An Evidence-Based Strategic Approach to Prevention and Treatment of Dry Eye Disease, a Modern Global Epidemic

Post-refractive Surgery Dry Eye: A Systematic Review Exploring Pathophysiology, Risk Factors, and Novel Management Strategies

Dry eye disease frequently manifests following corneal refractive procedures, significantly impacting patients' quality of life. This review systematically synthesizes current evidence on the pathophysiological mechanisms, risk factors, and therapeutic interventions for post-refractive surgery dry eye. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of literature published until August 2023 was conducted, focusing on post-refractive surgery dry eye. Eighteen relevant studies were identified through screening and eligibility assessment. A qualitative synthesis of outcomes was performed using narrative and thematic analysis methods. Surgically induced neurotrophic deficiency, stemming from nerve transection, triggers a cascade of events including apoptosis, inflammation, and lacrimal dysfunction, ultimately leading to tear film instability. Risk factors such as female gender, thyroid eye disease, meibomian gland dysfunction, higher ablation depths, and the use of LASIK over surface ablation exacerbate the condition. While conventional treatments like artificial tears provide temporary relief, emerging interventions such as nerve growth factors, matrix metalloproteinase inhibitors, serum eye drops, and specialized contact lenses show promise in promoting nerve regeneration and epithelial healing. Strategies such as customized ablation profiles, smaller optical zones, and nerve-sparing techniques like small incision lenticule extraction demonstrate potential advantages. A multifaceted therapeutic approach targeting neuroprotection, anti-inflammatory mechanisms, and tear film stabilization is imperative for effectively managing post-refractive surgery dry eye. Future research should focus on evaluating prognostic biomarkers, exploring precision medicine approaches, and investigating neuroprotective adjuvants to further enhance treatment outcomes.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Quality of life improvement in dry eye patients after intense pulsed light therapy compared to punctal plugs

PURPOSE

The purpose of the study was to evaluate the quality of life (QOL) improvement in evaporative dry eye patients after treatment with intense pulsed light (IPL) therapy compared to punctal plug insertion.

METHODS

A prospective comparative interventional study included 30 patients with moderate-to-severe evaporative dry eye. Patients' QOL affection before and after treatment was assessed by the Ocular Surface Disease Index (OSDI) questionnaire. Fifteen patients were treated with IPL therapy (Group 1). The other 15 patients were treated with silicone punctal plug insertion (Group 2).

RESULTS

Improvement of patients' QOL was noticed in all patients of Group 1, with significant improvement of OSDI score from a mean value of 56.9 to 22.9 (P = 0.001). Improvement was noticed in 80% of Group 2 patients (mean OSDI score pretreatment: 53.8 and posttreatment: 31.7, P = 0.017). The tear breakup time (TBUT) in Group 1 significantly improved from a mean of 3.2 s to 5.9 s (P = 0.001), whereas it showed no significant changes in Group 2 (mean TBUT pretreatment: 3.6 s and posttreatment: 3.9 s, P = 0.654). Complications occurred in 13.3% in Group 2, including punctal granuloma and proximal canalicular obstruction. No adverse effects were recorded in Group 1.

CONCLUSION

IPL therapy had better results with more improvement of patients' QOL compared to punctal plugs. It also showed a better safety profile with no reported complications.

Prevalence of dry eye during the COVID-19 pandemic: A systematic review and meta-analysis

OBJECTIVE

During the COVID-19 pandemic, many people devoted longer time to screen viewing due to the need for study, work, and online social activities, instead of outdoor activities, which may have led to an increase in dry eye symptoms. This study aimed to evaluate the prevalence of dry eye during the COVID-19 pandemic.

METHODS

PubMed, Cochrane Library, Embase, and Web of Science were searched from January 1, 2020 to October 20, 2022. Cross-sectional surveys on dry eye prevalence conducted after January 1, 2020 were included. Two review authors independently performed data extraction and assessed study quality. The random-effects model was used to analyze the prevalence of dry eye, and the odds ratio was used to assess the strength of the association between variables. Subgroup analysis was performed to detect heterogeneity, the leave-one-out method for sensitivity analysis, and the Egger test for publication bias.

RESULTS

A total of eleven studies with 15692 individuals met the eligibility criteria. The prevalence of dry eye during the COVID-19 pandemic was 61.0% (95%CI: 51.8%-70.2%) globally and 56.7% (95%CI: 45.3%-68.1%) in Asia. The prevalence of dry eye had significant differences in sex and visual display time, with higher prevalence among females and visual display time of more than 4 hours per day. Subgroup analysis was performed based on diagnostic tools, study population, and average age. A significant difference was found in diagnostic tools, but no significant change in heterogeneity (P<0.05). The leave-one-out method showed stable results, and the Egger test identified no significant publication bias.

CONCLUSION

The prevalence of dry eye during the COVID-19 pandemic is significantly higher than before, and a higher prevalence is found among females and those having a visual display time of more than 4 hours per day.

Perceived Eye-Related Symptoms and Influencing Factors in Hospital Nurses

Nurses are at risk of eye discomfort due to the increasing use of visual display terminals and wearing masks, which may worsen eye-related symptoms. This study was conducted in South Korea to identify the factors influencing eye-related symptoms among hospital nurses on/off duty. The study included 154 nurses who completed a self-reported questionnaire that assessed demographic characteristics, perceived health status, dry-eye symptoms, occupational stress, and eye-related symptoms. The results showed that nurses complained of more eye-related symptoms on duty than off duty, with female sex and dry-eye symptoms being the factors influencing eye-related symptoms on duty. On the other hand, computer use time (≥4 h) and dry-eye symptoms were the factors influencing eye-related symptoms off duty. The study suggests that assessing dry-eye symptoms can facilitate early interventions to relieve eye-related symptoms in hospital nurses, and they should pay attention to eye health during working hours as well as off hours.

Spotlight on Digital Eye Strain

Digital Eye Strain (DES) is a clinical syndrome manifested with visual disturbances and/or ophthalmic dysfunction related to the usage of screen-enabled digital equipment. This term is gradually replacing the older term computer vision syndrome (CVS) that focused on the same symptoms found on personal computer users. DES is encountered more frequently during the past years due to the explosive increase in the usage of digital devices and subsequent increase in time in front of any screens. It presents with a series of atypical symptoms and signs stemming from asthenopia, dry eye syndrome, preexisting untreated vision issues and poor screen ergonomics. This review summarizes research data to date to determine whether the concept of DES has been conclusively defined and demarcated as a separate entity and if sufficient guidance is offered on professionals and the lay public. The maturity of the field, grouping of symptoms, examination techniques, treatment and prevention modalities are summarily presented.

Prevalence of Dry Eye Disease Among Individuals Scheduled for Cataract Surgery in a Norwegian Cataract Clinic

Purpose

To determine the prevalence of dry eye disease (DED) in patients scheduled for cataract surgery in a Norwegian eye clinic.

Patients and Methods

218 patients scheduled for cataract surgery were examined for DED in one randomly selected eye and questioned regarding symptoms and risk factors. Patients were diagnosed with DED if they fulfilled the DEWS II criteria with symptom score >12/100 with Ocular Surface Disease Index (OSDI) questionnaire, and the presence of any of the three signs: tear osmolarity >307 mOsm/L in either eye or a difference in osmolarity between the two eyes of >8 mOsm/L, corneal fluorescein staining (CSF) ≥ grade 2 and non-invasive tear film breakup time (NIKBUT) of <10 seconds. Additional tests were the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, tear meniscus height (TMH), Schirmer 1, tear film thickness (TFT), corneal sensitivity and meibography (meiboscore). Dry eye test outcomes were correlated with risk factors for DED.

Results

The prevalence of DED was 55.5% according to the DEWS II criteria. The abnormal osmolarity percentage was 66.5, while 29.8% had shortened NIKBUT and 19.7% exhibited CFS ≥2. 57% had Schirmer 1 ≤ 10 mm/5 min, and 81.1% had a meiboscore of ≥1. 71.2% of subjects scored positive for DED symptoms using the OSDI questionnaire and 69.3% using SPEED. Logistic regression analysis showed that higher age correlated with a lower OSDI symptom score, reduced corneal sensitivity and increased meibomian gland atrophy. Female sex was associated with higher odds of having DED, abnormal NIKBUT and abnormal CFS. Ocular tests for DED did not correlate with OSDI symptom scores when assessed with Spearman`s rank analysis.

Conclusion

The prevalence of DED in an elderly Norwegian population scheduled for cataract surgery is high and associated with female sex. There was a lack of correlation between signs and symptoms of DED.

Understanding and Optimizing Ocular Biometry for Cataract Surgery in Dry Eye Disease: A Review

PURPOSE

To understand the impact of dry eye disease (DED) on the components of ocular biometry and ways to optimize the visual outcomes of cataract surgery in eyes with DED.

METHODOLOGY

A thorough literature review of the components pertaining to this review was undertaken using the databases, PubMed (from the year 2000), MEDLINE, CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials. com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). The keywords used for the search included "cataract surgery" or "phacoemulsification" combined with "dry eye", "dry eye disease","biometry", "keratometry".

RESULTS

Publications considered for this review included meta-analysis, systematic reviews, case-control and cohort studies, case series, and laboratory-based studies. Published articles reporting tear film alteration in DED, its impact on the quality of vision and optical aberrations, the effect of topical medications on keratometry variations, and reports on optimizing the ocular surface before cataract surgery were included.

CONCLUSIONS

DED is a common entity seen in patients presenting to routine cataract clinics and is known to impact the accuracy, reliability, and repeatability of ocular biometry and IOL power calculations in them. This review intends to emphasize the preoperative screening for the presence of DED, initiation of appropriate medical management for optimization of the ocular surface before cataract surgery, and recommendations for performing biometry. The algorithmic approach proposed will help the general ophthalmologists in routine practice to provide quality care and acceptable visual outcomes in patients with pre-existing DED.

Transepithelial Photorefractive Keratectomy Compared to Conventional Photorefractive Keratectomy: A Meta-Analysis

This meta-analysis review compares the primary and secondary outcomes of transepithelial photorefractive keratectomy (TPRK) to the conventional photorefractive keratectomy (PRK), in terms of efficacy, predictability, safety, and patient perspectives. A total of 1711 eyes with PRK (811 eyes) and TPRK (900 eyes) from 12 studies were included through bibliographic searches. The main outcomes were efficacy, predictability, and safety parameters, and the secondary outcomes included visual and patient-reported parameters. The effect measures were weighted mean differences with 95% confidence intervals (CI) which were derived from the random-effects model of the meta-analysis to account for possible heterogeneity. TPRK procedure presents a comparable status in the main outcome and a very dominant significance in all the secondary outcomes in this meta-analysis. This study updates the evidence of the accuracy of TPRK procedure for surgical correction of all refractive errors and was deemed safer with less surgical time required and an early healing time.

Anxiety and depression in dry eye patients during the COVID-19 pandemic: Mental state investigation and influencing factor analysis

Objective

Investigate the anxiety and depression states among dry eye (DE) patients during the COVID-19 outbreak and analyze their influence factors.

Methods

The study was conducted in a tertiary eye hospital in Tianjin, China from March–April 2021. Four hundred twenty-eight DE patients were tested with the Ocular Surface Disease Index, Short Healthy Anxiety Inventory, Hospital Anxiety and Depression Scale, and Pittsburgh Sleep Quality Index. Descriptive statistics was used to assess the difference between DE with depression or anxiety among different groups. And multiple linear regression was used to explore factors that influence anxiety and depression in DE patients.

Results

The incidence rates of anxiety and depression among DE patients during COVID-19 were 27.34 and 26.87%, respectively. The proportion with comorbid anxiety and depression was 24.30%. Patients' education level (t = −3.001, P < 0.05; t = −3.631, P < 0.05), course of disease (t = 2.341, P < 0.05; t = 2.444, P < 0.05), health anxiety (t = 3.015, P < 0.05; t = 2.731, P < 0.05), and subjective sleep quality (t = 3.610, P < 0.05; t = 4.203, P < 0.05) had certain influences on anxiety and depression.

Conclusion

The results showed that subjective symptoms of DE patients were related to depression and anxiety. Higher education, shorter disease duration, lower health anxiety levels, and better subjective sleep quality were associated with the reduced depressive and anxiety symptoms in DE patients. These findings could be deemed beneficial to the treatment and prevention of DE during the COVID-19 epidemic.

A Narrative Review of Current Understanding and Classification of Dry Eye Disease with New Insights on the Impact of Dry Eye during the COVID-19 Pandemic

Dry eye disease (DED) is a complex, progressive and multifactorial condition that is commonly seen in clinical practice and can be challenging to accurately diagnose. Untreated or suboptimally managed dry eye can progress to severe, chronic disease which may become resistant to treatment. Symptoms include ocular irritation and visual impairment. Patients frequently report negative consequences regarding quality of life (QoL), productivity and psychological wellbeing. Certain lifestyle factors (e.g. use of screen-based devices, air conditioning) can induce or exacerbate symptoms of DED, leading to progressive and debilitating complications. Exposures to such triggers are likely to have increased significantly during the ongoing COVID-19 pandemic with people across the globe living with heightened levels of stress/anxiety while being forced to adapt most aspects of their daily lives (from work and education through to social activities) to accommodate social distancing, primarily through the use digital technologies. This review aims to provide a concise and practical overview of current understanding regarding DED, highlighting proposals for refined diagnostic categories and therapeutic terminologies that are designed to improve identification and management of dry eye as well as reduce or slow disease progression. Finally, the findings of a European survey are shared to illustrate the impact of the COVID-19 pandemic on the lives of people with DED. The survey was conducted during the first lockdown period (March–September 2020) and explored issues relating to psychological wellbeing, QoL and engagement with healthcare services. The results demonstrate the ways in which the pandemic amplified the impact of dry eye on daily life and may be valuable in enhancing understanding among clinicians of the challenges faced by people with DED, which extend beyond the signs and symptoms of disease.