Discomfort symptoms reduction and ocular surface parameters recovery with Artelac Rebalance treatment in mild-moderate dry eye

Recent Advances in Nanotechnology for the Treatment of Dry Eye Disease

Dry eye disease (DED) incidence is continuously growing, positioning it to become an emergent health issue over the next few years. Several topical treatments are commonly used to treat DED; however, reports indicate that only a minor proportion of drug bioavailability is achieved by the majority of eye drops available on the market. In this context, enhancing drug ability to overcome ocular barriers and prolonging its residence time on the ocular surface represent a new challenge in the field of ocular carrier systems. Therefore, research has focused on the development of multi-functional nanosystems, such as nanoemulsions, liposomes, dendrimers, hydrogels, and other nanosized carriers. These systems are designed to improve topical drug bioavailability and efficacy and, at the same time, require fewer daily administrations, with potentially reduced side effects. This review summarizes the different nanotechnologies developed, their role in DED, and the nanotechnology-based eyedrops currently approved for DED treatment.

Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs

In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.

Real Life Impact of Dry Eye Disease

Dry Eye Disease (DED) is an increasingly common condition that affects between 5% and 50% of the global population. Even though DED is most frequently diagnosed in older people, it has also been diagnosed in young adults and adolescents more frequently in recent years (employees, gamers). People can experience different types of symptoms and find it challenging to read, watch TV, cook, climb stairs, and meet friends. Mild and severe dry eye can reduce quality of life similarly to mild psoriasis and moderate-to-severe angina. Furthermore, DED patients experience serious difficulties driving vehicles, especially at night, and show a decrease in work productivity, which, when combined with the relevant indirect cost that this condition produces, poses a serious challenge in our days. In addition, DED patients are more likely to develop depression and suicidal ideations and experience frequent sleep disorders. Finally, it is discussed how lifestyle changes, such as increased physical activity, blinking exercises, and a proper diet, have positive implications for the management of this condition. Our aim is to draw attention to the negative effects of dry eye in real life, which are unique to each patient, especially as they relate to the non-visual symptoms experienced by DED patients.

Performance and Safety of a Sodium Hyaluronate Tear Substitute with Polyethylene Glycol in Dry Eye Disease: A Multicenter, Investigator-Masked, Randomized, Noninferiority Trial

Purpose: To compare the performance and safety of 2 tear substitutes containing sodium hyaluronate (SH); one containing 0.15% SH and polyethylene glycol (PEG) 8000, and the other containing 0.18% SH. Methods: In this multicenter, randomized, investigator-masked, noninferiority trial, 83 patients with moderate or severe dry eye disease underwent a 2-week washout, and were then randomly assigned (1:1) to receive SH plus PEG tear substitute (n = 45) or comparator SH tear substitute (n = 38) 3-6 times daily for 3 months. The primary performance endpoint was the change from baseline in the ocular surface fluorescein staining (OSFS) score on day 28 in the per-protocol (PP) population, according to the 15-point Oxford Scheme, with a noninferiority margin of 2. Results: Both groups improved significantly in terms of signs and symptoms. Among the 78 patients without major protocol deviations (the PP population), the OSFS score decreased by 2.9 ± 2.0 on day 28 from 5.4 ± 1.3 at baseline in the SH plus PEG group and by 2.3 ± 2.2 from 5.2 ± 1.4 in the comparator group (95% confidence interval of the difference: -1.2 to 0.3), demonstrating noninferiority. On day 90, the improvement in OSFS scores was significantly greater in the SH plus PEG group (P = 0.0002). The safety profiles were satisfactory in both groups. Conclusion: SH plus PEG tear substitute was noninferior to SH tear substitute in the studied population and may provide additional benefits in the long term. ClinicalTrials.gov ID: NCT02975102.

Lipid, Aqueous and Mucin Tear Film Layer Stability and Permanence within 0.15% Liposome Crosslinked Hyaluronic Acid versus 0.15% Non-Crosslinked Hyaluronic Acid Measured with a Novel Non-Invasive Ocular Surface Analyzer

To evaluate the stability and permanence of the liquid film created after the instillation of 0.15% crosslinked hyaluronic acid with liposomes and crocin versus the effect of 0.15% standard hyaluronic acid, a prospective, longitudinal, single-blind, single-center study was conducted in symptomatic populations with a novel noninvasive ocular surface analyzer. Limbal and bulbar redness classification, lipid layer thickness, tear meniscus height, and first and mean noninvasive break-up time (FNIBUT and MNIBUT) were performed before and 30 and 45 min after liposome-crosslinked hyaluronic acid (LCHA) and standard hyaluronic acid (HA) eye drop instillations. LCHA had a higher lipid layer thickness than HA (grades 2.00 ± 0.83 and 1.17 ± 0.63 on the Guillon pattern, respectively). LCHA achieved a better tear meniscus height than HA (0.23 ± 0.02 and 0.21 ± 0.02 mm, respectively). LCHA improved FNIBUT and MNIBUT more than HA (for FNIBUT, 6.30 ± 0.94 and 4.77 ± 0.89 s, respectively. For MNIBUT, 17.23 ± 5.11 and 12.41 ± 4.18 s, respectively). Crosslinking hyaluronic acid with liposomes and crocin significantly increases the permanence and stability of the lipid, aqueous, and mucin tear film layers. In a short-term period, liposome and crosslinked hyaluronic acid achieved better first and mean noninvasive break-up times than standard hyaluronic acid.

Effect of oral vitamin D supplementation on dry eye disease patients with vitamin D deficiency

CLINICAL RELEVANCE

Dry eye disease (DED) and vitamin D deficiency are both common clinical entities. Vitamin D has been reported to play a significant role in ocular surface homeostasis.

BACKGROUND

This study aimed to determine the therapeutic effect of oral vitamin D supplementation in dry eye disease patients with vitamin D deficiency.

METHODS

A randomized, controlled study was completed in 100 patients with dry eye disease and concurrent vitamin D deficiency (< 20 ng/ml). Participants were randomly allocated to 8 weeks of oral vitamin D supplementation with both groups receiving conventional dry eye treatment with artificial tears. Schirmer's, tear break-up time (TBUT) and osmolarity tests were measured before and after eight weeks of treatment.

RESULTS

The mean age of participants was 36.8 ± 8.56 years in the treatment group (n: 50) and 34.8 ± 10.13 year in the control group (n: 50). After eight weeks of treatment the mean differences in Schirmer's, TBUT and tear osmolarity were 2.38 ± 1.55 mm, 3.95 ± 1.48 s and -16.9 ± 6.28 mOsm/L, respectively in the treatment group, and 0.7 ± 0.86 mm, 0.92 ± 1.57s and -3.34 ± 2.0 mOsm/L respectively in the control group (p < 0.001 for all parameters). The treatment group demonstrated a more significant improvement than the control group in Schirmer<apos;>s, TBUT and osmolarity values (p < 0.001).

CONCLUSION

Vitamin D supplementation as an adjuvant to routine dry eye treatment improves ocular surface hemostasis parameters, results in better tear stability and a more improved tear osmolarity in patients with vitamin D deficiency.

Modern approach to the treatment of dry eye, a complex multifactorial disease: a P.I.C.A.S.S.O. board review

Dry eye disease (DED) is a growing public health concern affecting quality of life and visual function, with a significant socio-economic impact. It is characterised by the loss of homoeostasis, resulting in tear film instability, hyperosmolarity and inflammation of the ocular surface. If the innate immune response is unable to cope with internal bodily or environmental adverse conditions, the persistent, self-maintaining vicious circle of inflammation leads to the chronic form of the disease. Treatment of DED should be aimed at the restoration of the homoeostasis of the ocular surface system. A proper diagnostic approach is fundamental to define the relevance and importance of each of the DED main pathogenic factors, namely tear film instability, epithelial damage and inflammation. Consideration also needs to be given concerning two other pathogenic elements: lid margin changes and nerve damage. All the factors that maintain the vicious circle of DED in the patient's clinical presentation have to be considered and possibly treated simultaneously. The treatment should be long-lasting and personalised since it has to be adapted to the different clinical conditions observed along the course of the disease. Since DED treatment is frequently unable to provide fast and complete relief from symptoms, empathy with patients and willingness to explain to them the natural history of the disease are mandatory to improve patients' compliance. Furthermore, patients should be instructed about the possible need to increase the frequency and/or change the type of treatment according to the fluctuation of symptoms, following a preplanned rescue regimen.

The Role of Nutrition and Nutritional Supplements in Ocular Surface Diseases

Dry eye disease (DED) is a multifactorial disease of the ocular surface system whose chore mechanisms are tear film instability, inflammation, tear hyperosmolarity and epithelial damage. In recent years, novel therapies specifically targeting inflammation and oxidative stress are being investigated and used in this field. Therefore, an increasing body of evidence supporting the possible role of different micronutrients and nutraceutical products for the treatment of ocular surface diseases is now available. In the present review, we analyzed in detail the effects on ocular surface of omega-3 fatty acids, vitamins A, B12, C, D, selenium, curcumin and flavonoids. Among these, the efficacy of omega-3 fatty acid supplementation in ameliorating DED signs and symptoms is supported by robust scientific evidence. Further long-term clinical trials are warranted to confirm the safety and efficacy of the supplementation of the other micronutrients and nutraceuticals.

[Prevention and treatment of degenerative changes in ocular surface epithelium in patients with dry eye syndrome]

In current understanding of the pathogenesis of xerotic changes of the ocular surface in patients with dry eye syndrome (DES), great importance is given to hyperosmolarity of the tear film, inflammatory process and oxidative stress. By now, no convincing data has been obtained on whether the oxidative stress is primary in relation to the inflammatory process in the ocular surface tissues, or if it is a complication. Furthermore, in the complex treatment of patients with DES, antioxidant therapy has so far received little attention. This problem can be solved with the 'artificial tears' preparation containing cyanocobalamin (vitamin B12), which antioxidant, anti-inflammatory and clinical effectiveness has been convincingly proved in a number of experimental and clinical studies of recent years. Improving the methods of vital diagnostics of xerosis of the ocular surface also enables detection of subclinical changes in epithelium of the cornea and conjunctiva, thus allowing timely prescription of metabolic therapy. One of the promising directions of such treatment is the use of 5% dexpanthenol, which stimulates the processes of reparative regeneration and possesses an anti-inflammatory effect.

Ocular Surface Workup With Automated Noninvasive Measurements for the Diagnosis of Meibomian Gland Dysfunction

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.

Semifluorinated Alkane Eye Drops for Treatment of Dry Eye Disease Due to Meibomian Gland Disease

Purpose: Meibomian gland disease is generally accepted as the leading cause for evaporative dry eye disease (DED). In a previous study, perfluorohexyloctane, a semifluorinated alkane, has been demonstrated to significantly increase tear film breakup time and to reduce corneal fluorescein staining in patients with evaporative DED, thereby vastly reducing dry eye-related symptoms. This study was set up to evaluate perfluorohexyloctane in a larger population of patients with Meibomian gland dysfunction.

Methods: Seventy-two patients with Meibomian gland disease and associated dry eye received 1 drop of perfluorohexyloctane 4 times daily during an observational, prospective, multicenter, 6–8-week study. Clinical assessment included best-corrected visual acuity, intraocular pressure, Schirmer test I, tear film breakup time, anterior and posterior blepharitis assessment, number of expressible Meibomian glands, meibum quality and quantity, ocular surface fluorescein staining, lid margin and symptom assessment, and Ocular Surface Disease Index (OSDI^©).

Results: From the 72 patients recruited, 61 completed the trial per protocol. Nine patients did not apply the medication as recommended and 2 patients were lost to follow-up. Tear film breakup time, corneal and conjunctival fluorescein staining, number of expressible Meibomian glands, and severity of anterior and posterior blepharitis significantly improved after 6–8 weeks of perfluorohexyloctane application. In addition, symptoms improved as demonstrated by a significant decrease of OSDI-values from 37 (±13) to 26 (±16).

Conclusions: In concordance with previous findings, 6–8 weeks of topical application of perfluorohexyloctane significantly improves clinical signs of Meibomian gland disease and associated mild to moderate DED.

Randomized, masked, in vitro comparison of three commercially available tear film osmometers

Purpose

The purpose of this study was to compare the precision and accuracy of commercially available tear film osmometers.

Methods

Contrived tear solution target values representing the physiological range of tear osmolarity (normal eyes 297 mOsm/L, moderately dry eyes 342 mOsm/L, and severe dry eyes 383 mOsm/L) were constructed using a mix of mono- and divalent electrolytes, metabolites, serum albumin, and pH balanced to 7.4. Solution values were randomized and masked from the investigators during testing. Osmometers (Wescor 5520 Vapro Pressure Osmometer: device A, TearLab Osmolarity System: device B, and i-Med Pharma i-Pen: device C) were calibrated according to manufacturer instructions. Each level was tested 64× on each osmometer across two sites. Accuracy was reported as a correlation coefficient against expected linear dilutions, precision was calculated as percent coefficient of variation.

Results

Device A reported a correlation with known solutions of r²=0.98, with averages of 305.6±4.0, 352.2±5.5, and 389.8±4.0 mOsm/L, and coefficient of variations (CVs) of 1.3%, 1.6%, and 1.0%, respectively. Device B reported an r²=0.96, with averages of 300.6±3.7, 341.4±7.9, and 376.8±5.1 mOsm/L, and CVs of 1.2%, 2.3%, and 1.4%, respectively. Device C reported an r²=0.03, with averages of 336.4±21.5, 342.0±20.7, and 345.7±22.0 mOsm/L, and CVs of 6.4%, 6.1%, and 6.4%, respectively.

Conclusion

In this randomized, masked, in vitro study, device A and device B had significantly better accuracy and precision in measuring osmolarity of contrived tear solutions of known target values compared to device C. Device C showed insufficient performance to accurately and precisely delineate osmolarity levels in the physiological range. Furthermore, in vivo studies would be required to compare performance in human subjects.

Semifluorinated Alkane Eye Drops for Treatment of Dry Eye Disease--A Prospective, Multicenter Noninterventional Study

Purpose: Evaporation of the tear film is heavily discussed as one core reason for dry eye disease (DED). Subsequently, new artificial tear products are developed that specifically target this pathomechanism. Perfluorohexyloctane (F6H8, NovaTears^®) from the family of semifluorinated alkanes is a novel substance that has been approved as a medical device, as a nonblurring wetting agent for the ocular surface.

Methods: Thirty patients with hyperevaporative dry eye received F6H8 during a prospective, multicenter, observational 6-week study. Patients were advised to apply 1 drop 4 times daily in both eyes. Parameters assessed included best corrected visual acuity, intraocular pressure, Schirmer I test, tear fluid, tear film breakup time (TFBUT), corneal staining, meibum secretion, and Ocular Surface Disease Index (OSDI^©).

Results: From the 30 patients recruited, 25 completed the trial per protocol. Four patients discontinued F6H8 and 1 patient did not present for follow-up. F6H8 treatment led to significant reduction of corneal staining and significant increase of Schirmer I and TFBUT. In addition, OSDI score dropped significantly from a mean of 55 (±23.0) to 34 (±22.4). Visual acuity and ocular pressure did not change.

Conclusions: This prospective observational study shows significant beneficial effects in patients suffering from evaporative DED, using F6H8 in all the relevant parameters tested. The decrease of the OSDI by a mean of 21 points was particularly remarkable and clearly exceeds minimal, clinical important differences for mild or moderate and severe disease. Overall, F6H8 (NovaTears) seems to be safe and effective in treating mild to moderate hyperevaporative DED.