1
|
Wang MTM, Meyer JJ, Xue AL, Power B, Craig JP. Predictive performance of corneal and lid margin sensitivity for dry eye disease: An investigator-masked, prospective, prognostic accuracy study. Ocul Surf 2024; 33:11-15. [PMID: 38554989 DOI: 10.1016/j.jtos.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE To evaluate the prognostic ability of non-contact esthesiometry corneal and lid margin sensitivity measurements in detecting symptoms and signs of dry eye disease, as defined by the global consensus TFOS DEWS II criteria. METHODS A total of 87 community residents (58 females; mean ± SD age, 53 ± 16 years) were recruited in an investigator-masked, prospective, prognostic accuracy study. Dry eye symptomology, tear film parameters, and ocular surface characteristics were evaluated in a single clinical session, and non-contact esthesiometry corneal and lid margin sensitivity measurements performed by an independent masked assessor. RESULTS Overall, 49 (56%) participants fulfilled the TFOS DEWS II criteria for dry eye disease, while 57 (66%) exhibited clinical symptoms, and 67 (77%) had positive signs. The prognostic abilities of corneal and lid margin sensitivity measurements were significantly greater than chance for the detection dry eye signs (both p ≤ 0.03), but not for symptoms or overall disease diagnosis (all p > 0.10). The Youden-optimal prognostic cut-offs for corneal and lid margin sensitivity thresholds were both ≥0.8 mbar for the detection of clinical dry eye signs. Lid margin sensitivity demonstrated marginally higher predictive performance than corneal sensitivity (C-statistic, 0.688 versus 0.658), and was significantly correlated with tear film stability, corneal, conjunctival and lid wiper staining (all p < 0.05). CONCLUSIONS Corneal and lid margin sensitivity demonstrated moderate prognostic utility for detecting clinical dry eye signs. Future research is warranted to investigate the utility of incorporating non-contact esthesiometry in the workup for dry eye disease and neurotrophic keratopathy.
Collapse
Affiliation(s)
- Michael T M Wang
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - Jay J Meyer
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - Ally L Xue
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand
| | - Barry Power
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand; Department of Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, New Zealand.
| |
Collapse
|
2
|
Rathore T, Dattatri M. Exploring Sjögren's syndrome through interdisciplinary perspectives: a concise review. J Immunoassay Immunochem 2024; 45:153-177. [PMID: 38748045 DOI: 10.1080/15321819.2024.2353766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Dr. Henrik Sjögren after whom Sjögren's Syndrome is named, was a Swedish ophthalmologist who identified the syndrome which had three main symptoms namely, dry eyes, dry mouth, and arthritis. His contributions also highlighted the systemic complications of the syndrome which made our understanding of this disease better. Since then, there have been several studies on Sjögren's Syndrome (SS) of which two of them have changed the perception of the disease's prevalence. The first was a British study in the late 1990s which indicated this syndrome was no more a rare condition. The second is a 2008 study in the US which placed the syndrome as the second most prevalent autoimmune disease after rheumatoid arthritis (RA). Being one of the most prevalent autoimmune disease, there is a pressing need for a more profound and comprehensive understanding of the syndrome. This review endeavors to offer a comprehensive overview of the disease, encompassing its prevalence, manifestations, mechanisms, genetic factors, diagnostic methods, and treatment options. This review additionally offers the āyurvedic viewpoint on SS and its symptoms. This supplementary insight has the potential to contribute to the development of an integrated and holistic approach to managing the condition.
Collapse
Affiliation(s)
- Tanisha Rathore
- Department of Chemistry and Biochemistry, M. S. Ramaiah College of Arts, Science and Commerce, Bengaluru, India
| | - Mayur Dattatri
- Department of Sanskrit, M. S. Ramaiah College of Arts, Science and Commerce, Bengaluru, India
| |
Collapse
|
3
|
Sullivan BD, Smith GT, Gupta A, Harman F, Ansari E. Impact of Clinician Subjectivity on the Assessment of Dry Eye Disease Prevalence in a UK Public Health Care Patient Population. Clin Ophthalmol 2024; 18:743-753. [PMID: 38476359 PMCID: PMC10929644 DOI: 10.2147/opth.s452149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
Purpose To understand the impact of subjectivity on diagnosis rates of dry eye disease (DED) in an unbiased population. Patients and Methods A multicenter study enrolled 818 subjects with complete report forms (465 females, 67.1 ± 16.7 years, 353 males, 65.0 ± 15.9 years). Subjects were evaluated for staining, TBUT, tear osmolarity, meibomian gland disease, and OSDI. Results Physicians diagnosed 48.7% of subjects as having DED, ranging from 42.9% to 62.3% between sites. Positivity rates for staining (≥ grade 1) ranged from 41.3% to 84.1% (mean = 0.8 ± 0.9 grade), TBUT (<10s) ranged from 39.1% to 61.6% (mean = 10.4 ± 6.6 seconds), osmolarity (>308 mOsm/L) ranged from 63.7% to 72.4% (mean = 319.7 ± 20.8), MGD grading ranged from 28.9% to 51.3% (mean = 0.5 ± 0.7), and symptoms measured by OSDI ranged from 57.6% to 71.0% (mean = 23.5 ± 20.5) between sites. Tear osmolarity was the most consistent between sites (max/min positivity = 114%), followed by OSDI (123%), TBUT (158%), MGD (178%), and staining (204%). DED markers were uncorrelated (average r2 = 0.05 ± 0.07). A substantial number of subjects (N = 110) exhibited positive symptoms (OSDI = 32.4 ± 15.7) and hyperosmolarity (338.1 ± 20.1 mOsm/L) but no other obvious signs of DED (MGD grade = 0.2 ± 0.4, TBUT = 13.5 ± 7.0 seconds, staining grade = 0.4 ± 0.5). Conclusion Subjective signs of DED varied considerably, whereas objective measurements of OSDI and osmolarity were the most consistent between sites. A large proportion of subjects exhibited high symptoms and hyperosmolarity but no other obvious signs of dry eye disease, most of whom were undiagnosed by clinical assessment without access to the osmolarity measurement.
Collapse
Affiliation(s)
| | - Guy T Smith
- The Great Western Hospital NHS Trust, Swindon, UK
| | - Arun Gupta
- Ashford and St Peters NHS Trust, Ashford, UK
| | | | - Ejaz Ansari
- Department of Ophthalmology, Maidstone & Tunbridge Wells Hospitals, Maidstone, Kent, UK
| |
Collapse
|
4
|
Wu KY, Serhan O, Faucher A, Tran SD. Advances in Sjögren's Syndrome Dry Eye Diagnostics: Biomarkers and Biomolecules beyond Clinical Symptoms. Biomolecules 2024; 14:80. [PMID: 38254680 PMCID: PMC10812982 DOI: 10.3390/biom14010080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Sjögren's syndrome dry eye (SSDE) is a subset of Sjögren's syndrome marked by dry eye symptoms that is distinct from non-Sjögren's syndrome dry eye (NSSDE). As SSDE can lead to severe complications, its early detection is imperative. However, the differentiation between SSDE and NSSDE remains challenging due to overlapping clinical manifestations. This review endeavors to give a concise overview of the classification, pathophysiology, clinical features and presentation, ocular and systemic complications, clinical diagnosis, and management of SSDE. Despite advancements, limitations in current diagnostic methods underscore the need for novel diagnostic modalities. Thus, the current review examines various diagnostic biomarkers utilized for SSDE identification, encompassing serum, salivary, and tear analyses. Recent advancements in proteomic research and exosomal biomarkers offer promising diagnostic potential. Through a comprehensive literature review spanning from 2016 to 2023, we highlight molecular insights and advanced diagnostic modalities that have the potential to enhance our understanding and diagnosis of SSDE.
Collapse
Affiliation(s)
- Kevin Y. Wu
- Division of Ophthalmology, Department of Surgery, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.); (A.F.)
| | - Olivia Serhan
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Anne Faucher
- Division of Ophthalmology, Department of Surgery, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.); (A.F.)
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
| |
Collapse
|
5
|
Song MS, Lee Y, Paik HJ, Kim DH. A Comprehensive Analysis of the Influence of Temperature and Humidity on Dry Eye Disease. KOREAN JOURNAL OF OPHTHALMOLOGY 2023; 37:501-509. [PMID: 37899282 PMCID: PMC10721396 DOI: 10.3341/kjo.2023.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/03/2023] [Accepted: 10/06/2023] [Indexed: 10/31/2023] Open
Abstract
PURPOSE To investigate the effects of humidity and temperature on dry eye disease (DED). METHODS A retrospective, clinic-based study was conducted on DED patients undergoing dry eye treatment. Patients were followed up at least twice, and symptoms and signs were evaluated using the Symptoms Assessment Questionnaire in Dry Eye (SANDE) score, tear secretion, tear film breakup time (TBUT), ocular staining score, and tear osmolarity. Mean humidity and temperature values for 1 week before ocular examinations were used as the environmental exposure level. The relationship between humidity and temperature, with DED clinical parameters was analyzed in single- and multi-environmental factor models. RESULTS The study included 33 patients with a mean age of 53.9 ± 12.2 years. The low humidity group showed significantly higher SANDE scores (p = 0.023) and tear osmolarity (p = 0.008), and the low temperature group had higher SANDE scores (p = 0.004), ocular staining scores (p = 0.036), and tear osmolarity (p < 0.001). In the linear mixed model, single factor analysis showed that an increase in humidity resulted in decreased SANDE scores (p = 0.043), and an increase in temperature led to a decrease in SANDE score (p = 0.007), ocular staining score (p = 0.007), and tear osmolarity (p = 0.012). In the multifactor analysis, changes in humidity had no significant effect on dry eye parameters, but an increase in temperature was significantly correlated with decreased SANDE score (p = 0.026), ocular staining score (p = 0.024), and tear osmolarity (p = 0.002). CONCLUSIONS Lower temperature led to aggravated symptoms and signs of DED and the effect of temperature on DED was more pronounced than humidity. Tear osmolarity was the most sensitive clinical parameter to be affected by climate factors in DED patients.
Collapse
Affiliation(s)
- Myung-Sun Song
- Department of Ophthalmology, Korea University College of Medicine, Seoul,
Korea
| | - Yunjin Lee
- Department of Ophthalmology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Hae Jung Paik
- Department of Ophthalmology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon,
Korea
| | - Dong Hyun Kim
- Department of Ophthalmology, Korea University College of Medicine, Seoul,
Korea
| |
Collapse
|
6
|
Zheng N, Zhu SQ. Randomized controlled trial on the efficacy and safety of autologous serum eye drops in dry eye syndrome. World J Clin Cases 2023; 11:6774-6781. [PMID: 37901024 PMCID: PMC10600870 DOI: 10.12998/wjcc.v11.i28.6774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/31/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Autologous serum eye drops (ASEDs), a novel treatment derived from blood serum, have emerged as a groundbreaking solution for managing dry eye syndrome (DES). These drops have shown significant promise in relieving the distressing symptoms of DES. This study aimed to evaluate the safety and effectiveness of ASEDs compared to traditional treatments, which often prove inadequate or result in unwanted side effects, particularly in individuals with moderate-to-severe DES. AIM To evaluate whether ASEDs are safer and more effective than conventional artificial tears in the treatment of moderate-to-severe DES. METHODS This multi-centered randomized controlled trial included 240 patients with moderate-to-severe DES from three ophthalmology clinics in China. They were randomly assigned to receive either ASEDs or artificial tears for 12 wk. The primary outcome was the change in the ocular surface disease index (OSDI) score, with secondary outcomes including tear break-up time (TBUT), Schirmer I test, corneal fluorescein staining (CFS), and conjunctival impression cytology (CIC). Statistics analysis was performed using an analysis of covariance with adjustments made for baseline values. RESULTS Our findings revealed that both ASEDs and artificial tears significantly improved the OSDI score, TBUT, Schirmer I test, CFS, and CIC from baseline to week 12. The ASEDs group showed significantly greater improvement in all these measures than the artificial tears group (all P values < 0.05). The average difference in the OSDI score between the two cohorts was -10.3 (95% confidence interval: -13.6 to -7.0), indicating a substantial improvement in the ASEDs group. The occurrence of adverse events was comparable between cohorts, with no reports of severe adverse events. CONCLUSION ASEDs are more effective and safer than artificial tears for mitigating symptoms of moderate-to-severe DES. ASEDs could be an alternative/supplementary therapy for patients with DES less responsive to traditional treatments.
Collapse
Affiliation(s)
- Na Zheng
- Department of Ophthalmology, Chengdu University of Traditional Chinese Medicine, Chengdu 610032, Sichuan Province, China
| | - Si-Quan Zhu
- Department of Ophthalmology, Beijing Anzhen Hospital Affiliated to China Medical University, Beijing 100029, China
| |
Collapse
|
7
|
Papas EB. Diagnosing dry-eye: Which tests are most accurate? Cont Lens Anterior Eye 2023; 46:102048. [PMID: 37544866 DOI: 10.1016/j.clae.2023.102048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE To demonstrate how the likelihood of making a correct diagnosis of dry eye disease varies according to the clinical test methods used. METHODS The probability of a person having dry eye, given that they return a positive test, was calculated for a range of standard tests, using the Bayes-Price rule. Global specificity and sensitivity values for each test were estimated by employing the Beta distribution to combine all relevant data obtained from a literature review. RESULTS At an assumed prevalence of 11.6%, the single test with the highest probability of a correct diagnosis was corneal staining (probability = 0.28) and the lowest was the ocular surface disease index - OSDI (0.14). The best combination of symptoms with a single test of tear film homeostasis was the 5-item dry eye questionnaire (DEQ-5) + corneal staining (0.42) while OSDI + tear film break up time (TBUT) was the worst (0.23). The simultaneous observation of conjunctival and corneal staining was associated with a probability of 0.49. The probability of a correct diagnosis increased with the number of positive tests, up to a maximum of 0.90 when all of DEQ-5, conjunctival and corneal staining, osmolarity and TBUT were positive. CONCLUSION A significant risk of misdiagnosis is associated with using any single test for dry eye disease, or the minimum TFOS DEWS II criterion of symptoms plus any single test of tear film homeostasis. To minimize this risk, the maximum number of tests available should be performed and the results used to inform diagnosis. The simultaneous occurrence of conjunctival and corneal staining should be considered a key outcome and be specified in future guidelines.
Collapse
Affiliation(s)
- Eric B Papas
- School of Optometry & Vision Science, L3 Rupert Myers Building, UNSW, Kensington, NSW 2052, Australia.
| |
Collapse
|
8
|
De La Parra-Colin P, Palacios-Aguirre K, Perez-Pria-Kasusky A, Espinosa-Morales R, Hidalgo-Bravo A. Diagnostic Performance of the Tear Meniscus Osmolarity Measurement for Dry Eye Disease in Rheumatoid Arthritis Patients. Diagnostics (Basel) 2023; 13:2994. [PMID: 37761361 PMCID: PMC10528091 DOI: 10.3390/diagnostics13182994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The aim of our study was to evaluate the diagnostic capacity of the tear meniscus osmolarity measurement for dry eye disease (DED) in patients with rheumatoid arthritis (RA), using a portable osmometer based on electrical impedance and an integrated circuit technology (TearLab® (Escondido, CA, USA)). METHODS We included 101 RA patients, 81 patients with DED and 20 without DED (controls). We measured tear osmolarity and assessed other clinical diagnostic tests as suggested by the TFOS DEWS II composite reference standard diagnostic criteria for DED using Ocular Surface Disease Index (OSDI), Five-item Dry Eye Questionnaire (DEQ-5), fluorescein tear break-up time (F-TUBT), ocular surface staining (SICCA score), and other clinical parameters to classify DED subtypes. We analyzed the agreement between osmolarity and the TFOS DEWS II composite reference standard for DED diagnosis. We conducted receiver operating characteristic (ROC) curve analyses using the DED variable and its subtypes as dependent variables and the continuous variable for osmolarity or the inter-eye difference in osmolarity as independent variable. Sensitivity, specificity, and area under the curve for all potential cut-off points were obtained and reported from ROC curves. RESULTS We found that tear meniscus osmolarity had a low diagnostic capacity for DED (AUC = 0.57). Tear meniscus osmolarity measurement had a sensitivity of 35% and a specificity of 80% with a kappa level of agreement of 0.08 compared to the TFOS DEWS II composite reference standard. The low diagnostic capacity of the tear meniscus osmolarity was similar for aqueous-deficient DED and for evaporative DED, being only fair for severe DED with a 57% sensitivity and 80% specificity and a kappa level of agreement of 0.36. CONCLUSIONS Our findings suggest that in patients with RA, tear meniscus osmolarity measured by the TearLab® showed low sensitivity, low specificity, and limited agreement with the TFOS DEWS II composite reference standard for DED diagnosis.
Collapse
Affiliation(s)
- Paola De La Parra-Colin
- Cornea and Ocular Surface Clinic, Department of Ophthalmology, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ministry of Health, Mexico City 14389, Mexico; (K.P.-A.); (A.P.-P.-K.)
| | - Karen Palacios-Aguirre
- Cornea and Ocular Surface Clinic, Department of Ophthalmology, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ministry of Health, Mexico City 14389, Mexico; (K.P.-A.); (A.P.-P.-K.)
| | - Andrea Perez-Pria-Kasusky
- Cornea and Ocular Surface Clinic, Department of Ophthalmology, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ministry of Health, Mexico City 14389, Mexico; (K.P.-A.); (A.P.-P.-K.)
| | - Rolando Espinosa-Morales
- Department of Rheumatology, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ministry of Health, Mexico City 14389, Mexico;
| | - Alberto Hidalgo-Bravo
- Department of Genetics, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Ministry of Health, Mexico City 14389, Mexico
| |
Collapse
|
9
|
van Setten GB. Ocular Surface Allostasis-When Homeostasis Is Lost: Challenging Coping Potential, Stress Tolerance, and Resilience. Biomolecules 2023; 13:1246. [PMID: 37627311 PMCID: PMC10452761 DOI: 10.3390/biom13081246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/20/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
The loss of ocular surface (OS) homeostasis characterizes the onset of dry eye disease. Resilience defines the ability to withstand this threat, reflecting the ability of the ocular surface to cope with and bounce back after challenging events. The coping capacity of the OS defines the ability to successfully manage cellular stress. Cellular stress, which is central to the outcome of the pathophysiology of dry eye disease, is characterized by intensity, continuity, and receptivity, which lead to the loss of homeostasis, resulting in a phase of autocatalytic dysregulation, an event that is not well-defined. To better define this event, here, we present a model providing a potential approach when homeostasis is challenged and the coping capacities have reached their limits, resulting in the stage of heterostasis, in which the dysregulated cellular stress mechanisms take over, leading to dry eye disease. The main feature of the proposed model is the concept that, prior to the initiation of the events leading to cellular stress, there is a period of intense activation of all available coping mechanisms preventing the imminent dysregulation of ocular surface homeostasis. When the remaining coping mechanisms and resilience potential have been maximally exploited and have, finally, been exceeded, there will be a transition to manifest disease with all the well-known signs and symptoms, with a shift to allostasis, reflecting the establishment of another state of balance. The intention of this review was to show that it is possibly the phase of heterostasis preceding the establishment of allostasis that offers a better chance for therapeutic intervention and optimized recovery. Once allostasis has been established, as a new steady-state of balance at a higher level of constant cell stress and inflammation, treatment may be far more difficult, and the potential for reversal is drastically decreased. Homeostasis, once lost, can possibly not be fully recovered. The processes established during heterostasis and allostasis require different approaches and treatments for their control, indicating that the current treatment options for homeostasis need to be adapted to a more-demanding situation. The loss of homeostasis necessarily implies the establishment of a new balance; here, we refer to such a state as allostasis.
Collapse
Affiliation(s)
- Gysbert-Botho van Setten
- St. Eriks Eye Hospital, 171 04 Solna, Sweden;
- Lab of DOHF and Wound Healing, Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Eugeniavägen 12/Level 6, 171 04 Solna, Sweden
| |
Collapse
|
10
|
Lucius A, Chhatwal S, Valtink M, Reinach PS, Li A, Pleyer U, Mergler S. L-Carnitine Suppresses Transient Receptor Potential Vanilloid Type 1 Activation in Human Corneal Epithelial Cells. Int J Mol Sci 2023; 24:11815. [PMID: 37511574 PMCID: PMC10380586 DOI: 10.3390/ijms241411815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Tear film hyperosmolarity induces dry eye syndrome (DES) through transient receptor potential vanilloid type 1 (TRPV1) activation. L-carnitine is a viable therapeutic agent since it protects against this hypertonicity-induced response. Here, we investigated whether L-carnitine inhibits TRPV1 activation by blocking heat- or capsaicin-induced increases in Ca2+ influx or hyperosmotic stress-induced cell volume shrinkage in a human corneal epithelial cell line (HCE-T). Single-cell fluorescence imaging of calcein/AM-loaded cells or fura-2/AM-labeled cells was used to evaluate cell volume changes and intracellular calcium levels, respectively. Planar patch-clamp technique was used to measure whole-cell currents. TRPV1 activation via either capsaicin (20 µmol/L), hyperosmolarity (≈450 mosmol/L) or an increase in ambient bath temperature to 43 °C induced intracellular calcium transients and augmented whole-cell currents, whereas hypertonicity induced cell volume shrinkage. In contrast, either capsazepine (10 µmol/L) or L-carnitine (1-3 mmol/L) reduced all these responses. Taken together, L-carnitine and capsazepine suppress hypertonicity-induced TRPV1 activation by blocking cell volume shrinkage.
Collapse
Affiliation(s)
- Alexander Lucius
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Sirjan Chhatwal
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Monika Valtink
- Faculty of Medicine, Institute of Anatomy, TU Dresden, 01216 Dresden, Germany
- Equality and Diversity Unit, Faculty of Medicine, TU Dresden, 01307 Dresden, Germany
| | - Peter S Reinach
- School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou 325027, China
| | - Aruna Li
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Uwe Pleyer
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| | - Stefan Mergler
- Klinik für Augenheilkunde, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353 Berlin, Germany
| |
Collapse
|
11
|
Amano S, Shimazaki J, Yokoi N, Hori Y, Arita R. Meibomian Gland Dysfunction Clinical Practice Guidelines. Jpn J Ophthalmol 2023; 67:448-539. [PMID: 37351738 DOI: 10.1007/s10384-023-00995-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/21/2022] [Indexed: 06/24/2023]
Affiliation(s)
- Shiro Amano
- Ochanomizu Inoue Eye Clinic, 4-3 Kandasurugadai, Chiyoda-ku, Tokyo, 101-0062, Japan.
| | - Jun Shimazaki
- Department of Ophthalmology, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Norihiko Yokoi
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichi Hori
- Department of Ophthalmology, Toho University Omori Medical Center, Tokyo, Japan
| | | |
Collapse
|
12
|
Cartes C, Segovia C, Calonge M, Figueiredo FC. International survey on dry eye diagnosis by experts. Heliyon 2023; 9:e16995. [PMID: 37484334 PMCID: PMC10361019 DOI: 10.1016/j.heliyon.2023.e16995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/12/2023] [Accepted: 06/02/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To evaluate patterns and opinion from international experts with respect to dry eye disease (DED) diagnosis in clinical practice. Methods An online survey was distributed to worldwide DED experts. The use of diagnosis tests was evaluated including: symptoms questionnaires, functional tests, tear stability, tear volume, tear composition, surface damage and inflammation, and eyelid assessment. After the subjective importance of symptoms, tear break up time (TBUT), non-invasive TBUT, Schirmer's test, tear meniscus height, tear osmolarity, tear metalloproteinase 9, blepharitis assessment and non-contact meibography was evaluated according to likert scale. Results The survey was sent to 109 experts, and 77 completed the questionnaire (rate of response = 70.6%). Most of the participants were from North America (27%) and Europe (40%). A majority of respondents (73%) diagnose DED using clinical signs and symptoms, but not fulfilling a specific criteria. Seventy-six participants (98.7%) use symptoms questionnaires. All participants evaluate damage to ocular surface, and fluorescein staining is the most frequent method used (92%). Also, all the respondents perform meibomian gland and blepharitis assessment. On the other hand, only 69.8% evaluate tear composition, being osmolarity the most common test used (66.2%). Regarding to the importance of tests, TBUT (p = 0.002) and Schirmer's (p = 0.021) were found to be more important to experts from Europe than North America. No differences were found in any other test (p > 0.05). Conclusions This survey offers updated and day-to-day diagnostic clinical practice by DED worldwide experts. The results highlight the importance of symptoms and clinical signs, but not necessarily following a strict criteria.
Collapse
Affiliation(s)
- Cristian Cartes
- Unidad Oftalmología, Departamento de Especialidades, Facultad de Medicina, Universidad de la Frontera, Temuco, Chile
- Centro de la Visión, Red Centro Oftalmológico Laser, Santiago, Chile
| | - Christian Segovia
- Departamento de Tecnología Médica, Facultad de Ciencias de la Salud. Universidad Católica del Maule, Talca, Chile
| | - Margarita Calonge
- OBA (Institute of Applied Ophthalmobiology), CIBER-BBN, University of Valladolid, 47011, Valladolid, Spain
| | - Francisco C. Figueiredo
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Bioscience Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
13
|
Azieva G, Makrynioti D, Ablordeppey RK, Lin C, Benavente-Perez A. Development of a novel protocol to evaluate contact-lens related ocular surface health on marmosets (Callithrix jacchus). Exp Eye Res 2023; 231:109472. [PMID: 37137437 DOI: 10.1016/j.exer.2023.109472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/28/2023] [Accepted: 04/08/2023] [Indexed: 05/05/2023]
Abstract
Contact lens wear affects the ocular surface and can cause contact lens-induced dry eye (CLIDE). The purpose of this study was bifold: (1) to develop a novel protocol to assess the ocular surface in a non-human primate (NHP) model, the common marmoset (Callithrix jacchus), and (2) to characterize central corneal thickness (CCT), tear osmolarity, blink rate and tear meniscus height (TMH) longitudinally, in untreated marmosets (controls) compared to animals treated with contact lenses (CL). Longitudinal changes in CCT (N = 10 control; N = 10 treated with contact lenses, CL-treated), osmolarity (N = 4 control; N = 6 CL-treated), blink rate (N = 8 control; N = 10 CL-treated) and TMH (N = 8 control; N = 6 CL-treated) were assessed using high frequency A-scan ultrasound, the I-PEN Vet Tear Osmolarity System, a video recording system (745 frames/minute) and Image J respectively, from 70 days to 224 days (5 months) at approx. 9am, and again after 9hrs of CL wear (methafilcon A, 55% water content; Capricornia, Australia) after every 4 weeks of contact lens wear for a total of 22 weeks of treatment. Repeated measures ANOVA was used to compare eyes over time and student t-test was used to compare treated to control eyes at each time point. At baseline, untreated marmosets had a CCT (mean ± SD) of 0.31 ± 0.01 mm, tear osmolarity (mean ± SD) 311.67 ± 11.48 mOsms/L, blink rate (mean ± SD) 1.83 ± 1.79 blinks per minute (bpm) and TMH (mean ± SD) 0.07 ± 0.02 arbitrary units (au), all of which remained stable over 5 months, except blink rate that increased to 5.32 ± 1.58 bpm (p < 0.01) after 5 months. In CL-treated marmosets, however, CCT progressively increased with CL wear (baseline: 0.30 ± 0.01 mm; 5 months: 0.31 ± 0.02 mm, p < 0.05), while osmolarity decreased after 2 and 3 months of CL wear (baseline: 316.11 ± 13.63; 2 months: 302.63 ± 11.27, p < 0.05; 3 months: 302.92 ± 14.58, p < 0.05). The decrease in osmolarity occurred in parallel to an increase in blink rate (baseline: 0.98 ± 1.18 bpm; 2 months: 3.46 ± 3.04 bpm, p < 0.05; 3 months: 3.73 ± 1.50 bpm, p < 0.001). TMH decreased during the third month of CL wear (baseline: 0.06 ± 0.00 au; 3 months: 0.05 ± 0.01 au, p < 0.05), and increased after 4 months (0.08 ± 0.01 au, p < 0.05). As TMH decreased, tear osmolarity increased in both control (R = -0.66, p < 0.05) and CL-treated marmosets (R = -0.64, p < 0.05). The results suggest that marmosets treated with CL for 5 months experienced an increase in blink rate, CCT and TMH, along with a decrease in osmolarity within the first few months of CL treatment that differed from the unaffected stable ocular surface findings observed untreated animals. We hypothesize that CL wear in marmosets might induce mild corneal edema, an increased blink rate and TMH, in turn delaying the development of hyperosmolarity. These findings confirm that the marmoset is a good novel animal model for ocular surface research for the assessment of novel contact lens materials aimed to alleviate CLIDE.
Collapse
Affiliation(s)
| | | | | | - Carol Lin
- SUNY College of Optometry, New York, USA
| | | |
Collapse
|
14
|
Wu KY, Kulbay M, Tanasescu C, Jiao B, Nguyen BH, Tran SD. An Overview of the Dry Eye Disease in Sjögren's Syndrome Using Our Current Molecular Understanding. Int J Mol Sci 2023; 24:ijms24021580. [PMID: 36675090 PMCID: PMC9866656 DOI: 10.3390/ijms24021580] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
Sjögren's syndrome is a chronic and insidious auto-immune disease characterized by lymphocyte infiltration of exocrine glands. The patients typically present with ocular surface diseases related to dry eye and other systemic manifestations. However, due to the high prevalence of dry eye disease and the lack of objective and clinically reliable diagnostic tools, discriminating Sjögren's syndrome dry eye (SSDE) from non-Sjögren's syndrome dry eye (NSSDE) remains a challenge for clinicians. Diagnosing SS is important to improve the quality of life of patients through timely referral for systemic workups, as SS is associated with serious systemic complications such as lymphoma and other autoimmune diseases. The purpose of this article is to describe the current molecular understanding of Sjögren's syndrome and its implications for novel diagnostic modalities on the horizon. A literature review of the pre-clinical and clinical studies published between 2016 and 2022 was conducted. The SSDE pathophysiology and immunology pathways have become better understood in recent years. Novel diagnostic modalities, such as tear and saliva proteomics as well as exosomal biomarkers, provide hope on the horizon.
Collapse
Affiliation(s)
- Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Merve Kulbay
- Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Cristina Tanasescu
- School of Optometry, University of Montreal, Montreal, QC H3T 1P1, Canada
| | - Belinda Jiao
- Department of Medicine, Division of Internal Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Bich H. Nguyen
- CHU Sainte Justine Hospital, Montreal, QC H3T 1C5, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
- Correspondence:
| |
Collapse
|
15
|
Dry Eye Disease: What Is the Role of Vitamin D? Int J Mol Sci 2023; 24:ijms24021458. [PMID: 36674972 PMCID: PMC9860626 DOI: 10.3390/ijms24021458] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/13/2023] Open
Abstract
Dry eye disease (DED) is a multifactorial condition resulting from reduced tear secretion from the lacrimal glands, increased tear water evaporation or the production of poor-quality tears. Such tear instability can lead to inflammation and damage of the ocular surface, as well as to abnormal nociception. Historically, tear substitutes and corticosteroids have been the bastion of DED therapy, but a substantial number of patients still suffer from residual symptoms even after being treated with traditional treatments. Aiming to find safe and effective alternative therapies, recent efforts have been focused on the role of vitamin D in the cellular physiology of the eye. Possibly because of its positive effect in modulating the immune and inflammatory responses, the systemic supplementation of vitamin D seems, indeed, to be an effective therapeutic strategy, especially, but not only, for patients affected by DED that does not respond to conventional treatments. In this context, this review focuses on the literature reporting on the pathogenesis and treatment of DED, with a special emphasis on the recent investigations reporting on the potential role of the systemic administration of vitamin D as a therapeutic approach in the management of such condition.
Collapse
|
16
|
Lindgren ES, Cil O, Verkman AS, Pasricha ND. Ocular Surface Ion Transport and Dry Eye Disease. CURRENT OPHTHALMOLOGY REPORTS 2022; 10:188-197. [PMID: 38213468 PMCID: PMC10783585 DOI: 10.1007/s40135-022-00295-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 10/24/2022]
Abstract
Purpose of Review To review the role of ocular surface epithelial (corneal and conjunctival) ion transporters in the pathogenesis and treatment of dry eye disease (DED). Recent Findings Currently, anti-inflammatory agents are the mainstay of DED treatment, though there are several agents in development that target ion transport proteins on the ocular surface, acting by pro-secretory or anti-absorptive mechanisms to increase the tear fluid Film volume. Activation or inhibition of selected ion transporters can alter tear fluid osmolality, driving water transport onto the ocular surface via osmosis. Several ion transporters have been proposed as potential therapeutic targets for DED, including the cystic fibrosis transmembrane conductance regulator (CFTR), calcium-activated chloride channels (CaCCs), and the epithelial sodium channel (ENaC). Summary Ocular surface epithelial cell ion transporters are promising targets for pro-secretory and anti-absorptive therapies of DED.
Collapse
Affiliation(s)
- Ethan S. Lindgren
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Onur Cil
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Alan S. Verkman
- Departments of Medicine and Physiology, University of California San Francisco, San Francisco, CA, USA
| | - Neel D. Pasricha
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
17
|
Ma P, Pan X, Liu R, Qu Y, Xie L, Xie J, Cao L, Chen Y. Ocular adverse events associated with anti-VEGF therapy: A pharmacovigilance study of the FDA adverse event reporting system (FAERS). Front Pharmacol 2022; 13:1017889. [PMID: 36467087 PMCID: PMC9716077 DOI: 10.3389/fphar.2022.1017889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/07/2022] [Indexed: 07/30/2023] Open
Abstract
Background: The purpose of this study is to identify and characterize ocular adverse events (AEs) that are significantly associated with anti-VEGF drugs for treatment of neovascular age-related macular degeneration and compare the differences between each drug, and provide clinical reference. Methods: Ocular AEs submitted to the US Food and Drug Administration were analyzed to map the safety profile of anti-VEGF drugs. The Pharmacovigilance tools used for the quantitative detection of signals were reporting odds ratio and bayesian confidence propagation neural network. Results: A total of 10,608,503 AE reports were retrieved from FAERS, with 20,836 for ranibizumab, 19,107 for aflibercept, and 2,442 for brolucizumab between the reporting period of Q1, 2004 and Q3, 2021. We found and analyzed the different AEs with the strongest signal in each drug-ranibizumab-macular ischaemia (ROR = 205.27, IC-2SD = 3.70), retinal pigment epithelial tear (ROR = 836.54, IC-2SD = 7.19); aflibercept-intraocular pressure increased (ROR = 31.09, IC-2SD = 4.61), endophthalmitis (ROR = 178.27, IC-2SD = 6.70); brolucizumab-retinal vasculitis (ROR = 2930.41, IC-2SD = 7.47) and/or retinal artery occlusion (ROR = 391.11, IC-2SD = 6.10), dry eye (ROR = 12.48, IC-2SD = 2.88). Conclusion: The presence of AEs should bring clinical attention. The use of anti-VEGF drugs should be based on the patient's underlying or present medical condition to reduce any adverse event associated with the treatment.
Collapse
Affiliation(s)
- Pan Ma
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xinmei Pan
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ruixiang Liu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ya Qu
- Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Linli Xie
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Jiangchuan Xie
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Liya Cao
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yongchuan Chen
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University, Chongqing, China
| |
Collapse
|
18
|
Tear matrix metalloproteinase-9 levels may help to follow a ocular surface injury in lagophthalmic eyes. PLoS One 2022; 17:e0274173. [PMID: 36084126 PMCID: PMC9462780 DOI: 10.1371/journal.pone.0274173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022] Open
Abstract
The preocular tear film is critically important for maintaining healthy ocular surface. In lagophthalmos, increased evaporation and tear film instability can occur. The level of tear matrix metalloproteinase 9 (MMP-9) is considered as a possible marker of ocular surface damage and inflammation. The aim of this study was to evaluate the possible usefulness of measuring tear film levels of MMP-9 in patients with lagophthalmos. Sixteen adult patients with unilateral lagophthalmos due to cerebellopontine angle mass surgery were included. Basic clinical examination including tear film osmolarity, degree of lagophthalmos, ocular surface sensitivity testing, corneal fluorescein staining, and tear break-up time (TBUT) were performed. Furthermore, tear MMP-9 quantification was performed and the values from lagophthalmic and contralateral healthy eye were compared. Possible correlations between tear MMP-9 levels and other parameters were analyzed. The Oxford score was higher in lagophthalmic eyes in comparison to healthy eyes. TBUT and corneal sensitivity were lower in lagophthalmic eyes. There was no difference in osmolarity between the two groups. Tear MMP-9 values were higher in lagophthalmic eyes. A higher MMP-9 value was associated with an increase in ocular surface fluorescein staining and a decrease of TBUT in lagophthalmic eyes. Tear MMP-9 may be used for monitoring ocular surface damage, contribute to early detection of inflammation progression and facilitate treatment adjustments.
Collapse
|
19
|
Shen H, de Leon AR. Model-Based Clustering and Prediction With Mixed Measurements Involving Surrogate Classifiers. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2020.1863257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Hua Shen
- Department of Mathematics and Statistics, University of Calgary, Calgary, AB, Canada
| | - Alexander R. de Leon
- Department of Mathematics and Statistics, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
20
|
Doctor MB, Basu S. Lacrimal Gland Insufficiency in Aqueous Deficiency Dry Eye Disease: Recent Advances in Pathogenesis, Diagnosis, and Treatment. Semin Ophthalmol 2022; 37:801-812. [PMID: 35587465 DOI: 10.1080/08820538.2022.2075706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mariya B Doctor
- Academy of Eye Care Education, L V Prasad Eye Institute, Hyderabad, India.,The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Sayan Basu
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.,Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, India
| |
Collapse
|
21
|
Rodriguez-Garcia A, Babayan-Sosa A, Ramirez-Miranda A, Santa Cruz-Valdes C, Hernandez-Quintela E, Hernandez-Camarena JC, Ramos-Betancourt N, Velasco-Ramos R, Ruiz-Lozano RE. A Practical Approach to Severity Classification and Treatment of Dry Eye Disease: A Proposal from the Mexican Dry Eye Disease Expert Panel. Clin Ophthalmol 2022; 16:1331-1355. [PMID: 35520107 PMCID: PMC9061212 DOI: 10.2147/opth.s351898] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.
Collapse
Affiliation(s)
- Alejandro Rodriguez-Garcia
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Cornea and External Disease Service, Monterrey, Mexico
| | - Alejandro Babayan-Sosa
- Cornea and Refractive Surgery Service, Fundación Hospital Nuestra Señora de la Luz, I. A. P, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Arturo Ramirez-Miranda
- Cornea and Refractive Surgery Service, Instituto de Oftalmología Conde de Valenciana, I.A.P, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Concepcion Santa Cruz-Valdes
- Cornea and Refractive Surgery Service, Instituto de Oftalmología Conde de Valenciana, I.A.P, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | | | - Julio C Hernandez-Camarena
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Cornea and External Disease Service, Monterrey, Mexico
| | | | - Regina Velasco-Ramos
- Cornea and Refractive Surgery Service, Fundación Hospital Nuestra Señora de la Luz, I. A. P, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Raul E Ruiz-Lozano
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Cornea and External Disease Service, Monterrey, Mexico
| |
Collapse
|
22
|
Sergio P, Giancarlo I, Matteo F, Maria DSC, Gianni P, Parrilla R, Valente P, Luca B. Analysis of tear film in cystinosis patients treated with topical viscous cysteamine hydrochloride (Cystadrop ®). Eur J Ophthalmol 2022; 32:3358-3362. [PMID: 35125035 PMCID: PMC9527349 DOI: 10.1177/11206721221078649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The aim of this study was to evaluate in vivo the tear film
in infantile nephropathic cystinosis patients with corneal crystals treated
with topical viscous cysteamine hydrochloride (Cystadrops®). Methods Ten eyes of five patients with nephropathic cystinosis aged from 10 to 35
years were included in this study. The patients were under treatment with
viscous cysteamine hydrochloride formulation containing 3.8 mg/mL cysteamine
(vCH 0.55%, equivalent to 0.55% CH; Cystadrops®; Recordati rare
Diseases, Puteaux, France) to reduce corneal crystal density. Five age and
sex matched individuals were randomly selected as control group. Tear
osmolarity testing (TearLabTM) was performed to assess the
in vivo osmolarity of patients under treatment and
compared to control group values. Tear film break-up time (TBUT) and basic
tear secretion (Schirmer test) were also assessed. Results Mean tear osmolarity was 294.8 mOsms/L (±10.4), with a mean absolute
difference of 1.85 mOsms/L (±2.13) between the eyes. There was no
statistically significant difference between the osmolarity readings of
cystinosis and the control group (294.8 ± 10.4 vs 299.4 ± 6.2mOsm/L,
respectively; p = 0.39). The mean TBUT was 10.2 ± 0.83 s in the study group
versus 10 ± 0.7 s in controls (p = 0.62). The mean Schirmer test score was
9.2 ± 0.83 mm in the patients versus 10.2 ± 0.83 mm in the controls
(p = 0.14). Conclusions The TearLabTM osmolarity system test showed good reliability and
precision in repeated measurements. This is the first report using the
TearLab osmolarity system to assess tear film in patients with cystinosis
treated with vCH 0.55%. TearLabTM examination showed that the use
of vCH 0.55% drops does not determine alterations of the tear film
quality.
Collapse
Affiliation(s)
- Petroni Sergio
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Iarossi Giancarlo
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federici Matteo
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Petrocelli Gianni
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rosa Parrilla
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Valente
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Buzzonetti Luca
- Ophthalmology Department, 9342Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| |
Collapse
|
23
|
Wu Y, Wang C, Wang X, Mou Y, Yuan K, Huang X, Jin X. Advances in Dry Eye Disease Examination Techniques. Front Med (Lausanne) 2022; 8:826530. [PMID: 35145982 PMCID: PMC8823697 DOI: 10.3389/fmed.2021.826530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/24/2021] [Indexed: 01/13/2023] Open
Abstract
Dry eye-related ocular surface examination is very important in the diagnosis and treatment of dry eye disease. With the recent advances in science and technology, dry eye examination techniques have progressed rapidly, which has greatly improved dry eye diagnoses and treatment. However, clinically, confusion remains about which examination to choose, how to ensure the repeatability of the examination, and how to accurately interpret the examination results. In this review, we systematically evaluate previous examinations of dry eye, analyze the latest views and research hotspots, and provide a reference for the diagnosis and management of dry eye.
Collapse
|
24
|
Brito FLDC, Voitena JN, Marinho TOC, Moore BA, Montiani-Ferreira F. Assessment of tear film osmolarity using the IPen ® Vet osmometer in Pug and Shih-Tzu dogs with and without keratoconjunctivitis sicca. Vet Ophthalmol 2021; 25:219-224. [PMID: 34929058 DOI: 10.1111/vop.12966] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To establish tear film osmolarity (TFO) values in Pugs and Shih-Tzus, with and without keratoconjunctivitis sicca (KCS). ANIMALS STUDIED A total of 82 adult dogs were evaluated. PROCEDURE The inclusion criteria for the healthy group was a Schirmer tear test (STT-1) ≥15 mm/min with no clinical signs of KCS, whereas those with KCS had clinical signs and a STT-1 ≤10 mm/min. All animals underwent complete ophthalmological evaluation prior to STT-1 and TFO. Student's t tests were used to compare STT-1 and TFO in KCS and healthy eyes as well as possible differences in TFO between breeds. In addition, a linear regression to model the relationship between the two variables (STT-1 and TFO) was performed. A P-value ≤ 0.05 was considered statistically significant. RESULTS STT-1 results were significantly lower (p = 0.0001) in the KCS group (4.46 ± 1.74) compared with the control group (18.80 ± 2.02). Mean TFO results were significantly higher in the KCS group (353.02 ± 16.58 mOsm/L) (p < 0.0001) compared with the control group (315.27 ± 6.15 mOsm/L). The formula Y = 365.059-2.625 * X significantly predicts (p < 0.001) the value of the variable Y (TFO mOsm/L) as a function of the variable X (STT-1 mm/min), with a coefficient of determination of 0.71. CONCLUSIONS The results revealed differences in TFO and STT-1 between KCS and healthy dogs. Additionally, STT-1 and TFO values were correlated with the aim to use STT-1 values to predict TFO values in brachycephalic breeds.
Collapse
Affiliation(s)
| | - Jéssica N Voitena
- Faculdade Qualittas, São Paulo, Brazil.,Pós-graduadas em Oftalmologia Veterinária e Microcirurgia Ocular, Faculdade Qualittas, São Paulo, Brazil
| | - Tatiane O C Marinho
- Faculdade Qualittas, São Paulo, Brazil.,Pós-graduadas em Oftalmologia Veterinária e Microcirurgia Ocular, Faculdade Qualittas, São Paulo, Brazil
| | - Bret A Moore
- College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | | |
Collapse
|
25
|
Tavakoli A, Markoulli M, Flanagan J, Papas E. The validity of point of care tear film osmometers in the diagnosis of dry eye. Ophthalmic Physiol Opt 2021; 42:140-148. [PMID: 34665479 DOI: 10.1111/opo.12901] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the repeatability of TearLab and I-PEN osmometers in vivo and their accuracy in vitro. DESIGN Prospective, single-visit study. METHODS The tear osmolarity of 28 participants was evaluated with TearLab and I-PEN on two occasions in random order, over a 2-h period. Both eyes were measured in a randomised order. Coefficients of repeatability (CoR) were determined for each device, together with the bias and limits of agreement between them. For the in vitro experiment, the osmolarity was measured by both osmometers in five solutions (290, 297, 342, 338 and 383 mOsm/L) at two different temperatures (22 and 37°C) with a total of four consecutive measures. RESULTS The CoRs for the TearLab and I-PEN in the right and left eyes were 26.2, 21.3, 33.6 and 28.3 mOsm/L, respectively. Across the first and second repeats, TearLab showed consistency of diagnosis for 50% of participants with 29% as dry eye positive, while I-PEN indicated 68% consistency of diagnosis with 57% dry eye positive. The instruments agreed on the diagnosis in 46.5% of cases. In vitro comparison showed that the average measurement errors for TearLab and I-PEN were -10 ± 13 and 31 ± 39 mOsm/L at 22°C, and 4 ± 13 and 20 ± 51 mOsm/L at 37°C. CONCLUSIONS In vitro, both instruments showed reasonable accuracy and repeatability at mid-range osmolarities, but repeatability generally declined at higher and lower levels. While TearLab accuracy remained consistent across the osmolarity range, measurement errors for I-PEN noticeably increased outside the mid-range. In vivo, both instruments displayed poor repeatability. This casts doubt on the value of utilising either instrument to establish osmolarity as a factor in the diagnosis of dry-eye, according to currently recommended diagnostic guidelines (TFOS DEWS II), if only a single measurement is taken from each eye.
Collapse
Affiliation(s)
- Azadeh Tavakoli
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,Brien Holden Vision Institute, Sydney, New South Wales, Australia
| | - Maria Markoulli
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| | - Judith Flanagan
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia.,Brien Holden Vision Institute, Sydney, New South Wales, Australia
| | - Eric Papas
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
26
|
Prevalence of Tear Film Hyperosmolarity in 1150 patients presenting for refractive surgery assessment. J Cataract Refract Surg 2021; 48:387-392. [PMID: 34393181 DOI: 10.1097/j.jcrs.0000000000000771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To present an analysis of tear film hyperosmolarity in a large, consecutive population and evaluate the correlation of ocular and systemic conditions with tear film osmolarity. SETTING Private practice Sydney, Australia. DESIGN Single-centre, retrospective, consecutive cohort. METHOD 1404 patients (n=1357 standard, n=47 post-refractive) undergoing screening for laser refractive surgery from October 2017 to October 2020 were reviewed. Routine examination included tear film osmolarity (TFO) and Ocular Surface Disease Index questionnaire). TFO was conducted prior to further tests and patients refrained from topical eye drops minimum two hours before the appointment. RESULTS Mean highest TFO in the standard population was 299.12±11.94mOsm/L with 82.3% of eyes <308mOsm/L indicating normal tear film homeostasis. The mean inter-eye TFO difference was 8.17±8.60mOsm/L with 65.2% of eyes <=8mOsm/L. Mean highest TFO in the post-refractive subgroup was 299.72±11.00mOsm/L with a mean inter-eye difference of 9.02±6.92mOsm/L. Post-refractive surgery patients indicated higher mean OSDI values of 15.28±14.46 compared to the remainder of the population 9.69±10.56 (p=0.012). Significant correlation was demonstrated between TFO scores and OSDI normal classification in the standard population only (p=0.005, r=0.077). The use of contact lens correlated inversely with TFO and OSDI scores (p=0.000, r=-0.136 and p=0.000, r=-0.152 respectively). CONCLUSION Our study represents the largest available cohort of TFO scores in a standard population presenting for refractive surgery. We found that although the majority of patients can be expected to fall within normal ranges, a reasonable percentage will be diagnosed with tear hyperosmolarity and therefore at risk of dry eye disease.
Collapse
|
27
|
Braun RJ, Luke RA, Driscoll TA, Begley CG. Dynamics and mechanisms for tear breakup (TBU) on the ocular surface. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:5146-5175. [PMID: 34517482 DOI: 10.3934/mbe.2021262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The human tear film is rapidly established after each blink, and is essential for clear vision and eye health. This paper reviews mathematical models and theories for the human tear film on the ocular surface, with an emphasis on localized flows where the tear film may fail. The models attempt to identify the important physical processes, and their parameters, governing the tear film in health and disease.
Collapse
Affiliation(s)
- Richard J Braun
- Department of Mathematical Sciences, University of Delaware, Newark, DE 19711, USA
| | - Rayanne A Luke
- Department of Mathematical Sciences, University of Delaware, Newark, DE 19711, USA
| | - Tobin A Driscoll
- Department of Mathematical Sciences, University of Delaware, Newark, DE 19711, USA
| | - Carolyn G Begley
- School of Optometry, Indiana University, Bloomington, IN 47405, USA
| |
Collapse
|
28
|
Pérez-Silguero MA, Pérez-Silguero D, Rivero-Santana A, Bernal-Blasco MI, Encinas-Pisa P. Combined Intense Pulsed Light and Low-Level Light Therapy for the Treatment of Dry Eye: A Retrospective Before-After Study with One-Year Follow-Up. Clin Ophthalmol 2021; 15:2133-2140. [PMID: 34045848 PMCID: PMC8149274 DOI: 10.2147/opth.s307020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/20/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose To assess the effectiveness of a combination of intense pulsed light and low-level light therapy (IPL/LLLT) for the treatment of dry eye. Study Design Retrospective before-after single-center clinical study. Materials and Methods Patients diagnosed with dry eye, refractory to conventional treatment, underwent four sessions of combined IPL/LLLT over 3 months. The Ocular Surface Disease Index (OSDI) questionnaire, non-invasive breakup time (NIBUT), tear film osmolarity and meniscus height were measured 6 months before intervention, at baseline, post-intervention (3 months), 9 and 15 months. Results NIBUT, osmolarity and meniscus height significantly worsened during the 6 months before treatment, whereas symptoms did not change. OSDI scores significantly improved at post-intervention (MD = −44.0, 95% CI −38.1, −50.0), and then increased again until the at last follow-up, but still significantly different from baseline (MD = −30.0, 95% CI −23.4, −36.8). The three clinical signs showed a similar pattern, with one-year improvements of 3.6 seconds for the NIBUT (95% CI 3.1, 4.2, p <0.001), 28 mOsm/L for osmolarity (95% CI 23.6, 32.4, p <0.001) and 0.03 mm for meniscus height (95% CI 0.02, 0.04, p <0.001). No adverse effects were observed. Conclusion IPL/LLLT is safe and produces an important reduction in symptoms and signs of dry eye disease, still relevant one year after the end of treatment in a sample with high symptoms’ severity. Therefore, it represents a promising treatment option for patients who do not improve with conventional treatment. Randomized trials are needed to determine the added benefit provided by LLLT.
Collapse
Affiliation(s)
| | - David Pérez-Silguero
- Department of Ophthalmology, Pérez-Silguero Ophthalmologic Clinic, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Amado Rivero-Santana
- Department of Health Technology Assessment, Fundación Canaria Instituto de Investigación Sanitaria de Canarias (FIISC), Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Maria Inmaculada Bernal-Blasco
- Department of Community and Family Medicine, Primary Care Center of Cuevas Torres, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Pablo Encinas-Pisa
- Department of Ophthalmology, La Paloma Hospital, Las Palmas de Gran Canaria, Canary Islands, Spain
| |
Collapse
|
29
|
Luke RA, Braun RJ, Driscoll TA, Awisi-Gyau D, Begley CG. Parameter Estimation for Mixed-Mechanism Tear Film Thinning. Bull Math Biol 2021; 83:56. [PMID: 33835298 DOI: 10.1007/s11538-021-00871-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Abstract
Etiologies of tear breakup include evaporation-driven, divergent flow-driven, and a combination of these two. A mathematical model incorporating evaporation and lipid-driven tangential flow is fit to fluorescence imaging data. The lipid-driven motion is hypothesized to be caused by localized excess lipid, or "globs." Tear breakup quantities such as evaporation rates and tangential flow rates cannot currently be directly measured during breakup. We determine such variables by fitting mathematical models for tear breakup and the computed fluorescent intensity to experimental intensity data gathered in vivo. Parameter estimation is conducted via least squares minimization of the difference between experimental data and computed answers using either the trust-region-reflective or Levenberg-Marquardt algorithm. Best-fit determination of tear breakup parameters supports the notion that evaporation and divergent tangential flow can cooperate to drive breakup. The resulting tear breakup is typically faster than purely evaporative cases. Many instances of tear breakup may have similar causes, which suggests that interpretation of experimental results may benefit from considering multiple mechanisms.
Collapse
Affiliation(s)
- Rayanne A Luke
- Department of Mathematical Sciences, University of Delaware, Newark, DE, 19716, USA.
| | - Richard J Braun
- Department of Mathematical Sciences, University of Delaware, Newark, DE, 19716, USA
| | - Tobin A Driscoll
- Department of Mathematical Sciences, University of Delaware, Newark, DE, 19716, USA
| | - Deborah Awisi-Gyau
- Department of Mathematical Sciences, University of Delaware, Newark, DE, 19716, USA
| | - Carolyn G Begley
- Department of Mathematical Sciences, University of Delaware, Newark, DE, 19716, USA
| |
Collapse
|
30
|
Badugu R, Szmacinski H, Reece EA, Jeng BH, Lakowicz JR. Sodium-Sensitive Contact Lens for Diagnostics of Ocular Pathologies. SENSORS AND ACTUATORS. B, CHEMICAL 2021; 331:129434. [PMID: 33551571 PMCID: PMC7861470 DOI: 10.1016/j.snb.2021.129434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The ability to measure all the electrolyte concentrations in tears would be valuable in ophthalmology for research and diagnosis of dry eye disease (DED) and other ocular pathologies. However, tear samples are difficult to collect and analyze because the total volume is small and the chemical composition changes rapidly. Measurements of electrolytes in tears is challenging because typical clinical assays for proteins and other biomarkers cannot be used to detect ion concentrations tears. Here, we report the contact lens which is sensitive to sodium ion (Na+), one of the dominant electrolytes in tears. The Na ions in tears is diagnostic for DED. Three sodium-sensitive fluorophores (SG-C16, SG-LPE and SG-PL) were synthesized by derivatizing the sodium green with 1-hexadecyl amine, 1-oleoyl-2-hydroxy-sn-glycero-3-phosphoethanolamine or poly-L-lysine, respectively. These probes were bound to modern silicone hydrogel (SiHG) contact lens, Biofinity from Cooper Vision. Doped lenses were tested for sodium ion dependent spectral properties of probes within the contact lens. The probes displayed changes in intensity and lifetime in response to Na+ concentration, were completely reversible, no significant probe wash-out from the lenses, were not affected by proteins in tears and were not removed after repeated washing. These results are the first step to our long-term goal, which is a lens sensitive to all the electrolytes in tears. We presented design, synthesis and implementation of three new sodium sensitive probes within a silicon hydrogel lens. Contact lenses to measure the other electrolytes in tears can be developed using the same approach by synthesis and testing of new ion-sensitive fluorophores.
Collapse
Affiliation(s)
- Ramachandram Badugu
- Center for Fluorescence Spectroscopy, Department of Biochemistry and Molecular Biology University of Maryland School of Medicine, 725 West Lombard St., Baltimore, MD 21201, USA
| | - Henryk Szmacinski
- Center for Fluorescence Spectroscopy, Department of Biochemistry and Molecular Biology University of Maryland School of Medicine, 725 West Lombard St., Baltimore, MD 21201, USA
| | - E Albert Reece
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD 21201, USA
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, Md 21201, USA
| | - Bennie H Jeng
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, 419 W. Redwood Street, Baltimore, Md 21201, USA
| | - Joseph R Lakowicz
- Center for Fluorescence Spectroscopy, Department of Biochemistry and Molecular Biology University of Maryland School of Medicine, 725 West Lombard St., Baltimore, MD 21201, USA
| |
Collapse
|
31
|
Bron AJ, Willshire C. Tear Osmolarity in the Diagnosis of Systemic Dehydration and Dry Eye Disease. Diagnostics (Basel) 2021; 11:387. [PMID: 33668748 PMCID: PMC7996182 DOI: 10.3390/diagnostics11030387] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/23/2022] Open
Abstract
Systemic dehydration due to inadequate water intake or excessive water loss, is common in the elderly and results in a high morbidity and significant mortality. Diagnosis is often overlooked and there is a need for a simple, bedside diagnostic test in at-risk populations. Body hydration is highly regulated with plasma osmolality (pOsm) being tightly controlled over a wide range of physiological conditions. By contrast, normal tear osmolarity (tOsm) is more variable since the tear film is exposed to evaporation from the open eye. While plasma hyperosmolality is a diagnostic feature of systemic dehydration, tear hyperosmolality, with other clinical features, is diagnostic of dry eye. Studies in young adults subjected to exercise and water-deprivation, have shown that tOsm may provide an index of pOsm, with the inference that it may provide a simple measure to diagnose systemic dehydration. However, since the prevalence of both dry eye and systemic dehydration increases with age, the finding of a raised tOsm in the elderly could imply the presence of either condition. This diagnostic difficulty can be overcome by measuring tear osmolality after a period of evaporative suppression (e.g., a 45 min period of lid closure) which drives tOsm osmolality down to a basal level, close to that of the pOsm. The arguments supporting the use of this basal tear osmolarity (BTO) in the diagnosis of systemic dehydration are reviewed here. Further studies are needed to confirm that the BTO can act as a surrogate for pOsm in both normally hydrated subjects and in patients with systemic dehydration and to determine the minimum period of lid closure required for a simple, "point-of-care" test.
Collapse
Affiliation(s)
- Anthony J. Bron
- Nuffield Department of Clinical Neurosciences and Nuffield Laboratory of Ophthalmology, University of Oxford, Oxford OX2 6HZ, UK
| | - Catherine Willshire
- Ophthalmology Research, Hinchingbrooke Hospital, North West Anglia Trust, Huntingdon PE29 6NT, UK;
| |
Collapse
|
32
|
Kakkar S, Singh M, Mohan Karuppayil S, Raut JS, Giansanti F, Papucci L, Schiavone N, Nag TC, Gao N, Yu FSX, Ramzan M, Kaur IP. Lipo-PEG nano-ocular formulation successfully encapsulates hydrophilic fluconazole and traverses corneal and non-corneal path to reach posterior eye segment. J Drug Target 2021; 29:631-650. [PMID: 33410357 DOI: 10.1080/1061186x.2020.1871483] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The present study describes a special lipid-polyethylene glycol matrix solid lipid nanoparticles (SLNs; 138 nm; -2.07 mV) for ocular delivery. Success of this matrix to encapsulate (entrapment efficiency - 62.09%) a hydrophilic drug, fluconazole (FCZ-SLNs), with no burst release (67% release in 24 h) usually observed with most water-soluble drugs, is described presently. The system showed 164.64% higher flux than the marketed drops (Zocon®) through porcine cornea. Encapsulation within SLNs and slow release did not compromise efficacy of FCZ-SLNs. Latter showed in vitro and in vivo antifungal effects, including antibiofilm effects comparable to free FCZ solution. Developed system was safe and stable (even to sterilisation by autoclaving); and showed optimal viscosity, refractive index and osmotic pressure. These SLNs could reach up to retina following application as drops. The mechanism of transport via corneal and non-corneal transcellular pathways is described by fluorescent and TEM images of mice eye cross sections. Particles streamed through the vitreous, crossed inner limiting membrane and reached the outer retinal layers.
Collapse
Affiliation(s)
- Shilpa Kakkar
- UGC-Centre of Advanced Study, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Mandeep Singh
- UGC-Centre of Advanced Study, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Sankunny Mohan Karuppayil
- Department of Medical Biotechnology, Stem Cell & Regenerative Medicine, Center for Interdisciplinary Research, D. Y. Patil Educational Society, Kolhapur, India
| | - Jayant S Raut
- School of Life Sciences, SRTM University Nanded, Nanded, India
| | - Fabrizio Giansanti
- Department of Translational Medicine and Surgery, Eye Clinic, Florence, Italy
| | - Laura Papucci
- Department of Experimental and Clinical Biomedical Sciences, Section of Experimental Pathology and Oncology, University of Florence, Florence, Italy
| | - Nicola Schiavone
- Department of Experimental and Clinical Biomedical Sciences, Section of Experimental Pathology and Oncology, University of Florence, Florence, Italy
| | - T C Nag
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Nan Gao
- Departments of Ophthalmology and Anatomy/Cell Biology, Kresge Eye Institute, Kresge, MI, USA
| | - Fu-Shin X Yu
- Departments of Ophthalmology and Anatomy/Cell Biology, Kresge Eye Institute, Kresge, MI, USA
| | - Mohhammad Ramzan
- UGC-Centre of Advanced Study, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| | - Indu Pal Kaur
- UGC-Centre of Advanced Study, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India
| |
Collapse
|
33
|
Gjerdrum B, Gundersen KG, Lundmark PO, Aakre BM. Repeatability of OCT-Based versus Scheimpflug- and Reflection-Based Keratometry in Patients with Hyperosmolar and Normal Tear Film. Clin Ophthalmol 2020; 14:3991-4003. [PMID: 33239862 PMCID: PMC7680682 DOI: 10.2147/opth.s280868] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/13/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose To compare the repeatability of keratometry between different instruments in patients with hyperosmolar tear film and a control group. Patients and Methods Subjects with tear-film osmolarity of 316 mOsm/L or more in either eye or 308 m/Osm/L or lower in both eyes were assigned to the hyperosmolar and the control group, respectively. The test eye was the eye with higher osmolarity in the hyperosmolar group and randomly chosen in the control group. The repeatability of keratometry was compared between a reflectometry device (Haag-Streit Lenstar 900), a Scheimpflug device (Oculus Pentacam HR) and two optical coherence tomography (OCT) devices (Tomey Casia SS-1000 and Heidelberg Anterion), based on two measurements from each device. Results The study included 94 subjects (31 hyperosmolar and 63 controls). Both OCT devices had higher mean differences of average simulated keratometry (SimK) vs the Lenstar in both groups, though all differences in means were <0.07 D. The Casia had the highest mean vector difference of SimK astigmatism in the control group (differences in means <0.11 D). These differences of the instruments were statistically significant (p < 0.02), except for the Anterion in the control group. With all subjects, the coefficient of repeatability varied from 0.1 to 0.3 for average SimK (highest for both OCT devices) and from 0.4 to 0.7 for SimK astigmatism (highest for the Casia). Similar results were found for total corneal power (OCT devices compared to the Pentacam). Conclusion Both OCT devices show more variability in average SimK and the Casia more variability in SimK astigmatism compared to the Lenstar and the Pentacam. However, the results suggested that repeatability was not influenced by osmolarity.
Collapse
Affiliation(s)
- Bjørn Gjerdrum
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway.,Ifocus Eye Clinic, Haugesund, Norway
| | | | - Per Olof Lundmark
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway
| | - Bente Monica Aakre
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway
| |
Collapse
|
34
|
Gonzales JA, Shiboski SC, Bunya VY, Akpek EK, Rose-Nussbaumer J, Seitzman GD, Criswell LA, Shiboski CH, Lietman TM. Ocular Clinical Signs and Diagnostic Tests Most Compatible With Keratoconjunctivitis Sicca: A Latent Class Approach. Cornea 2020; 39:1013-1016. [PMID: 32251167 PMCID: PMC7410365 DOI: 10.1097/ico.0000000000002311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the ocular signs and tests for keratoconjunctivitis sicca (KCS) in the absence of a gold standard. METHODS Cross-sectional study of participants from the Sjögren's International Collaborative Clinical Alliance (SICCA) registry. Participants had oral/ocular/rheumatologic examinations, blood/saliva samples collected, and salivary gland biopsy. Latent class analysis (LCA) identified clusters of patients based on 3 to 4 predictor variables relating to signs or tests of KCS. The resulting model-based "gold standard" classification formed the basis for estimated sensitivity and specificity associated with these predictors. RESULTS A total of 3514 participants were enrolled into SICCA, with 52.9% classified as SS. LCA revealed a best-fit model with 2 groups. For the gold standard-positive group, an abnormal tear breakup time, ocular staining score (OSS), and Schirmer I had a sensitivity of 99.5%, 91.0%, and 47.4%, respectively. For the gold standard-negative group, an abnormal tear breakup time, OSS, and Schirmer I had a specificity of 32.0%, 84.0%, and 88.5%, respectively. OSS components (fluorescein and lissamine staining), exhibited a sensitivity of 82.6% and 90.5%, respectively, in the gold standard-positive group, whereas these signs in the gold standard-negative group had a specificity of 88.8% and 73.0%, respectively. CONCLUSIONS OSS and its components (fluorescein and lissamine staining) differentiated 2 groups from each other better than other KCS parameters and had relatively high sensitivity and specificity.
Collapse
Affiliation(s)
- John A. Gonzales
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Stephen C. Shiboski
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Vatinee Y. Bunya
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA
| | - Esen K. Akpek
- Ocular Surface Diseases and Dry Eye Clinic, The Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD
- The Johns Hopkins Jerome L. Greene Sjögren’s Syndrome Center,k Baltimore, MD
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
| | - Gerami D. Seitzman
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Lindsey A. Criswell
- Departments of Medicine; and Orofocial Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA
- Department of Orofocial Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA
| | - Caroline H. Shiboski
- Department of Orofocial Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA
| | - Thomas M. Lietman
- Department of Ophthalmology, Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| |
Collapse
|
35
|
Gagliano C, Visalli E, Toro MD, Amato R, Panta G, Scollo D, Scandura G, Ficili S, Amato G, Benenati A, Foti R, Malaguarnera G, Gagliano G, Falsaperla R, Avitabile T, Foti R. Dry Eye in Systemic Sclerosis Patients: Novel Methods to Monitor Disease Activity. Diagnostics (Basel) 2020; 10:diagnostics10060404. [PMID: 32545815 PMCID: PMC7344660 DOI: 10.3390/diagnostics10060404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background: In systemic sclerosis (SSc) patients, dry eye syndrome (DES) is the most frequent ocular feature. The aim of this study was to investigate ocular DES-related SSc patients and to establish any correlation with the severity of the disease. Methods: Retrospectively, data from 60 patients with SSc underwent ophthalmic examination, where non-invasive film tear break-up time (NIF-TBUT), tear film lipid layer thickness (LLT), anesthetic-free Schirmer test I, tear osmolarity measurement (TearLab System), and modified Rodnan skin score (mRSS) data were collected. The visual analog scale (VAS) and Symptom Assessment in Dry Eye (SANDE) methods were utilized. The results were correlated with mRSS and the duration of SSc. Results: Severe DES occurred in 84% of cases, and was more severe in women. The eyelids were involved in 86.6%, secondary to meibomian gland disease (MGD). A direct correlation was found between the tear osmolarity (mean 328.51 ± 23.8 SD) and skin score (mRSS) (r = 0.79; p < 0.01). Significantly reduced NIF-TBUT, LLT, and Schirmer test I values were observed in the case of severe skin involvement. Conclusions: SSc patients show lipid tear dysfunction related to the severity and duration of the disease due to inflammation and the subsequent atrophy of the meibomian glands.
Collapse
Affiliation(s)
- Caterina Gagliano
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
- Neurovisual Science Technology (NEST) srl, 95123 Catania, Italy;
- Correspondence: (C.G.); (M.D.T.); Tel.: +39-09-53-78-12-91 (C.G.)
| | - Elisa Visalli
- Rheumatology Unit, San Marco Hospital, Policlinico University of Catania, 95123 Catania, Italy; (E.V.); (G.A.); (A.B.); (R.F.)
| | - Mario Damiano Toro
- Department of General Ophthalmology, Medical University of Lublin, 20079 Lublin, Poland
- Faculty of Medical Sciences, Collegium Medicum Cardinal Stefan Wyszyñski University, 01815 Warsaw, Poland
- Correspondence: (C.G.); (M.D.T.); Tel.: +39-09-53-78-12-91 (C.G.)
| | - Roberta Amato
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
- Neurovisual Science Technology (NEST) srl, 95123 Catania, Italy;
| | - Giovanni Panta
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
| | - Davide Scollo
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
| | - Giovanni Scandura
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
| | - Salvatore Ficili
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
| | - Giorgio Amato
- Rheumatology Unit, San Marco Hospital, Policlinico University of Catania, 95123 Catania, Italy; (E.V.); (G.A.); (A.B.); (R.F.)
| | - Alessia Benenati
- Rheumatology Unit, San Marco Hospital, Policlinico University of Catania, 95123 Catania, Italy; (E.V.); (G.A.); (A.B.); (R.F.)
| | - Roberta Foti
- Faculty of Medicine, University of Catania, 95123 Catania, Italy;
| | - Giulia Malaguarnera
- Department of Biomedical and Biotechnological Science, University of Catania, 95123 Catania, Italy;
| | - Giuseppe Gagliano
- Neurovisual Science Technology (NEST) srl, 95123 Catania, Italy;
- Faculty of Medicine, University of Catania, 95123 Catania, Italy;
| | | | - Teresio Avitabile
- Ophthalmology Clinic, San Marco Hospital, Catania University, 95 123 Catania, Italy; (R.A.); (G.P.); (D.S.); (G.S.); (S.F.); (T.A.)
| | - Rosario Foti
- Rheumatology Unit, San Marco Hospital, Policlinico University of Catania, 95123 Catania, Italy; (E.V.); (G.A.); (A.B.); (R.F.)
| |
Collapse
|
36
|
Luke RA, Braun RJ, Driscoll TA, Begley CG, Awisi-Gyau D. Parameter Estimation for Evaporation-Driven Tear Film Thinning. Bull Math Biol 2020; 82:71. [DOI: 10.1007/s11538-020-00745-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
|
37
|
Utility of Tear Osmolarity Measurement in Diagnosis of Dry Eye Disease. Sci Rep 2020; 10:5542. [PMID: 32218518 PMCID: PMC7099018 DOI: 10.1038/s41598-020-62583-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 03/16/2020] [Indexed: 11/08/2022] Open
Abstract
The prevalence of dry eye disease is high worldwide and poses a great burden on patients' daily lives. Accurate diagnosis of the disease is important, and it requires application of various methods. Hyperosmolarity is believed to be the disease marker and thus measuring it provides useful information. In this study we investigated utility of tear osmolarity measured with TearLab osmometer, along with other diagnostic tests (Ocular Surface Disease Index questionnaire, Tear film break-up time, Ocular Protection Index, Ocular Surface Staining, Schirmer I test, Meibomian gland functionality in 757 patients (1514 eyes) with dry eye disease and 29 healthy controls (58 eyes). Statistical differences between the patient group and the control group were observed for all the tests apart from tear osmolarity, regardless of cut-off value (>308 mOsm/L, >316 mOsm/L, and inter-eye difference >8 mOsm/L). Moreover, in the receiver operating characteristics curve analyses tear osmolarity measurement could not discriminate dry eye disease pathological scores. Therefore, our study suggests that tear osmolarity measured with TearLab osmometer cannot be used as a key indicator of DED.
Collapse
|
38
|
Park B, Jo K, Lee TG, Lee IS, Kim JS, Kim CS. Polygonum cuspidatum stem extract (PSE) ameliorates dry eye disease by inhibiting inflammation and apoptosis. J Exerc Nutrition Biochem 2019; 23:14-22. [PMID: 32018341 PMCID: PMC7004570 DOI: 10.20463/jenb.2019.0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/12/2019] [Indexed: 01/05/2023] Open
Abstract
[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.
Collapse
|
39
|
Fogagnolo P, Torregrossa G, Tranchina L, Ferreras A, De Cillá S, Labbé A, Figus M, Ottobelli L, Rossetti L. Tear Film Osmolarity, Ocular Surface Disease and Glaucoma: A Review. Curr Med Chem 2019; 26:4241-4252. [PMID: 31345142 DOI: 10.2174/0929867326666190725160621] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/23/2018] [Accepted: 01/10/2019] [Indexed: 12/16/2022]
Abstract
Glaucoma is the second leading cause of blindness in the world, affecting more than 60 million people globally. In order to reduce the progression of the disease, both medical and surgical treatments are used. Frequent side effects of both treatments include a range of modifications of the ocular surface grouped as the Ocular Surface Disease (OSD), which include Dry Eye Disease (DED). DED and other OSD negatively impact on the success of anti-glaucoma treatments and reduce the adherence to medical therapies. Tear film osmolarity (TFO) is a relatively novel test which has become a hallmark of DED. The aim of this paper was to review the association between OSD, DED and glaucoma in view of published TFO data, and to discuss future fields of research and treatments on the topic of glaucoma iatrogenic damage.
Collapse
Affiliation(s)
- Paolo Fogagnolo
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| | | | - Laura Tranchina
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| | - Antonio Ferreras
- Department of Ophthalmology, Miguel Servet University Hospital, University of Zaragoza, Zaragoza, Spain
| | - Stefano De Cillá
- Unit of Ophthalmology, Ospedale Maggiore della Carita, Novara, Italy
| | - Antoine Labbé
- Department of Ophthalmology III, Quinze-Vingts National Ophthalmology Hospital, Vision Institute, Versailles Saint-Quentin en Yvelines University, 75012 Paris, France
| | - Michele Figus
- Ophthalmology, Department of Neurosciences, University of Pisa, Pisa, Italy
| | - Laura Ottobelli
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| | - Luca Rossetti
- Eye Clinic, San Paolo Hospital, University of Milan, Milan, Italy
| |
Collapse
|
40
|
Cartes C, López D, Salinas D, Segovia C, Ahumada C, Pérez N, Valenzuela F, Lanza N, López Solís RO, Perez VL, Zegers P, Fuentes A, Alarcón C, Traipe L. Dry eye is matched by increased intrasubject variability in tear osmolarity as confirmed by machine learning approach. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2019; 94:337-342. [PMID: 31122680 DOI: 10.1016/j.oftal.2019.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Because of high variability, tear film osmolarity measures have been questioned in dry eye assessment. Understanding the origin of such variability would aid data interpretation. This study aims to evaluate osmolarity variability in a clinical setting. MATERIAL AND METHODS Twenty dry eyes and 20 control patients were evaluated. Three consecutive osmolarity measurements per eye at 5min intervals were obtained. Variability was represented by the difference between both extreme readings per eye. Machine learning techniques were used to quantify discrimination capacity of tear osmolarity for dry eye. RESULTS Mean osmolarities in the control and dry eye groups were 295.1±7.3mOsm/L and 300.6±11.2mOsm/L, respectively (P=.004). Osmolarity variabilities were 7.5±3.6mOsm/L and 16.7±11.9mOsm/L, for the control and dry eye groups, respectively (P<.001). Based on osmolarity, a logistic classifier showed an 85% classification accuracy. CONCLUSIONS In the clinical setting, both mean osmolarity and osmolarity variability in the dry eye group were significantly higher than in the control group. Machine learning techniques showed good classification accuracy. It is concluded that higher variability of tear osmolarity is a dry eye feature.
Collapse
Affiliation(s)
- C Cartes
- Centro de la Visión, Filial Clínica Las Condes, Santiago, Chile
| | - D López
- Centro de la Visión, Filial Clínica Las Condes, Santiago, Chile
| | - D Salinas
- Centro de la Visión, Filial Clínica Las Condes, Santiago, Chile
| | - C Segovia
- School of Medical Technology, Faculty of Medicine, University of Chile, Independencia, Santiago, Chile
| | - C Ahumada
- School of Medical Technology, Faculty of Medicine, University of Chile, Independencia, Santiago, Chile
| | - N Pérez
- School of Medical Technology, Faculty of Medicine, University of Chile, Independencia, Santiago, Chile
| | - F Valenzuela
- Fundación Oftalmológica Los Andes, Vitacura, Santiago, Chile
| | - N Lanza
- Bascom Palmer Eye Institute, University of Miami, Miami, Fl, Estados Unidos
| | - R O López Solís
- Institute for Biomedical Sciences (Cellular and Molecular Biology), Faculty of Medicine, University of Chile, Independencia, Santiago, Chile
| | - V L Perez
- Duke Eye Center for Ocular Immunology, Duke University School of Medicine, Durham, NC, Estados Unidos
| | - P Zegers
- College of Engineering and Applied Sciences, Universidad de los Andes, Santiago, Chile
| | - A Fuentes
- College of Engineering and Applied Sciences, Universidad de los Andes, Santiago, Chile
| | | | - L Traipe
- Centro de la Visión, Filial Clínica Las Condes, Santiago, Chile.
| |
Collapse
|
41
|
Özalp O, Atalay E, Alataş İÖ, Küskü Kiraz Z, Yıldırım N. Assessment of Phosphate and Osmolarity Levels in Chronically Administered Eye Drops. Turk J Ophthalmol 2019; 49:123-129. [PMID: 31245971 PMCID: PMC6624467 DOI: 10.4274/tjo.galenos.2018.43827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives To assess phosphate and osmolarity levels of chronically administered eye drops commercially available in Turkey. Materials and Methods A total of 53 topical eye drops including 18 antiglaucoma drugs, 4 nonsteroidal anti-inflammatory drugs (NSAIDs), 10 corticosteroids, 7 antihistaminics, and 14 artificial tears identified using the Vademecum Modern Medications Guideline (2018) were included in the study. Phosphate levels were assessed using Roche Cobas C501 analyzer (Roche Diagnostics GmbH, Mannheim, Germany) and the respective kits. Osmolarity was assessed using Vescor Vapro 5600 vapor pressure osmometer (Sanova Medical Systems, Vienna, Austria). Mean phosphate and osmolarity levels were obtained after averaging three measurements. Eye drops were categorized as isoosmolar, hypoosmolar and hyperosmolar based on physiologic tear osmolarity range (296.5±9.8 mOsm/L). Results The highest phosphate concentration was found in the antiglaucoma group (20.3±35.4 mmol/L), followed by antihistaminics (17.3±17.9 mmol/L), corticosteroids (15.2±19.1 mmol/L), artificial tears (0.8±1.0), and NSAIDs (0.04±0.08). Percentage of medications in the hyperosmolar category was highest in the NSAI group (75%), followed by antihistaminics (43%), corticosteroids (20%), and antiglaucoma drugs (19%). Nearly all of the artificial tear formulations were in the hypoosmolar (71%) or isoosmolar (21%) categories. Conclusion Approximately 40% of glaucoma medications and approximately 60% of corticosteroid and antihistaminic medications had a phosphate concentration higher than the physiologic tear phosphate level (1.45 mmol/L).
Collapse
Affiliation(s)
- Onur Özalp
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - Eray Atalay
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| | - İbrahim Özkan Alataş
- Eskişehir Osmangazi University Faculty of Medicine, Department of Medical Biochemistry, Eskişehir, Turkey
| | - Zeynep Küskü Kiraz
- Eskişehir Osmangazi University Faculty of Medicine, Department of Medical Biochemistry, Eskişehir, Turkey
| | - Nilgün Yıldırım
- Eskişehir Osmangazi University Faculty of Medicine, Department of Ophthalmology, Eskişehir, Turkey
| |
Collapse
|
42
|
Aktaş S, Temiztürk F. Evaluation of tear osmolarity and tear function in patients with Behçet's syndrome. Can J Ophthalmol 2019; 54:176-179. [PMID: 30975340 DOI: 10.1016/j.jcjo.2018.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To evaluate the effects of Behçet's syndrome (BS) on tear osmolarity and tear film function tests. METHODS Thirty patients with BS and 41 control subjects were enrolled in this study. Tear osmolarity was measured with an osmometer. Tear film function tests involved corneal fluorescein staining, tear film breakup time (TBUT), Schirmer's 1 test, and an Ocular Surface Disease Index (OSDI) Questionnaire. RESULTS The patients with BS had significantly higher tear osmolarity (p = 0.000) and OSDI scores (p = 0.000) than the healthy controls. The TBUT (p = 0.000) and Schirmer's 1 test (p = 0.033) results were significantly lower in the BS group, but the fluorescein staining results were not statistically different. A significant correlation was found between tear osmolarity, OSDI, and the activity of BS. CONCLUSIONS BS is associated with hyperosmolarity of the tear film, which can damage the ocular surface and affect tear functions.
Collapse
Affiliation(s)
- Serdar Aktaş
- Department of Ophthalmology, Dumlupinar University School of Medicine, Kütahya, Turkey.
| | - Fatih Temiztürk
- Department of Physical Medicine and Rehabilitation, Dumlupinar University School of Medicine, Kütahya, Turkey
| |
Collapse
|
43
|
van Setten GB. Osmokinetics: A new dynamic concept in dry eye disease. J Fr Ophtalmol 2019; 42:221-225. [PMID: 30851972 DOI: 10.1016/j.jfo.2018.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Tear fluid osmolarity has been increasingly accepted as an accessible parameter in the diagnosis of ocular surface and dry eye disease. After having been proposed as the gold standard, recent results have put this into question. However, the most recent guidelines for dry eye disease identify specific values of osmolarity as thresholds to help to differentiate between various stages of severity of ocular surface disease. The limits of this approach were investigated to propose a new concept, that of osmokinetics. MATERIALS AND METHODS Available data on tear fluid osmolarity in normal and diseased eyes were compared. The possibility of normo-osmolar dry eye was investigated and repeated measurements of osmolarity performed. RESULTS The currently applied static model of a threshold value of osmolarity for diagnosing dry eye disease is apparently insufficient. Not only does it not take into account normo-osmolar dry eye, but it also applies too much significance to a single parameter. Instead, it was found that there is a daily variation in osmolarity (DVO), which appears to be higher in eyes with tear film deficiencies than in healthy eyes. DISCUSSION Tear film osmolarity does vary considerably throughout the day. Its value should be considered in a kinetic model taking into account the dynamics of osmolarity changes moreso than the current static model. The terms of osmotic stress and diurnal variation of osmolarity were found to offer a more physiological understanding of osmolarity. CONCLUSION A more dynamic model for osmolarity is presented in which not the value itself but the daily variation of osmolarity is identified. It is suggested that the amplitude of change in osmolarity over the course of a day or even shorter time periods could play a decisive role as a stress factor for the surface cells. The varying osmolar stress could be one of the key mechanisms leading to the cell death, inflammation, apoptosis, and goblet cell disappearance as observed in dry eye disease. Perhaps it is the mean osmolarity level at which these changes occur together with the magnitude of DVO which could identify the level of severity of dry eye disease.
Collapse
Affiliation(s)
- G-B van Setten
- St Eriks Eye Hospital, Karolinska Institutet, Polhemsgatan 50, 11282 Stockholm, Sweden.
| |
Collapse
|
44
|
Review of Biomarkers in Ocular Matrices: Challenges and Opportunities. Pharm Res 2019; 36:40. [PMID: 30673862 PMCID: PMC6344398 DOI: 10.1007/s11095-019-2569-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/07/2019] [Indexed: 02/05/2023]
Abstract
Biomarkers provide a powerful and dynamic approach to improve our understanding of the mechanisms underlying ocular diseases with applications in diagnosis, disease modulation or for predicting and monitoring of clinical response to treatment. Defined as measurable indicator of normal or pathological processes, biomarker evaluation has been used extensively in drug development within clinical settings to better comprehend effectiveness of treatment in ocular diseases. Biomarkers in the eye have the advantage of access to multiple ocular matrices via minimally invasive methods. Repeat sampling for biomarker assessment has enabled reproducible objective measures of disease process or biological responses to a drug treatment. This review describes the usage of biomarkers with respect to four commonly sampled ocular matrices in clinic: tears, conjunctiva, aqueous humor and vitreous. Issues that affect the evaluation of biomarkers are discussed along with opportunities to leverage biomarkers such that ultimately, they can be used for customized targeted therapy.
Collapse
|
45
|
Shared Medical and Environmental Risk Factors in Dry Eye Syndrome, Sjogren's Syndrome, and B-Cell Non-Hodgkin Lymphoma: A Case-Control Study. J Immunol Res 2019; 2019:9060842. [PMID: 30805374 PMCID: PMC6360537 DOI: 10.1155/2019/9060842] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/10/2018] [Accepted: 12/16/2018] [Indexed: 12/13/2022] Open
Abstract
Objectives To assess whether there are shared exposures associated with Sjogren's syndrome (SS), dry eye syndrome (DES), and B-cell non-Hodgkin lymphoma (B-NHL), in order to determine whether they are etiologically related. Methods In a clinic-based case-control study, 702 participants (91 SS, 120 DES, 211 (age and sex frequency-matched) controls, and 280 B-NHL cases) were recruited and interviewed regarding exposures, medical history, and family history. Results Female predominance was noted in SS (ratio 9.2 : 1). Eye dryness was severest in SS compared to DES and controls (P < 0.001). Compared to controls, alcohol consumption was inversely associated with NHL, DES, and SS (odds ratio (OR) = 0.47, 95% confidence interval (CI): 0.31-0.71; OR = 0.54, 95% CI: 0.33-0.88; and OR = 0.26, 95% CI: 0.14-0.49, respectively), while a previous history of infection requiring hospitalization was positively associated with all three conditions: NHL (OR = 1.92; 95% CI: 1.23-2.99), DES (OR = 3.29; 95% CI: 1.97-5.47), and SS (OR = 4.74; 95% CI: 2.66-8.44). NHL patients were more likely to report first-degree relatives with hematologic cancer, while having first-degree relatives with an autoimmune disease (AID) was associated with SS (OR = 5.25; 95% CI: 2.59-10.63) and DES (OR = 3.55; 95% CI: 1.83-6.91) compared to controls. Conclusions Some exposures are associated with all three conditions (such as an inverse association with alcohol consumption and a positive association with serious past infection), while a family history of AID appears to be shared by DES and SS, but not NHL subjects. Shared risk factors for all three conditions indicate possible mutual etiological pathways.
Collapse
|
46
|
Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology 2019; 126:P286-P334. [DOI: 10.1016/j.ophtha.2018.10.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 01/04/2023] Open
|
47
|
Brissette AR, Drinkwater OJ, Bohm KJ, Starr CE. The utility of a normal tear osmolarity test in patients presenting with dry eye disease like symptoms: A prospective analysis. Cont Lens Anterior Eye 2018; 42:185-189. [PMID: 30236650 DOI: 10.1016/j.clae.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 08/12/2018] [Accepted: 09/13/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To explore the diagnostic utility of normal tear osmolarity in patients with symptoms suggestive of dry eye disease (DED). METHODS Prospective observational cohort study of 100 patients that underwent tear osmolarity testing (TearLab™) if they endorsed one or more symptoms of potential DED. Patients were included for the study if they had a normal tear osmolarity test (value <308 mOsm/L in each eye, and an inter-eye difference <8 mOsm/L). The main outcome measure was the presence of any alternate diagnosis to explain the patient's symptoms. Results were recorded and descriptive and univariate statistics were employed. RESULTS Mean tear osmolarity was 293.40 mOsms/L (±6.82), with a mean absolute difference of 2.85 mOsms/L (±1.98) between the eyes. A possible alternate diagnosis was established in 89% of patients with normal tear osmolarity testing. The most frequent diagnoses included anterior blepharitis (26%) and allergic conjunctivitis (21%). CONCLUSIONS Common symptoms of DED overlap significantly with a wide variety of other ocular surface diseases, and a normal tear osmolarity test should increase clinical suspicion for alternate causes of those symptoms. Anterior blepharitis and allergic conjunctivitis were the most common diagnoses made in symptomatic patients with normal tear osmolarity who may have otherwise been misdiagnosed and treated for DED.
Collapse
Affiliation(s)
| | - Owen J Drinkwater
- Weill Cornell Medicine, Department of Ophthalmology, New York, NY, USA
| | - Kelley J Bohm
- Weill Cornell Medicine, Department of Ophthalmology, New York, NY, USA
| | | |
Collapse
|
48
|
Correlations of In Vitro Assays for Assessing Cytotoxicity and Biocompatibility of Contact Lens Multipurpose Solutions. Eye Contact Lens 2018; 44 Suppl 1:S97-S105. [DOI: 10.1097/icl.0000000000000338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
49
|
Variability of Tear Osmolarity Measurements With a Point-of-Care System in Healthy Subjects-Systematic Review. Cornea 2018; 37:938-945. [PMID: 29620566 DOI: 10.1097/ico.0000000000001562] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the variability of osmolarity measured by the point-of-care TearLab system in healthy eyes. METHODS A systematic review was performed by searching MEDLINE, Scopus, and the Web of Science Databases until November 2016 and checking reference lists of included articles and reviews. The requirements for inclusion were the availability of TearLab results in healthy subjects and a minimum study sample of 20 eyes. Two reviewers assessed articles against the inclusion criteria, extracted relevant data, and examined the methodological quality. We computed the weighted mean osmolarity using the study size as the weighting factor and calculated the rate of subjects with osmolarity values >308 mOsm/L, the Dry Eye Workshop Report 2017 (DEWS) cut-off value for dry eye disease (DED). We repeated the analysis after excluding reports with a possible conflict of interest or missing description of subject selection. RESULTS Searches retrieved 105 nonduplicate articles, and we included 33 studies investigating 1362 eyes of healthy participants who were asymptomatic and showed no clinical signs of DED. Sixty-three percent were female, and mean age was 37.3 years (range: 21.5-69.0 yr). Weighted mean osmolarity was 298 mOsm/L (95% confidence interval, 282-321 mOsm/L). The result of the subgroup analysis was similar. Overall, 386 of 1362 eyes (28.3%) fulfilled the DEWS's definition of DED (>308 mOsm/L). CONCLUSIONS There is a high variability of osmolarity measurements with the TearLab system. A substantial number of healthy subjects fulfill the DEWS's definition of DED. We propose interpreting the TearLab osmolarity results cautiously and in the context of other established methods.
Collapse
|
50
|
Giannaccare G, Vigo L, Pellegrini M, Sebastiani S, Carones F. Ocular Surface Workup With Automated Noninvasive Measurements for the Diagnosis of Meibomian Gland Dysfunction. Cornea 2018; 37:740-745. [PMID: 29300267 DOI: 10.1097/ico.0000000000001500] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To analyze diagnostic performance of an ocular surface workup based on automated noninvasive measurements in the diagnosis of meibomian gland dysfunction (MGD). METHODS Two hundred ninety-eight eyes of 149 patients with MGD and 54 eyes of 27 control patients were analyzed. Ocular Surface Disease Index (OSDI), noninvasive breakup time (BUT), lipid layer thickness, meibomian gland loss, and tear osmolarity were calculated. The correlations among variables in the MGD group were analyzed. The area under the curve (AUC) of receiver operating characteristic curves was calculated. RESULTS OSDI, noninvasive BUT, and meibomian gland loss were significantly different between MGD and control groups (respectively, 37.9 ± 19.6 vs. 7.1 ± 2.8; 8.8 ± 3.6 vs. 11.0 ± 3.0; 28.0 ± 17.6 vs. 21.2 ± 13.0; always P < 0.05). Positive correlations were found between lipid layer thickness and noninvasive BUT and between meibomian gland loss and OSDI (respectively, r = 0.169, P = 0.004; r = 0.187, P = 0.004). Noninvasive BUT had the highest diagnostic power as a single parameter, followed by meibomian gland loss (respectively AUC = 0.686, AUC = 0.598). When the diagnosis of MGD was made based on either noninvasive BUT or meibomian gland loss being abnormal, sensitivity was 86.2% and specificity 38.5%. When the diagnosis was made on both noninvasive BUT and meibomian gland loss being abnormal, sensitivity was 39.3% and specificity 85.6%. CONCLUSIONS This automated noninvasive ocular surface workup may represent a useful screening tool for the diagnosis of MGD. In case of positivity of either noninvasive BUT or meibomian gland loss, subsequent qualitative clinical tests should be performed to achieve a reliable diagnosis and more precise characterization of MGD.
Collapse
Affiliation(s)
- Giuseppe Giannaccare
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Luca Vigo
- Carones Ophthalmology Center, Milan, Italy
| | - Marco Pellegrini
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Stefano Sebastiani
- Ophthalmology Unit, DIMES, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | | |
Collapse
|