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Anam A, Liu C, Tong L, Liu YC. Blood-Derived Eye Drops for the Treatment of Corneal Neuropathic Pain. J Ocul Pharmacol Ther 2024; 40:281-292. [PMID: 38648544 PMCID: PMC11296151 DOI: 10.1089/jop.2023.0155] [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: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
Blood-derived preparations, including autologous or allogenic serum, umbilical cord serum/plasma, and platelet-rich plasma eye drops, contain various growth factors, cytokines, and immunoglobulins that resemble natural tears. These components play important roles in corneal cell migration, proliferation, and wound healing. Blood-derived eye drops have demonstrated clinical effectiveness across a spectrum of ocular surface conditions, encompassing dry eye disease, Sjögren's syndrome, graft-versus-host disease, and neuropathic corneal pain (NCP). Currently, management of NCP remains challenging. The emergence of blood-derived eye drops represents a promising therapeutic approach. In this review, we discuss the benefits and limitations of different blood-derived eye drops, their mechanisms of action, and treatment efficacy in patients with NCP. Several studies have demonstrated the clinical efficacy of autologous serum eye drops in relieving pain and pain-like symptoms, such as allodynia and photoallodynia. Corneal nerve parameters were also significantly improved, as evidenced by increased nerve fiber density, length, nerve reflectivity, and tortuosity, as well as a decreased occurrence of beading and neuromas after the treatment. The extent of nerve regeneration correlated with improvement in patient-reported photoallodynia. Cord plasma eye drops also show potential for symptom alleviation and corneal nerve regeneration. Future directions for clinical practice and research involve standardizing preparation protocols, establishing treatment guidelines, elucidating underlying mechanisms, conducting long-term clinical trials, and implementing cost-effective measures such as scaling up manufacturing. With ongoing advancements, blood-derived eye drops hold promise as a valuable therapeutic option for patients suffering from NCP.
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Affiliation(s)
- Ansa Anam
- Department of Ophthalmology, MTI Khyber Teaching Hospital, Peshawar, Pakistan
| | - Chang Liu
- Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Louis Tong
- Department of Corneal and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
- Ocular Surface Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Yu-Chi Liu
- Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore, Singapore
- Department of Corneal and External Eye Disease, Singapore National Eye Centre, Singapore, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
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2
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Zhuang D, Misra SL, Mugisho OO, Rupenthal ID, Craig JP. NLRP3 Inflammasome as a Potential Therapeutic Target in Dry Eye Disease. Int J Mol Sci 2023; 24:10866. [PMID: 37446038 DOI: 10.3390/ijms241310866] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Dry eye disease (DED) is a multifactorial ocular surface disorder arising from numerous interrelated underlying pathologies that trigger a self-perpetuating cycle of instability, hyperosmolarity, and ocular surface damage. Associated ocular discomfort and visual disturbance contribute negatively to quality of life. Ocular surface inflammation has been increasingly recognised as playing a key role in the pathophysiology of chronic DED. Current readily available anti-inflammatory agents successfully relieve symptoms, but often without addressing the underlying pathophysiological mechanism. The NOD-like receptor protein-3 (NLRP3) inflammasome pathway has recently been implicated as a key driver of ocular surface inflammation, as reported in pre-clinical and clinical studies of DED. This review discusses the intimate relationship between DED and inflammation, highlights the involvement of the inflammasome in the development of DED, describes existing anti-inflammatory therapies and their limitations, and evaluates the potential of the inflammasome in the context of the existing anti-inflammatory therapeutic landscape as a therapeutic target for effective treatment of the disease.
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Affiliation(s)
- Dian Zhuang
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Stuti L Misra
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Odunayo O Mugisho
- Buchanan Ocular Therapeutics Unit, Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Ilva D Rupenthal
- Buchanan Ocular Therapeutics Unit, Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
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Wróbel-Dudzińska D, Przekora A, Kazimierczak P, Ćwiklińska-Haszcz A, Kosior-Jarecka E, Żarnowski T. The Comparison between the Composition of 100% Autologous Serum and 100% Platelet-Rich Plasma Eye Drops and Their Impact on the Treatment Effectiveness of Dry Eye Disease in Primary Sjogren Syndrome. J Clin Med 2023; 12:jcm12093126. [PMID: 37176566 PMCID: PMC10179661 DOI: 10.3390/jcm12093126] [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: 04/02/2023] [Revised: 04/22/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
PURPOSE The aim of the study was to compare the difference in composition between 100% autologous serum (AS) and 100% platelet-rich plasma (PRP) eye drops and assess their impact on the clinical outcomes after the treatment of severe dry eye (DE) in primary Sjogren Syndrome patients (pSS). MATERIALS AND METHODS This is an interventional, non-randomized, comparative, three-month study. 22 patients with severe DE in pSS were treated with 100% AS (22 eyes) and 100% PRP (22 eyes) eye drops 5 times per day in monotherapy mode. The quantifications of growth factors (GFs) such as fibroblast growth factor (FGF), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), nerve growth factor (NGF), transforming growth factor (TGF-b), insulin-like growth factor (IGF), fibronectin, and substance p in hemoderivates were done. The main outcome measures were: Ocular Surface Disease Index (OSDI), Best Corrected Visual Acuity (BCVA), the Schirmer test, tear break-up time (TBUT), corneal and conjunctival staining according to the Oxford scale, conjunctival hyperaemia, and Meibomian gland parameters. The results were compared at baseline, 1 month, and 3 months following the treatment. The clinical results were correlated with the concentration of GFs in the biological tear substitutes. RESULTS Significant differences were observed in the concentration of FGF (4.42 ± 0.86 vs. 15.96 ± 7.63, p < 0.0001), EGF (4.98 ± 0.97 vs. 39.06 ± 20.18, p < 0.0001), fibronectin (929.6 ± 111.5 vs. 823.64 ± 98.49, p = 0.0005), VEGF (175.45 ± 65.93 vs. 717.35 ± 488.15, p < 0.0001), PDGF AB (619.6 ± 117.30 vs. 349.66 ± 79.82, p < 0.0001), NGF (85.22 ± 23.49 vs. 8.29 ± 9.06, p < 0.0001), PDGF (935.38 ± 434.26 vs. 126.66 ± 54.41, p < 0.0001), substance p (112.58 ± 27.28 vs. 127.51 ± 26.56, p = 0.0125) in PRP compared to AS. The level of TGF-β was undoubtedly higher in AS than in PRP (1031.37 ± 330.23 vs. 726.03 ± 298.95, p = 0.0004). No significant differences between AS and PRP were observed in the concentration of IGF. Therapy with blood products relieved the signs and symptoms in pSS DE patients. There was a statistically significant improvement in BCVA, the Schirmer test, TBUT, Meibomian gland parameters, and the reduction of the OSDI scores, Oxford staining, and conjunctiva hyperaemia in each of the groups. However, the clinical changes were more significant in the PRP group. There were numerous correlations between the level of GFs and the mean change in clinical outcomes. No adverse events were reported. CONCLUSIONS Despite the fact that blood derivatives differ in composition, they seem to be effective and safe in the treatment of severe DE in pSS patients. The signs and symptoms of DE were reduced in both groups, but only the mean change in OSDI was statistically significant. A greater reduction in OSDI scores was observed in the PRP group. The obtained results and the composition of haemoderivates may indicate the superiority of PRP in relieving the symptoms of DE in pSS patients compared to AS.
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Affiliation(s)
- Dominika Wróbel-Dudzińska
- Department of Diagnostics and Microsurgery of Glaucoma, Medical University of Lublin, 20-059 Lublin, Poland
| | - Agata Przekora
- Independent Unit of Tissue Engineering and Regenerative Medicine, Medical University of Lublin, 20-059 Lublin, Poland
| | - Paulina Kazimierczak
- Independent Unit of Tissue Engineering and Regenerative Medicine, Medical University of Lublin, 20-059 Lublin, Poland
| | | | - Ewa Kosior-Jarecka
- Department of Diagnostics and Microsurgery of Glaucoma, Medical University of Lublin, 20-059 Lublin, Poland
| | - Tomasz Żarnowski
- Department of Diagnostics and Microsurgery of Glaucoma, Medical University of Lublin, 20-059 Lublin, Poland
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Pérez ML, Barreales S, Sabater-Cruz N, Martinez-Conesa EM, Vilarrodona A, Casaroli-Marano RP. Amniotic membrane extract eye drops: a new approach to severe ocular surface pathologies. Cell Tissue Bank 2021; 23:473-481. [PMID: 34549352 DOI: 10.1007/s10561-021-09962-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
A protocol for processing amniotic membrane as an extract to be re-hydrated and administered topically as eye drops (amniotic membrane extract eye drops, AMEED) has been developed. Safety and efficacy of AMEED was assessed in patients with severe ocular surface pathologies. prospective clinical follow-up of ocular surface symptoms before and after regular application of the AMEED for at least 4 weeks on patients with severe ocular surface disorders as chronic dry eye disease, limbal stem cell deficiency, neurotrophic ulcer and permanent and disabling symptomatology that were refractory to conventional treatment. Efficacy and tolerability were assessed based on patient-reported symptoms, objective measurements, and reports of adverse events. Thirty-six eyes from 25 patients were included. Although the visual quality function score, by means of a VQF25 questionnaire, was not statistically different after the treatment (p = 0.4657), there was a clear trend, statistically significant, towards the improvement in ocular symptoms like foreign body sensation, itching and stinging (p < 0.05) and clinical presentation of the pathology. All patients with corneal ulcer showed complete epithelization. Topically applied AMEED proved to be safe, well tolerated and effective in reducing the symptoms and clinical signs of severe ocular disease. Further studies are needed to confirm the best indications for AMEED use.
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Affiliation(s)
- Maria Luisa Pérez
- Barcelona Tissue Bank- Banc de Sang i Teixits (BTB), Barcelona, Spain. .,Institute of Biomedical Research (IIB-Sant Pau; SGR1113), Barcelona, Spain.
| | - Saúl Barreales
- Barcelona Tissue Bank- Banc de Sang i Teixits (BTB), Barcelona, Spain
| | - Noelia Sabater-Cruz
- Institut Clinic d'Oftalmologia (ICOF), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Eva Maria Martinez-Conesa
- Barcelona Tissue Bank- Banc de Sang i Teixits (BTB), Barcelona, Spain.,Institute of Biomedical Research (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Anna Vilarrodona
- Barcelona Tissue Bank- Banc de Sang i Teixits (BTB), Barcelona, Spain.,Institute of Biomedical Research (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Ricardo P Casaroli-Marano
- Barcelona Tissue Bank- Banc de Sang i Teixits (BTB), Barcelona, Spain.,Department of Surgery, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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Mahelkova G, Jirsova K, Seidler stangova P, Palos M, Vesela V, Fales I, Jiraskova N, Dotrelova D. Using corneal confocal microscopy to track changes in the corneal layers of dry eye patients after autologous serum treatment. Clin Exp Optom 2021; 100:243-249. [DOI: 10.1111/cxo.12455] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/02/2016] [Accepted: 06/04/2016] [Indexed: 11/26/2022] Open
Affiliation(s)
- Gabriela Mahelkova
- Department of Ophthalmology for Children and Adults, Charles University, 2nd Faculty of Medicine and University Hospital in Motol, Prague, Czech Republic,
- Department of Physiology, Charles University, 2nd Faculty of Medicine, Prague, Czech Republic,
| | - Katerina Jirsova
- Laboratory of the Biology and Pathology of the Eye, Institute of Inherited Metabolic Disorders, Charles University, 1st Faculty of Medicine, Prague, Czech Republic,
| | - Petra Seidler stangova
- Department of Ophthalmology, Charles University, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic,
| | - Michalis Palos
- Department of Ophthalmology, Charles University, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic,
| | - Viera Vesela
- Cell Therapy Department, Institute of Hematology and Blood Transfusion, Prague, Czech Republic,
| | - Ivan Fales
- Department of Ophthalmology, Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic,
| | - Nada Jiraskova
- Department of Ophthalmology, Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic,
| | - Dagmar Dotrelova
- Department of Ophthalmology for Children and Adults, Charles University, 2nd Faculty of Medicine and University Hospital in Motol, Prague, Czech Republic,
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6
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Yu AT, Lee GA, Vincent S, Shah P. Patient perceptions of autologous serum eye drops for severe dry eye disease. Clin Exp Ophthalmol 2020; 48:1109-1111. [PMID: 32710460 DOI: 10.1111/ceo.13832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Alice T Yu
- City Eye Centre, Brisbane, Queensland, Australia
| | - Graham A Lee
- City Eye Centre, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Birmingham Institute for Glaucoma Research, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen Vincent
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Peter Shah
- Birmingham Institute for Glaucoma Research, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,University College London, London, UK.,Centre for Health & Social Care Improvement, University of Wolverhampton, Wolverhampton, UK
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7
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Jirsova K, Seidler Stangova P, Palos M, Mahelkova G, Kalasova S, Rybickova I, Utheim TP, Vesela V. Aberrant HLA-DR expression in the conjunctival epithelium after autologous serum treatment in patients with graft-versus-host disease or Sjögren's syndrome. PLoS One 2020; 15:e0231473. [PMID: 32315325 PMCID: PMC7173771 DOI: 10.1371/journal.pone.0231473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 03/24/2020] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to determine the effect of autologous serum (AS) eye drops on the density of human leucocyte antigen (HLA)-DR-positive epithelial cells and Langerhans cells on the ocular surface of patients with bilateral severe dry eye disease (DED) due to graft-versus-host disease (GvHD) or Sjögren’s syndrome (SS). The study was conducted on 24 patients (48 eyes). AS was applied 6–10 times daily for 3 months together with regular artificial tear therapy. HLA-DR-positive cells were detected by direct immunocytochemistry on upper bulbar conjunctiva imprints obtained before and after treatment. The application of AS drops led to a statistically significant increase in the mean density of aberrant HLA-DR-positive conjunctival epithelial cells (p < 0.05) and HLA-DR-positive Langerhans cells (p < 0.05) in the GvHD group. Aberrant HLA-DR-positive epithelial cells in the SS group were decreased non-significantly. All patients reported a significant decrease in the Ocular Surface Disease Index (p < 0.01), which indicates improvement of the patient’s subjective feelings after therapy. There was an expected but non-significant decrease of aberrant HLA-DR-positive conjunctival epithelial cells in the SS group only. However, the increased density of HLA-DR-positive cells, indicating slight subclinical inflammation, does not outweigh the positive effect of AS in patients with DED from GvHD.
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Affiliation(s)
- Katerina Jirsova
- Laboratory of the Biology and Pathology of the Eye, Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
- * E-mail:
| | - Petra Seidler Stangova
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michalis Palos
- Department of Ophthalmology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Gabriela Mahelkova
- Department of Ophthalmology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, and Department of Physiology, Second Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Sarka Kalasova
- Laboratory of the Biology and Pathology of the Eye, Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ivana Rybickova
- Laboratory of the Biology and Pathology of the Eye, Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Tor Paaske Utheim
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
| | - Viera Vesela
- Laboratory of the Biology and Pathology of the Eye, Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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8
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Bernabei F, Roda M, Buzzi M, Pellegrini M, Giannaccare G, Versura P. Blood-Based Treatments for Severe Dry Eye Disease: The Need of a Consensus. J Clin Med 2019; 8:E1478. [PMID: 31533289 PMCID: PMC6780616 DOI: 10.3390/jcm8091478] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 01/08/2023] Open
Abstract
The use of blood-based eye drops as therapy for various diseases of the ocular surface has become increasingly popular in ophthalmic practice during recent years. The rationale for their use is based on the promotion of cellular proliferation and migration thanks to the supply of metabolically active substances, in particular growth factors. Blood-derived eye drops have been used for the treatment of several ocular surface disorders, such as dry eye disease, corneal ulcer, persistent epithelial defect, neurotrophic keratitis, ocular surface burn, recurrent corneal erosion, and limbal stem-cell deficiency. Both autologous (from patients themselves) and heterologous (from adult donors or from cord blood sampled at birth)-derived products exist, and each source has specific pros and cons. Despite an extensive literature, several issues are still under debate and the aim of this manuscript is to review the indications, preparation methods and storage, characterization of content, rationale for clinical outcomes, patient stratification, length of treatment, and rationale for repeated treatments at disease relapse. A rationale based on a "5 Ws and 2 Hs" protocol is proposed as a way of thinking, with the attempt to clarify Who, Why, When, Where, What, and How to use these treatment options.
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Affiliation(s)
- Federico Bernabei
- Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, S.Orsola-Malpighi Teaching Hospital, 40138 Bologna, Italy.
| | - Matilde Roda
- Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, S.Orsola-Malpighi Teaching Hospital, 40138 Bologna, Italy.
| | - Marina Buzzi
- Emilia Romagna Cord Blood Bank-Transfusion Service, S.Orsola-Malpighi Teaching Hospital, 40138 Bologna, Italy.
| | - Marco Pellegrini
- Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, S.Orsola-Malpighi Teaching Hospital, 40138 Bologna, Italy.
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy.
| | - Piera Versura
- Ophthalmology Unit, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, S.Orsola-Malpighi Teaching Hospital, 40138 Bologna, Italy.
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Marchand M, Harissi-Dagher M, Germain M, Thompson P, Robert MC. Serum drops for ocular surface disease: national survey of Canadian cornea specialists. Can J Ophthalmol 2018; 53:266-271. [DOI: 10.1016/j.jcjo.2017.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 08/04/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
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10
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Abstract
Impression cytology (IC) is a technique which permits the retrieval of the outermost layer of ocular surface cells via the use of various types of filters. It is a minimally invasive method of evaluating human conjunctival epithelial cell morphology in the diagnosis of dry eye disease, a common and distressing disorder associated with ageing, contact lens wear, autoimmune disorders and refractive (LASIK) surgery. IC may also be utilized in the diagnosis of other ocular diseases, such as keratoconus and thyroid orbitopathy. More recently, IC has been utilized for the subsequent investigation of gene and protein expression of conjunctival cells in order to identify novel diagnostic biomarkers and to further our understanding of the mechanisms underlying ocular surface disease. This review will therefore examine the literature concerning the role of IC in identifying cellular markers of eye disease, systemic diseases with ocular involvement and potential novel therapeutic targets.
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Affiliation(s)
- Suzanne Hagan
- Vision Sciences, Dept. of Life Sciences, Glasgow Caledonian University, G4 0BA, Scotland, UK
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11
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Dieckmann G, Goyal S, Hamrah P. Neuropathic Corneal Pain: Approaches for Management. Ophthalmology 2017; 124:S34-S47. [PMID: 29055360 DOI: 10.1016/j.ophtha.2017.08.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 01/16/2023] Open
Abstract
Neuropathic pain is caused by a primary lesion or dysfunction of the nervous system and can occur in the cornea. However, neuropathic corneal pain (NCP) is currently an ill-defined disease. Patients with NCP are extremely challenging to manage, and evidence-based clinical recommendations for the management of patients with NCP are scarce. The objectives of this review are to provide guidelines for diagnosis and treatment of patients with NCP and to summarize current evidence-based literature in this area. We performed a systematic literature search of all relevant publications between 1966 and 2017. Treatment recommendations are, in part, based on methodologically sound randomized controlled trials (RCTs), demonstrating superiority to placebo or relevant control treatments, and on the consistency of evidence, degree of efficacy, and safety. In addition, the recommendations include our own extensive experience in the management of these patients over the past decade. A comprehensive algorithm, based on clinical evaluation and complementary tests, is presented for diagnosis and subcategorization of patients with NCP. Recommended first-line topical treatments include neuroregenerative and anti-inflammatory agents, and first-line systemic pharmacotherapy includes tricyclic antidepressants and an anticonvulsant. Second-line oral treatments recommended include an opioid-antagonist and opiate analgesics. Complementary and alternative treatments, such as cardiovascular exercise, acupuncture, omega-3 fatty acid supplementation, and gluten-free diet, may have additional benefits, as do potential noninvasive and invasive procedures in recalcitrant cases. Medication selection should be tailored on an individual basis, considering side effects, comorbidities, and levels of peripheral and centralized pain. Nevertheless, there is an urgent need for long-term studies and RCTs assessing the efficacy of treatments for NCP.
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Affiliation(s)
- Gabriela Dieckmann
- Cornea Service, New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Sunali Goyal
- Department of Ophthalmology, Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Pedram Hamrah
- Cornea Service, New England Eye Center, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
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12
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Jones L, Downie LE, Korb D, Benitez-del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu Y, Seo KY, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II Management and Therapy Report. Ocul Surf 2017; 15:575-628. [DOI: 10.1016/j.jtos.2017.05.006] [Citation(s) in RCA: 578] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
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13
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Sanchez-Avila RM, Merayo-Lloves J, Riestra AC, Anitua E, Muruzabal F, Orive G, Fernández-Vega L. The Effect of Immunologically Safe Plasma Rich in Growth Factor Eye Drops in Patients with Sjögren Syndrome. J Ocul Pharmacol Ther 2017; 33:391-399. [DOI: 10.1089/jop.2016.0166] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ronald Mauricio Sanchez-Avila
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universdiad de Oviedo, Oviedo, Spain
| | - Jesus Merayo-Lloves
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universdiad de Oviedo, Oviedo, Spain
| | - Ana Cristina Riestra
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universdiad de Oviedo, Oviedo, Spain
| | - Eduardo Anitua
- Fundación Eduardo Anitua, Vitoria, Spain
- Biotechnology Institute (BTI), Vitoria, Spain
| | - Francisco Muruzabal
- Fundación Eduardo Anitua, Vitoria, Spain
- Biotechnology Institute (BTI), Vitoria, Spain
| | - Gorka Orive
- Biotechnology Institute (BTI), Vitoria, Spain
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country, School of Pharmacy, Vitoria, Spain
- Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria, Spain
| | - Luis Fernández-Vega
- Instituto Universitario Fernández-Vega, Fundación de Investigación Oftalmológica, Universdiad de Oviedo, Oviedo, Spain
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14
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Doughty MJ. A Grid-Based Nucleus Counting Method for Estimates of the Density of Superficial Conjunctival Cells from Impression Cytology Samples Taken from Normal Healthy Human Eyes. Curr Eye Res 2017; 42:1228-1234. [DOI: 10.1080/02713683.2017.1307414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Michael J. Doughty
- Glasgow-Caledonian University, Department of Vision Sciences, Glasgow, Scotland
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Nassiri N, Rodriguez Torres Y, Meyer Z, Beyer MA, Vellaichamy G, Dhaliwal AS, Chungfat N, Hwang FS. Current and emerging therapy of dry eye disease. Part A: pharmacological modalities. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1327350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nariman Nassiri
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yasaira Rodriguez Torres
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Zachary Meyer
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Michael A. Beyer
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Gautham Vellaichamy
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Amar S. Dhaliwal
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Neil Chungfat
- Department of Ophthalmology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Frank S. Hwang
- Kresge Eye Institute - Department of Ophthalmology, School of Medicine, Wayne State University, Detroit, MI, USA
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16
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Marks DC, van der Meer PF. Serum eye drops: a survey of international production methods. Vox Sang 2017; 112:310-317. [PMID: 28332214 DOI: 10.1111/vox.12502] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Serum eye drops (SEDs) are used to treat dry eye syndrome and non-healing corneal lesions when other treatments fail. Despite many clinical studies demonstrating the efficacy of both autologous and allogeneic SEDs, there is no internationally harmonized method for producing SEDs. MATERIALS AND METHODS A 40-question survey requesting information regarding donor selection, blood collection and processing, infectious disease screening, shelf life and regulatory requirements for the production of autologous and allogeneic SEDs was developed by the Biomedical Excellence for Safer Transfusion Collaborative. Survey data were collected into a database via a secure web interface and then downloaded into Excel for further analysis. RESULTS A total of 55 responses were received, with 21 responses from centres indicating they produce SEDs. Based on the responses, collection and processing practices differ widely, according to the size of the centre making the SEDs, and their ability to collect, process and test the blood. CONCLUSION Despite divergences in the methods for producing SEDs, the end result is a small-volume aliquot of serum that can be administered by a patient at home. If more centres move from producing autologous to allogeneic SEDs, this may provide an opportunity for production methods to become more standardized internationally.
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Affiliation(s)
- D C Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - P F van der Meer
- Department of Product and Process Development, Sanquin Blood Supply, Amsterdam, The Netherlands
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17
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Ma IH, Chen LW, Tu WH, Lu CJ, Huang CJ, Chen WL. Serum components and clinical efficacies of autologous serum eye drops in dry eye patients with active and inactive Sjogren syndrome. Taiwan J Ophthalmol 2017; 7:213-220. [PMID: 29296554 PMCID: PMC5747232 DOI: 10.4103/tjo.tjo_102_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
PURPOSE: Autologous serum eye drops are considered safe and efficient for the treatment of various ocular surface disorders, including dry eye diseases (DED) caused by the primary and secondary Sjogren syndrome (SS). However, the serum components in patients of SS may be different from those of normal patients and can thus lead to unpredictable therapeutic effects. This study divided the SS patients into active and inactive types based on the erythrocyte sedimentation rate and the presence or absence of active rheumatoid arthritis. METHODS: We compared the serum components of these two groups with standard and multiplex enzyme linked immunosorbent assay arrays and predicted the therapeutic effects of topical autologous serum for the treatment of DED with ocular surface disease index (OSDI) and Oxford Schema scale (OSS). RESULTS: Hyaluronic acid and transforming growth factor b1 levels were significantly higher in the active SS group compared to the inactive SS group (P < 0.01), whereas epidermal growth factors, insulin growth factor 1, and fibroblast growth factor b had no significant differences between these two groups. Active SS group had significantly higher expressions of interleukin (IL) 1 beta, IL 6, and tumor necrosis factor alpha compared to inactive SS patients (P < 0.05). There were no statistical differences in therapeutic effects between these two groups, as measured with the OSDI or OSS. CONCLUSION: Dividing the Sjogren dry eye patients into active and inactive groups may appear as a reasonable method to predict the quality of autologous serum eye drops, but there seems to be no significant predictability to the therapeutic effects.
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Affiliation(s)
- I-Hsin Ma
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Lily Wei Chen
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Hui Tu
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ju Lu
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Jung Huang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Li Chen
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan.,Center of Corneal Tissue Engineering and Stem Cell Biology, National Taiwan University Hospital, Taipei, Taiwan
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18
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Rybickova I, Vesela V, Fales I, Skalicka P, Jirsova K. Apoptosis of conjunctival epithelial cells before and after the application of autologous serum eye drops in severe dry eye disease. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:271-5. [DOI: 10.5507/bp.2016.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/20/2016] [Indexed: 11/23/2022] Open
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19
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Merayo-Lloves J, Sanchez-Avila RM, Riestra AC, Anitua E, Begoña L, Orive G, Fernandez-Vega L. Safety and Efficacy of Autologous Plasma Rich in Growth Factors Eye Drops for the Treatment of Evaporative Dry Eye. Ophthalmic Res 2016; 56:68-73. [DOI: 10.1159/000444496] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 02/07/2016] [Indexed: 11/19/2022]
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20
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van der Meer PF, Seghatchian J, Marks DC. Quality standards, safety and efficacy of blood-derived serum eye drops: A review. Transfus Apher Sci 2016; 54:164-7. [PMID: 26847866 DOI: 10.1016/j.transci.2016.01.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Serum eye drops (SEDs) are being used increasingly to treat dry eye syndrome and persistent corneal epithelial defects, and are usually prescribed when conventional treatments fail. SEDs are commonly sourced from the patient's own blood via an autologous collection. Although SEDs are clearly beneficial, they are not available for those patients that cannot donate sufficient blood, and some centres are moving to allogeneic SEDs. Many studies have reported that both allogeneic and autologous SEDs are effective. However, few large randomised controlled trials have been conducted to date, and clinical evidence is therefore limited to smaller studies. Alternatives to serum are also being explored, such as platelet lysate and products made from platelet rich plasma, as they are a rich source of growth factors. This article reviews how some centres are approaching allogeneic collections for SEDs, and alternatives to serum that are currently being explored.
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Affiliation(s)
- Pieter F van der Meer
- Sanquin Blood Supply, Department of Product and Process Development, Amsterdam, The Netherlands
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvements, Audit/Inspection and DDR Strategies, London, UK.
| | - Denese C Marks
- The Australian Red Cross Blood Service, Sydney, Australia
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21
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Abstract
OBJECTIVE To examine the evidence for the role of autologous serum eye drops (ASD) in disease of the ocular surface. METHODS A search of the literature published through May 2014 using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Qualified articles were selected after review of titles, abstracts, and references. RESULTS There was a significant improvement in either symptoms or some of the clinical examination findings, including tear breakup time, corneal staining, Schirmer values, and impression cytology in eyes with persistent corneal epithelial defect, graft-versus-host disease, Sjögren- and non-Sjögren-related dry eye disease, limbal stem-cell deficiency, recurrent corneal erosion, superior limbic keratoconjunctivitis, and postrefractive surgery. However, most of the studies were nonrandomized in nature. CONCLUSIONS Despite the paucity of strong supporting evidence from randomized double-masked clinical studies, there seems to be a trend toward superiority of ASD in alleviating some of the clinical signs and symptoms associated with corneal pathology in a variety of conditions that affect the ocular surface compared with conventional lubricating drops/ointments.
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Mondy P, Brama T, Fisher J, Gemelli CN, Chee K, Keegan A, Waller D. Sustained benefits of autologous serum eye drops on self-reported ocular symptoms and vision-related quality of life in Australian patients with dry eye and corneal epithelial defects. Transfus Apher Sci 2015; 53:404-11. [DOI: 10.1016/j.transci.2015.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Merayo-Lloves J, Sanchez RM, Riestra AC, Anitua E, Bego�a L, Orive G, Fernandez-Vega L. Autologous Plasma Rich in Growth Factors Eyedrops in Refractory Cases of Ocular Surface Disorders. Ophthalmic Res 2015; 55:53-61. [DOI: 10.1159/000439280] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 11/19/2022]
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Human Serum Eye Drops in Eye Alterations: An Insight and a Critical Analysis. J Ophthalmol 2015; 2015:396410. [PMID: 26504592 PMCID: PMC4609447 DOI: 10.1155/2015/396410] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/07/2015] [Indexed: 12/13/2022] Open
Abstract
Human serum contains a physiological plethora of bioactive elements naturally released by activated platelets which might have a significant effect on the regeneration of corneal layers by stimulating the cell growth. This mechanism supported the use of human serum eye drops in some ocular diseases associated with dystrophic changes and alterations of the tear film, such as persistent corneal epithelial defects and dry eye syndrome. We focused our effort on potential benefits and limitations of the use of human serum eye drops when conventional therapies failed. We reviewed the recent literature by reporting published studies from 2010 to 2014. Despite the limited evaluated study populations, most of the clinical studies have confirmed that serum eye drop therapy is effective in corneal healing by reducing ocular symptom, particularly during the short-term follow-up. In addition, three recent published studies have shown the efficacy of the serum eye drop therapy in comparison to traditional ones in intractable patients. Besides, reported ongoing clinical studies confirmed the open debate regarding the use of biologic tools for cornea regeneration. Results from these studies might open novel challenges and perspectives in the therapy of such refractory patients.
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25
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Effectiveness of Autologous Serum Eye Drops Combined With Punctal Plugs for the Treatment of Sjögren Syndrome–Related Dry Eye. Cornea 2015; 34:1214-20. [DOI: 10.1097/ico.0000000000000542] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Marks DC, Fisher J, Mondy P, Segatchian J, Dennington PM. Serum eye drop preparation in Australia: Current manufacturing practice. Transfus Apher Sci 2015; 53:92-4. [DOI: 10.1016/j.transci.2015.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Doughty MJ. Assessment of Consistency in Assignment of Severe (Grade 3) Squamous Metaplasia to Human Bulbar Conjunctiva Impression Cytology Cell Samples. Ocul Surf 2015; 13:284-97. [PMID: 26164095 DOI: 10.1016/j.jtos.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/29/2015] [Accepted: 05/12/2015] [Indexed: 01/09/2023]
Abstract
Nucleus-to-cytoplasm (N:C) characteristics of published images of human bulbar conjunctival cells designated as showing severe (grade 3) squamous metaplasia were retrospectively assessed. From publications over a 40-year period, measurements were made from images of cell and nucleus size (based on areas and dimensions) and four different calculations were made for nucleo-cytoplasmic (N:C) ratios. From 54 published images, the mean nucleus-to-cytoplasm area ratio (NU/CYT AREA ratio) was 0.145 +/- 0.077 (range 0.052 to 0.346), compared to two different reference set values of 0.069 +/- 0.017 and 0.080 +/- 0.021. Similarly, a nucleus-to-cytoplasm length ratio (as LNLONG) was 0.308 +/- 0.080 (range 0.191 to 0.475) compared to reference values of 0.226 +/- 0.032 and 0.236 +/- 0.034. Similar differences in reference values were obtained using two other N:C ratio calculations. A wide range of values was found for morphometric N:C indices from published images, especially those without a scale bar, indicating a high incidence of inconsistent grading assignments. Overall, only about 30% of the published images showed morphological features consistent with severe squamous metaplasia (i.e., with the rest neither enlarged nor showing substantially changed N:C ratios) with no substantial pictorial evidence indicating that cells from the human bulbar conjunctiva have pyknotic nuclei. Current evidence indicates that grade 3 squamous metaplasia cells should be substantially enlarged.
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Affiliation(s)
- Michael J Doughty
- Glasgow-Caledonian University, Department of Vision Sciences, Glasgow, Scotland.
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Semeraro F, Forbice E, Braga O, Bova A, Di Salvatore A, Azzolini C. Evaluation of the efficacy of 50% autologous serum eye drops in different ocular surface pathologies. BIOMED RESEARCH INTERNATIONAL 2014; 2014:826970. [PMID: 25136628 PMCID: PMC4130192 DOI: 10.1155/2014/826970] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/18/2014] [Indexed: 12/04/2022]
Abstract
PURPOSE This study evaluated the efficacy of 50% autologous serum eye drops in ocular surface diseases not improved by conventional therapy. METHODS We analyzed two groups: (1) acute eye pathologies (e.g., chemical burns) and (2) chronic eye pathologies (e.g., recurrent corneal erosion, neurotropic keratitis, and keratoconjunctivitis sicca). The patients were treated for surface instability after conventional therapy. The patients received therapy 5 times a day until stabilization of the framework; they then reduced therapy to 3 times a day for at least 3 months. We analyzed the best corrected visual acuity, epithelial defects, inflammation, corneal opacity, and corneal neovascularization. We also analyzed symptoms such as tearing, burning, sense of foreign body or sand, photophobia, blurred vision, and difficulty opening the eyelids. RESULTS We enrolled 15 eyes in group 1 and 11 eyes in group 2. The average therapy period was 16 ± 5.86 weeks in group 1 and 30.54 ± 20.33 weeks in group 2. The epithelial defects all resolved. Signs and symptoms improved in both groups. In group 2, the defect recurred after the suspension of therapy in 2 (18%) patients; in group 1, no defects recurred. CONCLUSIONS Autologous serum eye drops effectively stabilize and improve signs and symptoms in eyes previously treated with conventional therapy.
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Affiliation(s)
- Francesco Semeraro
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedale Civili 1, 25123 Brescia, Italy
| | - Eliana Forbice
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedale Civili 1, 25123 Brescia, Italy
| | - Osvaldo Braga
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedale Civili 1, 25123 Brescia, Italy
| | - Alessandro Bova
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedale Civili 1, 25123 Brescia, Italy
| | - Attilio Di Salvatore
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedale Civili 1, 25123 Brescia, Italy
| | - Claudio Azzolini
- Department of Surgical and Morphological Sciences, Section of Ophthalmology, University of Insubria, Ospedale di Circolo, Via F. Guicciardini 9, 21100 Varese, Italy
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