

Our FFV test may complement standard clinical measurements by providing functionally relevant visual field information.

Impact of the COVID-19 pandemic on eye strain and dry eye symptoms

Purpose

Among adult individuals with dry eye, assess the self-reported impact of the COVID-19 pandemic on (1) dry eye-related visual function, (2) reading efficiency, and (3) dry eye treatments used.

Methods

In June–July 2020, we conducted an online survey of adults with dry eye who spent at least somewhat more time at home during the pandemic than before. Consistent with TFOS DEWS II guidelines, we categorized respondents into mild, moderate, or severe dry eye based on treatment usage.

Results

We included 388 respondents: 97 respondents (25%) with mild, 80 (21%) with moderate, and 211 (54%) with severe dry eye. In all three groups, screen/reading time generally doubled during the pandemic. Reduced work-related efficiency was noted by a considerable proportion of respondents (moderate dry eye: 51%, mild: 39%, and severe: 38%). Compared with respondents with mild dry eye, respondents with moderate dry eye were considerably more likely to note worsening symptoms: eye pain (OR = 2.57, 95% CI 1.22–5.41), headache from eye symptoms (OR = 2.34, 95% CI 1.11–4.90), and difficulty concentrating because of eye symptoms (OR = 2.79, 95% CI 1.37–5.66). Respondents with moderate dry eye with Sjögren's syndrome were most likely to note these. Respondents with severe dry eye were more likely than respondents with mild dry eye to report losing access to dry eye-related treatments (OR = 2.62, 95% CI 1.36–5.03).

Conclusions

The COVID-19 pandemic-related eye strain may be impacting symptoms, performance, and ultimately employment, especially for those with moderate dry eye. This may be compounding the already-high dry eye-related societal burden.

Efficacy, Safety, and Tolerability of a Novel Cyclosporine, a Formulation for Dry Eye Disease: A Multicenter Phase II Clinical Study

PURPOSE

The purpose of this study was to explore the efficacy, safety, and tolerability of a novel cyclosporine formulation for dry eye disease (DED).

METHODS

This is an exploratory, multicenter, single-blind, randomized, positive-controlled Phase II clinical trial between cyclosporine ophthalmic gel (CyclAGel) and an open-label comparator (Restasis, positive control). A total of 240 eligible patients with moderate to severe DED were randomized to 4 study groups: CyclAGel 0.05%/once daily (QD) (n = 59), CyclAGel 0.05%/BID (n = 60), CyclAGel 0.1%/QD (n = 60), and Restasis 0.05%/BID (n = 61). After receiving BID dosing of hypromellose eye drops during a 2-week run-in period, patients were randomized to the respective treatment group and dosed QD or BID for 12 weeks. Efficacy was assessed based on a number of sign and symptom end points, including eye dryness score (visual analog scale), 6 other parameters of symptoms for dryness (burning/stinging, itching, foreign body sensation, discomfort, sensitivity to light, and pain), and corneal fluorescein staining. The Schirmer test was used to assess dry eye symptoms (visual analog scale severity) at visit 3 (week 2), visit 4 (week 6), and visit 5 (week 12).

FINDINGS

CyclAGel showed a consistent improvement in eye dryness score and the 6 other parameters of symptoms for dryness, corneal fluorescein staining, breakup time, and Schirmer test scores compared with Restasis over the 12-week treatment period. However, there were no statistically significant differences between CyclAGel and Restasis after baseline corrections were made, and the results of the full analysis set remained consistent with those of the per-protocol set (P > 0.05). Moreover, each CyclAGel-treated group (0.05%/QD, 0.05%/BID, and 0.1%/QD) exerted better effects than the Restasis group, and CyclAGel 0.05%/QD showed the most significant improvement. The number of ocular-related treatment-emergent adverse events was low in all treatment groups, with no serious drug-related treatment-emergent adverse events.

IMPLICATIONS

CyclAGel showed excellent safety, tolerability, and comfort profiles at 2 concentrations and frequency in moderate to severe DED.

Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review

Glaucoma-related ocular surface disease (G-OSD) is a significant, yet often underdiagnosed, ocular co-morbidity affecting 40% to 59% of glaucoma patients worldwide. Although the use of topical glaucoma medications represents a proven strategy to control the untoward effects of high intraocular pressure, this treatment can profoundly disrupt the homeostasis of the tear film. The cumulative effect of medications, preservatives, and excipients alter underlying cellular structures which results in tear film abnormalities and instability of the ocular surface. Furthermore, these chronic inflammatory changes have been shown to impact efficacy of glaucoma treatment, patient compliance with therapy and overall quality of life. The pathogenesis of G-OSD is multifactorial and involves a vicious self-perpetuating cycle of inflammatory cytokines and proteins. The diagnosis of such disease is based on similar tests used in assessing traditional dry eye, taking into consideration findings specific to this patient population. The hallmark of treatment for these patients is to minimize the ocular surface inflammatory response by choosing glaucoma therapies that spare the ocular surface such as preservative free formulations and initiating dry eye treatment early in the course of care. In summary, glaucoma affects millions of patients around the world and chronic use of topical glaucoma medications may negatively impact the patient's ocular surface, symptoms, and vision. Understanding the pathogenesis of G-OSD, recognizing its risk factors and incorporating diagnostic and therapeutic strategies that restore and maintain ocular surface homeostasis will result in improved care for our patients.

Impact of glaucoma on executive function and visual search

PURPOSE

Executive function and visual search are linked to a number of activities of daily living including driving and mobility. Using a computerised version of the Trail Making Test B (TMT-B), we compared the executive function and visual search ability of older adults with glaucoma to age-similar controls and identified which visual function tests best predict TMT-B performance. Novel low-contrast and shifting-target variations of the test were incorporated to explore the effects of different levels of test complexity.

METHODS

Thirty-one older adults with mild to moderate glaucoma (mean age = 71.2 years [SD 6.9]; better-eye mean deviation [MD]: median = -1.9 dB [IQR = -1.2 to 0.4], worse-eye MD: median = -11.1 dB [IQR = -14.0 to -7.7]) and 24 age-similar controls (mean age = 71.9 years [SD 6.6]) with normal vision participated. The groups were matched in age, sex, and cognitive status (mini-mental state examination [MMSE]). Participants underwent measurements of visual acuity, contrast sensitivity (CS), visual fields, and visual processing speeds using the useful field-of-view (UFoV). Participants then completed four variations of a computerised TMT-B test, with different levels of complexity based on target contrast (high/low-contrast) and shifts in target position (fixed/shifting locations). Linear mixed-effect models were used to explore the effects of group, target contrast and shift on TMT-B completion time.

RESULTS

The glaucoma group took 17.3s longer than controls to complete the TMT-B (P = 0.028). All participants took 6.5s longer to complete the low- compared to the high-contrast tests (P = 0.012), and 10.6s longer for the shifting TMT-B compared to the fixed version (P < 0.001). There was no interaction effect between group, contrast, or target shift on completion time. Across all tests and participant groups, longer completion time was associated with slower UFoV processing speeds (divided attention: P = 0.003; selective attention: P = 0.006). Poorer CS was associated with longer completion times for the low (P = 0.007), but not the high-contrast tests.

CONCLUSIONS

Our findings suggest that older adults with mild to moderate glaucoma have poorer visual search ability and executive function relative to controls. However, decreasing target contrast or shifting target position did not exacerbate the effects of glaucomatous visual impairment on performance. The UFoV was a strong predictor of TMT-B performance.

The worse eye revisited: Evaluating the impact of asymmetric peripheral vision loss on everyday function

In instances of asymmetric peripheral vision loss (e.g., glaucoma), binocular performance on simple psychophysical tasks (e.g., static threshold perimetry) is well-predicted by the better seeing eye alone. This suggests that peripheral vision is largely 'better-eye limited'. In the present study, we examine whether this also holds true for real-world tasks, or whether even a degraded fellow eye contributes important information for tasks of daily living. Twelve normally-sighted adults performed an everyday visually-guided action (finding a mobile phone) in a virtual-reality domestic environment, while levels of peripheral vision loss were independently manipulated in each eye (gaze-contingent blur). The results showed that even when vision in the better eye was held constant, participants were significantly slower to locate the target, and made significantly more head- and eye-movements, as peripheral vision loss in the worse eye increased. A purely unilateral peripheral impairment increased response times by up to 25%, although the effect of bilateral vision loss was much greater (>200%). These findings indicate that even a degraded visual field still contributes important information for performing everyday visually-guided actions. This may have clinical implications for how patients with visual field loss are managed or prioritized, and for our understanding of how binocular information in the periphery is integrated.

Beyond intraocular pressure: Optimizing patient-reported outcomes in glaucoma

Glaucoma, an irreversible blinding condition affecting 3-4% adults aged above 40 years worldwide, is set to increase with a rapidly aging global population. Raised intraocular pressure (IOP) is a major risk factor for glaucoma where the treatment paradigm is focused on managing IOP using medications, laser, or surgery regimens. However, notwithstanding IOP and other clinical parameters, patient-reported outcomes, including daily functioning, emotional well-being, symptoms, mobility, and social life, remain the foremost concerns for people being treated for glaucoma. These outcomes are measured using objective patient-centered outcome measures (PCOMs) and subjective patient-reported outcome measures (PROMs). Studies using PCOMs have shown that people with glaucoma have several mobility, navigational and coordination challenges; reading and face recognition deficits; and are slower in adapting to multiple real-world situations when compared to healthy controls. Similarly, studies have consistently demonstrated, using PROMs, that glaucoma substantially and negatively impacts on peoples' self-reported visual functioning, mobility, independence, emotional well-being, self-image, and confidence in healthcare, compared to healthy individuals, particularly in those with late-stage disease undergoing a heavy treatment regimen. The patient-centred effectiveness of current glaucoma treatment paradigms is equivocal due to a lack of well-designed randomized controlled trials; short post-treatment follow-up periods; an inappropriate selection or availability of PROMs; and/or an insensitivity of currently available PROMs to monitor changes especially in patients with newly diagnosed early-stage glaucoma. We provide a comprehensive, albeit non-systematic, critique of the psychometric properties, limitations, and recent advances of currently available glaucoma-specific PCOMs and PROMs. Finally, we propose that item banking and computerized adaptive testing methods can address the multiple limitations of paper-pencil PROMs; customize their administration; and have the potential to improve healthcare outcomes for people with glaucoma.

Measuring Disability in Glaucoma

BACKGROUND

Glaucomatous visual field loss can have far-reaching and debilitating consequences on an individual, affecting one's ability to perform many important tasks. Although assessment of glaucoma-related disability constitutes an important part of clinical care, there remains a lack of organized, detailed information on the most suitable methods to capture disability in glaucoma.

PURPOSE

This review details the available methods to measure glaucoma-related disability and highlights important findings from studies utilizing these various methods.

METHODS

The literature was reviewed to identify papers evaluating disability in glaucoma and findings were summarized by research methodology used and area of impairment.

RESULTS

Identified methods for capturing glaucoma-related disability included qualitative descriptions, glaucoma-specific quality of life questionnaires, vision-specific questionnaires, general health questionnaires, functional domain-specific questionnaires, evaluation of task performance, event assessment (ie, falls and motor vehicle accidents), and real-world behavior (ie, daily physical activity). Findings using these methods show a strong relationship between glaucoma and/or glaucoma severity and difficulties with reading, driving, mobility, and other tasks such as prehension and facial recognition. In addition, glaucoma has financial and psychological implications on the patient, and can affect caregivers in some cases as well.

CONCLUSIONS

A wide variety of research tools have been used to characterize the disability resulting from glaucoma. Together, these tools show that glaucoma affects many abilities which are important for independent living. Strengths and limitations of the various research techniques are discussed so that future studies may use the method(s) most suitable for answering the research question posed.

Research Questions and Outcomes Prioritized by Patients With Dry Eye

Importance

Dry eye is a common ocular surface condition with significant influence on patient quality of life and societal economic burden. There is an urgent need to prioritize new research for dry eye.

Objective

To identify and rank research questions and outcomes important to patients with dry eye.

Design, Setting, and Participants

This study was conducted using the following 6 steps: (1) identifying research questions from a previous survey of clinicians who treat patients with dry eye; (2) identifying outcomes from existing research (systematic reviews and their cited clinical trials in the Cochrane Eyes and Vision US Satellite database of eyes and vision reviews, and National Eye Institute-funded clinical trials registered on ClinicalTrials.gov) as of June 13, 2017; (3) identifying a sample of patients with dry eye from the email subscribers to the online newsletter KeratoScoop; (4) and (5) conducting a 2-round Delphi survey of those patients online in November and December 2017, respectively; and (6) designating and ranking questions and outcomes as important.

Main Outcomes and Measures

Importance assigned to research questions and outcomes for dry eye. A research question or outcome ranked by at least 75% of patients as 6 or higher on a scale of 0 to 10 was considered important.

Results

Among the 420 patients from 15 countries who completed both rounds of the Delphi survey, most were 60 years of age or older (233 [56%]), female (348 [83%]), white (393 [94%]), and of non-Hispanic ethnicity (398 [95%]). Among the 12 questions that clinicians had previously prioritized, patients rated 8 as important. The top 3 questions pertained to effectiveness of patient education, environmental modifications, and topical anti-inflammatory eye drops for dry eye. Among the 109 outcomes identified in existing research on dry eye, patients rated 26 as important. Ten of these 26 were unpopular in existing research, with fewer than 10% of 158 studies reporting these outcomes. Of the 10 most important outcomes, 9 were associated with symptoms or quality of life. The 3 outcomes rated most important by patients were ocular burning or stinging, ocular discomfort, and ocular pain.

Conclusions and Relevance

This study identified research questions and outcomes important to patients with dry eye. A considerable gap was noted between outcomes in existing research on dry eye and outcomes patients consider important. Future research on dry eye should consider addressing the important research questions and outcomes identified herein, taking into account the patient perspective.

Topical cyclosporine A therapy for dry eye syndrome

BACKGROUND

Topical cyclosporine A (also known as ciclosporin A) (CsA) is an anti-inflammatory that has been widely used to treat inflammatory ocular surface diseases. Two CsA eyedrops have been approved by US Food and Drug Administration for managing dry eye: Restasis (CsA 0.05%, Allergan Inc, Irvine, CA, USA), approved in 2002, and Cequa (CsA 0.09%, Sun Pharma, Cranbury, NJ, USA), approved in 2018. Numerous clinical trials have been performed to assess the effectiveness and safety of CsA for dry eye; however, there is no universal consensus with regard to its effect.

OBJECTIVES

To assess the effectiveness and safety of topical CsA in the treatment of dry eye.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 16 February 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people with dry eye regardless of age, sex, severity, etiology, or classification of dry eye. We included RCTs in which different concentrations of topical CsA were compared with one another or with artificial tears, placebo, or vehicle. We also included RCTs in which CsA in combination with artificial tears was compared to artificial tears alone.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodology and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 30 RCTs (4009 participants) with follow-up periods ranging from 6 weeks to 12 months. We studied dry eye of various severity and underlying causes. The interventions investigated also varied across RCTs: CsA versus artificial tears; CsA with artificial tears versus artificial tears alone; and in some studies, more than one concentration of CsA. Artificial tears were used as adjunctive to study medication in all but five trials. Almost all trials had deficiencies in the reporting of results (e.g. reporting P values or direction only), precluding the calculation of between-group estimates of effect or meta-analysis.Eighteen trials compared topical CsA 0.05% plus artificial tears versus vehicle plus artificial tears or artificial tears alone. One trial reported subjective symptoms of dry eye at 6 months and the results were in favor of CsA (mean difference (MD) -4.80, 95% confidence interval (CI) -6.41 to -3.19; low-certainty evidence). Two trials reported MD in ocular surface dye staining at 6 months, but the results were inconsistent in these two trials (MD -0.35, 95% CI -0.69 to -0.01 in one and MD 0.58, 95% CI 0.06 to 1.10 in the other; low-certainty evidence). Four trials reported MD in Schirmer test scores at 6 months and the estimates ranged from -4.05 (95% CI -6.67 to -1.73) to 3.26 (95% CI -1.52 to 5.00) (low-certainty evidence). Three trials reported risk ratio (RR) of improved Schirmer test scores at 6 months; estimates ranged from 0.98 (95% CI 0.83 to 1.17) to 3.50 (95% CI 2.09 to 5.85) (low-certainty evidence). Four trials reported MD in tear film stability measured by tear break-up time at 6 months and the estimates ranged from -1.98 (95% CI -3.59 to -0.37) to 1.90 (95% CI 1.44 to 2.36) (low-certainty evidence). Three trials reported RR of improved tear break-up time at 6 months and the estimates ranged from 0.90 (95% CI 0.77 to 1.04) to 4.00 (95% CI 2.25 to 7.12) (low-certainty evidence). Three trials reported frequency of artificial tear usage at 6 months without providing any estimates of effect; the direction of effect seem to be in favor of CsA (low-certainty evidence). Because of incomplete reporting of the results data or considerable statistical heterogeneity, we were only able to perform a meta-analysis on mean conjunctival goblet cell density. Mean conjunctival goblet cell density in the CsA treated group may be greater than that in the control group at the end of follow-up at four and 12 months (MD 22.5 cells per unit, 95% CI 16.3 to 28.8; low-certainty evidence). All but two trials reported adverse events that included burning and stinging. Participants treated with CsA may be more likely to have treatment-related adverse events than those who treated with vehicle (RR 1.33, 95% CI 1.00 to 1.78; low-certainty evidence).Other comparisons evaluated were CsA 0.05% plus artificial tears versus higher concentrations of CsA plus artificial tears (4 trials); CsA 0.05% versus placebo or vehicle (4 trials); CsA 0.1% plus artificial tears versus placebo or vehicle plus artificial tears (2 trials);CsA 0.1% cationic emulsion plus artificial tears versus vehicle plus artificial tears (2 trials); CsA 1% plus artificial tears versus placebo plus artificial tears (3 trials); and CsA 2% plus artificial tears versus placebo plus artificial tears (3 trials). Almost all of these trials reported P value or direction of effect only (mostly in favor of CsA), precluding calculation of between-group effect estimates or meta-analyses.

AUTHORS' CONCLUSIONS

Despite the widespread use of topical CsA to treat dry eye, we found that evidence on the effect of CsA on ocular discomfort and ocular surface and tear film parameters such as corneal fluorescein staining, Schirmer's test, and TBUT is inconsistent and sometimes may not be different from vehicle or artificial tears for the time periods reported in the trials. There may be an increase in non-serious, treatment-related adverse effects (particularly burning) in the CsA group. Topical CsA may increase the number of conjunctival goblet cells. However, current evidence does not support that improvements in conjunctival mucus production (through increased conjunctival goblet cells) translate to improved symptoms or ocular surface and tear film parameters. All published trials were short term and did not assess whether CsA has longer-term disease-modifying effects. Well-planned, long-term, large clinical trials are needed to better assess CsA on long-term dry eye-modifying effects. A core outcome set, which ideally includes both biomarkers and patient-reported outcomes in the field of dry eye, is needed.